HÆMORRHAGES
I. Extra-dural hæmorrhage.
Extra-dural hæmorrhage may be arterial or venous in origin. In the former case the blood is derived almost exclusively from the middle meningeal artery. When of venous origin the source is usually to be found in a laceration of one of the sinuses of the brain. When blood is poured out from a torn sinus it tends to occupy, and be widely diffused in, the subdural space. A venous extra-dural extravasation is relatively of infrequent occurrence, and the pressure exercised on the brain seldom suffices to permit of the development of local or general symptoms of cerebral compression. On these grounds extra-dural hæmorrhage may be regarded as almost necessarily of arterial origin, and as derived from a torn middle meningeal artery.
Middle meningeal hæmorrhage.
General considerations.
The middle meningeal artery enters the middle fossa of the skull through the foramen spinosum, and divides, after a short intracranial course, into two main terminal divisions, anterior and posterior. The anterior branch passes forwards towards the anterior inferior angle of the parietal bone, then changing direction and turning upwards and backwards towards the vertex of the skull. The posterior branch passes horizontally backwards—grooving the squamous portion of the temporal bone—towards the posterior inferior angle of the parietal bone.
Throughout their intracranial course the main trunk and its terminal branches are embedded in the outer wall of the dura mater, except in the spheno-parietal region, where the anterior branch of the artery usually occupies a channel in the bone—one between 1⁄2 and 1 inch in extent.
The anterior branch overlies the pre-Rolandic motor area, whilst the posterior division is related to the temporo-sphenoidal and lower parietal regions—‘silent’ areas of the brain.
Middle meningeal hæmorrhage occurs most commonly in connexion with a fissured or comminuted fracture of the temporal region—the result of direct violence. A fracture, however, is not necessarily present, the hæmorrhage may take place on the side opposite to that at which the injury was received (laceration by contre-coup), and both vessels may be involved. Crisp English narrates three cases in which bilateral extravasation resulted. These more rare examples of middle meningeal hæmorrhage are more or less confined to patients suffering from marked arterial degeneration.
Middle meningeal hæmorrhage, uncomplicated by brain injury, is of infrequent occurrence, the associated injuries to bone and brain confusing the diagnosis. Moreover, the special pressure effects are dependent not only on the absence of serious brain lesion, but also on the non-existence of a safety-valve, such, for instance, as is afforded by a comminuted fracture of the bones entering into the formation of the temporal fossa, or of the roof of the middle and external ears. In the former case, blood will force its way into the temporal region, there forming a temporal hæmatoma—one that may pulsate—whilst, in the latter case, the blood escapes freely from the external auditory meatus. It should be noted, however, that pressure applied to the temporal hæmatoma may lead to the development of irritative or paralytic symptoms confined to the muscles of the opposite side of the body, whilst the restriction of aural bleeding, by means of plugs inserted into the ear, will lead to the early development of compression symptoms.
The amount of blood extravasated varies—according to the calibre of the vessel involved—from a drachm to several ounces. The largest coagulum that has come under my observation was 41⁄2 inches in the long diameter and 1 inch in thickness. Krönlein narrates a case in which the clot weighed 9 ounces.
Fig. 50a. The Inner Aspect of the Skull.
Fig. 50b. The Inner Aspect of the Skull seen on Transillumination.
In shape the clot is elliptical; in consistency it is either fluid or jelly-like. During the early stages of its formation it can be readily removed. Later on, it adheres to the dura mater, and, when removed, leaves that membrane rough and discoloured.
Some uncertainty exists as to the relative frequency with which the trunk and the two terminal branches are exposed to injury. There can be no doubt that the majority of cases in which typical clinical symptoms are present are such as evidence injury to the anterior terminal division; this is due to the anatomical relation of the clot to the motor cortex. Injury to the main trunk is of the rarest occurrence, for the foramen spinosum lies immediately anterior to the petro-sphenoidal suture, the course pursued by typical middle fossa fractures. I have seen one case only, and have read the accounts of two others, in which the foramen spinosum was directly implicated.
The attachment of the dura mater to the sides and base of the skull exercises a most important influence on the direction in which the blood spreads. Firmly adherent to the lesser wing of the sphenoid in front and to the summit of the petrous bone behind, the membrane intervening between these two regions is but loosely attached to, and readily stripped away from, the floor of the middle fossa. As the clot increases in size it exerts considerable mechanical pressure and tends to separate still further the dura from the bone. The anterior and posterior limitations compel the blood to extend first in the outward direction and then upwards towards the vertex of the skull.
