Head injury

“ No injury of the head, in fact, is too slight to be despised, or too severe to be despaired of.
Punctured and lacerated wounds, more especially those penetrating all the layers of covering, are frequently followed by violent and extensive inflammation of all the tissues, with severe constitutional disturbance, and with delirium and other symptoms denoting functional derangement of the brain. The swelling is often extensive, involving the whole scalp, together with the integuments of the face, and completely shutting the eyelids. ”

“ After such consideration of local complications, it would appear that the middle fossa of the skull presents the greatest dangers. Another factor must, however, be taken into consideration—injury to the brain—the commonest cause of death in all head injuries. ”

“ Cases of head injury are often more grave in their consequences than in their immediate symptoms. Sometimes the patient appears to be getting better when really he is worse. Rest and quiet should be observed for several weeks after an accident which has in any way affected the brain. ”

“ In the first instance, careful search should be made for any sign of injury, especially on the head. The discovery of a severe scalp wound or of a fracture of the skull, in association with the symptoms of concussion or compression, will in most cases raise the presumption that the unconsciousness is due to some traumatic intra-cranial lesion. ”

“ If the patient complains that he has constant pain in his head on the same side as that on which the injury was originally inflicted, that the pain is steadily increasing in severity, and that in addition he feels a sensation of pulsation in his head; and if, furthermore, you inspect closely the site of the original wound, and pass your finger cautiously over the spot, but fail to discover any appreciable external swelling, you may feel almost certain that a splinter or a spicule of bone projects from the inner table of the skull cap into the substance of the brain. ”

“ We must immediately bleed those who have headach from a blow (unless the injury be superficial) , and use suitable embrocations to the head; bathe it with sweet oil; cover it with wool; and make the patients abstain from wine and a rich diet, more especially if they have fever; and, upon the whole, we are to accommodate our treatment as for the inflammation of nervous parts, and especially of the membranes of the brain. If there be a wound it must be treated accordingly. ”

“ Ogston mentions the case of a young lady on whom a cricket ball inflicted a wound across the forehead, immediately above, and of the length of, one of the eyebrows, which he could not distinguish from a wound by a cutting instrument. All injuries to the head are more or less severe and dangerous, and great care is required in forming a prognosis with regard to the ultimate effect of an injury to the head. Inflammation of the brain does not, as a rule, supervene for about a week after the accident, and patients should not be considered safe from danger till two or three weeks after. ”

“ Contusion of the skull may result from a fall, a blow, or a gun-shot injury. In the majority of cases the damage to soft parts—scalp, meningeal vessels, or brain—overshadows the osseous lesion, which of itself is comparatively unimportant. ”

“ For instance, if a man is hit by a metal instrument shaped like the clapper of a bell or by a heavy key, or by a rounded instrument made of lead—this would remind one very much of the lead pipe of the modern time, so fruitful of mistakes of diagnosis in head injuries—special care must be taken to look for symptoms in spite of the lack of an external [Pg 240] penetrating wound. Where there is good reason to suspect a fracture because of the severity of the injury, the scalp should be incised and a fracture of the cranium looked for carefully. ”

“ Everyone knows that the surest way to fasten the head is to knock the handle on the ground, as the concussion drives it further in; so that, if the human head were carried on a straight support, similar concussions would be caused to the brain and other vital organs, to their serious if not fatal injury. Of course, extra muscular strength is required to support the increase of weight caused by those curves; and this is effected by an extra stress on the muscles of the back. ”

“ Basal fractures are frequently associated with contusion and laceration of the brain, and also with injuries of one or more of the cranial nerves.
Fracture of the anterior fossa may result from a blow on the forehead, nose, or face; or from a punctured wound of the orbit or of the nasal cavity. Often the injury is at first considered trivial, and it is only when infective complications, in the form of meningitis or cerebral abscess, develop, that its true nature is suspected. ”

“ Certain forms of wounds or wounds in certain localities are especially liable to end fatally after a long delay, but as the direct result of the wound. These are wounds of the head and of the spine. As to the first class, the injured person may apparently recover and be doing well, when he may suddenly die from a cerebral abscess, for instance. This is the result of the injury, but remains a longer or shorter time latent. In wounds of the spine the patient is generally paralyzed below the point of fracture, but is apparently in good health. ”

“ The contents of the head, like the contents of all hollow forms, receive the vibratory influence of force externally applied. The brain receives the concussion of the force applied to its osseous envelope; and when this latter happens to be fractured, the danger to life is not in proportion to the extent of the fracture here, any more than elsewhere in the skeleton fabric, but is solely in proportion to the amount of shock or injury sustained by the nervous centre. ”

“ But it is necessary, if the wound has occurred at the sutures, and the weapon has impinged on the bone or the parts about it, to pay attention and find out what injury the bone has sustained. For a person wounded to the same, or a much smaller, extent, and by weapons of the same size and quality, and even much less, will sustain a much greater injury, provided he has received the blow at the sutures, than if it was elsewhere. And many of these require trepanning, but you must not apply the trepan to the sutures themselves, but on the adjoining bone. ”

