Chapter XIV: Part 14

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.

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.

A man fell down stairs and received an injury on the head from the fall which rendered him nearly insensible at the moment. There were no signs or appearances on the outside of the head indicative of any serious mischief, nor were any found on examination after death. The pulse was quick, and rose to 140; the left side was paralytic; the breathing not stertorous, but accompanied by a little puff on the right side of the mouth; the pupils somewhat dilated; he could not speak, convulsions supervened, and he died the day afterward. On dissection, the peculiar flatness of the convolutions of the brain on the right side was so remarkable, when compared with that of the left, as to leave little doubt of its having been occasioned by something which had pressed them forcibly upward against the inside of the cranium; and, on slicing off a portion of the brain, a larger coagulum of blood was found below than is usually observed to exist without the almost immediate death of the patient. The same thing has been so distinctly marked in other instances that no doubt can be entertained of those convolutions of the brain which were situated between the coagulum and the cranium having undergone a considerable degree of compression. It is worthy of remark that the pulse of this person was always regular and remarkably quick from the first examination after the receipt of the injury until the period of his death, showing, perhaps, that the action of the heart is not affected directly by pressure acting only on the upper surface of the brain.

256. Convulsive actions of the muscles, or positive convulsive fits, are always important symptoms; yet they seem in some persons to be dependent on idiosyncrasy, particularly when they appear early, and after the loss of blood, in which case they are less dangerous. They occur at different periods after the receipt of the injury, and have been supposed to depend in general upon laceration of the substance of the brain, although experiments on animals would seem to show that they may be caused directly by irritation of the cerebro-spinal axis within the skull, in which case the patients are more likely to recover. They have been observed particularly on the side opposite to that which is paralytic, so as to give rise to the idea that the paralysis is dependent on injury of one side of the cerebrum, and convulsions on injury of the other. When the effect of the mischief is so great as to cause complete paralysis, convulsive twitches do not take place, although they frequently precede, and may in many cases be considered as premonitory signs, while the evil which gives rise to the paralysis is gradually accumulating. When the paralysis is not complete, the side so affected suffers sometimes from slight convulsive twitches, while well-marked spasms prevail in the other, leading to the belief that, while paralysis is an affection of only half the brain of the opposite side, or of half the spinal marrow of the same side, convulsions are the effect of a more general irritation, capable, however, of being confined to a part; for partial convulsive motions do very frequently occur without any paralysis accompanying them on the opposite side. Several cases have occurred in which the convulsions have ceased, and the patients recovered after the removal of a portion of bone which was irritating the brain; but convulsions have generally been the forerunners of death when the seat of injury was unknown and effective relief could not be given. When they occur in cases apparently of pure concussion, accompanied by inflammation of the brain or of its membranes, and the patient recovers after many days of the strictest antiphlogistic treatment, it is possible that the brain may have been lacerated, and the cure have been effected by adhesion. Convulsions, it must be remarked, are among the most common symptoms of inflammation of the membranes of the brain, without any such lesion of its substance, although they are frequently wanting. They may be expected to take place about and after the fifth day in injuries of the head, when inflammation of the brain or of its membranes is about to extend to or to become continuous with the neighboring parts, and may be more or less severe, varying from a state of partial trembling of a limb to that of general agitation and restlessness of the body generally--from a slight, irregular movement of the eyelids, or of the muscles of the face, to the more marked spasmodic startings of the whole of one side, grinding of the teeth, and contraction of the limbs. It is far different with those convulsive movements which, at a late period, become nearly permanent, or with rigid spasms, resembling tetanus, in which the body is drawn in different directions, forward, backward, or to one side. These are for the most part forerunners of death. Examination after death, in such cases, has frequently shown nothing discoverable beyond inflammation of the pia mater, and an effusion of fluid, generally purulent, on the surface of the brain, or in its ventricles, or between the pia mater and the tunica arachnoides.

The three following cases are intended to show the different forms of paralysis that ensue after injuries accompanied by compression or irritation of the brain:--

Charles Murray, private in the 2d battalion of 1st Foot Guards, aged thirty-three, was wounded on the 18th of June, at Waterloo, by a piece of shell which struck him on the superior part of the _left_ parietal bone. He remained insensible about half an hour, and on recovering from that state, was affected with nausea and some bleeding from the left ear, and found himself unable to move his _right_ arm and _right_ leg, which hung as if they were dead, and had lost their feeling. Admitted into the Minimes General Hospital at Antwerp on the 29th; he suffered much from pain in the head, which was relieved by his being twice bled. The paralytic affection having remained without change from the moment he was wounded, a piece of the parietal bone, about three-fourths of an inch long, and several smaller fragments, were extracted four days after admission into the hospital, two perforations with the trephine having been necessary. Immediately after the removal of the bone he recovered the use of his right arm and leg, so far as to be able to move them, and to be sensible of their being touched. He gradually recovered by the 14th of August, so as to be sent to the General Hospital at Yarmouth, never having had a bad symptom, the only defect remaining on the right side being an inability to grasp anything in his hand with force. The pulsation of the brain was still visible at the bottom of the wound for about the space of half the circumference of the crown of the trephine. September 16th, 1815: the wound has filled up with healthy granulations, and has nearly cicatrized. A small sinus remains at the superior part, through which the edge of the bone can be felt. His health has been invariably good, although he has suffered a good deal of pain twice previously to the coming away of little pieces of bone, and toward evening he has been generally subject to slight vertigo. Discharged cured.

William Mitchel, of the Royals, aged forty, was wounded by a musket-ball on the 18th of June, at Waterloo; it struck the side of the head near the vertex, and, passing across through the sagittal suture, fractured and depressed _both_ parietal bones. When he had recovered his senses he suffered great pain in the part, and found that he had lost the use of BOTH his legs, and was benumbed even from the loins and lower part of the chest; he was often sick, and felt low and ill. On the 28th, ten days after the battle, the trephine was applied in two places, and the whole of the detached and depressed portions of bone were removed. The sickness, lowness of spirits, and general illness immediately subsided, and the loss of power in the lower extremities gradually began to diminish, but he was not able to walk without assistance until the first week in August. On the 10th he arrived at Yarmouth, not having had a bad symptom after the depressed bone had been removed; and by the end of September he was discharged, able to walk well with the assistance of a stick.