Treatment.—The administration of bromides is only palliative. Operation is indicated only when the “signal symptom” indicates a limited and accessible portion of the brain as the seat of the lesion, or when there is a depression of the skull or other definite evidence of cranial injury. The more recent the injury the better is the prospect, as secondary changes are less likely to have taken place, and the peculiarly irritable state of the brain—sometimes referred to as the “epileptic habit”—has not developed. The operation consists in opening the skull freely, and removing any discoverable cause of irritation—depressed bone, thickened and adherent membranes, a cyst, or sclerosed patch of cortex; it may be necessary to interpose a layer of tissue, a flap of fascia lata, for example, between the bone and the cortex of the brain. The point at which the skull is opened is determined by the seat of the injury and the focal brain symptoms.

The return of fits within a few days of the operation does not necessarily mean failure, as they often pass off again. Complete and permanent cure is not common, but the number and severity of the attacks are usually so far diminished that life is rendered bearable.

Traumatic insanity may follow injury to any part of the brain, and it may come on either immediately or after an interval. It may or may not be associated with epilepsy. Any form of insanity may occur, either as a direct result of the trauma, or from the resistance of the brain being lowered by the injury in a patient predisposed to insanity. When insanity follows as a direct consequence of injury, the organic lesion is usually a superficial one, and the disturbance of brain function is generally due to reflex irritation of the dura mater (Duret). These facts possibly explain the immediate improvement which occasionally follows the opening of the skull at the point of injury and removal of the exciting cause. Cases occurring within a few days of the injury usually recover within a month or two. The later the condition is in developing the less obvious is the relationship between the trauma and the insanity, and therefore the worse is the prognosis.

Meningitis, sinus thrombosis, and cerebral abscess may follow upon any form of head injury attended with infection. The clinical features—save for the history of a trauma—correspond so closely with those of the same conditions occurring apart from injury, that they are most conveniently considered together ([p. 374]).

CHAPTER XIII
INJURIES OF THE SKULL

The bones of the skull may be contused or fractured. These injuries are not in themselves serious: their clinical importance is derived from the injury to the intra-cranial contents with which they are liable to be associated.

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.

FRACTURES OF THE SKULL

While it is convenient to consider separately fractures of the vault and fractures of the base of the skull, it is to be borne in mind that it is not uncommon for a fracture to involve both the vault and the base. Fractures in either situation may be simple or compound.