HEAD INJTJRIES.
As the most serious results may follow injuries of the skull or brain which at first show no signs of grave significance, the surgeon will be wise in considering every case as potentially a grave one even when no external mark is left by the injury. It is better to regard every case as if a fracture of the vault or base were present than to treat these injuries as trivial because no symptoms immediately follow.
A point of vital importance as regards diagnosis and treatment is to investigate the nature and intensity of the force which has caused the injury. Serious middle meningeal artery may follow localised blows sometimes; the diffused force of a heavy object falling upon the skull is, however, almost certain to cause serious concussion or laceration of the brain substance even when no scalp wound or a trifling abrasion is only visible.
When symptoms of concussion are present the case must be treated by the most absolute rest possible, as detailed in the articles on Con cussion of the Brain and Collapse. The patient should be placed upon his back in a silent and darkened room, with his head slightly raised and a cold lotion applied to the scalp. As soon as symptoms and signs of reaction appear the ice-cap should be employed and any violence of reaction controlled by leeching the temples, or by venesection. An active purgative—I min. Croton Oil with 5 grs. Calomel—should be placed upon the base of the tongue.
The pathology of concussion must be differentiated from that of shock or collapse, in which latter the chief condition is one of exhaustion (not paralysis) of the vasomotor centres. To treat cerebral concussion as shock or collapse by the injection of saline solution and strychnine, adrenalin, &c., would be to increase the danger of intracranial hxmor rhage. The temptation " to do something " must be resisted by the surgeon when the best practice is obviously one of waiting and watching.
Rest, quiet and freedom from all excitement must be maintained till after the disappearance of every sign and symptom of reaction, and for a week or two more should any evidence of cerebral irritation supervene. The diet should consist at first of a few spoonfuls of diluted milk, which may afterwards be more freely permitted, but animal food, even beef tea, must he prohibited, and alcohol should never be allowed. Restlessness should not he relieved by opium, but Bromides may be given in com bination with small doses of Antipyrine should headache be troublesome.
When simple fracture of the vault complicates the case the less surgical interference the better—at all events, till deformity is established by X-ray examination; compound fracture should be thoroughly disinfected and the scalp wound enlarged if necessary. Depressed fractures should be treated by elevation or removal of loose spiculm, and even when no symptoms of compression are present the consensus of opinion is in favour of trephining with the view of forestalling the advent of menin gitis, epilepsy, mental weakness, &c., even in most cases where there is
no scalp wound, but where the depression is marked. In children opera tive procedures may be postponed, as in them spontaneous elevation of frontal depressed fractures is common. In punctured fractures the routine use of the trephine is a good practice. Fractures of the base of the skull are best treated by absolute and prolonged rest. Should signs of compression supervene, trephining may be resorted to in the temporal region to permit of the evacuation of the serous or blood stained effusion. Spinal puncture has been advocated. It gives little help in diagnosis, but by relieving tension is a most valuable therapeutic agent. When rupture of the tympanum is present care should be taken to prevent sepsis by syringing gently with an antiseptic solution, after which the meatus should be loosely drained with antiseptic gauze. Similar precautions are necessary when the nasal and pharyngeal mucous surfaces are lacerated, in which cases antiseptic sprays must be constantly employed to disinfect the naso-pharvnx and nasal cavities.
Warren advises trephining in basal fractures with the view of providing drainage; he drills the cribriform plate and trephines above the auditory meatus or over the occiput, in order to drain the anterior, middle, or posterior fossa, according to the indications present regarding the seat of injury.
Ikemorrhage from the middle meningeal artery, which may not show itself till after the lapse of some hours, must be promptly net by trephin ing over the anterior inferior angle of the parietal or behind the external ear. If the case comes under observation when the compression of the brain is first showing itself, Murphy advocates ligature of the external carotid artery, in order to avoid trephining. This will immediately control the internal maxillary, from which the middle meningeal vessel springs, and avoid the great difficulty of ligaturing the branches of the middle meningeal vessel in the cranium.
In cases of head injury caused by a fall or by a blow from a large heavy object the general brain contusion or laceration may cause a fatal collapse. Surgical measures are seldom indicated in these cases, but should the patient survive the initial concussion or shock, and com pression or encephalitis supervene, trephining may be indicated for the evacuation of pus or clots, or for sinus injury.
For the condition known as Cerebral Irritation, liable to supervene when there has been severe contusion or laceration of the frontal region, there is nothing but prolonged rest of body and mind in a dully lighted room. The greatest difficulty sometimes will be found to be in the feeding. After large doses of Bromides the rubber tube may be tried, but this should be avoided when possible.