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[(1) "The state of the pulse," says ASTLEY COOPER, " is curious, although, when the patient is undisturbed, it is natural; it scarcely ever fails to be quickened if the patient is capable of making any effort to rise, and exerts himself for that purpose. The carotid arteries sometimes beat, under an exertion, with a force disproportionate to the other arteries of the body; but generally this symptom is not observed until after a few hours." (p. 254.) Not only is the pulse excited by the patient's effort to rise, but even the mere shaking him to arouse him will often produce quickening of the pulse, as I have seen again and again.-J. F. S.

(2) Many curious instances are recorded of the loss of memory in regard to an acquired language, and the re-employment of the vernacular tongue of the patient, following concussion. ASTLEY COOPER mentions the case "of a man who, in St. Thomas's Hospital, was found talking in a language which was not understood, until a Welshwoman entering the ward, heard him talking Welsh; the blow on his head having occasioned the loss of his recollection of English. I once witnessed a very similar circumstance:-I attended a German sugar-baker, with disease in his brain, and when I first saw him, he could speak to me in English; but as his disease increased he lost his English, and I was obliged to have an interpreter, for he could answer only in his native tongue." (p. 255.) Sometimes the patient forms a new language for himself, as in LARREY'S case (a) of the soldier wounded in the head, who expressed assent by the word "baba," instead of “oui," dissent by "lala," and his wants by "dada," and "tata." In other cases of irritation of the brain, language appears to have been entirely lost, and the patient to have made his necessities known by manual signs, as in CLINE'S case. (p. 418.)

HENNEN observes:-"The powers of speech are often lost, while those of memory remain, and the sight is impaired while the hearing is perfect, and vice versa. I have met with numerous instances of this, and have had patients who told me that they could hear distinctly what I said, and distinguish my voice from that of others, and have repeated my words, as a proof both of this fact and of their retention of memory, while they could not distinguish my person, nor give utterance to their thoughts." (p. 305.) He also mentions a very remarkable instance, after compound fracture with depression of the skull from gun-shot, in which, though the patient continued sensible, he lost the power of utterance, and, although his efforts to speak were continuous, only on the sixth day did he manage to "utter audibly, though with much labour, the monosyllable ther,' to which in the course of the day he added, 'o;' and for the three next days, whenever addressed, he slowly, distinctly, and in most pathetic tone, repeated the words, o; ther: o; ther;' as if to prove his powers of pronunciation. His general appearance, during all this time amended considerably, and my hopes now began to revive. I therefore resolved to write to his family, and before doing so, I printed in large characters on a sheet of paper the following words, Shall I write to your mother?' that being the wish which it appeared to me he so long and ardently laboured to utter. It is impossible to describe the illumination of his countenance on reading these talismanic words; he grasped and pressed my hand with warmth, burst into tears, and gave every demonstration of having obtained the boon which he had endeavoured to solicit." (p. 308.) The recital of this interesting case is an ample proof of the kindness of HENNEN's heart, and of the sincerity with which he inculcated the propriety of " tenderness and sympathising manner" in the conduct of Surgeons towards their patients.

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(3) To the symptoms above enumerated ASTLEY COOPER adds:-" At first a torpor exists in the intestinal canal, and a considerable difficulty in procuring an evacuation; but afterwards the faces are involuntarily discharged in a few hours the bladder is distended from the accumulation of urine, which demands the introduction of a catheter for its removal; but after some time the urine also passes involuntarily.” (p. 254.)]

421. The following circumstances distinguish concussion from pressure of the brain, depending on extravasation of blood: the earlier or later occurrence of symptoms in extravasation depends indeed on the quantity of blood and the quickness with which it is poured out; but the symptoms once set in increase or continue in the same degree. In concussion which immediately follows external violence the patient usually recovers himself in some degree. In extravasation he lies in an apoplectic state, with snoring difficult breathing, hard irregular intermitting pulse; with wide pupils, but there is not any vomiting. In concussion the body is cold, the breathing easy, the pulse regular and small; the countenance little

(a) Mémoires, vol. iii. p. 322.

changed. Extravasation and concussion may occur together at the onset, or extravasation may accompany concussion.

[It is often very difficult to distinguish between drunkenness, and either concussion or compression; especial care should therefore always be taken to ascertain as far as possible the condition of the patient previous to the accident, lest he should be lost by too light consideration of his symptoms.

