Part 29

As to treatment, after the infliction of an injury, the scalp ought to be shaved, and the wound cleansed of coagula and foreign substances. If a large flap of integument is detached, it should be replaced, and retained as nearly as possible in its natural situation; and if, for this latter purpose, slips of uninitiating adhesive plaster and methodical compression prove insufficient, it will be necessary to employ a very few points of interrupted suture: these, however, must be removed at an early period, that is, when either adhesion or suppuration has commenced, and ought, if possible, to be altogether dispensed with, being apt in this situation to produce injurious effects by their irritation. Light dressing is afterwards applied. On the accession of swelling, heat, and pain, the parts are to be well fomented with a hot decoction of chamomile flowers, or hops, and afterwards covered with a warm and soft poultice; and should these symptoms continue, the fomentation ought to be frequently repeated. Fomentation and poultice are also the best applications when a day or two has elapsed between the receipt of the injury and the patient’s application for cure. The constitutional symptoms are to be moderated, and may in many instances be averted, by the exhibition of antimonials and purgatives; and by general bloodletting, when demanded and authorised by the symptoms, and the state of the constitution. Punctures or incisions are to be employed according to circumstances, in order to lessen the vascular congestion of the part, and prevent the formation of matter, to evacuate it if already secreted, or to relieve inflammatory tension and promote the formation of pus at the incised parts, where erysipelatous inflammation is threatened, healthy suppuration in such circumstances often appearing to be critical. In many unpromising cases of lacerated scalp, when a great part of the cranium has been exposed, and partially deprived of its periosteum, a rapid cure has taken place without the formation of much matter. The detached scalp, though much torn and bruised, ought not at first to be removed, it being more prudent to leave nature to determine how much must be destroyed. After the sloughs, if any, have separated, and granulation has commenced, the loss of substance is rapidly repaired in this region, more especially when the patient is young and healthy. General or partial support, by bandaging, is required in many cases, as by a handkerchief, split cloths, or a roller applied in various forms.

_Wounds of the Temporal Artery_ are either the result of accident, or made intentionally for the purpose of abstracting blood; and it may be here proper to make a few remarks regarding this latter circumstance. When it is wished to take away blood from the head, no one thinks of opening the trunk of the temporal artery; its anterior branch is generally chosen. By some the vessel is first exposed by means of a scalpel, and then opened with a lancet. But preliminary incisions are altogether unnecessary. The vessel ought not to be cut entirely through, and the incision should extend obliquely across its course; and care is to be taken that the external aperture shall be larger than that in the cellular tissue involving the artery, as thus the blood escapes freely, and no risk is incurred of its becoming infiltrated into the surrounding parts. When the branch is of the ordinary size, a sufficient quantity of blood is readily obtained from it; but if, from its small size, or a faulty form of incision, blood does not flow freely and quickly, a cupping-glass may be applied, and its lower edge slightly raised. This latter precaution is absolutely necessary, for if neglected, little or no blood can escape, the artery being firmly compressed against the cranium by the edge of the exhausted glass. No other mode of cupping ought to be practised on the temples, for the cupping by scarification is here both unwarrantable and unnecessary—unwarrantable, because the cicatrised scarifications leave an unseemly and permanent mark on a prominent part of the countenance,—and unnecessary, since there can be no occasion for six or eight incisions when one is fully sufficient. The bleeding may be readily stopped, after the requisite quantity has flowed, by a small graduated compress placed over the wound, and retained by bandages, which surround the head, and are afterwards twisted and brought under the chin in order to increase the security. If by these means the bleeding is not readily restrained, the vessel may be divided throughout its whole circumference, by entering the lancet at the original wound, and moving its point laterally. Then compression is to be again employed, by the assistance of which the natural processes for closing the divided extremities are speedily accomplished.

When this artery has been injured by external violence, the wound of the integuments is generally large, and the bleeding profuse. In such cases, both ends of the vessel must be pulled out by means of forceps, and tied separately; afterwards the integuments are to be approximated and supported.

