Part 31

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.

LECTURE XVII.

WOUNDS OF THE HEAD.

253. Compression of the brain means a diminution of the size of certain parts of it, resulting from the pressure of an extraneous body, whether it be fluid or solid, in consequence of which particular symptoms are generally known to ensue. When they occur, it is said that the sufferer is laboring under symptoms of compression of the brain, and apoplexy from the rupture of a blood-vessel may be considered as the best form or illustration of the complaint. These symptoms sometimes take place from the presence of a foreign substance, such as a point or piece of bone, which from the smallness of its size can hardly compress, although it may displace; and it is then said that the symptoms arise from irritation of the brain. Many of them have also been found to occur from loss of blood, or the absence of pressure, or from insufficient pressure arising from changes in the circulation; and several different opinions have been entertained on all the points connected with these subjects. It has been argued that as the brain is incompressible, no compression can take place. There is no proof, however, of the fact of its being incompressible as a whole, although it has been stoutly maintained by Monro secundus, Sir C. Bell, and others.

The brain is surrounded by membranes capable of secreting a halitus or a fluid whenever it may be necessary to fill up space; it is intersected by partitions apparently for the prevention of jar and pressure, and is permeated in every part by vessels of various sizes, both venous and arterial. It has been presumed that it contains at all times the same quantity, or nearly the same quantity, of blood, in consequence of its freedom from atmospheric pressure, through the intervention of the bones of the skull. If this conjecture be correct, the quantity cannot be materially increased, unless something be displaced to make room for the addition; nor can it be essentially diminished without something being added to supply its place. The question turns, however, very much on the words “materially increased or diminished;” for a very small additional quantity may be the cause of serious mischief, and the subtraction of even less may give rise to great cerebral disturbance; but there can be little doubt that the actual quantity contained in the head is less at one time than at another, the deficiency being usually on the side of the arteries; when congestion takes place, it is for the most part venous. When a person is about to faint on the first passage of a catheter through the urethra, the blood deserts his face, he feels sick, his pulse nearly ceases, and he would faint if he were allowed to remain in the erect position. Let his head now be bent down between his knees for a minute; his face fills with blood, his brain does the same, and he recovers almost immediately. Young ladies, when about to faint, are prevented from doing so by these means being adopted, which they declare, nevertheless, to be very unladylike, although they may be doctorial and effective.

254. The motions of the brain covered by the dura mater are but little observable under ordinary circumstances when a circular portion of bone has been removed by the trephine; the surface of the dura mater remains in general perfectly LEVEL; it is of a reddish-silvery color, and is firmly attached to the cut edge of the bone. The surface is raised, however, on a full expiration, and it falls on a deep inspiration. Fluid secreted or placed upon it is seen to move synchronously with the pulse; but the dura mater never rises up into the hole made by the removal of the bone, unless some fluid be retained beneath it. If the quantity of fluid extravasated or collected under it be large, it rises immediately on the removal of the bone; but the protrusion of this membrane does not always take place for some hours afterward if the fluid be more diffused. The motions of the brain, when the dura mater is thus protruded into the opening, become very indistinct, even if they can be perceived. These two points, viz., the protrusion into the opening and the absence of pulsation, are important facts, little noticed by surgical writers, to be borne in mind in connection with the practice to be pursued.

If we sometimes see the natural and ordinary size of the brain diminished under pressure, and that certain symptoms, such as insensibility, syncope, convulsions, and paralysis, are consequent on this state, and are relieved by the removal of the pressure and the restoration of the compressed brain to its ordinary state, we may safely conclude that some derangement takes place in its integral parts, which may be best understood by the word compression. If we further consider that compression can rarely exist without irritation, and that sometimes of a formidable nature, there does not appear to be so much difficulty in the subject as is frequently represented, although the physiological explanation may not be so simple. In the present state of our knowledge, we apprehend that in many cases approaching to apoplexy, in which the symptoms are similar to those arising from compression, all, or nearly all, the vessels, as far as we can ascertain, are actually full of blood, instead of being partially empty and containing less than the natural quantity. When we see a patient, lying in a state of insensibility with a fracture of the cranium, immediately recover his senses after the application of the trephine and the removal of a large coagulum of blood, we are apt to suppose that the coagulum of blood and the insensibility stand in the relation to each other of cause and effect. It is not unreasonable to conclude that the pressure of the extravasated blood confined by the bone had occasioned the insensibility, and that this did not depend alone upon some few vessels containing less blood than usual; for the brain must be considered as a whole in all these investigations, and reference should not be made to its vascular structures only in explanation of the cause of its derangements.

