Respiration was irregular, sometimes sighing; in the late stage often of the Cheyne-Stokes type; actual stertor was exceptional, but the respiration was often noisy.
The temperature was often raised from an early stage to 99° or 100°, and if the patient survived a day or two, it often rose to 103° or 104°. How far the secondary rise depended on sepsis it was not always easy to determine. The urine was usually retained.
Cases presenting the above characters were usually those suffering from lesions such as are described in class I., and mostly died in twenty-four to forty-eight hours. The correspondence of the train of symptoms with those due to combined brain destruction and severe concussion is at once apparent.
To illustrate the nature of the symptoms in patients suffering from the less extensive forms of injury, such as those included in classes II. and III. under the heading of anatomical lesion, the relation of a short series of histories will be advisable. I may first premise, however, that the special characteristics of these were in some instances the almost entire absence of primary symptoms of gravity; in others general symptoms of a severity out of apparent proportion to the external lesion; while in all destructive lesions, very widely distributed radiation symptoms developed, often disappearing with great rapidity.
The symptoms consisted in those of concussion, irritation, local pressure, and actual destruction.
The symptoms of concussion were either general, and then usually transient, or local paralysis of the radiation variety, which also rapidly improved.
Signs of irritation consisted in irritability of temper, drowsiness, closure of the eyes and objection to light, contracted pupils sometimes unequal, a tendency to the assumption of the flexed position at all the joints, twitchings, and sometimes convulsions. Sometimes these appeared early as a direct result of mechanical irritation from bone fragments or blood-clot; sometimes only in the course of a few days, as a result of irritation of parts recovering from the radiation effects which had prevented earlier nervous reaction. Possibly in some cases the symptoms of irritation depended upon an increase in the amount of hæmorrhage, and in others upon the development of local inflammatory changes.
Local pressure, or actual destruction of brain tissue, was evidenced by temporary paralysis in the former, permanent loss of function in the latter, condition.
Fractures of the anterior fossa of the skull were attended by very marked evidence of orbital hæmorrhage, as subconjunctival ecchymosis (rarely pure), increased tension, and proptosis.
Injuries to the cranial nerves at the base, with the single exception of lesion of the optic nerves, which was not rare, were in my experience uncommon in the hospitals—a fact pointing to the very fatal nature of direct basal injuries, except in the anterior fossa of the skull. Signs indicative of injury to the olfactory lobe were occasionally observed.