SURGERY
ITS PRINCIPLES
AND PRACTICE
BY VARIOUS AUTHORS
EDITED BY
WILLIAM WILLIAMS KEEN,
M.D.. LL.D.
EMERITUS PROFKSSOR OF THE PRINCIPLES OF SURGERY AND OF CLINICAL SURGERY,
JEFFERSON MEDICAL COLLEGE, PHILADELPHIA
VOLUME
With 562
Text-Illustrations
III
and 10 Colored Plates
PHILADELPHIA AND LONDON
W.
B.
SAUNDERS COMPANY
1908
SURGERY OF THE HEAD.
66
—
and resistance to pressure have been the objects of special study by
Rauber, who has shown that resistance to pressure is a third greater
than tensile strength. This, however, does not mean that fractures are
less hkely to occur at the pole of impact than at a distance, for other
factors
come
into play.
Before going further, specific examples of the direct and the indirect
effects of an impact may be given to illustrate the difference between the
bending and the bursting fractures of von Wahl.
man was
struck on the forehead by the
There resulted a local indentation with
Here was a typical
a round, cup-shaped depression about 8 cm. in diameter.
bending fracture, the injury having been restricted to a comminution of the area
immediately surrounding the pole of impact, due to overcoming the resistance to
pressure without any radiating lines of fracture from bursting.
On the other hand, a sliip-carpenter's head was caught between the flat surfaces of the side of a vessel upon which he was working and a heavy swinging
beam. The poles of impact, as represented by the bruises subsequently found,
were practically over the parietal eminences. There was no local injury to the
bone at these poles, but a single linear fracture connected them by running
across both temporal bones and into the middle fossse of the base of the skull.
Here we have a typical bursting fracture, the bony injury having taken place at
a distance from the poles of impact, due to the overcoming of the tensile
strength or cohesion of the particles at the base in consequence of the increased
In a drunken brawl
a
laboring
corner of a heavy bottle used as a club.
As
equatorial diameters.
is
usually the case, the fracture had occurred in the
direction of a meridian connecting the poles
and
in
the line of that particular
meridian wliich passes through the weakest part of the
base where cohesion
is
most
skull;
namely, at the
easily overcome.
—
Local Character of Injuries through Bending. These fractures
usually result from the sharp impact of a body with a comparatively
small surface.
Such a blow expends its force quickly and a rebound
occurs before the form of the skull, as a whole, has been sufficiently
altered to produce lesions at a distance.
At the pole of impact the bone
is
broken and the displaced fragments do not resume their former
position (Fig. 35).
greater thickness and vaulted construction fractures
more common on the exposed calvarium than at the
inaccessible base.
The character of the lesion, furthermore, is influenced
by the structural peculiarity of the bone; namely, its two dense tables
separated by a spongy diploe.
Owing to this, an indentation which
leads to a bending fracture will cause the inner table to splinter and give
In spite of
its
of this sort are
way
In consequence we not infrequently find fractures
a circumstance known even to the earliest
writers in medicine, who explained the phenomenon on the supposition
that the inner table was more fragile or brittle than the outer one;
hence the "vitreous" surface. Not until Teevan's studies was the
process satisfactorily explained on the ground of tensile strength or
cohesion of particles on the one hand and of resistance to pressure on
the other. There is no simpler illustration than the oft-used one of
before the outer.
limited to the inner table
—
FRACTURES OF THE SKULL.
67
a green stick broken across the knee. The cranial impact leads to
a local indentation, which tends to pull apart the particles comprising
In
the inner table and to drive together those of the outer (Fig. 36).
certain rare cases the process may be reversed and the outer table alone
Fig. 35.
Odtek and Inner Cranial Surfaces, Showing Fixed Indentation prom Bending
Fracture of the Vault, Involving Both Tables.
Note general
circular outline with single radial fracture
by
diastasis
(Surgeon General's Museum.)
— compare with
(D) Fig. 36.
suffer; this implies a
blow from within.
have given instances
of such lesions; thus, after traversing the cranial
Both Teevan and Bergmann
cavity, a spent bullet may strike the inner surface of the skull
fracture the overlying outer table alone.
and
SURGERY OF THE HEAD.