Unpleasant consequences sometimes result from the simple operation of opening the temporal artery, and occasionally also from accidental wounds of that vessel. The integuments unite, and may soon heal; but, from the compression not being sufficient, a small quantity of blood is insinuated into the cellular tissue, which becomes condensed for a considerable extent around the wound, and ultimately a sac is formed, which communicates with the ununited opening in the artery, and is consequently filled with sanguineous clots; in short, an aneurismal tumour is formed. For the cure of this untoward occurrence, the artery may be tied between the heart and tumour, as in the case of spontaneous aneurism; but in consequence of the free inosculation which exists between the numerous ramifications of the artery, this measure may not prove successful, and it will be found necessary, either then or afterwards, to secure the vessel beyond the tumour. But there is another mode of procedure. From the tumour being generally small and circumscribed, excision of the whole of it can be effected easily, and so as to leave but a slight scar: this operation is not liable to failure, and is not more severe than the first mentioned. After the removal of the diseased part by elliptical incisions, the two ends of the artery are to be included in separate ligatures, and the edges of the wound kept together.

A more troublesome accident sometimes takes place,—ulceration of, and over, the vessel, with effusion of serous and purulent fluids into the surrounding cellular tissue, often to a great extent. A profuse flow of blood bursts from the ulcerated surface, perhaps twelve, fifteen, or twenty days after the vessel had been opened, and, if active means are not speedily adopted, the hemorrhage by its recurrence may prove very dangerous. In such cases compression is of no avail; the bleeding may be staid for a time by this means, but upon the circulation becoming again active, fresh hemorrhage must and does take place; the parts around are separated and engorged more and more, the blood escapes in alarming quantities, and the patient is saved only by the occurrence of syncope. To search for, and make a clean dissection of the wounded part of the vessel in such cases, is impossible. A long and deep incision must be made through the swollen and diseased parts in the course of the arterial branch, and a ligature passed under it, on each side of the ulcerated point, by means of the common curved suture-needle, or of one in a fixed handle. The ligatures should be at a considerable distance from each other, in order that they may surround healthy parts of the vessel; after they have been firmly tied, all risk of further hemorrhage is gone. Of course the ligatures should enclose as little as possible of the parts surrounding the artery. A poultice is perhaps the best application for a few days, and under its soothing influence the effects of the continued compression, which had been previously employed, soon subside. The after applications must be varied according to the appearances which the part presents.

Laceration of a large or small bloodvessel is a frequent consequence of _bruise_ of the scalp.—Blood is effused, and the surrounding parts are thereby separated to a greater or less extent; and thus a tumour is formed, either rapidly or slowly, according to the size of the injured vessel. The swelling is in general large, soft in the centre, and hard towards its circumference; the blood in the latter situation being coagulated, and firmly impacted in the condensed cellular tissue; whilst in the centre it is fluid, or at least partially so, and occupies a free cavity. These characters of the tumour are apt to mislead a careless or inexperienced examiner, the feel being in some degree similar to that attending fracture with depression, but still easily distinguishable from it by attentive and experienced manipulation. By pressing the finger or thumb firmly on the centre of the tumour, the blood is displaced, and the bone felt distinctly. In slight cases of this affection, no treatment is required, as the tumour is of no importance, and soon disappears, by the effused blood being absorbed. When, however, the swelling is accompanied with unpleasant symptoms, cold applications are to be made to the part, and low diet, with occasional purgatives, enjoined. If inflammatory symptoms occur, local abstraction of blood may be necessary, followed by hot fomentations to the part. When the pain has ceased, and the swelling is not speedily removed, absorption is promoted by stimulating applications, such as fomentation with a solution of the muriate of ammonia in a decoction of the anthemis nobilis, in the proportions of ℥ss. to ℔ii.; a spirit lotion containing the tincture of arnica montana, in the proportion of one part to fifteen or twenty of water, will be found a good application in many such cases.

Such tumours may ultimately require to be laid open, in consequence of the blood putrefying and becoming mixed with purulent secretion. Under no other circumstances is incision warrantable, as unhealthy, troublesome, and tedious suppurations are sure to follow.