In persons of drunken habits delirium tremens may come on after concussion, as well as after any other accident. I have seen one example of this kind, but believe it to be rare. The treatment will require the closest attention, and the administration of opium is necessary as in other cases of the same disease.-J. F. S.]

422. Inflammation of the brain may be connected with concussion, and then the symptoms of oppressed sensation and motion may be accompanied with those of irritation. The pulse becomes fuller, the patient more restless, appears wild, is delirious, convulsions come on, respiration is slow and snoring, and subsequently symptoms of pressure on the brain

ensue.

423. The changes produced on the brain by concussion are various, and may be divided into primary and consecutive. They consist either in a sudden depression of the activity of the brain and nerves, in which after death no trace of any mechanical injury, frequently only a sinking together of the brain, which does not completely fill the cavity of the skull, is found; or in tearing of the vessels, or even of the brain itself, and inflammatory congestion (1). In concussion the vessels of the brain are always more or less debilitated, so that, when the first symptoms of concussion have passed by, they cannot withstand the subsequent influx of the blood, and in this way gorging with blood and its effusion through the relaxed walls of the vessels takes place. In concussion of the brain there are, therefore, various conditions to be remembered, namely, torpor and weakness of the nervous system, irritation and inflammation, extravasation, and not unfrequently concurrent affection of the liver.

DUPUYTREN (a) distinguishes, in reference to these various changes of the brain, be tween Commotion and Contusion; the former he considers to depend on sudden depres sion of the activity of the brain and nerves, in which no trace of any injury can be dis cerned; the latter he holds as a similar change in the brain to that which occurs in bruises, viz., bruising, tearing, and extravasation of blood. The patient recovers from the symptoms; in the next few days inflammatory symptoms occur and cause death, as has been already mentioned in unfavourable inflammation of the brain. (par. 404–406.) In tearing of the substance of the brain the symptoms should, according to WAL THER (b), come on at once and without remission, but continue till the setting in of encephalitis without increasing or diminishing. Only in a single case has WALTHER DO ticed a perfect intermission of the symptoms. The most constant symptoms are loss of consciousness, the deepest coma without possibility of wakening, convulsions, vomiting, subsequently palsy comes on, probably at first as a symptom of inflammation and perspiration. This statement does not concur with that of others. ASTLEY COOPER (c) relates a case wherein, from tearing of the substance of the brain, no other symptom of brain affection except loss of speech occurred, and this came on after three days.

["With respect to the state of the brain under concussion, when the injury has not been excessively severe, it seems that the symptoms are merely the effect of a disturbance of the natural course of the blood through the brain. A fit of vomiting, by forcing the blood through the brain, will sometimes almost immediately restore the functions of the mind and body. It seldom happens that this state of the brain destroys; but when it does, nothing is found upon the examination which will account for the symptoms. It is therefore an alteration of functions, but not a disorganization. But when the con cussion is very violent it is attended with lesion of the brain, with slight laceration of it accompanied with slight extravasation.”—A. COOPER. (p. 262.)]

424. The causes of concussion are either shaking of the whole body (1), (a) Leçons Orales de Clinique Chirurgicale, p. 503. (b) Above cited, p. 70. (c) Above cited, p. 263.

to wit, by a fall upon the feet; or violence which strikes the skull itself and acts upon it to a certain extent. Most commonly in concussion the skull remains entire; it may, however, be injured in various ways.

[(1) ASTLEY COOPER says::-"I have known concussion arise from the general shake of the whole body, unaccompanied by any blow upon the cranium, pain in the head succeed, with the usual symptoms of concussion, and the patient's life be greatly endangered." (p. 262.)

"A very curious example of pure concussion," quoted by HENNEN, " is given us by SCHMUCKER (a), in which a cannon-ball took away the queue from the nape of a soldier's neck, without injuring the integuments in any sensible degree. He continued in a complete state of stupor for many days, during which he was bled at least twenty times. Twenty-four grains of tartar emetic, given at short intervals, produced some stools, but no apparent inclination to vomit, after having suffered a relapse from having been moved prematurely on a march with the army." (pp. 318, 19.)]

425. The prognosis is guided by the degree and complication of the concussion. In its most severe form convalescence is always tedious, and there frequently remains disturbance of some of the mental faculties, loss of memory, weakness of sight, amaurosis, loss of smell and taste, great irritability of the stomach, and so forth. Complication of concussion with extravasation and inflammation always renders it extremely dangerous.