Krönlein divides middle meningeal extravasations, according to their regional distribution, into three main groups:—
Temporo-parietal (the most common variety).
Parieto-occipital (rare).
Parieto-frontal (very rare).
Middle meningeal hæmorrhages yielding typical clinical symptoms are of infrequent occurrence, yet such extravasations are very commonly present in severe lesions of the skull. This is evidenced by the fact that middle meningeal hæmorrhage—of a greater or lesser degree—was found in 20 per cent. of all cases of fractured skull, and in 45 per cent. of those in which the middle fossa was involved. My experience is confirmed by Dwight and Nichols. For example, Dwight, in 149 autopsies, notes that middle meningeal hæmorrhage was existent in 49 cases (29 per cent.). He maintains further that the artery is injured in nearly every case in which the fracture, extending from vault to base or vice versa, involves the middle fossa of the skull. Nichols reports 11 cases in 32 autopsies (34 per cent.).
Symptomatology.
As the direct result of the blow the patient is ‘concussed’, remaining in that condition for a variable period of time, a matter of seconds, minutes, or hours, according to the nature of the associated damage to the bone and brain. In the most typical cases, the patient, on regaining consciousness, should recover—again for a variable period of time—complete control over mind and body, returning to work, walking home or visiting hospital or doctor. More usually, however, he remains slightly dazed, though recognizing his surroundings and capable of answering questions. In any case—unless the hæmorrhage is accompanied by grave cerebral lesion—there should be some attempt at recovery, some return to consciousness. The importance of this ‘lucid interval’ cannot be over-estimated. It should be noted, however, that this interval of consciousness is not of itself absolutely diagnostic of middle meningeal hæmorrhage—it ought to be associated with definite localizing symptoms of brain compression (see below). I have encountered several cases in which this lucid interval was present, and in which operative procedures were carried out in the anticipation of finding an extra-dural extravasation, only to find a subdural hæmorrhage. Such subdural hæmorrhages are not infrequently associated with a similar return to the conscious state, but are rarely—if ever—accompanied by the early development of symptoms of localized brain compression. In the event of doubt as to whether the surgeon has to deal with an extra or subdural extravasation lumbar puncture will probably clear up the diagnosis.
The duration of this ‘lucid’ interval is exceedingly variable. It is usually a matter of minutes or hours, though both König and Wiesman narrate cases in which eight days elapsed before the onset of definite localized compression symptoms. I also have recollections of a case in which the patient walked some miles across the moor to see his doctor, and finding him away from home, walked home again, then becoming unconscious and dying shortly afterwards.
All depends on the calibre of the vessel injured and on the existence of a safety-valve, by means of which some of the extravasated blood can escape externally (see [p. 97]).
No rule can be laid down as to the duration of this ‘lucid’ interval, but all authorities are agreed as to its existence, even though it may be of exceeding short duration. Its importance, from a clinical point of view, cannot be overestimated. It was present in 43 out of 63 cases reported by Jacobson, well marked in 32 (50 per cent.), less marked in 11 (18 per cent.). It was observed in 60 per cent. of cases that came under my care.
During this period the blood is occupied in stripping away the dura from the bone—the larger the vessel the easier the task and the shorter the ‘lucid’ interval.
The further progress of the case may be considered according to the general and local effects of the hæmorrhage.
General effects.
As soon as the clot becomes of sufficient size as to exert general pressure on the brain, symptoms of compression become evident, the patient first entering on the stage of ‘slow cerebration’. He is dull and apathetic, showing marked delay in responding to questions. As the pressure increases, he gradually passes into a state of unconsciousness.
The pulse becomes full and slow, the blood-pressure rises progressively (to 200 or more mms. of Hg.), respiration is laboured and stertorous, and the temperature raised (rising progressively). The skin is hot, the face turgid and cyanosed. If the pressure is unrelieved, stimulation of the medullary centres gives place to exhaustion, the pulse becoming irregular and rapid, blood-pressure falls rapidly, and respiration is of irregular rhythm and finally Cheyne-Stokes in character. Finally, the patient becomes completely comatose, the pupils are widely dilated, and the cornea insensitive. Both urine and fæces may be passed (through paralysis of the sphincters), the extremities exhibit flaccid paralysis and the reflexes are abolished. Death occurs primarily through paralysis of the respiratory centre.