_Of Concussion._—Concussion, in a greater or less degree, attends most injuries of the head. The functions of the brain are either disturbed or suspended; there is loss of sensibility, of volition, and frequently of the power of motion. The confusion of intellect or stunning may disappear in a short time, or may continue, though diminished in intensity, for many days, and even for weeks; it is seldom, however, that the functional disorder exceeds in duration two or three days, and in general it disappears before that length of time has elapsed. The stupor is seldom complete; the patient can perhaps be roused, though with difficulty, so as to answer questions by a hurried monosyllable, or make signs in regard to the seat of pain, or for such things as he may suppose himself to be in need of. At first the circulation is weak; the pulse is fluttering, often intermitting, and scarcely to be felt in the extremities; the countenance is pale, and the surface cold; there is occasional vomiting, a symptom which seldom occurs when compression of the brain exists, and the breathing is difficult, though scarcely ever stertorous. The pupils are generally contracted, but not uniformly so; one pupil may be contracted and the other dilated; at first, they are insensible to light, neither dilating when in darkness, nor contracting further when the light is suddenly increased; not unfrequently a considerable degree of squinting exists. The muscles are neither much relaxed, nor spasmodically contracted. After a time, the circulation is restored, and the heat of the surface returns, with more or less of regained sensibility. The pulse either becomes altogether natural, or else more slow or more rapid than in health. The circulation is then easily excited; by even raising the patient in bed, the pulsations of the carotids are increased, in some cases, by fifteen or twenty beats. Sensibility returns, always very gradually, and in some cases more slowly than in others; frequently the patient becomes quite collected after the lapse of some hours or a few days, but in other instances a degree of mental confusion remains for many weeks; occasionally the intellect continues weak for a lengthened period, and sometimes even for the remainder of life.

When the insensibility has begun to diminish, the patient can be roused with less difficulty; if pinched, he complains of it by uttering some inarticulate sounds, or by attempting to move himself further from the quarter whence he supposes the injury to come; he answers, though with unwillingness, loud questions regarding the pain which he suffers, and points to the part where it is chiefly felt. As the stupor goes off, symptoms of inflammatory action, or a threatening of it in a greater or less degree, manifest themselves. The pulse becomes more rapid and sharp, the skin is hot and dry, the face is flushed, the conjunctiva is redder than usual, and the pupils are often much contracted: the patient is restless, and tosses about in bed; mutters confusedly to himself; often attempts to enact a part in some fanciful scene which he supposes to be passing around him, or talks rapidly and incoherently concerning circumstances which have formerly occurred. His flitting ideas are often of an alarming nature; he endeavours to get out of bed, and struggles violently if opposed. He frequently puts his hand towards his head, and gives other indications of suffering acute pain in that region, much increased by any movement of the part.

Such symptoms are often followed by vomiting and rigors, and too frequently by convulsions, more furious delirium, and coma. On examination after death, an increased vascularity of the cerebral membranes is observed; there is an effusion of gelatinous-looking matter on the surface of the membranes, and in the cellular tissue beneath the arachnoid. In more advanced cases, thin patches of lymph, or more extensive strata of it, cover the arachnoid and the inner surface of the dura mater; a puriform fluid is found effused between these membranes, and sometimes blood and matter are deposited in some part of the cerebral substance; bloody serum is effused into the cavities, and at the base of the brain. The above symptoms and appearances sometimes follow injuries not at first thought severe, but are most frequently the result of such as are attended with læsion of the bone, or of the internal parts.

It is not at all improbable that concussion is produced after a manner somewhat resembling the following. The brain has a natural tendency to remain at rest, but is liable to be brought into a state of commotion by impulses on the cranium being communicated to it. When a slight blow is inflicted on the skull, only a slight commotion of the brain is induced, the cranial contents are, as it were, slightly jumbled, and a temporary and trifling confusion of its functions follows. When, however, the stroke is more severe, the brain is separated from its cranial attachments, both at the point struck and at the part directly opposite,—it is thrown upon itself towards its centre; its substance is thereby condensed, its diameter in the direction of the impulse is diminished, and a separation between the brain and cranium is formed at each extremity of that diameter. By post mortem examinations, it has been ascertained that condensation of the substance of the brain does exist in cases of severe concussion. Such commotion may be sufficient to cause instant extinction of life, or the brain may gradually resume its former condition, or with only such slight incited action as may be required to reunite the dura mater with the inner table of the skull. Extravasation of blood or serum is extremely liable to occur in such cases, the vessels being either compressed, stretched, or otherwise thrown out of their natural relations along with the other cranial contents, reparation can only take place by absorption of the extravasated fluid, and gradual deposition of plastic matter. When extravasation takes place to a greater extent, compression is the consequence, as will be more fully explained further on. Perhaps the brain does not recover itself gradually, but suddenly; the impulse, which was at first directed from the circumference towards the centre, now acting from the centre towards the circumference; and then the propulsions and recoilings may be repeated, though gradually lessening in their intensity, until the effect of the original impulse is lost, and all vibration consequently ceases. But concussion may be caused by an impulse received not immediately on the cranium, but on some other part of the body, as when a person falls from a considerable height and alights on the feet or buttocks; and in such a case also its effects may be indirectly communicated to it through the brain, and may produce equally violent effects, without there ever being any appreciable lesion of the cerebral matter.