426. As to the treatment of concussion; this must be various, according to the different conditions of the patient (par. 426); as in concussion there is always gorging of the brain with blood, and subsequently attacks of inflammation to be dreaded, general and local blood-letting, cold fomentations, purging and irritating clysters are especially indicated. Large bloodlettings are in most cases fatal; small bleedings are to be made as often as the pulse again becomes hard; if, however, it becomes weak and intermitting, no blood must be taken away; nor at the onset, when the pulse is scarcely to be felt, the countenance is pale, and so on, is blood-letting to be used, but only when the pulse rises (1). Too frequent bleeding often brings on convulsions. If the patient be found in a weak state, if the pulse after bleeding become smaller and weaker, spirituous frictions, a blister over the whole head, stimulating clysters, vomiting with tartar emetic, should be employed, the latter, however, with the greatest caution, because if blood be extravasated, or there be disposition to apoplexy, the patient's condition is thereby considerably damaged (2). Stimulating remedies, as arnica, musk, fluid alkalies, even wine as recommended by many, are, on account of the danger of subsequent inflammatory irritation, rather disadvantageous, and to be used only with especial caution.

[(1) I presume there is now scarcely a Surgeon who would take blood from a patient who was stunned, immediately after a blow on the head; a practice formerly advised, though in reality rarely carried into effect, as almost invariably some time elapses between the receipt of the injury and the arrival of the Surgeon. No bleeding must be resorted to till the constitution have recovered the shock; till the coldness has subsided, and the heart has recovered its power: to encourage which the patient should be quickly put to bed, bottles of hot water or heated bricks applied to his feet; and, if he be very cold, and his pulse weak and low, a little brandy with hot water should be at once given, and repeated if necessary. When the patient has been brought round, when the warmth is returned and the pulse is improved, the Surgeon must act according to circumstances. Bleeding is not always necessarily though it is generally required. But I do not think it advisable to bleed largely, although only at the first bleeding, as recommended by ASTLEY COOPER; for, with the disturbed circulation in a brain labouring under concussion, a large bleeding may and in some instances will produce fatal fainting. The quantity of blood to be taken at the first bleeding, so soon as the quickness of the pulse requires it, which is generally in six or eight hours, but sometimes later, must therefore

(a) Chirurgische Wahrnehmungen. Berlin, 1759. p. 393.

be proportioned to the patient's constitution and the condition of the pulse; and if even after a very few ounces only have been drawn the pulse should intermit, the bleeding should be immediately stopped, or fainting and convulsions will ensue. Five or ten grains of calomel should be given immediately, and the best mode of administering it is to mix it with a little sugar, or with a little honey, and put it on the tongue, so that it may gradually pass with the spittle, down the throat. If in the course of a few hours it have not operated, (and even if it have, there will be no objection,) a clyster of a pint of warm infusion of senna with Epsom salts, or castor oil in gruel, may be thrown up, which will at least empty the lower bowel, and often encourage the purging action above.

If the patient after some hours continue insensible, and congestion in the brain be presumed, or if inflammation have begun, then bleeding must be employed again and again, either generally or locally, or both, according to the severity of the symptoms. But above all calomel or mercurial friction must be employed till the symptoms yield, or till ptyalism is produced, and then sufficient only used to keep up that condition. If the treatment be successful the symptoms will gradually subside; but sometimes before this happens alarming fits of an epileptic character may occur, which happened to a young man under my care some years since, who, whilst labouring under inflammation after concussion, on the morning of the sixth day after the accident, had three such fits at intervals of two hours, became completely comatose, and had dilatation of the pupils; and on the following day had two more, so that I presumed effusion had taken place, and that he would die. Upon the eighth day, however, he began to answer questions, and on the thirteenth began to comprehend his condition; in the course of the day became perfectly sensible, and at last completely recovered.—J. F. S.

The quantity of blood which has been withdrawn, during concussion and its consecutive inflammation, is enormous. ASTLEY COOPER mentions an instance in which "the whole quantity of blood, taken by bleeding from the arm, opening the temporal artery, and the application of leeches, as far as this could be estimated, amounted to about two hundred and eight ounces; of which one hundred and eighty ounces were taken from the arm. *** This gentleman recovered." (p. 272.)

