Chapter XXVI

, page 264.) A blood clot within the cranium which fails to resorb is essentially a hematoma, in whose interior softening and conversion into a cyst may easily occur. These cysts make room for themselves at the expense of surrounding brain tissue, and when located in the motor area give rise to localizing symptoms as well as to epileptic convulsions. They may be often diagnosticated with certainty after an accurate history of the case and a study of the phenomena which it presents. As they grow older their walls become firmer, and it is often possible to dissect them out.

That _foreign bodies may be encapsulated_ and remain without producing disturbance is now well known. This is particularly true of bullets. As a rule, however, though encapsulated, they produce symptoms like headache, vertigo, etc. (See Plate XLIII.)

=Symptoms.=--The general features of brain lacerations are those of _contusion_. So long as the disturbances are minute, even if multiple, or the foreign body small, compression symptoms are not produced, or at least in very incomplete degree. Minute diagnosis is not easily obtained. The most essential thing is to decide upon the question of operative interference. In the absence of distinctly localizing symptoms or other external markings it is not usually performed. Upon the other hand a lesion which can be localized is probably due to extravasation sufficiently large to be easily reached by opening the skull; and, unless there be other and sufficient reason to the contrary, this should be done (Fig. 378).

In many instances, however, contractures or paralyses of muscle groups occur later, and are followed by spastic conditions which may be permanent. More can be done in these cases by massage, by internal medication, perhaps with external counterirritation, than by distinctly surgical procedures. Tendoplastic or neuroplastic measures for their relief may also be considered. Both albuminuria and glycosuria are known to be the result of injuries herein described, as well as bulbar paralysis and disturbances of special senses. More immediate dangers after these head injuries are those of bronchopneumonia or hemorrhagic or edematous infiltration of the lower lobes of the lungs--conditions often spoken of as _hypostatic pneumonia_, much resembling those produced experimentally in bilateral division of the pneumogastrics. Some of them are produced by paralysis of the glottis, the result of which is incomplete closure, with aspiration of fluids and solids from the mouth, whose decomposition sets up an infection within the lungs, and is often referred to as _aspiration pneumonia_. Some form of pulmonary disturbance follows in perhaps one-third of the cases of the injuries above alluded to, and should be anticipated and prevented.

[Illustration: FIG. 378

Bullet embedded in anterior fossa. (U. S. Army Med. Museum.)]

GUNSHOT WOUNDS OF THE HEAD.

These have already been extensively considered in a previous chapter, so that but little more need be said of them here. Such wounds in the scalp are likely to be followed by sloughing. So far as gunshot fractures of the skull are concerned, there is frequently a marked discrepancy between the wounds of the inner and outer tables, that last perforated by the bullet being almost splintered. Penetrating wounds of the cranium by Mauser and similar bullets are not necessarily fatal. Many men were shot through the head during the Cuban and South African wars and yet did not die as a result of the wound. (See