68
the force of the blow has been expended by the time the inner
it alone suffers fracture; if it continues, the outer gives
as well, but in the latter case it is always to be borne in mind that
the inner table splinters over a
wider area than the outer. A lesion
which is limited to the inner table
alone can only occur in a skull well
If
table gives way,
way
provided with diploe, and consequently in infancy and old age the
bone will usually give way throughout its entire thickness at the same
moment.
may be
with little or no displacement of fragments; they may,
on the other hand, lead to a marked
depression whose floor is made up
of firmly wedged fragments from the
two tables. They, furthermore, are
These bending fractures
associated
usually
bounded by an
D
point of impact.
Fig. 36.
irregular
which lines of
fracture radiate from the central
circular fissure, into
Illustrating Mechanical Prin-
ciple OF Bending Fractdkes.
and B, Arrow shows direction of impact [3 and 4 are dragged apart until tensile
strength is overcome
1 and 2 are crowded
together until resistance to pressure is over-
An
excellent ex-
ample of such a circular fracture
from bending occurs among the
comparatively rare instances of this
form of fracture at the base, when,
as the result of a fall upon the butcome (Teevan)]. C, showing possible effect
on inner table alone; D, showing possible effect
tock the impact is transmitted to the
on both tables.
occipital bone through the spinal
column, and the circular fracture more or less clearly surrounds the
A
;
foramen magnum.
Distant Effects of Injuries through Bursting. A diffuse blow
from a flat surface is prone to cause effects at a distance, just as a concentrated one from a small body is apt to produce local effects.
A
bursting fracture of typical form, comparable to the lesions which von
Bruns has produced experimentally by compressing skulls in a vice to
the point of fracture, was cited in the clinical note given above, but it is
unusual for the head to be caught and squeezed in this way. An
analogous injury may occur when, lying on a hard surface, it is struck
by a falling body, though a violent blow against one side of the cranium
alone the head itself usually being the moving force is the more
common method. Though the striking surface, favorable for a bursting
effect, should be a flat one, it is common enough for some forms of
impact, which produce primarily an indentation, to cause a bursting
of the skull as well, in case there is no immediate rebound and if the
Thus, we often find meridional fissures
force exerted be sufficient.
which radiate from a local bending fracture (Figs. 35, 37, 46) situated
—
—
—
SUEGERY OF THE HEAD.
74
fragmentation or splintering. The comminution may be confined to
the area of impact or the entire cranium may be broken into pieces.
Being a common result of local deformation or inbending at the point
of injury, they are usually situated on the vault and depend for their
production on the character not only of the blow (a sharp one with
quick rebound), but also of the striking body.
From the standpoint of the bony lesion itself they are more serious
than linear fractures, owing to the usual displacement of fragments
fractures with depression. This in its simple form is schematically
shown in Fig. 36. Extensive comminution, however, may occur with
little, if any, dislocation of the broken pieces (Fig. 44).
We may,
furthermore, in the elastic skulls of infants have depression with no
comminution or, indeed, with a total absence of fracture. Finally, in certain rare cases fracture may occur with actual elevation of a fragment
Fig. 40.
(Fig.
Skull Showing Healed Angular Fracture of Frontal Eone (Linear and bt
Diastasis) with Elevation of Fragment.
(Warren Museum.)
These
40).
depression
effects,
however, are unusual; comminution and
in hand.
Hence they will be considered
commonly go hand
together.
The comminution and depression may
(Fig. 41) or
affect the inner table alone
both tables, in which case the fragments
may
consist of the
entire thickness of the skull or, in diploetic skulls, of the separated
When
thus separated the fragmentation of the inner is always
The fragments may form
of the outer.
a cup-shaped depression, often termed by English writers "pond
fracture" (Fig. 43), or they may become tilted at the peripher}^ and
slip under the intact cranial edge.
We thus have peripheral or central
tables.
more widespread than that
depressions (Fig. 42).
From the pole of impact in comminuted fractures there are often
numerous radiating or meridional fissures; these in turn are often connected by zonal lines of fracture, like the connecting strands of a spider's
FRACTURES OF THE SKULL.
