The Surgery of the Skull and Brain

by Louis Bathe Rawling

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 The gauze plugs (see [above]) may be allowed to remain for twenty-four hours or more, and then carefully withdrawn.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.