The Modern Treatment of Cranio-Cerebral Injuries with Especial Reference to the Maximum Permissible Mortality and Morbidity *

Introduction. Ever since John Abernethy' protested 125 years ago against the "propriety and necessity of trephining the cranium under various circumstances consequent upon injuries of the head," as then advocated by "the members of the Academy of Surgery in France and Mr. Pott in England," the treatment of cranio-cerebral injuries has been under dispute. At that time the pathological background was provided by the terms "concussion" or "commotio cerebri," "contusion," and "compression." These were still the diagnostic criteria 100 years later26, at which time operation in the form of a subtemporal decompression was again the therapy of choice. A major step in the comprehension of the physiology involved had been taken, however, by virtue of Cushing's completion of Kocher's work"3. This led directly to the division of the old stage of "compression" into four parts and a demonstration of the fact that the symptoms produced at that time were caused by varying degrees of failure of the cerebral circulation26. Treatment, aside from the subtemporal decompression, still included venesection. Lumbar puncture, though new and therefore dangerous, was being mentioned. Compound and depressed fractures and meningeal hemorrhage were then and had been for 50 years legitimate excuses for operative interference"5 41. After the World War the further and final steps in elucidating the physiology of the cerebrospinal fluid were taken by Weed42 and Dandy'6. These led directly to the introduction of a new method of treatment-ehydration21 43 and the renewal of interest in and finally the adoption of an older one-lumbar puncture24 3' 34. The subtemporal decompression was reserved for use in those cases whose intracranial pressure could not be lowered by repeated lumbar punctures and where the other old indications for operative inter-