75
web; and in these cases the farther
from the point of impact, the
farther apart are the zonal lines,
and consequently the larger the
When comminution
fragments.
the result of diffuse blows, as
in the skull of the "butting"
negro in the Surgeon-General's
is
Museum,
or
when
follows falls
it
from
a great height, irregular
fragmentation, like a broken eggfissures
shell, may occur, with
having no definite configuration.
Almost
all
punctured or pene-
wounds are accompanied
by more or less local fragmen-
trating
with
tation,
depression,
which
particularly affects the inner table.
may
Depressed fragments
and
in place
heal
their irregularities
become, in the course of time,
largely
smoothed
Comminuted and Depressed Fracture
Fig. 41
Limited to Inner Table.
eral's Museum.)
off (Fig. 43).
(Surgeon Gen-
Perforating fractures are due
to cuts, to stab-wounds, to the penetration of sharp tools which
have fallen from a height, to the blow of a pick, the thrust of a bayonet,
A
_
-^^r~^
'
and what not. They are associated
with more or less fissuring. with
fragmentation and with depression
fragments,
of
especially
of
those
broken from the inner table about
the margin of the wound.
Their
•
jQ
"
•
"J
course, diagnosis, compUcations,
treatment do not
Cing,
differ
and
materially
from that
(p.
^
"^^^r-M
Kii^^^lT^-^^
63),
of wounds of the skull
unassociated with fractur-
though
by
produced
similar
agencies.
When
has
carried away, leaving
been
a portion of bone
a
defect, they are called fractures with
loss of
substance (Fig. 42).
One
particular group of perforating fractures deserves special conDiagram OF (A) Comminuted Fracture WITH Central Depression; (B)
ONE with Peripheral Depression; (C)
ONE with Loss op Substance.
Fig. 42.
sideration; namely, those
the result of
Gunshot
which are
wounds from
—
firearms.
Fractures. In
their
simplest form these are perforating
fractures which produce a circular loss of substance.
When the result
of a wound at short range from the modern small-arm, we have seen
SURGERY OF THE HEAD.
170
HSi.
50% R'
—
Sylvian line connects external
Fig. 90.
angular process, A, with point 75 per cent, of
Superior Rolandic point, R'
distance
to /.
lies finch behind mid naso-inionic point (50 per
lies
at
Inferior Rolandic point, PJ'
cent.).
junction of Sylvian line with perpendicular
re-auricular
point.
to Raid's base-line, R-B, at p
Sylvian point lies at junction of Sylvian line
with line from meatus to 25 per cent, of naso-
N
,
inionic line.
NO = Kocher's equatorial line,
Fig. 92.
= Poirier's Sylvian line
nasion to inion.
lambda.
Kocher's antenasion
to
from
rior meridian drawn 60° from median line at
midsagittal point; lies over precentral convolution and crosses
at Sylvian point.
Sfs
superior frontal sulcus at one-third of MA;
Sfi = inferior frontal sulcus at two-thirds oi^
MA.
Kocher's posterior meridian, also
60° from mid-line. Lines crossing at Sts = supe-
Nh
NL
—
MP =
rior
temporal sulcus.
MA =
—
Fig. 91.
Forty-five per cent, of median
naso-inionic line -- pre-Rolandic point; 55 per
Sylvian
cent.
Rolandic point; 70 per cent.
line; 80 per cent.
lambda; 95 per cent, gives
=
=
=
Line from A,
lower edge of occipital lobe.
external angular process, to 70 per cent, gives
iS
Sylvian point = junction
Sylvian fissure.
of second and third tenths of this line, while
R" = inferior Rolandic point junction of its
third and fourth tenths.
=
=
—
=
German "base-line" from
G-B
Fig. 93.
inferior edge of orbit through upper edge of
upper horizontal, parallel to
meatus.
and
through upper border of orbit.
Z perpendicular at posterior border of mas-
GB
UH =
MC
=
The Rolantoid, at condyle and mid-zygoma.
dic line unites the points of crossing of the posteriorperpendicular and sagittal lines, i?',andthe
upper horizontal and anterior perpendicular,
The Sylvian
ferior
line bisects the angle
R' SH.
S.
