Manual of Surgery Volume Second: Extremities—Head—Neck. Sixth Edition.

by Alexis Thomson; Alexander Miles

Treatment.—The immediate treatment is the same as that of shock. Absolute rest and quietness are called for. When the symptoms begin to pass off, the head should be raised on pillows to prevent congestion and to diminish the risk of bleeding from damaged blood vessels in the brain. The value of applying an ice-bag or Leiter's tubes with a view to arresting hæmorrhage inside the skull, is more than doubtful. Lumbar puncture, venesection, or the application of leeches over the temple or behind the ear may be employed with benefit. The use of small doses of atropin and ergotin was recommended by von Bergmann. The bowels should be thoroughly opened by calomel, croton oil, or Henry's solution, and a light milk diet given. The patient is kept in a shaded room, and should be confined to bed for from fourteen to twenty-one days. It is often difficult to convince the patient of the necessity for such prolonged confinement, but the responsibility for curtailing it must rest upon him or his friends. Reading, conversation, and argument must be avoided to ensure absolute rest to the brain.

Cerebral Irritation.—In some cases of injury to the head—particularly of the anterior part and the parietal region—as the symptoms of concussion are passing off, the patient begins to exhibit a peculiar train of symptoms, which was graphically described by Erichsen under the name of cerebral irritation. “The attitude of the patient is peculiar, and most characteristic: he lies on one side and is curled up in a state of general flexion. The body is bent forwards and the knees are drawn up on the abdomen, the legs bent, the arms flexed, and the hands drawn in. He does not lie motionless, but is restless, and often, when irritated, tosses himself about. But, however restless he may be, he never stretches himself out nor assumes the supine position, but invariably maintains an attitude of flexion. The eyelids are firmly closed, and he resists violently every effort made to open them; if this be effected, the pupils will be found to be contracted. The surface is pale and cool, or even cold. The pulse is small, feeble, and slow, seldom above 70. The sphincters are not usually affected, and the patient will pass urine when the bladder requires to be emptied; there may, however, though rarely, be retention.

“The mental state is equally peculiar. Irritability of mind is the prevailing characteristic. The patient is unconscious, takes no heed of what passes, unless called to in a loud tone of voice, when he shows signs of irritability of temper or frowns, turns away hastily, mutters indistinctly, and grinds his teeth. It appears as if the temper, as much as or more than the intellect, were affected in this condition. He sleeps without stertor.

“After a period varying from one to three weeks, the pulse improves in tone, the temperature of the body increases, the tendency to flexion subsides, and the patient lies stretched out. Irritability gives place to fatuity; there is less manifestation of temper, but more weakness of mind. Recovery is slow, but though delayed, may at length be perfect....”

The treatment consists in keeping the patient quiet, in a darkened room, on much the same lines as for concussion.

Compression of the Brain.—This term is used clinically to denote the train of symptoms which follows a marked increase of the intra-cranial tension produced by such causes as hæmorrhage, œdema, the accumulation of inflammatory exudate, or the growth of tumours within the skull. The only pathological idea the term conveys is that there is more inside the skull than it can conveniently hold.

Clinical Features.—The following description refers to compression due to hæmorrhage within the skull as a result of injury. In a majority of such cases, the symptoms of compression supervene on those of concussion; in certain conditions, notably hæmorrhage from the middle meningeal artery, there is an interval, during which the patient regains complete consciousness, in others the symptoms of concussion gradually and imperceptibly merge into those of compression. The rapidity of onset of the symptoms and their course and duration vary widely according to the nature and extent of the brain lesion. Death may occur in a few hours, or recovery may take place after the patient has been unconscious for several weeks.

The first symptoms are of an irritative character—dull pain in the head, restlessness, and hyper-sensitiveness to external stimuli. The face is suffused, and the pupils at first are usually contracted. The temperature falls to 97°, or even to 95° F. Vomiting is not infrequent.

As the pressure increases, paralytic symptoms ensue. The patient gradually loses consciousness, and passes into a condition of coma. The face is cyanosed, and the distension of the veins of the eyelids furnishes an index of the severity of the intra-cranial venous stasis (Cushing). The pulse becomes slow, full, and bounding. The respiration is slow and deep, and eventually stertorous or snoring in character from paralysis of the soft palate, and the lips and cheeks are puffed out from paralysis of the muscles of these parts. The temperature, which at first falls to 97° or even 95° F., in the course of three or four hours usually rises (100.5° or 102.5° F.). If the temperature reaches 104° F., or higher, the condition usually proves fatal. Sometimes it rises as high as 106° or 108° F.—cerebral hyperpyrexia ([Fig. 185]). Retention of urine from paralysis of the bladder, and involuntary defecation from paralysis of the sphincter ani, are common.