SYMPTOMS AND DIAGNOSIS. — The symptoms and results of the wound vary according to the age of the patient, seat, and extent of the injury, septic conditions of the weapon and wound, etc. In some cases the symptoms are very slight and much delayed, but more often are severe and promptly mani fested, and are proportionate to the ex tent of the injury.
If the injury be moderate, headache occurs, with all the symptoms of en cephalitis in course, followed by coma and death if not soon relieved. The most valuable symptoms tending toward such relief are the localizing symptoms, which may often reveal a hidden injury. If the injury involve the structures at the base of the brain involving the respiratory tract, immediate death must ensue. If the anterior lobes and upper parts of the hemispheres be injured, but slight symptoms may occur. Twitch ing of the muscles and epileptiform fits are symptoms of cerebral laceration, and those complicating stertor or alternating with it make the diagnosis clear.
In those cases in which no external wound exists we may suspect laceration if we find that the ordinary signs of compression or concussion are associated with symptoms that do not ordinarily present themselves in those conditions when uncomplicated, such as contrac tion of one pupil, dilatation of the other, or an alternation of these states with convulsive twitchings of the limbs, hemi plegia of one side, or paralysis of one arm and the opposite leg, with perhaps involuntary spasmodic movements of the other members (Erichsen). In lacera tion of the brain without compression the pupils are contracted. When lacer ation and compression are both present, one pupil may be dilated and the other contracted; or both will be dilated or contracted according to the predomi nance of the symptoms of compression or of laceration. These irregular symp toms accompanied by much coldness of the surfaces, slow pulse, and depression of vital power indicate cerebral lacera tion. Paralysis due to a cerebral lesion is always manifested on the opposite side of the body, but not necessarily op posite to that on which the blow was received, as the injury may be from contrecoup.
Saccharin diabetes is an occasional consequence of injury to the brain, and the location is usually referred to cen tral part of the medulla oblongata and the floor of the fourth ventricle. Blind
ness may result from injury to the optic nerves at any part; ptosis and strabismus in different direction result from injury to the third, fourth, or sixth nerve. The seventh nerve most commonly suffers, being not uncommonly torn across in fractures of the petrous portion of the temporal bone, either in its facial or auditory portion, producing either facial paralysis or deafness. Injury to the eighth nerve is rare, and patients rarely survive who give evidence of the lesion. Motor aphasia points to a wound above and in front of left ear; word-blindness, or apraxia, points to an injury above and behind the ear; hemianopsia indicates a wound of the cuneus; paralysis of face, arm, or leg would point to their respect ive cortical centres as the seat of injury.
A final summary of all the evidence at command in reference to traumatic cere bral oedema serves to confirm the con clusions already advanced: 1. That traumatic cerebral oedema can find no place as a pathological or clinical entity. 2. That it is primarily the inevitable sequence in time of that complex of pathological conditions which we desig nate contusion. 3. That inasmuch as contusion of the brain and its meninges is most commonly met with as a concom itant lesion to the more macroscopical lesions designated haemorrhage and lac eration, the primary seat and extent of its accompanying oedema will be largely fortuitous. 4. That in the rare instances in which the application of a traumatiz ing force is expended in the production of a local contusion of the brain-cortex or its meninges the brain is of itself abundantly able to rid itself of the oedema through its venous channels. 5. That in the remaining cases in which the contusion is primarily extensive in the cerebrum, or when it affects the cere bellum or bulb, the factors which enter into the mechanism of the production of the (edema are such as to preclude the possibility of operative relief. 6. That contusion can, per cc, easily cause death. 7. That death in such cases results from anaemia of the bulb. J. W. Courtney (Boston. Med. and Surg. Jour., Apr. 27, '99).