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.