Elements of Surgery

by Robert Liston

It is not at all improbable that concussion is produced after a manner somewhat resembling the following. The brain has a natural tendency to remain at rest, but is liable to be brought into a state of commotion by impulses on the cranium being communicated to it. When a slight blow is inflicted on the skull, only a slight commotion of the brain is induced, the cranial contents are, as it were, slightly jumbled, and a temporary and trifling confusion of its functions follows. When, however, the stroke is more severe, the brain is separated from its cranial attachments, both at the point struck and at the part directly opposite,—it is thrown upon itself towards its centre; its substance is thereby condensed, its diameter in the direction of the impulse is diminished, and a separation between the brain and cranium is formed at each extremity of that diameter. By post mortem examinations, it has been ascertained that condensation of the substance of the brain does exist in cases of severe concussion. Such commotion may be sufficient to cause instant extinction of life, or the brain may gradually resume its former condition, or with only such slight incited action as may be required to reunite the dura mater with the inner table of the skull. Extravasation of blood or serum is extremely liable to occur in such cases, the vessels being either compressed, stretched, or otherwise thrown out of their natural relations along with the other cranial contents, reparation can only take place by absorption of the extravasated fluid, and gradual deposition of plastic matter. When extravasation takes place to a greater extent, compression is the consequence, as will be more fully explained further on. Perhaps the brain does not recover itself gradually, but suddenly; the impulse, which was at first directed from the circumference towards the centre, now acting from the centre towards the circumference; and then the propulsions and recoilings may be repeated, though gradually lessening in their intensity, until the effect of the original impulse is lost, and all vibration consequently ceases. But concussion may be caused by an impulse received not immediately on the cranium, but on some other part of the body, as when a person falls from a considerable height and alights on the feet or buttocks; and in such a case also its effects may be indirectly communicated to it through the brain, and may produce equally violent effects, without there ever being any appreciable lesion of the cerebral matter.

The circulation may be merely disturbed, or laceration of the brain may occur with extravasation of blood into its substance. It may present the appearance of having been bruised, or the tear of its substance may be extensive. A multitude of minute vessels may be torn without the substance of the brain being much broken, in which case bloody specks will be observed over a large surface of the interior of the organ. In many fatal cases no change in the state, either of the vessels or of the cerebral substance, is perceptible on minute examinations. The organ in these cases has been merely disturbed and shaken, without visible rupture or hurt having occurred. Again, many patients are supposed to labour under concussion only, in whom fracture of the base of the cranium, or extravasation of blood on the surface, or into the substance of the brain, are discovered after death. It is always difficult to distinguish between the effects of mere concussion and those of compression of the brain by extravasated fluid; for, in the greater number of cases, the symptoms of both affections are blended together. In both there is insensibility from the first; but if an interval of sensibility occur, diagnosis is rendered more easy and certain, it being a fact well verified by experience, that the state of stupor which precedes the return of correct intellectual function is the effect of concussion, and that there is every reason to believe that the insensibility into which the patient subsequently sinks, is caused by compression of the brain; if compression existed from the first, the stupor might not be of longer duration than if it were the effect of concussion, but its stillness would not be interrupted by any restoration of mental exercise, however short. Remarkable effects sometimes result from commotion of the brain; the patient may suffer loss of vision or of hearing, either partial or complete; or partial paralysis may occur; of the muscles, for instance, supplied by the portio dura. In many cases such affections may be supposed to arise from compression of nerves, or other læsion subsequent to and caused by the effects of concussion, and probably connected with fracture of the base of the cranium. Again, it occasionally happens that the senses are rendered more acute than previously, and of this I shall mention an example which came under my own observation. An old nurse sustained fracture of the vertex, with slight depression of the broken part, in consequence of some rubbish having fallen on her from a considerable height. Stupor, along with the other symptoms of concussion, was the immediate effect of the injury, but disappeared in two or three days. Her hearing, which previously to the accident had been long so obtuse as to render it necessary for her to discontinue her employment, became so intensely acute, that the most trifling noise became a source of pain. She gave immediate orders for the clock to be stopped, the ticking of which annoyed her greatly. Her hearing gradually became of the natural intensity, and continued perfect. In this case there can be little doubt that restoration of a sense which had long remained dormant arose entirely from cerebral commotion, for no discharge of blood or other fluid occurred from the ears, by which cerumen accumulated in these organs might have been displaced. People sometimes forget languages from hurts of the brain, whilst they retain memory in other respects; or, rather, the memory on certain things becomes injured, but remains quite perfect on others.