Local effects.
In many cases considerable help to diagnosis may be obtained by external examination—bruising and ecchymosis, or definite hæmatomata, in the temporal or parietal regions. In some cases the hæmatoma may pulsate, and in others the application of pressure to the hæmatoma will lead to the development of fits involving the face and extremities on the contra-lateral side. Copious hæmorrhage from the ear should always arouse suspicion as to the probability of an extra-dural hæmorrhage (see [p. 97]).
The anterior branch of the artery, as it passes upwards towards the vertex, overlies the pre-Rolandic or motor area. The pressure exercised on that region of the brain leads—according to the site of extravasation and the degree of pressure exercised—to the development of twitchings, convulsions, spasticity, or paralysis of the muscles of the face, upper and lower extremities on the contra-lateral side of the body.
Fig. 51. To illustrate Compression of the Brain. As produced by an extra-dural hæmorrhage from the posterior branch of the middle meningeal artery.
The late Professor von Bergmann[26] pointed out that the arm area is most commonly affected, and that the leg area is never alone implicated. Wiesmann[27] states ‘that isolated paralysis of the leg area is never seen, but only paresis when the arm is paralysed, or both may be similarly affected at once; convulsions may precede the affection’.
In discussing the frequency of local compression effects, Wiesmann points out that some abnormal condition of the opposite extremities was only absent in 16 out of a total of 257 cases. In 37 cases reported by Jacobson,[28] hemiplegia, of a greater or lesser extent, was present in 19 (50 per cent.). The same authority explains that ‘with regard to the onset of convulsions, if there be restlessness, spasmodic twitchings, or movements of the limbs, it is only too probable that in addition to middle meningeal hæmorrhage, contusion or laceration of the brain-substance will be found at more places than one’.
In cases that have come under my observation twitchings of the muscles of the face and upper extremities were observed in 37 per cent. of cases, and paralysis in the same number. Some alteration in the condition of the muscles on the contra-lateral side was present therefore in 74 per cent. of cases.
If the hæmorrhage be situated on the left side of the brain, both motor and sensory cortical speech areas may be involved, especially the former.
With respect to reflexes, it has previously been stated that the reflexes are abolished. This is true with respect to the later stages of fully-developed compression. In the earlier state the reflexes on the contra-lateral side may be increased, the difference between the two sides affording some help in the differential diagnosis.
Pupillary changes
are variable. According to Jonathan Hutchinson, the pupil on the affected side becomes dilated, the blood extending inwards towards the cavernous sinus and exercising direct compression of the third nerve. The frequency with which a dilated pupil occurs in cases of middle meningeal hæmorrhage, and the causation thereof, are, however, matters of dispute. Phelps writes as follows: ‘Reference to cases cited show that the so-called Hutchinson pupil may be observed as well in hæmorrhages occurring in other situations than the middle fossa, and in some cases of cerebral lesion without injury at all. There is no reason to doubt that it is the result of cerebral contusion, but in what relation they stand to specific cerebral injuries is undetermined.’
Walton states that ‘doubtless various factors play an important part in producing the dilated pupil, but if disorders of any simple mechanism are to be credited with the production of the Hutchinson pupil or other pupillary changes, the only lesion worthy of the place is disturbance, irritative or paralytic, of the intracranial fibres of the cilio-spinal tract’.
The late Professor von Bergmann, from 70 cases, reports as follows:—
In 39 cases both pupils were markedly dilated (56 per cent.).
In 7 cases both pupils were markedly contracted (10 per cent.).
In 20 cases the pupil on the same side was dilated (30 per cent.).
In 4 cases the pupil on the opposite side was dilated (6 per cent.).
Parsons, in answering some queries in 1903, writes:—
‘I should anticipate from cortical irritation bilateral pupillary dilatation, perhaps more marked on the opposite side: from pressure the opposite effects, so far as mere cortical paralysis goes, but this would be more liable to be vitiated by vascular changes—the complex condition seen in coma. It is very difficult to elicit pupillary constriction by cortical stimuli—very easy to elicit dilatation, but always bilateral though often more marked on the opposite side.’