(2) Vomiting with tartarized antimony, or any other emetic, should never be resorted to, as the effort to empty the stomach drives more blood to the brain, which is precisely contrary to that which is desired.-J. F. S.]

427. If the patient be improved by either of the prescribed treatments, he must long avoid every exertion and over-heating; if any palsy remain the employment of stimulating strengthening remedies, mineral baths, emetics, electricity, and so on, are useful. If the concussion be accompanied with fracture and impression of the skull, these must be first treated according to the rules already laid down.

428. In order to prevent the insidious inflammation of the brain, which often first arises some time after concussion, the patient must be closely watched, kept very quiet, cold applications, spare diet, purgings, tartar emetic in small doses, and long continued, must be employed, and the gastric symptoms especially looked after.

In order to get rid of the remaining consequences of concussion, cold washes to the head, washes with caustic liquor of ammonia and water, the application of species cephalica (a), blisters, often an issue upon the head itself should be used; in long-continued determination of blood to the head, repeated blood-letting and aperient medicines, with a properly regulated diet, must be employed.

D. OF TREPANNING IN INJURIES OF THE HEAD. 429. The opinions of surgeons as to the application and necessity for the trepan in injuries of the head are very different. Some (DEASE, DESAULT RICHTER, ABERNETHY, A. COOPER, BRODIE, LANGENBECK, WALTHER, and others) considerably restrict, and only have recourse to it when the secondary symptoms of irritation and pressure have set in severely. Others (a) Under this title are included several kinds of powders consisting of farragos of herbs.

(especially PETIT, QUESNAY, POTT, SABATIER, LOUVRIER, MURSINNA, ZANG, SCHINDLER, and others) apply the trepan more generally, do not restrict it to the appearance of secondary symptoms, but determine its necessity according to the injury which is always to be feared on account of the peculiar condition of the coverings of the brain. Trepanning is, in their opinion, a preventive remedy in most cases.

430. The reasons which the former surgeons offer in support of their opinion are:

1. Experience shows, that in fractures of the skull, with and without impression, under proper treatment, the cure very often takes place, as they are counterbalanced, or the brain becomes accustomed to the pressure. Trepanning should therefore not be performed before the most pressing symptoms of irritation or pressure require it.

2. The same applies to effusions of blood, the absorption of which experience also shows may take place.

3. Trepanning is an operation not free from danger; to the existing injury fresh violence is added, the result of which cannot be determined. A more especial ground of danger in the operation is, that the coverings of the brain are bared. If inflammation then ensue, the brain is thrust up into the opening, the dura mater ulcerates, fungous excrescences (1), and so on, protrude; this occurs particularly in children, in whom the dura mater is firmly connected with the skull. (ABERNETHY.)

[(1) Fungus of the brain, after trephining, is not within my knowledge of so frequent occurrence as ABERNETHY's observations would infer. I have seen and operated on several cases of compound depressed fracture of the skull, and can scarcely recollect an instance of fungus, when the operation was performed early and the dura mater was uninjured. The fear of it, therefore, should not deter the surgeon from using the trephine in compound fracture.—J. F. S.]

431. To these objections it is replied, that the condition of the internal table of the skull, which is fragile, brittle, and glasslike, renders the fracture in it of greater extent than in the outer table, and that it spreads in a radiated form, and is accompanied with splintering; that in these injuries the vessels connecting the dura mater with the skull are torn, and that effusion of blood will occur. If it be remembered that in sabre and shotwounds these conditions must be so much more certainly present, that in all these injuries the diploë is so bruised that inflammation and suppuration must occur, so it must be perceived that the absence of pressure and irritation can afford no certainty, as if these have once set in, the brain and its investments are already so decidedly diseased that trepanning can be rarely considered as a means of cure. The same happens also in employing the trepan in extravasation of blood. If the surgeon, in expectation of absorption in these cases, delay trepanning till the symptoms have arisen to a high degree, is it not then to be feared that, on account of the active inflammation of the brain and its membranes, perhaps even on account of the putrid state of the extravasated blood,little more can be done by trepanning? They cannot deny that fractures of the skull with and without impression have been cured without trepanning; and it may be even added, that of ten cases which were trepanned, under the above-mentioned circumstances, in two the operation was perhaps unnecessary (which, however, could not have been previously determined.) But if the patient be trephined upon appearance of the consecutive symptoms, the result will be unsatisfactory in most cases. Trepanning is not to be considered in itself as a

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