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.= I regard venesection as a valuable means of reducing the intracranial pressure. It is mainly of use in those cases that hover between slight compression and the fully-developed condition. Venesection may therefore be regarded as of special advantage in those cases that show elevation of temperature to about 101° and there ‘mark time’. The ‘bleeding’ should be carried out after exposure of the median basilic, external jugular, or internal saphenous veins, preferably from the first-named site. The amount of blood to be withdrawn varies according to the individual circumstances of the case, but, in general, the escape of blood should be encouraged till the pulse becomes soft, frequent and compressible. On an average, the quantity of blood withdrawn varies from 10-20 ounces. The operation not infrequently turns the scale in favour of the patient. Venesection may also be carried out in combination with ‘decompression’ operations.
When applied to suitable cases and carried out with discrimination, venesection often tides the patient over the stage of ‘crisis’. The most careful observation is needed in estimating the quantity of blood to be withdrawn, the pulse, blood-pressure, respiration, and temperature affording an adequate guide.
_Lumbar puncture._ In spite of the apparent advantages of this method, it must, I think, be acknowledged that lumbar puncture is of but little use in reducing the general intracranial pressure. Consequently, in spite of the fact that this procedure has been strongly recommended, experience shows that it is of little practical use. This statement, based on personal experience, is at variance with the opinion of some other surgeons. For instance, de Quènu reports 7 cases of fractured skull which were ‘cured’ by this treatment, one of them requiring to be punctured eight times. Lumbar puncture assists the diagnosis, but I am doubtful whether it improves the prognosis.