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.