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·PRACTITIONERS POCKET BOOKS
FLUID AND ELECTROLYTE THER IPY
Franklin L. Ashley N D
Horace G Love, MD
ATOPIC DERVIATITIS
Edited by Rudolf L Baer MD
TALKING IVITH P41IENTS
Brian Bird VID
REGIONAL ENTERITIS
Frederich F Boyce M D
PARKINSONISV AND ITS TREATVENT
Edited by Lewis J Doshay A D
STRESS SITUATIONS
Edited by Samuel Liebman VID
LOW BACK PAIN AND SCIATICA
Louis T Palumbo MD
VIANAGEMENT OF STROLES
keith 1 Sheldon AID
ALCOHOLISM
Jackson A. Smith VD
HYPOTENSIOV SHOCK IND CARDIO
CIRCULATORY FAILUR
Iaul C lleil MID Ph. D

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·HEAD INJURIES
AND THEIR
MANAGEMENT
XID
FRANCIS ASBURİ ECHLIN
CV VSC VED SC.D FLA CAS
Pofesor Cl nick eurosurgery new york Uni
1071117-Postgraduate Aledical School New OSUT
geon Lenox Hill Hosp lal Allending Teuto
surgcon Bellevue Hospital and low York Eye
and Ear Infirmary, Consulting Neurosurgeoi
St Luk s Hopital leburgli and hingston
Hospital
JB LIPPINCOTT COMPANY
Philadelphia and Alontreal

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·HEAD INJURIES
AND THEIR
MANAGEMENT
VID
FRA CIS ASBURI ECHLIN
CV MISC. VIED SC.D FACS
Professor Clinical lexrosurgery lew York Un
vers 17-Postgraduale Vedical School Teurosur
geon Lenox Hill Hospital Allending euro
surgeon Bellevue Hospital and let lork Eye
and Ear Infirmary Consulting Teurosu geon
St Lukes Hospić i ledburgh and Kingston
Hospital
J BLIPPINCOTT COMPANY
Philadelphia and Vontreal

·Shis matcrial «ds published in
American Practitioner and Digest of I realment for
Vay, 1950 Copyright © 19:01 J Blippincott Company
Published in Book Torm, July, 1956
IIJIS BOOK 15 TULI Y PROTECTED BY COPYRIGHT
AVI, WILL TIL IXCEPTION OD PRIFT EXCERPIS
JOR RIVII 11, 10) PARI OJ JI VAY BIRI PRODUCII
IN AVTORY WITHOUT SIII WRITIN L'ERVIS
SJON OG INI PUBLISILRS
Distributed in Great Britain by
Pulman Medical Publishing Co, Limited

·PREFACE
In this monograph an attempt has been made to
describe briefly the essentials in diagnosis and treat
ment of head injuries The objective has been to
make this knouledge casily accessible and of practical
value to residents as well as to the practicing surgeon
and physician
A representative bibliography has
been added At least three excellent monographs on
acute head trauma are already available one dealing
with peacetime injuries and stressing their pathologic
aspects (Evans, 1950) and the other two with war
wounds of the skull and brain (Penfield 1911 Vatson
1919) In addition many outstanding and much more
comprehensive volumes on the subject of cranial and
intracranial injury are at the disposal of the specialist
(Vunro 1938 Gross and Ehrlich 1910 Ron botham
1919 Brock 1919) but these are mostly too extensive,
and only too often unavailable, to be of immediate
value to the doctor who must initially care for
the patient and frequently decides upon subsequent
manageinent.

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·INTRODUCTION In treating a patient with a head injury the doctor should decide whether he is dealing with a surgical or a nonsurgical (nonoperable) case, for all head in juries may be to dividel" To make such a decision one must have at least an aquaintance with the important surgical and nonsurgical lesions of the head and brain and the clinical picture they produce Certain well-established, conservative measura should be used in the treatment of every head injury keeping in mind that all cases are potentially surgical Fortunately apart from cases with obvious externally vuible head wounds and their complications, only a small per cent of know injuries, in peace ume will require surgery for an intracranial hematoma or other leis common laion The purpose of this monograph is to state in sumple terms what may happen to the head and brain follow ing an injury and how such lesions and their complı cations may be recognized and managed.