Treatment.—Whilst the circulation remains depressed after injuries of the head, or of other parts of the body, it is a common practice to abstract blood; but it is one which cannot be too much reprobated, for it is attended with great risk, and can be productive of no benefit; the feeble remains of vital power, whilst struggling as it were against the depressing cause, may by depletion be quickly annihilated, when the vigour which they still retained might have been sufficient, if encouraged and supported, to overcome those effects of external injury which had so far reduced them.

When a patient is seen insensible, it is highly proper and necessary to examine carefully the trunk, head, and limbs, in order to ascertain whether either fractures or displacements have occurred; for it is by no means creditable to the care or science of a surgeon to be made aware of such accidents when the patient regains his senses, after the lapse perhaps of weeks, and when they can be remedied, if at all, with much difficulty.

In the first stage of concussion, as was already observed, the circulation is much weakened, and it is therefore necessary to adopt means for sustaining and strengthening it; and with this view, warmth is to be applied to the surface, more especially to the extremities and epigastrium.

When the powers of life appear to be failing, stimulants must be administered internally. Perhaps the most convenient stimulus is ardent spirit, the only objection to its use being, that when imprudently given in large quantities, its effects, though at first stimulant, become sedative; it ought to be given in small quantities, and at short intervals. Other stimuli, as preparations of ammonia, may be given by the mouth; and much advantage will often be found to follow the employment of a turpentine enema, free motion of the bowels, as well as excitement of the system, being thereby procured.

Stimuli, however, should always be used with much caution and prudence, and never unless fully warranted by the train of symptoms under which the patient is labouring at the time; when the circulation is restored in the limbs, and is becoming throughout steady and more natural, all sources of excitement must be abandoned and carefully avoided, as there is considerable risk of reaction proceeding to too great a height. The patient is to be kept quiet in a darkened room, cold applications made to the head, previously shaved, and free motion of the bowels procured by neutral salts with antimony, or by other purgatives not of an irritating nature, and not given in such doses as to prove violently cathartic. Enemata are in some cases preferable, and are always a valuable adjunct, to the employment of purgatives by the mouth; they procure evacuation from the larger intestines, in which feculent matter chiefly accumulates; they ought to contain asafœtida and turpentine; with these additions more salutary effects are produced than from mere evacuants. The latter ingredient would seem, by its local stimulus, to impart energy to the bowels sufficient for the correct performances of their functions, while the former tends to allay spasm and irritation, both locally and generally.

If the circulation becomes unduly excited, abstraction of blood from the system, in sufficient quantities and at proper intervals, is absolutely necessary; and the depletion must be regulated by the symptoms and circumstances of each case. The action will in general be more speedily and effectually moderated by one copious bleeding at the commencement, than by repeated bleedings to a less extent. An easy and open state of the bowels is of much importance in the excited stage. Mercurial preparations are sometimes useful, as they are known to possess the power of causing the absorption of coagulated lymph and serum, and probably of preventing their effusion.

In cases where insensibility continues after the arterial excitement has been subdued, counter-irritation on the head or the back of the neck is often useful, as the application of blisters, or the rubbing in of antimonial ointment. These are supposed to act by causing an unusual influx of blood to the surface, producing a change in that fluid by the copious purulent, serous, and lymphatic secretions from the irritated part, and thereby diminishing the distended and engorged state of the internal vessels, which might produce considerable compression of the brain.