“ If the patient, after the external wound has healed, complains of a throbbing and roaring in his head, not merely in the region of the actual injury but involving the entire head, and if the symptoms tend rather to increase than to diminish, and eventually become so severe that the patient is almost beside himself with the pain, then is the surgeon justified in believing that a clot of blood is imprisoned somewhere beneath the cranium and is gradually being converted into an abscess or a condition of ulceration. ”

“ Therefore the lower end of the cord is never again in functional connection with the brain. These injuries are more rapidly fatal the higher up they are. If the injury is above the fourth cervical vertebra death is nearly immediate, for then even diaphragmatic breathing is impossible, and the injured person dies of asphyxia. Fracture of the odontoid process of the axis, which regularly occurs in hanging, may occur from falls on the head, etc., and is not always immediately fatal. ”

“ Hemorrhage may be controlled by continued pressure upon the bones of the skull, and if an artery is cut, it can in this way be kept from bleeding till the physician arrives. Most wounds of the head, even though large, generally heal quickly, but the most trifling ones may assume serious proportions, and even prove fatal. If within two or three days heat, pain, redness, and swelling appear, pus is probably forming beneath the scalp, and this, within a few hours, may spread under a large surface and do serious injury, or erysipelas may be set up. ”

“ In injuries resulting from indirect violence, however, pain localised to a spot at some distance from the point of impact is strongly suggestive of fracture—as, for example, when a patient complains of pain over the clavicle after a fall on the hand, or over the upper end of the fibula after a twist of the ankle. Pain elicited by attempts to move the damaged part, or by applying pressure over the seat of injury, is more significant of fracture. ”

“ So far as my observation goes, the injury to the head, supposed to be the cause of general paralysis, often has appeared to probably come from an accident due to the impaired physical strength and to the vaso-motor disturbance in the brain incident to the early stage of the disease and while it was still unrecognized. Cases are observed in which no predisposing or exciting cause is found by the physician. ”

“ Another effect of an injury which has caused concussion of the brain is an extravasation or effusion of blood. Extravasation of blood in or on the brain is one of the commonest causes of death from injury to the head. It may occur with or without marks of external injury. A person suffering from such an extravasation of blood may recover from the first effects of the injury, and at a varying time afterward the symptoms may return and increase so as to result fatally. ”

“ Other local injuries occur, such as rupture of cervical muscles, fracture of the larynx, and even lacerated wounds of the neck. The head has even been severed completely from the body, and the deep structures of the neck have even been so lacerated that the body has hung by skin only, stretched to the thickness of two or three fingers. Death is said to take place from shock, pressure on the vagi, and asphyxia, probably also cerebral apoplexy. When death is instantaneous, the body hangs motionless, the head fallen over the side opposite the knot, and the neck stretched. ”

“ In fact, death itself may result though the marks of contusion are very slight or even imperceptible. Intracranial hemorrhage, laceration with ecchymosis of the brain, on the same or opposite side to the injury, and concussion of the brain may result. ”

“ For the rest of the head surrounds the whole forehead, and the wounds wherever situated become inflamed and swelled, owing to an influx of blood from surrounding parts. And neither must you apply cataplasms and bandages to the forehead at all times; but when the inflammation is stopped and the swelling has subsided, you must give up the cataplasms and bandages. A wound in any other part of the head must not be treated with tents, bandages, or cataplasms, unless it also requires incision. ”

“ The upper part of the brain may bear pressure to a considerable degree without bad consequences ensuing, but compression at the origins of the nerves is always highly dangerous and generally fatal. Bleeding from the nose, mouth, and ears, when attended with other circumstances and symptoms evincing a violent injury and consequent cerebral disturbance, has been considered as decisive of fracture at the base having occurred. ”

“ When the scalp had been taken off it was discovered that the bones composing the skull had scarcely been marked by the blows of the instruments. There were no signs of congestion about the brain, but the lungs and pulmonary cavity were filled with blood, a condition which was explained by the fact that the head had been placed head downward in the catch-basin. A cut one-half inch deep was found upon the head and numerous bruises on the lower limbs. There were no signs of suffocation or any bruises about the neck such as would result from the choking of a man with a towel or rope. ”

“ Baron Percy reports a similar wound and case of lodgment in his Army Surgeon’s Manual; in this instance, the ball was known to pass away by the bowels, a fortnight after the injury was received.
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The liability to concussion of the cervical portion of the vertebral column, and to injury of the deep cervical and other nerves, must not be overlooked. Wounds of the neck are often accompanied by more or less loss of power in one of the upper extremities; and more extensive paralysis occasionally succeeds, although there was no primary evidence of the spine being implicated in the injury. ”

“ To send a patient to the operating room while in a state of shock is to court disaster. Abdominal and head injuries need to be wisely appraised. Many head injuries seem slight on casual examination; yet these, if not recognized and properly treated, will result in fatal complications.
All scalp wounds are serious, and sometimes it is a question for the surgeon to decide whether the metallic foreign body should be removed or not. Actually, there is a fifty-fifty chance that the man who has a bullet in his brain will develop epilepsy. ”

“ Lacerated wounds as a rule bleed less freely than those which are incised. Symptoms of concussion would favour the theory of the injury having been inflicted by a heavy instrument. Again, it is often difficult to decide whether the injury which caused death was the result of a blow or a fall. A heavy blow with a stick may at once cause fatal effusion of blood, but this might equally result from fracture of the skull resulting from a fall. ”