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.