Fig. 44. A Temperature Chart illustrating the Changes in Temperature observed in Head-injuries. (For description, see text.)

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Acting on these suggestions, I am accustomed to treat all head cases with this drug, 10-20 grains three times a day by mouth. It may be given per rectum, though probably with less satisfactory results. Traumatic cases are treated as soon as possible, other cases receive their dose for two or three days previous to the operation, the drug being continued till all fear of possible meningeal infection has vanished.

In discussing the general treatment of basic fractures, it must be accepted that the basic fracture in itself requires no treatment. Danger or death is dependent on intracranial complications, and an uncomplicated basic fracture demands no active surgical treatment. The special treatment applicable to cases complicated by hæmorrhages, both external to and beneath the dura mater, is discussed in the next chapter. It is therefore only necessary to enter into those cases of fractured base which are associated with concussion, irritation, and compression of the brain—in other words, the average case of fracture of the base of the skull.

The surgeon must always be guided by the general condition of the patient—the blood-pressure, character of pulse, state of respiration, depth of unconsciousness, &c.—but, in my opinion, the temperature chart affords perhaps the most valuable basis on which rules can be formulated guiding the surgeon in his general line of treatment.

Thus (1) when the temperature remains subnormal the patient is in a condition of severe cerebral shock, due, in the majority of cases, to contusion or laceration of the brain, the grosser lesion being most commonly situated either at the apex of the temporo-sphenoidal lobe or at the anterior inferior part of the frontal lobe. The patient is, however, suffering from shock, and the treatment advocated for that condition in general is equally applicable to these cases in particular. The patient should be placed in the so-called head-down position, and the extremities firmly bandaged from below upwards. The vaso-motor depression should be combated by the administration of rectal or intra-venous infusions of saline solution, to each pint of which is added 1 drachm of a 1 in 1,000 solution of Adrenalin Chloride. It is at once obvious that, whilst combating the condition of shock, this mode of treatment may tend at the same time to encourage fresh bleeding if the brain should have been lacerated, or if intracranial vessels should have been torn. For this reason I regard rectal infusion as the more safe of the two methods, in spite of the fact that intra-venous infusion brings about a more rapid improvement in the patient’s condition. The effect of the infusion must be carefully observed, and as soon as the blood-pressure rises and the temperature shows a tendency to rise—say from the subnormal to the normal—the infusion process must be stopped, and the further progress of the case observed.

The risks attendant on this mode of treatment are obvious, but in their consideration, it must also be borne in mind that if the patient remains in the collapse stage, without evidencing any sign of reaction, he will inevitably die. If the treatment advocated should tide the patient over this stage and induce a definite reaction, as exemplified by rise of blood-pressure and elevation of temperature, the further treatment of the case can be considered under the next group.

(2) When the temperature rises progressively the patient evidences symptoms pointing to compression of the brain—coma, slow pulse, noisy and stertorous respiration, hot skin and turgid face. Later on, as a result of the increasing pressure, the medullary centres begin to show signs of exhaustion, the pulse-rate increasing, and the respiration becoming Cheyne-Stokes in character.

Whether these symptoms result primarily from the nature of the lesion, or secondarily after the adoption of those measures advocated for the collapse stage, it matters not. Our indications with respect to treatment are clear. The increasing intracranial pressure must be reduced. This desideratum is preferably carried out by the ligature of a bleeding meningeal artery, or by the occlusion of a torn venous sinus, but unfortunately, such a course is frequently out of the question. We have, therefore, to deal with an increased and increasing intracranial pressure, without definite localizing features. For this condition we have at our disposal the following measures: venesection, lumbar puncture, and ‘decompression’ operations.

Venesection.