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HEAD                                                                 253

(3)   Bleeding,   or   discharge   of   cerebro-spinal   fluid   from   the   nose,
mouth, or one or both ears.

(4)   Lesions  of the nerves issuing from the base of the skull giving
rise to paralysis or loss of sensation of the parts supplied by them.

The result is not always fatal. Sometimes recovery takes place,
through headache, deafness, or other nervous derangements may persist for
a long time.

Contusions and Lacerations of the Brain.—These injuries are caused by
the application of violence to the head and may occur with or without
external injury to the scalp and fracture of the skull. They are seen super-
ficially on the surface of the brain or deep within its substance, and are
associated with punctate haemorrhages1 limited in small areas or multiple
haemorrhages diffused largely within the brain tissues.

These injuries are commonly found under the site of application of the
blow, but they are sometimes found on the surface of the brain diagonally
opposite to the site of impact, and are called contre-coiip injuries. They
are most commonly found on the undersurfaces of the frontal lobes and
near the tips of the temporal and frontal poles.

Contre-coup lesions of the brain were once thought to be caused by the
brain moving within the skull in a straight line with the force of the blow
and striking against its opposite side, but from experiments on mechanics
of head injuries Holbourn 5 has demonstrated that contre-coup lesions are
chiefly due to local distortion of the skull and sudden rotation of the head
as a result of a blow, which arouse shear strains produced by the pulling
apart of the constituent particles of the brain. Shear strains occur in all
parts of the brain, but they occur to a large extent at the base of the frontal
lobe and the tip of the temporal lobe, as the skull gets a good grip on the
brain in this region owing to the projecting ridge of the sphenoid bone.
Hence severe and extensive injuries occur in this region when a blow is
struck on the occiput. On the other hand, contre-coup injuries which are
caused by rotation will not occur, if the head is so well fixed that it cannot
rotate at all when it receives a blow.

Concussion of the Brain.—This is a rotational injury, as it will occur
only when the head is free to move but not when it is fixed. It is popularly
known as " stunning", and may be produced by direct violence on the
vertex, by a violent fall upon the feet or nates from a height, or by an
unexpected fall on the ground, when pushed forcibly by a running cart or
even by a bicycle.

Symptoms.—The symptoms depend upon the nature of the injury. Thus,
the patient may become dazed and giddy with or without falling, if there is
slight injury, and recovers in a short time, but he may remain mentally
confused for some time and will vomit once or twice.

With severe injury the patient falls down and becomes unconscious,
though he can often be partially roused by shouting. The muscles are
relaxed and flaccid, but there is no paralysis. The sphincters are relaxed
with involuntary passage of urine and faeces. The face is pale, and the
pupils are equal and usually contracted reacting to light but, in more severe
cases, are dilated and insensible to light. The skin is cold and clammy with
subnormal temperature. The pulse is rapid, weak, small and hardly
perceptible. The respirations are slow, irregular and sighing. Death
occurs rapidly from syncope, or recovery follows, with the setting* in of
nausea or vomiting. The skin becomes hot and dry, the pulse is full and
strong, and the respirations are increased in rate. After apparent recovery

5.   Lancet, Vol. II, 1943, p. 438.