When the fracture is associated with general cerebral irritation.
The patient should be put to bed in a quiet and darkened room, under the continuous attention of a trained nurse. An ice-bag or Leiter’s tubes may be applied to the head, though the patient seldom tolerates such attentions. I regard morphia as of the greatest service in this class of cases. It should be given freely, subcutaneously, either by itself or in combination with atropin. I generally order 1⁄4 gr. morphia with 1⁄100 gr. atropin every six hours, till the irritative symptoms subside.
Insomuch as all evidence tends to prove that general cerebral irritation, as resulting from injury, implies a condition of contusion or superficial laceration, a prolonged period of bodily and mental rest is essential before the patient is discharged from treatment and allowed to return to work—a period of not less than six months.
The operative treatment of fractures of the vault.
The usual preparatory treatment is carried out, the scalp-tourniquet applied, a suitable scalp-flap framed and turned down, advantage being taken of all existent scalp lacerations.
The subsequent details vary according to the circumstances of the case:—
Fissured fractures.
If, after thorough exposure of the parts, the operator is satisfied that he has to deal with an uncomplicated fissured fracture, the scalp-flap is accurately sewn into position (see [p. 16]). On the other hand, if the symptoms point to the presence of an extra-dural hæmorrhage, the bone is trephined where the fracture crosses the line of the suspected vessel and the conditions treated as described under middle meningeal hæmorrhage. In subdural extravasation the trephine is applied over that part of the brain, in the immediate vicinity of the fracture, from which the symptoms appear to emanate, and the conditions treated as described under subdural hæmorrhage.
In a certain proportion of cases the symptoms point to a marked increase of intracranial pressure without definite localizing features, a condition pointing to diffuse subdural hæmorrhage, with or without brain laceration. Under such circumstances much may be done to relieve the increased intracranial pressure by carrying out the operation of ‘cerebral decompression’ (see [p. 121]).