In cases examined by me the following conditions were found:—
| Pupils equal | 46 | per cent. of cases |
| Pupils constricted on the affected side | 36 | per cent. of cases |
| Pupils dilated on the affected side | 18 | per cent. of cases |
From my experience, therefore, and from that of the authorities quoted above, it would appear that alterations in the size of the pupil are of very doubtful significance in the diagnosis of middle meningeal hæmorrhage, and that the ‘Hutchinson pupil’ is but rarely observed.
The results obtained by ophthalmoscopic examination are of much greater value. Such investigations should be carried out as a routine procedure. In the earlier stages of the hæmorrhage some œdema of the disk, together with dilatation of retinal veins and diminution in the calibre of the arteries, will be observed on the affected side. This affords a most valuable aid in the differential diagnosis as to the side on which the hæmorrhage is situated—not always such a simple matter as appears at first sight.
Treatment.
Operation is indicated in all cases of middle meningeal hæmorrhage if the condition of the patient be compatible with such treatment. The earlier the operation is carried out the better.
Operation.
For Hæmorrhage from the anterior branch.
After the usual preparatory treatment, the ‘site of election’ for trephining is marked out on the scalp by taking a point which lies 2 inches posterior to the external angular frontal process, and the same distance above the zygoma. A bradawl may be introduced so as to indent the external table of the skull, thus aiding the subsequent accurate application of the trephine.
Fig. 52a. Exposure of the Branches of the Middle Meningeal Artery. First stage. Suitable scalp-flaps have been turned down, and the skull has been trephined over the ‘sites of election’ for exposure of both anterior and posterior branches.
Fig. 52b. Exposure of the Branches of the Middle Meningeal Artery. Second stage. The trephine-holes have been enlarged with the craniectomy forceps in the required directions.
The incision commences immediately posterior to the external angular frontal process, curves upwards and backwards along the temporal crest, and terminates in front of the tragus of the ear. The flap, comprising skin, temporal fascia and muscle, and pericranium, is turned to its zygomatic base and all bleeding-points secured.
The subsequent procedures vary according to the condition of the bone:—
If there be no fracture of the bone, the pin of the trephine is applied to the indented spot and the disk of bone removed. After the removal of the disk the clot will be exposed; but, in order to obtain full exposure, the gap must be enlarged with the craniectomy forceps, mainly in the upward and downward directions.
If a fissured fracture be found, the trephine is applied in close relation to the intersection of the line of the artery and the line of the fracture, the gap being enlarged in the required direction.
When the fracture is comminuted, the fragments of bone are either elevated or removed until sufficient room has been obtained.
The greater part of the clot can be removed with a Volkmann spoon, or with an ordinary teaspoon, and the region flushed out with hot saline solution.
To secure the bleeding-points.
When the artery is injured beyond the limits of the gap, the bone must be nibbled away till the bleeding-point is exposed. In some cases it may be necessary to remove a considerable portion of the bone entering into the formation of the temporal fossa. In the meantime, hæmorrhage may be controlled by plugging towards the base of the skull with strips of gauze. Sufficient room having been obtained, the gauze is withdrawn, when smart sponging should enable the operator to determine the source of the hæmorrhage. At this stage of the operation, a head-lamp is useful. After the exposure of the bleeding-points, the following measures can be adopted whereby to arrest the bleeding:—
(a) The application of a ligature or of silver ‘clips’ (see [Fig. 6]) on either side of the bleeding-point.
(b) The vessel may be underrun on either side of the bleeding-point.
(c) The vessel may be seized with artery forceps and twisted.
(d) The hæmorrhage may be arrested by means of gauze plugs.
(e) The foramen spinosum may be occluded with bone or wooden pegs.
(f) The common or external carotid arteries may be ligatured.
Every effort should be made to control the hæmorrhage by means of ligature, silver clip, underrunning, or torsion. Gauze plugs may usually be relied on to stop the bleeding, but they possess the great disadvantage of exercising pressure on the cortex and preventing expansion of the brain.
Occlusion of the foramen spinosum and ligature of the carotid arteries complicate and prolong the operation. The foramen spinosum is occluded in the following manner: the dura mater is quickly stripped up with the fingers away from the base of the skull, the soft parts gently but firmly retracted and the foramen identified. Its occlusion may be effected by means of a sterilized wooden match or bone peg, by a small piece of bone derived from those osseous fragments which have been removed during the operation, or with the aid of a piece of catgut; in each case the occluding medium should be well driven into the foramen.
