« ForrigeFortsæt »
inflammation on the second and third day after the injury, but they were easily combatted. The condition of the heart was unfavorable all the time, and the previous history brought out the fact that he had had for several years some organic disease of the heart. The profound stupor lasted nine days when he began to realize that something was wrong, and that he was not at home. He seemed to be awaking from a deep sleep; the nine days were a complete blank in his life. He did not come out of the stupor suddenly, but on the contrary it was a gradual thing. For several days before he knew where he was he would respond to questions in an incoherent manner, but would not speak unless aroused by pinching, shaking and loud talking. During this period he was induced to eat some daily, mostly milk with a little soft bread in it, but sometimes it was difficult to keep him sufficiently awake to swallow. During all this time there were no signs of paralysis except that of the bladder. The heart symptoms never improved.
Two days before his death, when the intellect had partially regained its natural strength and the power of the bladder to empty itself was being restored, inflammatory symptoms of this organ came up in the most violent manner. The already diseased and worn out heart was now over-taxed. During the first few hours of the inflammatory action the pulse was full and rapid but intermittent. Presently the full pulse became a mere thread, and the rapidity countless. Unconsciousness returned, the deep stupor came on, from which the patient could not be aroused, and death closed the scene in thirty hours from the time the cystic inflammation was ushered in. This is a brief history of the case; but enough of it is related to show that there was more in it than simple concussion. The fact that the patient was upon receipt of the injury immediately rendered unconscious, and within a few hours came to himself sufficient to recognize friends and respond to the calls of nature, and then went into the stupor more profoundly, would indicate that the first symptoms were due to concussion and the latter to extravasation. The hemorrhage from the nose and ear would indicate a fracture at the base of the brain, and the deep ecchymosis about the mastoid would also support this theory. The serous oozing mentioned in the report is put down as a most prominent symptom in fractures about the base of the brain.
I would further mention that the patient, when he began to come to himself, complained of great pain all along the spine. This symptom, taken with the paretic state of the bladder, would indicate some serious lesion along the track of the cord. I never saw a case wherein I more earnestly desired a post-mortem examination, and could it have been had I think there would have been found an extravasation, with possibly a fracture, without separation of bone in some part of the base, and some serious lesion along the spinal canal. Had it not been for the acute cystitis, and thereby the failure of the heart, I believe the patient would have recovered, for the gradual returning of the intellect, and the sensibilities in general, indicated that the brain was becoming accustomed to whatever injury it had sustained. Having so fully presented the side of the lesionist, it is fair that the non-lesionist should be heard.
The most recent advocate of that side of the question which I have read, admits all the foregoing to be true, but says it is fair to assume that there must be a capacity for serious results in the vibratory jar, as the discoverable lesions in many well examined cases have been in themselves insufficient to kill. In reply to this I would say that physiology has not so far pointed out all the most vital parts of the brain, and of those which have been discovered it requires but a very small injury to produce death; for example, the penetration of the spinal cord of an animal between the atlas and axis with an awl results in sudden death, and the injury could hardly be visible without the aid of a lens. Many cases have been reported where the injury to the brain substance has been extensive, and still recovery followed. Such a result can only be accounted for on the ground of a want of extreme vital force in the part so injured. I believe there are localities in the brain that would permit of great injury and end in recovery, while on the other hand there are other points where the least amount of injury would result in death. The rapidity of recovery of those who get well has been advanced as an argument in favor of the vibratory jar. This can be explained in the same way. The injury not being extensive and not being in an extremely vital part recovery soon followed. A word on the diagnosis and treatment and I have done.
It is of the utmost importance that the physician, whether he makes any pretentions to surgery or not, should be able to differ
entiate these injuries to the head, for it may often happen that by knowing the exact condition life may be saved. There is one symptom which, if present, is diagnostic, but it is not always present, and one has to depend upon a concatenation of symptoms to determine the condition. The symptom which I would mention is the interval that follows an injury to the head before the stupor or unconsciousness comes on. If, when called to a case, those present tell us that the patient was not unconscious for some time after the receipt of the injury, there is no doubt but that there is some serious lesion of the brain or its membranes.
