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Of Ce'rebral Daimiage in Petechial Haemorrhage, Ofteni

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Of Ce'rebral Daimiage in Petechial Haemorrhage, Ofteni NOV. 10 Tim Damsm Nov. 10, 1928719281 CEREBRAL STATES C&NSEQUENTCaNSEQUENT T-PONUPON -READHEAD INJURIES. rI MXDICALMunicanjouwu*zJOUPWAZ .29an petechial haemorrhage, ofteni -with maximal intensity at the point of contrecoup. In suich a case death has probably been due to direct or indir-ect damage to the mcedulla. ON In patients wiho recover witlh symptoms of cerebral damage THE DIFFERENTIAL DIAGNOSIS AND TREATMENT we may reasonably suippose that some lesser degree of OF CEREBRAL STATES CONSEQUENT such brulisinig is pseseiit. UPON HEAD INJURIES.'* Tle symptoms of cerebral contusion depend upon two factors: first, the effect uponi the intracranial ppressure, BY and secondly, the precise situation of the lesion. To take C. P. SYMONDS, M.D., F.R.C.P., the latter first, it is clear that the presence of paralysis, Physician in C-harge of Department for Nervous Diseases, loss of sensation, or altered reflexes in a case of cerebral Guy's Hospital; Assistant Physician, National contusion mIlUst be an accident of localization. If the Hospital, Queeni Square. lesion involves the pyramidal cells or fibres an extensor plani-tar lresponse wrill result, and so on. The focal signs TIE subject of lhead injuries is treated, as a rule, in the of cerebral contusion, therefore, are those of cerebral textbooks of surgery rather than of medicine. It might disease generally. It may, however, be remarked at once seem, therefore, that in choosing it for our discussion we that such focal signs are rarely to be detected, possibly were encroaching upon surgical -preserves. In practice, hiowever, the which because it is only in the relatively slight cases of contusion proportion of cases of head injury that recovery is possible. The effect upon the intracranial !equire immediate operative intervention is very small, and pressuire, and hence upon the intracerebral circulation, ik limited to those in which a compound fracture calls for will depenid upon the amount of haemorrhage and tile obvious surgical toilet, or the rupture of a meningeal exudation. aitery threatens life from cerebral compression. -In so far as the For purposes of clinical description I propose here latter is a cerebral state consequent upon head to distinguish between a major and a minor deg;ree of injury it miight be included within the limits of our title, cerebral contusion, takinlg as the distinguishing feature but in order that we may proceed to other and numerically of major. contusionl clouding of consciousness or stupor. rniore important 'aspects of our subject I shall propose to rcfer to it only in passing. TIme various nerve from The Genicral Symptoms of Major Contusion. crianial pal'sies which may result of fractures of the base are necessarily excluded as The injury wsill almost always' have 'been such a forming nature nio of a cerebral condition. from the imiimediate and degree as to liave caused concussion. Tlle part Apart been unconscious for a few surgical risks to whiclh I have referred and the rare con- patient, having completely dition of subdural haematoma which I shall mention later, moments, partially regains his- senses and passes into the state of as a of the the severity of any injury to the head varies with the stupor already described part clinical nature and of suffered the brain at the picture of severe conicussion. Subsequently, instead of amounlt damage by that tow'ards a normal mental i.omnent of injury. Such damage may in itself prove fatal. making riapid progress it state which is characteristic of simple concussion,, he WIrhen does Inot there wvill result symptoms of cerebral and disorder whose differential and treatment remains stuporose, restless, irritable. During' the diagnosis may davtime, if left to Iiimself, he is usually drowsy, lies properly be considered as topics for neurological discussion. hiis and resents interference. At IL attempting a brief description of these cerebral states curled up on side, night J shiall find it to draw 'certain lines of he is frequently- noisy,. hallucinated, and violent. The -necessary arbitrary temperature anid pulse rate, at first subnormal, are often (listinction. raised. CoxcussloN. This . condition may persist for days or weeks, the I shall define concussion as a condition of subtotal tendency beinig towards gradual improvemeint, first mani- cessation of cerebral funiction following immediately upon fested in the form of brief intervals of lucidity during the injury, and lasting only a few moments, wvith subsequent the daytime, wlhen the. patient mlay ask where he is and complete recovery within twenty-four houLrs. During .the for a few minutes behave and talk in a rational manner. iniitial stage the patient is completely unconscious and in Orn regaininig hlis senses lhe is found to have an amnesia a state of flaccid paralysis. In a severe case tIme respiratory for the period of clouded consciousness. Such )atients and cardiac functions may hardly continue. In a few are often said to have been unconscious during this whole minutes recovery begins; the visceral reflexes are the first period, but it' is imiportant to distinguish between complete to returni, and vomiting is common at this stage.. The unconscious.ness or coma and thle condition of stupor or other ceelebral funmctions,recover.more gradually, aid there clouded consciousness wMhich is cdharacteeristic of majoez Iiiay be a phiase of somle hours during whicll conisciousness contusion. is clouded. Following this 'againi there miiay be comnplaint It has already been assumed that the general symptoms cf headache and giddiness, but at the end of tweenty-four of cerebral contusion are due to increased intracranial liours in anI uncomplicated case of concussioni recovery pressure from capillary liaemorrhage and transudatioll. should be complete and permanenit. Direct proof of this may be obtained by lumbar puncture,. The simplest explanatio'n of conelussion is that. given by a maosometer being employed to -register the spinal fluid Trotter. The skull being in relation to. traumatic force pressure. This is usually found to be well above the normal gemii-elastic is dented or compressed by the blow, its limit, anid the fluid is often blood-stained, indicati'ng the ('ontents being momentarily squeezed dry. The loss of rupture of -surface capillaries. conisciousness aiid paralysis are due to sudden transient The effects of increased intracranial -pressure upon cerebral anaemia. The symptoms of the recovery stage are cerebral functioin are well known, and there is no doubt- flhose of a gradual return of function in physiological that they oare brought about by embarrassment of -the intra-- sequence fromii the medullary oentres upwards. The wvhole cerebral circulation. Here wve have to consider three groups, Ilinical syndrome being due to a temporary vascular of blood vessels: the arteries with a high internal pressure, cn barrasAment and independenit of aniy structural lesion, the capillaries with a much lower pressure, and the veins' recovery is complete and permanenit. in wlhiclh the pressure is lowest. It is clear, therefore, that when ther:e is any inc-rease of- intracranial pressure, suffi- CEREBRAL CONTUSTON. cient to embarrass the cerebral eirculationi, its first effect Distinet from concussion, thoulgh often associated with will be to compress and narrow the veins. Oozing fr om it, is the condition of cerebral contusion. A fair idea tile capillaries may cause such venous compression, for the of wlhat is meanit by this term may be obtained by anyone pressure in the capillai-ies is normally higher than that wh1io will visualize the picture of ce'rebral daimiage in in the veins. But oozing from the capillaries cannot result a case of fatal hlead injury. Apart from any direct lacera- in compr-ession of the capillaries themselves-that is to tion of the braini fri-om compoutnd fractRre there is almost say, the increased intracranial pressure due to cerebral always Ato be 'seen- in such a case diffuse hrunising and contusion may be sufficient to embaarrass the venous outflow Made in opening a (liscussion in the Section of MIental Diseases and so cause a state of relative cerebral anoxaemia, but anl Neurology of the Annual Meeting of -the British Medical Association, Cardiff, 1928 cannot reach the poinit of compressing the capillaries anid 13540J B80NOVb xo, I928] CER 13iL STAS CNSEQUENT7 UON REAYDINJIJRIE . IMEDCLwMJouENA*7,u ErI causing a state of cerebral iaacnaeia. Tlhe symntomis o'f pla-ntar ieflex 0o1 tile right side. The blow, which had been of a glaiicinig niature, lhad been on the left side of his niear the cerebral anaemia are comia anid alysis; of cer ebr al head, Ipar vertex, and as nearily as could be judged over the upper end of aroxaemia, stupor, irriitability, anid confusion. These latter the left precentral gyrus. He was treated over a period of three censtitute the true cliniical pictuire of mlajor conitioinoi. The montlhs. and theni returned to his work. At that time the right developmenit of coma or paralysis miiust indicate some other planitar response was flexor, but obtained less easily thani ' l4 anid more forimlidable source of compres'ionl, sUch as arterial left. He writes that at the present time he is well-, save for hiaemorrhage or subdural haemiatomia. occasional headaches which occur at times of mental or physical Having regained his full senses the patienit, uilder the strain or in thundery weather. terms of our definition, passes ou't of the category of major Apart from objective physical signs, there are certain contusion, and hiis furthelr symptoms are those of miinior symptomis whiich must be related to focal damage, amongst contusion. which permanient mental change and epilepsy are of importance. The General Symptomiis of 31ior Conltfsion. Permanent mental deterioratioon to the poinit of necessi- The injury may, or may not, have been such as to have tating institutional care would appear to be rare.
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