It is open to doubt whether ligature of the carotid arteries is ever necessary, though several cases have been recorded in which such a procedure was carried out. The external carotid should be tied in preference to the common vessel, further interference with the blood-supply of the brain increasing necessarily the risk of cerebral œdema, &c.
The hæmorrhage having been arrested by one or other of these methods, the cavity is thoroughly washed out with hot saline solution and drained, a small rubber drainage-tube being brought out through the scalp-flap. The tube should be removed after twenty-four to thirty-six hours, according to the circumstances of the case.
For hæmorrhage from the posterior branch.
The ‘site of election’ for exposure of the posterior branch lies at the intersection of the two following lines:—
A line drawn backwards from the upper border of the orbit parallel to Reid’s base-line.
A line drawn vertically upwards from the posterior border of the mastoid process.
The trephine is applied, the disk removed, and the gap enlarged with the craniectomy forceps in the forward and backward directions. The hæmatoma is evacuated and the bleeding arrested after the methods enumerated above.
Results.
The ultimate result of operation for middle meningeal hæmorrhage depends on two factors—the time at which operation is carried out, and the question of brain lesion. There is every reason to believe that, when treated early and when uncomplicated by brain injury, the prognosis, both immediate and remote, is wholly satisfactory.
Wiesman[29] collected 257 cases, of which 110 were submitted to operation, with a mortality of 27 per cent. Of the cases in which no operation was performed 88 per cent. died.
Duchaine[30] reports 27 cases in which operation was carried out, with death in 6 cases only, a mortality of 22 per cent.
Von Bergmann collected 110 cases treated by operation, with 74 recoveries and 36 deaths, a mortality of 32·27 per cent.
Blake only lost 3 cases out of a total of 42 submitted to operation.
Even when every allowance is made for the fact that operative measures were adopted in the more hopeful cases, the above statistics show conclusively that early operation affords great hope of cure.
Fig. 53. A Basic Fracture with Laceration of both Carotid Arteries.
Before passing on to subdural hæmorrhage, it will be convenient to discuss briefly the question of injury to the internal carotid artery.
This vessel, during its forward passage in the outer wall of the cavernous sinus, from the posterior to the anterior clinoid processes, crosses the line of the typical middle fossa fracture (see [p. 84]). The artery is loosely embedded in the sinus, it is protected by the third, fourth, ophthalmic division of the fifth and sixth nerves, and it is situated some distance above the level of the base of the skull. In spite of this degree of protection from injury, the artery may be lacerated in this part of its intracranial passage. The basic fracture is necessarily of a very severe nature. Two cases have come under my own care: one in which both arteries were torn across, the fracture passing from one middle fossa to the other, with such wide separation of the anterior and posterior segments of the skull that the two were freely movable on one another ([Fig. 53]), whilst in the second case, the fracture, originating in the left frontal region, passed backwards across the anterior fossa, comminuting the base in the region of the cavernous sinus, lacerating that sinus and tearing the artery ([Fig. 54]).
Fig. 54. A Basic Fracture with Laceration of the Cavernous Sinus. A, The optic nerve; B, The cavernous sinus; C, The third nerve; D, The internal carotid artery.
In both cases death was almost instantaneous, blood pouring from the nose and mouth.
In some few cases the vascular lesion is confined to a minute tear in the coats of the vessel, a fistulous communication being formed between the artery and the cavernous sinus—arterio-venous aneurysm. This condition is discussed on [p. 204].
II. Subdural hæmorrhage.
Hæmorrhage into the subdural space may be (a) diffuse, or (b) localized.
(A) Diffuse subdural hæmorrhage.
The blood may be derived from one of the great sinuses of the brain or from superficial cerebral vessels (laceration of the brain).
The superior longitudinal sinus may be torn by the in-driving of fragments of bone in a comminuted depressed fracture of the vertex, or by wide separation along the line of the sagittal suture. Blood is diffused throughout the subdural space, on one or on both sides of the falx cerebri, but always tending to gravitate towards the lower limits of the supra-tentorial space.
In the event of the wound being compound, air may enter into the sinus. Insomuch, however, as the sinus pressure is, under normal conditions, positive, this complication is of rare occurrence, unless the patient is in a state of profound shock, from loss of blood, or suffers from urgent dyspnœa.
