330 SURGERY 



and clinical microscopy have opened up the heretofore unexplored 

 field for operative interference. Cases of coma with no external 

 injury of the skull have heretofore been treated by the expectant 

 plan, with almost uniformly fatal results. Surgery owes much to 

 these two departments of medicine for valuable knowledge upon 

 a subject which is comparatively new, and which offers an additional 

 field for operative work. Intracranial tension is a condition which a 

 study of modern pathology has shown calls for surgical interference. 

 Intracranial hemorrhage is one of the most frequent causes of intra- 

 cranial pressure. It may also be caused by bone, pus, and foreign 

 body. In order clearly to understand the theory of intracranial 

 pressure, it is necessary to bear in mind two facts: (1) that the brain 

 itself is incompressible; and (2) that the cranial cavity itself is 

 incapable of expansion, therefore, the pressure of a clot of blood or 

 a fragment of bone, or a collection of pus, or any foreign body, must 

 be accommodated in the limited space in which the brain is lodged. 

 If the foreign body is of sufficient size to fill the intracranial space 

 by a twelfth, death results. 



The treatment of intracranial tension is a new subject, and one 

 which I have of late given special study. I am convinced that opera- 

 tive treatment is indicated in many of these cases. I have employed 

 this measure with most gratifying success. The indications for 

 operative interference are in some cases perfectly clear, while in 

 others the phenomena present would not justify resort to so severe 

 a measure. The greatest difficulty is to determine what the line of 

 deinarkation is between the cases that demand trephining or lumbar 

 puncture, and those in which the plan of expectancy can be adopted. 



These cases of intracranial tension can be divided into two classes 

 as regards operative interference. The first class includes those in 

 which intracranial tension is sufficient to produce profound coma. 

 Operation will save patients included in the first class that uni- 

 formly died under the expectant plan of treatment. Operation will 

 save the patients embraced in the second class when the symptoms 

 are gradually increased in severity. In regard to the indications for 

 operation to relieve intracranial tension in those cases included in the 

 second class in which coma is not present, the problem is difficult of 

 solution. I have been guided as to the operation by the condition 

 of the patient after a study of the symptoms from hour to hour and 

 from day to day. If the arterial pressure arises to a point and remains 

 stationary, and the vasomotor system does not fail, even with a well- 

 pronounced vagi disturbance, no operative procedure was practiced, 

 and recovery has taken place. In addition to the symptom of increase 

 of arterial pressure, the blood-count must be studied, the eye-grounds 

 examined, the urine tested, the reflexes studied, the disturbances 

 of cranial nerves noted, and all other phenomena investigated. If 



