1. Medicine: Head Injury
If you find something inaccurate, please email me. If you have questions that are not addressed, I'd be glad to add information to address them.
Warning! this is fairly graphic in a clinical way. Not for the very squeamish.
The healer should do a total body assessment especially the neck, since head injuries are often accompanied by neck injuries. (See trauma assessment section).
Mental state: Check mental state by asking questions the patient should know the answer to. A thorough exam would check the memory of immediate events, recent events, and remote events. For immediate and recent the healer simply tells the patient to repeat a string of numbers immediately (most people can do 7, which is a telephone number) and gives the patient a few words to remember for 5 minutes. Look at the pupils for reaction to light. With no flashlight, and the danger of bringing a torch too close to the face, this can be done in daylight by looking first to see if the pupils are small in the bright sunlight, and then blocking the light to see if the pupils dilate. The healer should have the character move arms and legs, grip the healer's hands, push with the feet, use various facial muscles to make sure they all work. The character should also be able to feel a touch on both arms, both legs, both sides of the face. Reflexes in arms and legs can be checked, no technology needed for that.
Concussion: is an alteration in mental status after head trauma that may or may not involve loss of consciousness. This can run the gamut from a very brief period of confusion, up to prolonged periods of coma. If awake, the character may have a vacant stare, be abnormally slow to answer questions or follow instructions, be confused and unable to focus attention, be easily distracted and unable to follow through with normal activities. He or she may be disoriented as in walking in the wrong direction; unaware of time, date and place; or other information they would normally know. The character may have slurred or incoherent speech, make disjointed or incomprehensible statements, be uncoordinated, stumbling, or unable to walk a straight line putting the back of the heel of one foot right in front of the toes of the other. Their emotions may be out of proportion to circumstances, as in crying for no apparent reason. The healer may see memory deficits as in the patient repeatedly asking the same question that has already been answered, or inability to memorize and recall 3 of 3 words, or 3 of 3 objects in 5 minutes. A more severe concussion would entail any period of loss of consciousness.
Any character who suffers more than a very brief confused episode may have headaches, nausea, vomiting, and dizziness. He or she can also have trouble with memory or concentration which can be brief, or can last for weeks to months. Someone who has been in a coma for a while and recovers should exhibit some of these symptoms, and the memory and concentration problems could even last for years or be permanent.
If you put your character in a prolonged coma, and you want him or her to survive, the character will have to be able to swallow water at least. This means that he or she must have a gag reflex, which some people in a coma do. If you try to give your character food or water without a gag reflex, it'll wind up in their lungs.
The "don't go to sleep" myth. Many non-medical people have the misunderstanding that it is dangerous to go to sleep after a head injury. This is incorrect, it is not dangerous to go to sleep. It is dangerous to assume that the person with the head injury is merely asleep, and not check to make sure that they are not in fact confused, comatose, or something in between. Have your healer wake head injured characters about every hour or two for 24 hours, to make sure the character responds normally when awake. If it's a crusty character (I imagine Gimli this way) normal might mean the character takes a swing at the healer until he is awake enough to realize what's happening. Someone could get very grumpy by the end of the night.
Bleeding in and around the brain: This can happen in many parts of the brain, but since there are only two problems a healer could do something about in Middle-earth, I will only discuss those. They are either a subdural or an epidural hematoma. A hematoma is a collection of blood, and subdural means the blood is between the hard membrane covering the brain, and the brain itself; while an epidural is between the membrane and the skull.
Epidural: Following injury, the patient may be continually comatose, briefly comatose and recovered, or continually conscious. Typical symptoms would be any combination of severe headache, vomiting, and sometimes, seizures. The patient can deteriorate rapidly and dramatically after a delay (think minutes to a few hours). He or she can be conscious and talking, and a minute later comatose. After the patient loses consciousness the healer may also notice a slow pulse and slow respirations.
This type of hematoma is often associated with a skull fracture, whether it is moved out of place or not. If it is moved out of place, the healer might feel where the skull has a sudden "step off" which is the piece that is sunken. I don't recommend giving a character a skull fracture with a depression deeper than .5 cm (about 1/4 inch) if you want him or her to survive, since the surgical skills for this are lacking in Middle-earth. A typical location for a skull fracture that would cause this type of bleeding would be on the side of the head, about 2 to3 cm (an inch) behind the ear, and about 2 to 3 cm (an inch) above the top of the ear.
Subdural: These patients usually lose consciousness, at least briefly, with the injury. The character is likely to be confused or be thinking abnormally in one of the ways listed under 'concussion'. The healer might see that one side of the body doesn't work properly, as in the arm and/or leg on the opposite side from the injury weaker than the other side, or not moving at all. (Yes, the weakness is on the opposite side to the injury). The pupil of the eye on the same side as the injury may be dilated (large black pupil) and not contract when bright light hits the eye. A typical place for this injury is near the top of the back half of the head.
So how will you know if your character has one of these two? Well, without a CT scan you won't know for sure, but with certain symptoms it would make sense for the healer to assume it and drill a hole.
Treatment For either type of hematoma, drilling or cutting a hole in the skull can be lifesaving, releasing the pressure that is pushing on the brain and is likely to cause neurologic injury or death if the hematoma is large.
It is interesting that this procedure (trephination, or trepanning) has been done since very primitive times, one source estimating since 7000 BC. Apparently the ancient Peruvians were particularly good at it, with many patients surviving the operation as shown by bone healing around the site of the hole. According to some of the history of Neurosurgery pages, making a simple hole in the skull without cutting into the membrane below (the dura) leaves the patient with a very good chance for survival. Going through the dura reduces the percentages of survival, but survival is still quite possible. The killer here is infection, and the Peruvians had a much better track record than medieval Europe.
"Trepanning drills have smooth wooden shafts and tips of very hard material, to cut into the bone as neatly as possible. The earliest trepanned skulls are from the Neolithic Stone Age long before the introduction of metallurgy. Their holes were cut not by a drill, but with a sharp-edged flint scraper or knife. A circular or rectangular groove was made. The practitioner would cut deeper and deeper until penetration to the dura mater was accomplished. In ancient Peru, people used knives of bronze or obsidian. They would cover the wound with a shell, a gourd, or even a piece of gold or silver.
The most common of the techniques was the bow drill. The bow was made of springy wood and had a leather thong wound around the drill several times. To perform the procedure, the operator positioned the drill tip on the head and thereby made the bore through the bone." This material is from
Trephination: An Ancient Surgery
In Middle-earth a metal bit for the drill would be quite reasonable. The hole should be made on the side of the fracture for an epidural, near but not right over the fracture. For a subdural the classic place is in front of the ear. In either place have the healer cut through the skin and muscle down to the bone first, then drill through the bone. The hole for the subdural must go through the membrane right under the skull, but no further.
After the hole is drilled the character should be kept lying down for a few days. They may recover immediately or more gradually over a few days. Only in fanfic will everyone in this situation recover.
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