In-
Rolandic point, R".
the nasion to 1 cm. below the lambda (Poirier); or with a line connecting the external
angular process with a point 80 per cent, of the distance from nasion to inion
(Chipault) or a point 75 per cent, of this distance (Taylor and Haughton) or with
;
;
a line bisecting the acute angle made by the lines (1) from the superior Rolandic
point to the Sylvian point and (2) from the upper border of the orbit and carried
INJURIES AND DISEASES OF THE CEREBRAL BLOOD-VESSELS.
INJURIES
199
AND DISEASES OF THE CEREBRAL BLOOD-VESSELS.
—The
Hemorrhages.
Intracranial
symptoms
of
intracranial
hemorrhages are necessarily so associated with those of concussion,
contusion, and compression of the brain that it has seemed wise to
defer until this time the discussion of all forms of bleeding within the
A single exception has been m.ade in favor of those forms which
skull.
Pachymeningitis hsemorrhagica has also been
occur in the newborn.
considered elsewhere.
The extravasated blood may be found between the skull and dura,
between dura and arachnoid, in the subarachnoid mesh work, between
pia and cortex, and finally as a true cerebral hemorrhage, whether
superficial or deep, in the brain substance itself.
Extradural Hemorrhage (Hematoma of the Dura Mater
Meningeal Apoplexy. Etiologi/. An extravasation between dura
and bone, though usually of arterial origin, may result as well from an
—
—
The clural vessels
injury to the veins, sinuses, or parasinoidal sinuses.
may have been injured by punctured or perforated w^ounds; by simple
linear fractures; by depressed fragments of bone in a comminuted
by a deformation
without fracture. If,
has been lacerated,
its vessels, bleeding may take place underneath
the membrane; or if there is an external wound in addition, the blood
may find its way outward, and thus an extradural hematoma need not
form. Likewise in depressed fractures, even though the fragments
have torn an arterial branch, they may be so wedged against the vessel
as to prevent extravasation, and serious bleeding often does not occur
until an operative attempt has been made to elevate the fragments.
Injuries to the venous sinuses, from wounds or fractures, providing
the lesion is confined to the outer surface alone of the sinus, may lead
Owing to the low tension of the
to an extradural extravasation.
venous blood, however, it does not succeed of itself, as does an arterial
extravasation, in stripping the dura away from the bone; hence, unless
some separation of the membrane has occurred as a direct result of the
injury, a dural hematoma from this source is rare.
The most common
extradural hemorrhage of venous origin is met with as a post-operative
complication of craniotomies; for, after the replacement of an osteoplastic bone-flap, dura and bone having been separated during the
operation, an extravasation from slow venous oozing may take place,
and, unless the wound be opened and the clot removed before pressure
symptoms are marked, such an extravasation may lead to serious
consequences (Fig. 106).
It may be noted that in cases of death from extensive burns extradural clots have been found at autopsy, not to l^e accounted for by any
fracture; or even
owing to the character
as well as some one of
of the skull
of the injury, the
dura
itself
cranial injury.
A
which crosses one of the meningeal
an anatomical groove in the bone, leading to an
extravasation^ is the more common source of a dural hematoma
fissured fracture, the line of
vessels as
arterial
it lies
in
No
fracture
is rare.
5-15%
SURGERY OF THE HEAD.
200
Though usual, a fracture is not essential, for the vessel
107).
be torn in consequence of cranial deformation alone without any
In some cases the extravasation
actual rupture of the cranial wall.
may take place by " contrecoup," on the side of the head opposite to
that which receives the blow; and, indeed, there may be a bilateral
(Fig.
may
extravasation.
Only when the cranial injury has been of such a nature, however,
that the dura has not been torn do the symptoms of this lesion assume
Consequently, the menintheir peculiar and characteristic sequence.
geal
hematomata which accompany more
serious forms of injury,
when
the bleeding escapes externally through an open wound or under the
dura through a laceration in the meml^rane, need not be considered
apart from intracranial hemorrhages in general.
Fig. 106.
Bone
Post-operative Extradural Hematoma from Slow Venous Oozing.
hours after operation, owing to symptoms of compression.
flap re-elevated forty-eight
— Being usually the
result of a laceration of the middle menmajority of extradural hematomata occur
under the lateral aspects of the skull and more particularly in the
temporal region. The extravasations also are more or less circumscribed, for only when one of the main branches of the vessel or the
trunk itself has been injured will there be a widespread escape of blood.