Allusion should also be made to the condition described by Stromeyer, as ‘sinus pericranii’, where a subpericranial hæmatoma communicates with a venous sinus. Such hæmatomata may pulsate, are more or less reducible on pressure, and are increased on straining or on the application of pressure to the internal jugular vein.
The lateral sinus may be laid open in any part of its course, more especially at the angle of junction between the lateral and sigmoid sinuses, in close relation to the occipito-mastoid suture, a region not infrequently involved in basic fractures. The blood effused will occupy the supra- or infra-tentorial spaces according to the situation of the rent in the sinus-wall.
The cavernous sinus is frequently involved in anterior and middle fossa fractures. The blood effused usually escapes into the nose and mouth.
Fig. 55. A Comminuted Fracture of Vault and Base, the Basic Fracture Involving both Middle and Posterior Fossæ. The middle fossa fracture, on the left side, follows the usual course. The posterior fossa fracture resulted in laceration of both lateral sinuses—at the usual site, junction of sigmoid and lateral sinuses. Probes are inserted at each site of laceration. The resultant hæmorrhage was mainly intradural, but, as is seen in this figure, the dura mater of the posterior fossa is stripped away from the bone by an extra-dural extravasation.
Symptoms.
The rapid diffusion of blood throughout the subdural space, and the usual coexistence of extensive injury to bone and brain, seldom permit of the development of such definite symptoms as might accurately define the localization of the hæmorrhage. The most important feature in the diagnosis lies in the fact that compression symptoms are early in onset and progressive in nature. The ‘lucid’ interval, so prominent a feature in middle meningeal extravasations, is either absent or of such short duration as to be difficult of recognition. The rapid development of symptoms pointing to brain compression, and the nature of the injury itself should enable the surgeon, in the majority of cases, to come to the conclusion that the patient is suffering from diffuse subdural hæmorrhage. In all cases of doubt, lumbar puncture should be carried out, the presence of blood-corpuscles in the cerebro-spinal fluid confirming the diagnosis.
Indications for operation.
Whether one considers the case from the point of view of the more immediate prognosis or from the more remote aspect of the case, operation is indicated, if the condition of the patient is compatible with such treatment. In considering the advisability of adopting an active form of treatment, it must be taken into account that, if the patient recovers without operation, the presence of an extensive subdural blood-clot must necessarily interfere, as an after-result, with the functions of the cortex, and that the removal thereof affords considerable hope of permanent cure.
Operation.
Operative measures may be considered as follows:—
The treatment of the fracture and of the dural rent.
The treatment of the subdural extravasation.
The treatment of the fracture and of the dural rent. A scalp-flap is framed, suited to the occasion and formed with due regard to existent scalp laceration. The fracture being fully exposed, depressed or comminuted fragments of bone are elevated or removed. Complete exposure of the sinus-wall, both in front and behind the site of laceration, is required, and for this purpose the craniectomy forceps may be called into requisition. In the event of copious bleeding during these procedures, strips of gauze should be inserted on either side of the sinus rent between the dura and the bone, thus compressing the sinus and stopping the bleeding.
The sinus rent may be treated after one or other of the following methods:—
1. It may be sewn up with mattress sutures of fine catgut, by which means it may be possible to stop the hæmorrhage without interfering with the sinus blood-stream.
2. The open mouth of the sinus may be puckered up by means of a purse-string suture.
3. The needle may be passed right round the sinus on either side of the rent, piercing the falx cerebri in the case of the superior longitudinal sinus and the tentorium cerebelli in wounds of the lateral sinus. The two ligatures are then tightened up and the bleeding controlled.
4. The gauze plugs (see [above]) may be allowed to remain for twenty-four hours or more, and then carefully withdrawn.
The treatment of the subdural hæmorrhage. Though the complete evacuation of the clot is seldom practicable, much may be done to remedy the condition. The tenseness of the dura mater, the absence of pulsation, and the peculiar plum-colour imparted to that membrane by the presence of underlying blood-clot point to the nature of the trouble.
The dura mater is incised and the presenting clot removed, as far as circumstances permit, with the aid of a spoon and irrigation (hot saline solution at a temperature between 110° and 115° Fahrenheit). Free drainage must be supplied, and it is necessary, therefore, that a counter incision should be made at the most dependent part of the clot. A suitable region may present itself if the bone be extensively comminuted. Under other circumstances, a narrow channel may be cut in the bone, prolonged in the downward direction, till the lower limits of the clot have been reached (see [Fig. 56]).