The following case is à fair illustration: A young man having been knocked down with a billiard cue got up and walked to another saloon, there he washed and then walked to a doctor's office and from there to a hotel, consuming in all about thirty minutes, when unconsciousness supervened, from which he could not be aroused, and he died in five hours. In this case there were no immediate symptoms of concussion, and the stupor that came on later depended wholly upon the large clot found. within the cranium at the autopsy. Had this man had the benefits of surgery he would possibly have been living to day. A French surgeon has lately reported three cases wherein symptoms did not come on for some time after the receipt of the blow. In his cases there was no external wound to guide him, nevertheless he diagnosed extravasation, and upon trephining removed large clots from off the brain. Two cases recovered and one died.
Alcoholism has to be differentiated sometimes. The history of the case and the odor of the breath will generally settle the question. If the patient is rendered immediately unconscious upon receipt of a fall or a blow, and remains so for any great length of time, we have a right to suspect some serious lesion of the brain. If the breathing is stertorous and there is partial paralysis on either side it is evident that there is pressure upon the brain, as of a clot, and the trephine should be used. But should the symptoms of pressure not be so marked the best plan to pursue is an expectant one. As to the treatment of simple concussion I believe that the expectant plan has the preference. Stimulants if they be administered at all. should be given very sparingly. I would not advise their use at all, for the reason that extreme reaction is liable to follow, and instead of relief you have added to the already extreme difficulty.
Careful attention to hygiene and perfect rest will bring the patient through if it be at all possible for him to recover.
Dr. Stemen-Mr. President, I think a paper of so much importance to the general practitioner should be discussed. We all, whether we pretend to be surgeons or not, have cases of accident where we have concussion of the brain and it will be necessary for us to differentiate between concussion and compression. The paper has presented the points very clearly, and is certainly of practical importance. The fact that after receiving the injuries and for several hours before stupor the symptoms of compression came on, is due to hemorrhage or extravasation. I remember a case where a man had been struck by a policeman's shillalah and walked about for a while and finally became bewildered and was taken to the hospital where he became unconscious. It was found to be a fracture and compression, but the symptoms of compression did not manifest themselves until after there was hemorrhage. I can recall cases, and many of you can, in railway surgery, where a man had been struck on the head in these over-head bridges, and would be able to get over the train into the caboose and make known that he had been injured before he became unconscious, and the result would be compression from hemorrhage. Of course, in the first instance it was concussion. In regard to the treatment, whether we should always trephine, my idea is that if we could locate the clot, if we know where it is, it would be well for us to trephine. If there is evidence of compression by depression of the bone it is well to trephine. I had a remarkable case a few weeks ago. A lad fell from a barn and struck his head on a piece of timber. He was suffering from concussion and not compression. He was semi-conscious. Immediately I noticed there was a depression of the skull. With a pair of forceps I took hold of the periosteum, and to my great surprise the bone was replaced without cutting. It was replaced by pressure from within. However, there were some symptoms of compression remaining which were due to extravasation. They remained a few weeks and disappeared, and now the lad is well.
Dr. Parsons-Mr. President, I only wish to thank the Society for the manner in which it has listened to me.
TREATMENT OF PHTHISIS PULMONALIS BY ENEMA OF SULPHURETTED HYDROGEN GAS.
BY ALLISON MAXWELL, M. D., INDIANAPOLIS, INDIANA.
The treatment of pulmonary disease by enema of hydrogen sulphide and carbonic acid gas was first advocated by a Frenchman, Claude Bernard, in 1857. He presented the subject to the Academy of Sciences, but he was derided and his treatment was not given a trial by his professional brethren.
About four years ago Dr. Bergeon, of Lyons, and his assistant, Dr. Morel, after experimenting upon animals, began the treatment of the genus homo. They have continued the treatment up to this time, and claim that out of more than two hundred patients some have been cured, and almost all have been more or less relieved from distressing symptoms.
In some, reported as cured, Dr. Bergeon states that the cavities became cicatrized, with no stethoscopic evidences present other than dry sounds due to cicatricial bands consecutive to old lesions, and that the patients have been able to resume laborious occupations.
In this country the treatment was first tried in the Philadelphia Hospital last February, by Dr. Thomas N. McLaughlin, resident Physician-in-Chief.
Being interested in any remedy that might relieve to some extent patients suffering from so fatal a malady, Dr. John Hurty, the chemist, by my request, constructed an apparatus for me, and the latter part of March I treated a patient with the hydrogen sulphide who was far advanced in phthisis. Shortly after, I went to Philadelphia to get the details of the treatment, with a view of giving it a thorough trial.
I met Dr. McLaughlin, who explained the course of treatment they had been pursuing for six weeks in the hospital.
The solution of sulphurous water which they used, consisted of