The terminal twigs of the artery, inasmuch as they do not deeply
groove the bone and have but slight communication with its inner
surface, are rarely the source of extensive bleeding.
Kronlein has given three chief seats for these extravasations an
anterior, middle, and posterior
in correspondence with the particular
branch of the artery which has suffered injury, and has indicated in his
familiar diagram (Fig. 108) points which he considers elective ones for
Seat.
ingeal
artery,
the large
—
—
The Problem - Until Radiology
INJURIES AND DISEASES OF THE CEREBRAL BLOOD-VESSELS.
201
An
extradural hemorrhage, however, may be difficult of
upon which side it has occurred is oftentimes more
so; to determine the particular branch of the vessel which has been
injured may be well-nigh impossible.
Hence, when a lesion of the
meningeal artery is suspected it is wise to select the middle ground over
the main trunk for exploration; and if focal symptoms have not been
trephining.
diagnosis
;
to decide
Case of Bursting Fracture of the Skull in which the Fissure Lacerated
A. Meningea Media at Foramen Spinosum.
Note low-lying clot not exposed by misplaced osteoplastic flap and necessitating further opening
Fig. 107.
with rongeur forceps.
As in a case which
exploration may be called for.
have recently reported, the main stem at its point of entrance through
the foramen spinosum may have been injured (Figs. 107 and 109).
Extradural hemorrhages, however, may take place elsewhere than
over the middle meningeal territory, even without any gross lesion of
the cranial vault.
Thus, they not uncommonly occur in the occipital
clear, a bilateral
I
SURGERY OF THE HEAD.
202
and one of the cerebellar lobes may become compressed from
such an extravasation just as may one of the hemispheres. They may
occur also in the frontal region as a result of cranial deformation alone
without fracture. In one of my patients, with no demonstrable fracture,
a large symmetrically placed frontal extravasation was found, amounting to 230 cc. of blood; the bleeding apparently originated from torn
emissary vessels which connected the longitudinal sinus and calvarium.
Form. The hematoma may be thinly spread out or, on the other
In its typical form it is more
hand, may be circumscribed and thick.
As it extravasates, the blood quickly
or less circularly lens-shaped.
fossa,
—
V
Fig. 108.
V
Kronlein's Scheme for Finding Points of Election (Circular) for Trepanation
IN
Meningeal Hemorrhage.
Also three usual sites of extravasation, S-0, linea horizontalis supra-orbitalis; A-0, linea
horizontalis auriculo-orbitalis; V-Z, linea verticalis zygomatica; V'—A, linea verticalis auricularis;
V"-R, linea verticalis retromastoidea.
clots
and the
disk-like
hematoma
(Fig.
110), being constantly
to at its central point, leads to the gradual stripping
added
away from
the
attached membrane. It is probably
this continuous increment to the ever-thickening center of the clot
which furnishes pressure directly against the membrane sufficient to
separate it from the skull.
The adherence of the dura differs greatly
at different ages, it being more firmly attached in the extremes of life.
Consequently these extradural hemorrhages are much less likely to
occur in infancy and advanced age. The amount of the extravasation
varies greatly in individual cases, and it is astonishing how large a clot
may at times be accommodated by the compressed brain before fatal
pressure symptoms result.
The occurrence of serious symptoms
depends partly on the situation of the clot; partly on its tension
whether it be due to arterial or venous extravasation; and partly on
bone
of the
more or
less firmly
•
INJURIES AND DISEASES OF THE CEREBRAL BLOOD-VESSELS.
203
uncommon, and even
have been recorded. Rarely, however, may the hematoma
reach such a size and be compatible with a continuance of circulation
its
size.
Clots of from 4 to 6 ounces are not
larger ones
in the medulla.
—
Symptoms. They naturally show considerable variability, depending
on the situation and size of the clot and the rapidity of its formation.
One feature, however, often serves to distinguish them from all other
forms of intracranial hemorrhage the so-called "free interval." As
a rule, the injury which has led to the vascular lesion has been sufficient
—
Fig. 109.