Fig. 56a. The Operative Treatment of Subdural Hæmorrhage. First stage. The skull has been trephined over the upper part of the clot and the bone cut away in the downward direction in order to reach the lower limits thereof. The dura mater has been incised, crucially in the upper part and vertically in the lower part.
Fig. 56b. The Operative Treatment of Subdural Hæmorrhage. Second stage. The clot has been removed and the dura mater sewn up. A drainage tube has been inserted so as to drain the subdural region through the lower part of the scalp-flap.
A rubber drainage-tube may be inserted in the manner depicted in the same [figure]. Except at the point of emergence of the tube, the dura mater is sewn up (with fine interrupted catgut sutures).
(B) Localized subdural hæmorrhage (subdural hæmatocele).
We are greatly indebted to Bowen[31] for our knowledge of subdural hæmatomata. That subdural hæmorrhage might take the form of a localized collection was a recognized fact, but the condition was but little understood, the typical clinical symptoms were not recognized, and surgeons hesitated to adopt surgical remedies. All these facts impeded advance in both diagnosis and treatment. Subdural hæmatoceles, even at this date, are often regarded as rarities, but, in the light of present knowledge, it would appear that wider recognition of the hæmorrhage in its clinical aspect will show that such ideas are erroneous.
In the preceding section it was shown that subdural extravasation resulting from sinus-injury tends to become diffused throughout the subdural space. With respect to localized hæmorrhages our data are by no means complete, but all available evidence tends to show that subdural hæmatoceles are dependent on laceration of the pia-arachnoid vessels—a condition practically synonymous with superficial laceration and contusion of the cortex. The blood, derived from small cerebral veins and minute cerebral arteries, exercises primarily but slight pressure effect. Its force is expended on compressing and emptying the subjacent and surrounding cerebral vessels, producing, in other words, a condition of local cerebral anæmia. This pressure is insufficient to lead to the development of general compression, but suffices to produce certain rather indefinite symptoms. We have, therefore, before us a very different picture to that depicted in cases of middle meningeal hæmorrhage. In such extra-dural hæmorrhages some definite period of time must elapse before the dura mater is sufficiently stripped from the bone to allow of the formation of a clot of size sufficing to exercise both local and general compression effects. Pressure effects then become very manifest.
On the other hand, in localized subdural extravasations there is an immediate effect, for the brain is contused or lacerated. On recovering from the immediate effects of the injury—concussion of a greater or lesser degree of intensity—the patient does not regain complete mental and bodily convalescence. He suffers from symptoms suggestive of brain irritation—headaches, photophobia, mental irritability, insomnia, loss of appetite, the pulse accelerated, and the temperature slightly raised. Later on, more definite symptoms arise, but, intervening between the day of the accident and the time at which these more definite localizing symptoms develop, there is an unmistakable latent period—a period to be sharply differentiated from the previously mentioned lucid interval (see [p. 139]).
This ‘latent’ period lasts for a variable period of time—seldom less than a week or more than three months. At the end of that time the picture changes, and the patient evidences symptoms obviously referable to local brain compression. From a clinical point of view it is fortunate that subdural hæmatoceles tend to involve the fronto-parietal region with the consequent development of motor symptoms, especially paresis or paralysis of the contra-lateral side. Hence the name sometimes applied to the condition—traumatic late apoplexy. The speech areas are implicated if the injury be situated on the left side. Paralysis limited to the lower extremity is exceedingly suggestive, such a palsy occurring only with the greatest rarity in extra-dural hæmorrhages (from the middle meningeal artery).
If the pressure be unrelieved by operation the patient passes from the excitatory to the paralytic stage of brain compression, gradually falling into a condition of coma, the pulse increasing in frequency and the respiration becoming more and more embarrassed.
In the study of this condition, the following are the points to which special attention should be paid:—
1. The comparative want of severity with respect to the injury received.
2. The absence of any ‘lucid’ interval, such as is present, for example, in middle meningeal hæmorrhage.
3. The presence of a definite ‘latent’ period.
4. The late development of symptoms pointing to general and local brain compression.
Finally, it may be stated in general that the more indefinite and the more deferred the pressure symptoms, the greater the probability that we have to deal with a localized subdural hæmorrhage. Lumbar puncture may materially aid in the differential diagnosis between extra-dural and subdural hæmorrhages.