The circulation may be merely disturbed, or laceration of the brain may occur with extravasation of blood into its substance. It may present the appearance of having been bruised, or the tear of its substance may be extensive. A multitude of minute vessels may be torn without the substance of the brain being much broken, in which case bloody specks will be observed over a large surface of the interior of the organ. In many fatal cases no change in the state, either of the vessels or of the cerebral substance, is perceptible on minute examinations. The organ in these cases has been merely disturbed and shaken, without visible rupture or hurt having occurred. Again, many patients are supposed to labour under concussion only, in whom fracture of the base of the cranium, or extravasation of blood on the surface, or into the substance of the brain, are discovered after death. It is always difficult to distinguish between the effects of mere concussion and those of compression of the brain by extravasated fluid; for, in the greater number of cases, the symptoms of both affections are blended together. In both there is insensibility from the first; but if an interval of sensibility occur, diagnosis is rendered more easy and certain, it being a fact well verified by experience, that the state of stupor which precedes the return of correct intellectual function is the effect of concussion, and that there is every reason to believe that the insensibility into which the patient subsequently sinks, is caused by compression of the brain; if compression existed from the first, the stupor might not be of longer duration than if it were the effect of concussion, but its stillness would not be interrupted by any restoration of mental exercise, however short. Remarkable effects sometimes result from commotion of the brain; the patient may suffer loss of vision or of hearing, either partial or complete; or partial paralysis may occur; of the muscles, for instance, supplied by the portio dura. In many cases such affections may be supposed to arise from compression of nerves, or other læsion subsequent to and caused by the effects of concussion, and probably connected with fracture of the base of the cranium. Again, it occasionally happens that the senses are rendered more acute than previously, and of this I shall mention an example which came under my own observation. An old nurse sustained fracture of the vertex, with slight depression of the broken part, in consequence of some rubbish having fallen on her from a considerable height. Stupor, along with the other symptoms of concussion, was the immediate effect of the injury, but disappeared in two or three days. Her hearing, which previously to the accident had been long so obtuse as to render it necessary for her to discontinue her employment, became so intensely acute, that the most trifling noise became a source of pain. She gave immediate orders for the clock to be stopped, the ticking of which annoyed her greatly. Her hearing gradually became of the natural intensity, and continued perfect. In this case there can be little doubt that restoration of a sense which had long remained dormant arose entirely from cerebral commotion, for no discharge of blood or other fluid occurred from the ears, by which cerumen accumulated in these organs might have been displaced. People sometimes forget languages from hurts of the brain, whilst they retain memory in other respects; or, rather, the memory on certain things becomes injured, but remains quite perfect on others.

_Treatment._—Whilst the circulation remains depressed after injuries of the head, or of other parts of the body, it is a common practice to abstract blood; but it is one which cannot be too much reprobated, for it is attended with great risk, and can be productive of no benefit; the feeble remains of vital power, whilst struggling as it were against the depressing cause, may by depletion be quickly annihilated, when the vigour which they still retained might have been sufficient, if encouraged and supported, to overcome those effects of external injury which had so far reduced them.

When a patient is seen insensible, it is highly proper and necessary to examine carefully the trunk, head, and limbs, in order to ascertain whether either fractures or displacements have occurred; for it is by no means creditable to the care or science of a surgeon to be made aware of such accidents when the patient regains his senses, after the lapse perhaps of weeks, and when they can be remedied, if at all, with much difficulty.

In the first stage of concussion, as was already observed, the circulation is much weakened, and it is therefore necessary to adopt means for sustaining and strengthening it; and with this view, warmth is to be applied to the surface, more especially to the extremities and epigastrium.

When the powers of life appear to be failing, stimulants must be administered internally. Perhaps the most convenient stimulus is ardent spirit, the only objection to its use being, that when imprudently given in large quantities, its effects, though at first stimulant, become sedative; it ought to be given in small quantities, and at short intervals. Other stimuli, as preparations of ammonia, may be given by the mouth; and much advantage will often be found to follow the employment of a turpentine enema, free motion of the bowels, as well as excitement of the system, being thereby procured.