To show the
situation
Coronal Section, Passing through the Pituitary Fossa.
hematoma in a case of injury of the meningeal
of the extradural
at the
foramen spinosum.
at the
same moment
to so stun the patient that
sciousness from concussion has been produced.
toms due to concussion
may
away
some grade of unconThese primary symp-
in the course of time and the
a degree restored. Then, after
a few hours of relative freedom from evidence of marked cerebral
disturbance, headache and possibly vomiting appear, and in a short
time the patient again sinks into a stuporous condition. Before this
has occurred, however, should he be under close scrutiny focal symptoms may have been observed.
These focal sym/ptoms are as important in determining whether the
extravasation is right or left as the free interval is important in determining whether it exists at all. They are commonly irritative, shown
patient's mental activity
pass
become
in
Lucid
interval
SURGERY OP THE HEAD.
204
by twitching of the face or arm; for, owing to the usual situation of the
hematoma, the centers at the lower end of the Rolandic strip are most
In left-sided lesions motor
likely to feel the pressure effects of the clot.
Hard to
talk - both aphasia is also a characteristic sign. These evidences of irritation may
to local paralyses of the same centers—a sequence of events
motor and advance
which may be observed before the patient loses consciousness and
cognitive before general symptoms of such a nature appear that they are entirely
in the more profound phenomena of compression.
Instances of actual hemiplegia from an extradural hemorrhage have
also been recorded, but they must be rare, since the centers for the
lower extremity lie so far away from the primary point at which an
extravasation of this sort is likely to arise, that a clot large enough to
implicate the upper ridge of the hemisphere would, in all probability,
either lead to such deep coma that symptoms of hemiplegia could not
masked
—
PiioTocHAiMi oi' ('at.\ vrium with Dura I!i:i
ri.;> >iiii'\\in'.
]~\i r.^dural Clot
Grooved by the Memngeae Artery, which had heen Torn ey the LI^EAR Fissure.
From a fatal case of meridional fracture. Arrows indicate lines of fracture. Compare with brain
Fig. 110.
i.i
of
be appreciated or
More
else
same patient
i
(Fig. 99, p. 189).
would cause death before they were apparent.
rarely evidences of sensory disturbances, whether subjective or
objective,
may
be elicited before the patient has become lethargic.
Hutchinson Other focal signs may become apparent. Thus, pupillary symptoms,
particularly inequalities, are common in this as in other forms of unipupil
lateral intracranial
hemorrhage.
The pressure
of the clot against the
on the same
This dilatation in the late stages may
affect both pupils, but even then the pupil on the side of the lesion
remains the wider. Changes in the eye-grounds are also common and
should always be looked for. Tortuosity of the veins and edema,
indicating an early stage of choked disk, due to the intracranial stasis
and usually appearing first upon the side of the lesion, is the most delicate and valuable of all objective signs.
hemisphere
is
said to cause
an early narrowing
side and, later on, a dilatation.
of the pupil
INJURIES AND DISEASES OF THE CEREBRAL BLOOD-VESSELS.
205
—
These focal symptoms may be fleeting a matter of a few hours;
duration depends entirely upon the rapidity with which the
their
hematoma
is
forming.
They
by
tive of general pressure,
are usually followed
by symptoms
indica-
stupor, unconsciousness, a slowed pulse,
a rise in blood pressure, respiratory symptoms, and other evidences of
In some cases
implication of the medulla in the general disturbance.
there is a considerable rise in temperature.
It must be borne in mind that the absence of focal symptoms and
the non-appearance of a free interval does not necessarily exclude the
For, instead of there being
presence of an extradural hemorrhage.
a simple concussion as a result of the primary trauma, contusion of the
brain may have occurred, with rapid extravasation of blood beneath
Under these circumstances the primary symptoms of conthe dura.
cussion would shade off into those of compression with no evidence
whatsoever of an "interval" marked by improvement in cerebral symptoms.
Furthermore, there are certain rare cases in which the cranial
injury may be of such a nature as to lead to a rupture of the meningeal;
and after what may be termed a free interval though preceded by no
stage of primary concussion symptoms indicative of an extradural
hemorrhage may occur. Such a case I have recently recorded one
in which, instead of by a blow with consequent concussion, the cranium
was deformed and fractured by being squeezed between two heavy
—
—
—
bodies.