The following case affords a typical example of subdural hæmatocele:—
An elderly man fell down, striking the right side of the head against the pavement. He lost his senses for a few minutes and was then brought to the hospital, dazed and complaining of headache (note the absence of any lucid interval). He was sent home in a cab and was assisted to bed by his wife. He kept to his bed during the next week, complaining of constant headache, and was exceedingly irritable (this is the ‘latent’ period). Towards the end of the third week his wife noticed that he seldom used the left upper and lower extremities. This paresis increased steadily, the face was drawn to the right side, and his condition became so serious that the wife brought him again to the hospital (this is the ‘manifest’ period).
When seen by me he was only partly conscious, the mental condition varying, however, during the day. He was exceedingly irritable, muttering to himself in a low tone, words being more or less unintelligible. The left upper extremity was paralysed, the face drawn to the right side, and the left lower extremity was but little used. The pupils were equal, the disks normal. The temperature in the left axilla was two degrees lower than on the opposite side.
The hæmatocele was exposed, cleared out, and the cavity drained. Recovery was rapid and complete. Two years later all was well.
Operation.
The lesion is usually of so gross a nature that little difficulty will be experienced in determining the site for trephining. The protective gauze and scalp-tourniquet are applied as usual (see [p. 14]), and a bradawl introduced through the scalp so as to indent the external table and allow of the subsequent accurate application of the trephine. A scalp-flap, suited to the occasion, is framed, the skull trephined, and the disk of bone elevated and removed. The appearance of the dura mater now allows the operator to verify his diagnosis—the membrane is non-pulsatile, it bulges markedly outwards and presents a blue-purple colour. The bone is then nibbled away in the downward direction towards the lower limit of the clot, the scalp incision being prolonged according to requirements.
In the region of the trephine-hole the dura is incised in a crucial manner, and the four flaps held aside by catgut sutures passed through the apex of each flap. A blunt director is introduced beneath the dura, passing towards the lower limit of the clot, and the membrane slit up to within a short distance of the lower margin of the gap. All meningeal vessels that cross the line proposed for dural section must first be underrun on either side of that line. Retraction of the dura will now allow of adequate exposure of the underlying hæmatoma. Its removal can be carried out with the aid of a spoon, and by means of gentle irrigation (hot saline at a temperature between 110° and 115° Fahrenheit). It is usually impossible to remove the whole of the coagulum, but the greater portion can be got rid of in the manner described.
The dura mater is approximated above by the cross-union of the four apical sutures, whilst the downward prolongation is also sutured except at the most dependent point, where a rubber drainage-tube is inserted beneath the dura mater and brought out through the scalp-flap (see [Fig. 56]). This tube should be anchored to the dura mater with a single fine catgut suture.
The tube should be allowed to remain in position for at least thirty-six hours. In this the surgeon must be guided by the amount of discharge and the general progress of the case.
Results.
The most complete results obtained by operative treatment are supplied by Bowen, who classifies a series of 72 cases as follows:—
Class A. Subdural hæmorrhage, apparently without other serious injury to bone or brain.
| 36 | cases. |
| 22 | recovered after operation. |
| 14 | died—11 without and 3 after operation. |
Class B. With serious brain-injury.
| 36 | cases. |
| 6 | recovered after operation. |
| 30 | died—10 without and 20 after operation. |
In other words, every case died in which no operative measures were adopted, whilst after operation 28 recovered and 23 died. My own experience is limited to 4 cases, 3 of which recovered.
Pia-arachnoid hæmorrhage.
From evidence obtained at post-mortem examinations, it may be concluded that the great majority of cases of severe head-injury—especially those in which ‘irritation’ of the brain is a prominent feature—are associated with pia-arachnoid hæmorrhage. This is evidenced by the presence of a film of blood and serum over certain regions of the brain, not confined to the region subjacent to the skull area primarily involved, but also present over the opposite pole of the brain (injury by contre-coup).
Subpial hæmorrhage differs from the subarachnoid variety in that the blood follows the invaginations of the pia mater, lining, therefore, both major and minor cerebral sulci. Subpial and subarachnoid hæmorrhages are, however, generally co-existent, and the term—pia-arachnoid hæmorrhage—aptly describes the conditions commonly found.
The symptoms resulting from such blood extravasations are such as are described in the sections dealing with concussion and irritation of the brain (see [p. 166]).