it may be inferred that the brain is contused or slightly lacerated. Under these circumstances operation is, for the time being, not required, and an expectant attitude should be adopted.
When the fracture is associated with compression
it may be inferred that the condition is dependent on depressed fragments of bone, or on extra- or intra-dural bleeding. Operative measures are now urgently indicated.
When the fracture is confined to the internal table
a diagnosis is only possible when symptoms of localized irritation ensue, either due to pressure exercised on the cortex by spicules of bone or resulting from injury to some intracranial vessel, e. g. the middle meningeal artery. In such cases operation is indicated. Under other circumstances the surgeon must await the developments of the case.
Treatment.
When the fracture is associated with mild concussion.
During the stage of concussion no active treatment is required, beyond putting the patient to bed—with the head low—enveloping him in hot blankets, and applying hot bottles to the extremities. These bottles are wrapped up in flannel: they should never be placed in contact with the patient’s skin. As soon as the reaction stage commences, the bottles and blankets should be removed, the patient covered with light clothing only, and an ice-bag applied to the head, over the region at which the injury was inflicted. Calomel, in suitable doses, should be given by mouth, and a copious enema administered per rectum. Perhaps the most essential point in the general consideration of the case is the after-treatment. The patient should be kept in hospital or home for at least one month, and for the next three months or more, according to the urgency of the case, he should abstain from all mental and bodily work. At the end of that period of time he may return to work, though still kept under observation.
When the fracture is associated with severe concussion.
In the event of persistence of concussion symptoms of a severe type the prognosis is decidedly unfavourable. This prolongation of cerebral shock is undoubtedly dependent in its persistence on severe vaso-motor depression, and in the majority of cases ending unfavourably it will be found that the brain is generally œdematous and regionally contused or lacerated. In cases of this nature the surgeon should confine his attention, for the time being, to an endeavour at terminating this vaso-motor depression, raising the blood-pressure and inducing a definite reaction; the patient being treated after the manner indicated on [p. 118].