When typical symptoms are present an unequivocal diagnosis may
usually be made.
Only in the complicated cases and in those lacking
the cardinal symptom of a free interval do uncertainties arise.
An
may often be necessary before it can be determined whether
an extradural or intradural hemorrhage. The presence of
bloody fluid in the lumbar arachnoid, though pointing to the latter, does
exploration
there
is
not necessarily exclude the former. It is often difficult also to determine
upon which side of the head the hemorrhage has occurred. Even if
focal symptoms are present they may be confusing.
Thus, it is sometimes impossible to tell whether pressure upon the cortex has led to
paralysis of the face or whether it is due to a peripheral lesion of the
facial nerve on the same side, owing to its implication in a fracture of
the base.
Similarly, dilatation of the pupil may be of cortical origin or
due to peripheral involvement of the motor oculi. The clot may be so
low (Figs. 107 and 109) that it does not involve the motor area; or, on
the other hand, it may be situated directly over it (Fig. 99) and lead
to focal paralyses from local anemia.
Prognosis.
From the study of a large number of records it is estimated that 90 per cent, of these meningeal apoplexies prove fatal if unrelieved surgically, 60 per cent, of them dying within the first twentyfour hours.
Of a large series of operated cases 67 per cent, recovered
a percentage which would be much larger were it possible to secure
prompt intervention before the onset of medullary symptoms in those
patients in whom the extravasation takes place rapidly.
Treatment.
Inasmuch as most of these cases when treated expec-
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206
SURGERY OF THE HEAD.
tantly terminate in death and inasmuch as
when operated upon they
furnish possibly the most satisfactory results of
all
cranial cases,
it is
A carefully conwise to explore whenever the diagnosis is in doubt.
ducted exploration cannot be harmful in cases of intracranial bleeding
from other sources and may be curative when it is extradural.
Much has been written in regard to methods of exploration and to
the treatment of the injured vessel when an extradural clot has been
found. The important thing is to find the extravasation; and this
should occasion no great difficulty when it has reached a size sufficient
to cause serious symptoms, provided the wrong side of the cranium has
not been entered. The precise measurements given by Kronlein to
determine fixed points at which the trephine should be applied do not
seem to me to be especially serviceable. The essential thing to bear in
mind is that the main stem of the meningeal runs across the middle
of the temporal fossa (Fig. 94) and branches near the pterion or,
roughly speaking, to use Vogt's rule, at a point two fingers' breadth
above the zygoma and a thumb's breadth behind the vertical process
of the malar.
Consequently an approach in this situation will expose
the main stem and in the majority of cases enable one to ligate the
The passage of a blunt
vessel if an extravasation has been found.
spatula toward the frontal, middle, and posterior divisions of the vessel
will serve to expose a clot, should one be limited to either of the three
zones described by Kronlein.
Krause advises an approach through an osteoplastic flap similar to
that which he uses in his Gasserian ganglion operation. This flap will
almost certainly expose the necessary field and is preferable, I believe,
to Kronlein' s trephine openings.
Still better, it seems to me, is the
intermusculotemporal operation which I have described, for it is much
less of an undertaking than the formation of a bone flap.
An incision
should be made through the muscle separating the fibers. They should
be held apart and an opening made through the thin cranial wall of the
temporal region. This may then be enlarged in any direction to the
extent which seems necessary. The meningeal is exposed and its
branches may be easily reached by a blunt instrument. In case a clot
is found it can be scooped out and the main trunk of the vessel itself be
ligated if necessary.
Through such a split-muscle opening drainage
can be more easily used than after a bone-flap operation. Furthermore,
the intermusculotemporal operation is so simple that a bilateral opening can be safely made in case no clot has been found on the side first
opened.
Subdural Hemorrhages. Bleeding in the free space between dura
and arachnoid is possibly a more common consequence of injuries than
the extradural form.
It is a frequent complication of basal fractures;
for, owing to the close attachment of the basal dura, these injuries almost
always tear this membrane so that the bleeding from the fissured bone
has free access to the subdural space. Similarly, fractures of the vault,
accompanied by laceration of the dura, lead to extravasations over the
hemispheres. The extravasation, however, may occur from an injury
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