Treatment.
—The treatment for this condition is essentially that for shock, and whatever may be called for in the way of attention to injuries about the head—e. g., sewing up a scalp wound, etc. (See [Chapter XVIII], on Blood Pressure.)
CONTUSION OF THE BRAIN.
The condition of shock (cerebral concussion), when of pure type, passes away with reasonable promptness, especially when aided by surgical treatment. Anything which persists in the way of muscle paralysis, disturbance of function of nerves of special sense, or other sign of importance, indicates something more than mere vibratory disturbance: it implies mechanical lesion which could be perceived by the eye were the parts exposed, and constitutes the condition known as contusion. This implies the existence of trifling exudates, or hemorrhages, which lead not only to absorption but even cicatrization. Contusion pure and simple differs from ordinary laceration as a contusion elsewhere may differ from a wound. It cannot be separated, however, from conditions in which there are minute separations of continuity and actual lacerations. It may be divided into three postmortem forms—general hyperemia, with or without edema; punctate or miliary hemorrhages; and thrombosis of minute vessels, which may occur separately or together. Moreover, there may exist similar lesions in the meninges, constituting meningeal contusion. Ordinarily minute vessels of the pia are ruptured and blood is effused in small and thin patches over various parts of the brain. The so-called compression apoplexies of certain authors are inseparable from the conditions above described. Such minute blood clots are only to be distinguished upon very careful sectioning of the brain, and are found most often in the region of the medulla and along the floor of the fourth ventricle. They are probably caused by the forcing into the fourth from the lateral ventricles of the fluid contained in the latter.
Symptoms.
—When the ordinary symptoms of shock, which follow all severe injuries to the head, especially when the deep lesions are not too severe, fail to disappear in a short time under proper treatment, and when new and irregular symptoms are superadded to those of shock alone, it is reasonable to suppose that the intracranial condition is one of contusion rather than of shock. When mental agitation changes into delirium, when the rapid, feeble pulse becomes stronger and slower, the respiration deeper, the limbs move in incoördinate ways, the speech disturbed from muscle incoördination, the patient selects wrong words, or when the mental condition becomes more serious and stupor or coma take place of the delirium, while external irritants have less and less effect, and when the pupils gradually enlarge while failing to respond to light, it may be said that the condition of contusion is making itself apparent. If along with muscle uncertainty there is also muscle spasm or rigidity, with fixation of the fingers in the athetoid position, the evidence to this effect is increasing. If with all this the thermometer fails to show that an active inflammatory condition—i. e., meningitis—is prevailing the diagnosis may be regarded as certain. Error may possibly arise when there are evidences of alcoholism. Coma following head injury ought not to be ascribed to the alcoholic condition except by the strictest process of exclusion. Temperature alone will be of the greatest service in this direction, since in alcoholism it is usually subnormal. In apoplexy and non-traumatic hemorrhages it is also usually subnormal at the commencement of the attack, rising to normal, and remaining there if the patient recover, but continuing to rise in cases where the prognosis is bad.
Treatment.
—The treatment of brain contusion should be managed largely in response to special symptoms. Physiological rest, attention to scalp wounds, fractures, etc., shaving of the scalp, application of ice to the head, with such stimulation to the heart as may be necessary in extreme cases by subcutaneous administration of adrenalin, atropine, etc., by local fomentations over the epigastrium, or by immersion in a hot bath when surroundings permit it—these in a general way constitute most of the methods of treatment in contusion. When only symptoms of diffuse and minute lacerations can be recognized the use of the trephine is impracticable except when indicated by some external marking—i. e., compound fracture or the like. When localizing symptoms are present the trephine is, of course, indicated. When the skull injury is recognized as a basal fracture, venesection or the application of leeches behind the ears will be most serviceable. In every such case there is the greatest necessity for regulating the excretions and preventing auto-intoxication. For this purpose diuretics and laxatives should be used, often in conjunction with intestinal antiseptics. The catheter should be employed whenever indicated by the condition of the bladder, which should be carefully watched. As the days go by, and patients lie more or less helpless and inert, the greatest care should be exercised for the prevention of bed-sores. When mental inertness, muscle rigidity, etc., fail to disappear, potassium iodide should be used internally.
BRAIN PRESSURE OR COMPRESSION.
That the cranial contents—brain, blood, lymph, and cerebrospinal fluid—completely fill the cranial cavity has been already amply shown, as well as that there is no room for anything in the shape of a foreign body without seriously affecting the equilibrium between the brain and the contents of the spinal canal. When, however, any foreign substance exerts pressure upon the brain the results are invariably the same, be this substance what it may, and compression signs are always the same, no matter what the compressing cause. Reduction in capacity of the cranial cavity (i. e., compression) may be produced—