255. When compression of the brain is caused by an extravasation of blood, the patient is insensible, breathes slowly, loudly, and in a heavy, labored manner, or with stertor, and cannot be awakened, although the noisy breathing may be for a time suspended. The breath is sometimes emitted from the corner of the mouth, like a whiff or puff of smoke, and with something of a similar noise: this, when permanent, is a more dangerous symptom than the common snoring or stertorous breathing. He sometimes froths at the mouth, and occasionally appears convulsed, but neither hears nor sees, nor takes the least notice of those about him. The countenance is generally flushed if the shock or blow has been slight, pale or livid if it should have been great. The pulse is usually slower than natural, sometimes irregular or intermitting, occasionally quick, even from the receipt of the injury. The pupils of the eyes may be contracted or dilated, being dependent for their condition more perhaps on the part of the brain affected than on the degree of injury. They are generally more contracted in the first instance than dilated; they may afterward pass into a medium or doubtful state; one may be even dilated, and the other not. In general, as the mischief is continued and augmented, they become dilated and immovable. The eyes may be turned upward, or may be fixed in the center, or be drawn irregularly outward or inward, causing strabismus, which is, however, a more rare occurrence. If the eyelids should be partially open, tickling the cilia or the conjunctiva of the ball with a straw or a feather will cause them to close, if the spinal cord be sound. The mouth and lips are more or less compressed, and fluids run out at the corners, unless placed on the very back of the tongue by a long, narrow spoon, when they are swallowed with difficulty. Paralysis of one side of the face and hemiplegia are common; paraplegia is more rare. In both kinds of palsy one part in one limb may be more completely affected than another, in which convulsive twitchings are sometimes present, as well as a frequent drawing up of the limb of the unaffected side. Tickling the soles of the feet or the palms of the hands will sometimes cause retraction of the toes or fingers when the limbs are apparently motionless; pricking them gently with a pin will often give rise to convulsive startings and tremblings of all the muscles of the extremity when tickling fails, showing that the capability to move the part remains, although the will to do so is wanting. The leg or arm is sometimes drawn toward the body when separated from it; it more often falls from the hand as if it belonged to the body of a dead person; the muscles are occasionally more stiff and rigid, and some power of motion remains, although but little of sensation; sometimes sensation is perfect when motion is lost, and sensation may be lost on one side and motion on the other. The urine at first retained may ultimately pass involuntarily, as well as the feces; nevertheless, irritating the verge of the anus will excite motion and contraction in the sphincter ani, if the functions of the spinal cord be not destroyed. The action of the involuntary muscles is little impaired in general, and the secretions are but slightly affected; when it is otherwise, the injury must have extended to the ganglionic system, and the whole of the nervous centers must be materially implicated.

The loss of motion, or of the power of moving parts of the body, is either perfect or imperfect according to the degree of injury which has been inflicted, varying from a sense of feebleness to an almost utter incapability of moving the part. It is accompanied in general by defective sensation, or numbness, or by the complete loss of sensation and of the power of resisting heat and cold; the whole side, or one extremity, or a part only of an extremity may be affected, and not the whole. The mischief which gives rise to the loss of motion usually occurs on the side of the brain opposite to that part of the body which is paralytic. This was known and stated by Hippocrates, and the subject has been pursued to the most complete demonstration by modern anatomists.

The pathological proofs are not less complete. Desault and Bichat were by no means satisfied that the paralysis which followed an injury always took place on the opposite side; and some pathologists since their time, while admitting the fact, have shown that there may be exceptions. It is acknowledged, although it is not clearly and satisfactorily accounted for as to the face, that an extravasation of blood into one hemisphere of the cerebrum, or even of the cerebellum, can cause paralysis of the complete half of the body on the opposite side. It has been demonstrated that the right side of the body and the left side of the face may be paralytic at the same time and from the same injury apparently of the left side of the head, the mischief which caused the paralysis of the right side being found, in by far the greater number of instances, on the left side of the brain, and that which gave rise to the paralysis of the left side of the face to have been caused by an injury in the course of the portio dura of the seventh pair of nerves when about to leave, or after it had left, the brain.

Burdach found, in 268 cases of lesion of one side of the brain, that 10 presented paralysis on both sides of the body, and 250 of one side; in 15 of these the paralysis was on the same side as the injury. Convulsions took place in 25 cases on the same side as the disease; in 3, on the opposite side. In cases of lesion of one corpus striatum, there were, in 36 instances, paralysis of the opposite side, and 6 with convulsions of the same side, and in no instance convulsions of the opposite side. In 28 cases of cerebral lesion of one side, the muscles of the opposite side of the face were paralyzed; in 10, those of the same side. Paralysis of the eyelid was in 6 cases on the same side, in 5 on the opposite side. Paralysis of the muscles of the eyeball occurred in 8 cases on the same side, in 4 on the opposite; paralysis of the iris, in 5 cases on the same side and in 5 on the opposite, the tongue being generally drawn toward the paralyzed side of the face.