The Surgery of the Skull and BrainRawling, Louis Bathe
Science
The Surgery of the Skull and Brain
Rawling, Louis Bathe
Brain -- Surgery; Skull -- Surgery
(_b_) _Of irritation._ The patient should be kept in a darkened room and
should not be worried more than is absolutely necessary for diagnostic
purposes. An attendant is usually required, whose methods should be
persuasive rather than forcible. Great tact is required.
Morphia is of the greatest value in the treatment of this condition. It
relieves the headache, acts as a damper on the hyperæmic brain, and
keeps the patient from threshing about in bed and injuring himself.
Sleep is essential for an early recovery and cure.
In the _more severe cases_ venesection should be carried out, and
operative measures will be required if the rising temperature and slowed
high-tension pulse herald the advent or indicate the presence of
compression of the brain.
(_c_) _Of compression._ The various operations carried out for the
relief of compression of the brain are discussed elsewhere. They include
such operations as are conducted for localized hæmorrhages, whether
subdural or extra-dural (see Chap. V), and such also as are described as
‘decompression’ operations (see p. 121).
With regard to the general indications for adopting active surgical
measures, the surgeon is, of course, guided in his estimation of the
case by the general condition of the patient--depth of unconsciousness,
&c.--but more especially by the temperature changes and alterations in
blood-pressure. In my own practice I am guided very largely by the
temperature changes--as described on p. 114. On the other hand, some
surgeons pin their faith more especially on the blood-pressure changes.
Thus Archibald writes: ‘If the blood-pressure be 130 mm. Hg. on
admission, an hour later 150, still later 200 or 250, we are immediately
in possession of the fact that the available intracranial space is being
steadily, dangerously reduced, and that the vaso-motor centre is
straining every nerve to stave off defeat.’
I am, of course, ready to concede the great value of blood-pressure
tracings, but, in my experience, the temperature changes have been even
more consistent, so much so that I base my treatment of a case very
largely on such changes. One word of warning--the temperature must be
taken every half-hour, and active surgical measures adopted _so soon as_
the rising temperature, slowing high-tension pulse, and deepening
unconsciousness point to advancing compression.
There is undoubtedly a growing tendency amongst those who have carefully
studied the effects of trauma on the skull and brain to carry out
exploratory and decompression operations at an early period, even in
cases which present no symptoms of special localizing significance. The
pathological conditions so commonly found and the excellent results that
have been obtained prove that the adoption of early surgical treatment
is founded on a very sound basis.
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