Emergency Trephining for Skull Fractures

URGENT CRANIECTOMY: TREPHINING. FRACTURE OF VAULT OF THE SKULL. There are two conditions which may accompany fracture of the skull, singly or together, either of which demands immediate relief (See Fracture of the Skull.) (A) The depressed fragments have contused and lacerated the brain; consciousness was immediately lost and was not regained. Under these circumstances, the fragments must be elevated without delay. (B) Hemorrhage has occurred within the cranial cavity and the clot compresses the brain. In this case, there is a “free interval” The patient regains consciousness and, perhaps, for a time—two to twenty-four hours—appears not to be seriously injured, but little by little the signs of compression develop, namely, restlessness, dizziness, stupor, coma; normal pulse at first, but which finally grows slow, full and bounding; and slow and seroroos breathing. Delay is dangerous. The clot must be removed and the hemorrhage checked. Nearly always it is the middle meningeal which is at fault. There is in consequence an extradural hematoma, Once in a while, however, the bleeding will be found to proceed from a ruptured sinus or fram the pial arteries and there exists at the same time an injury to the brain substance. There Is, in this case, an intradural or detracerebral brain su hematoma Whatever the form of compression, one is compelled to operate but he must first get the anatomy of the middle meningeal artery clearly in mind. The middle meningeal, a branch af the internal maxillary, ts the sadial, entering the cranial cavity at the base of the skull through the foramen spinosum. It is embedded in the dura and grooves (he inner surface of the skull. Above the level of the zygoma, the artery divides. The posterior branch descends upward and backward, and the anterior branch (Fig. 359), the more important, ascends vertically to the fronto-parietal suture, it lies a little posterior toit, As He reaches this ey, it constantly gives off a posterior branch. The anterior branch is in veins which occasionally assume the importance of a sinus. She directions for trephining over the middle meninges are quite definite, but usually unnecessary to regard in emergency surgery, for it isa mistake not to follow the exterior indications and guides furnished by the traumatism, Still one should be able to locate these points readily. apes ai iegon he peieal Ll are employed to locate the paths of the two branches of the middle meningeal, Draw the first (A) from the inferior border of the orbit along the zygoma to the external meatus. Draw the second ingen rn of ny orbit ward, and with the end. fd the'line of the mastoid