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·CONTENTS 1 2 7 11 3 23 25 30 Tric MFCIANISVS or HEAD AND BRAIN INJURI Head Injuries Brain Injuries MONSURGICAL CASCS or HLAD INJURY Nonsurgical Lasions of the Brin Diagnosis of Nonsurgical Cases of Head Injury Conservative Treatment of date Hard In juries SURGICAL CASTS OF HEAD INJURY INTRACRA VIAL HALATOSIAS Epidural Hemorrhage Subdural Hematoma Acute, Subacute and Chronic Subdural Hematoma in Infancy and Chili hood Subulural Hydronia or Hygroma Intraccrebral Hematoma and Localucl In tracerebral Incoration SURGICAL I FRIO» or TIC SCALP SEUIL AVP BRAIN Lesions of the Smp Fractures of the Shull l'enetrating 11 ounds of the Brain OTUIER SURGICAL COMPLICATIONS FOLLOWING HEAD I Y JURY Wound Infectiou Cerebrospinal Fluid Rhinorrhea Slull Delects and Their Repair Trachnoidal Cysts Lx 17 50 50 53 59 55 5 71 1 75 1 81 ·х Contents 81 84 87 87 91 93 94 Post-traumatic Epilepsy Cerebral Palsy 6 SPICIAL AIDS IN DIAGNOSIS Technics Intcrprctation of Pneunio encephalograms and Ventriculograms Angiography The Electro cncephalogram Associated with Head Trauma 7 SOVE NON SURGICAL COMPLICATIONS TOLI OW- IG HEAD INJURY Post-traumatic Syndrome of Headacht, Duziness and Ners ousness Neuroses Following Head Injury Psychoses Following Head Injury REHABILITATION 9 BIBLIOGRAPHY INDEX 99 99 102 109 105 109 117

·THE MECHANISMS OF
HEAD AND BRAIN INJURY
HEAD INJURIES
A knowledge of some of the mechanical factors in
volved in trauma to the head wull and one in under
standing how various types of injury have very differ
ent effect upon the skull and its contents 4 m 49 4 1.6
An injury to the head may be either director
indirect.
Direct Had Injury There are many ways in which
the head can be injured. The movable head may be
struck by a large moving object that jars the entire
brain and skull or by a small objea like a hammer
that penetrates causing local damage without a gen
eralized ellect. A mobile head can be thrown against
an immovable object, egy a sidewalk again produc
ing an elect on the entire cranium and its contents
An immovable head braced against the ground or
other firm rubstance may be generally auslied or
burit by a large object or a relatively small area of
skull and brain can be crushed, for instance by a
imall projecting portion of a jcep when the vehicle
rolls over on the patient s licad In this case as with
a hamna wound there may be sucre local brain
1

·2 The Mechanisms of Head and Biain Injury damage with no general eſfect on the brain and no loss of consciousness Other direct injuries can result fion penetrating instruments, bullets or shell fragments Indirect Head Injury Injury to the biain oi intra cranial blood vessels at times follows the application of force to other parts of the body as when one falls in a standing or sitting position or on some other area of the body Brain injury may also occur when foice is suddenly applied to the body by a rapidly moving object like an automobile or when, as a passenger in an automobile, one's head is thiown into violent mo tion on collıdıng with another cai or on coming 10 a sudden stop BRAIN INJURIES The type and degi ee of injury is of importance, for upon this will depend to a considerable extent what happens to the brain and other intracranial struc tuies (see Gurdjian, et al 3and Rowbotham 88) The brain may be injured by 1 Movement of the brain in iclation to the skull 2 Distortion of the shull 3 Acute compression of the thorax 4 Penetrating wounds (open head injury) 1 Injury by Movement of the Brain in Relation to the Skull In closed head injuries the most important manner in which the brain is injuied is by ils move ment in relation to the shull The movement may be linear, that is in a straight linc, or rotatory Brain Injury by Linear Movement I the head is throun into rapid motion in a straight linc, the ·Brain Injurias skull casa its movement first and thus often occurs abrupuy aspecally if it comes into contact with a fixed object. The brain on the other hand for a short period conunues its forward course and coma violently into contaa mith portions of the rigid skull or dural septa resulung in contusion or laceration At the opposite pole to that contused, the brain in moving forward apparently create an arca of dimin ushed pressure and a suction injury to cerebral uusue or blood vessels may result At the same time vessels aspecially veins arossing the subdural space may be torn as the brain slides fonsard or backwarul in a straight line Similar injury taka place at the onset of a rapid rovement of the head in a straight line but in this use the skull is set in motion first and stakes the brain which has lagged behind in its mouion Thus a contusion may occur at the site of the blou a contro coup injury in the opposite hemisphere and at the mmc cime petechial hemorrhages in the brain stern (Fig 1) The forces oponsible for the above injune will vary according to the rate of change of velocity with which the head is set in motion in a straight lineto-called lipcar acceleration-and to the abruptoess with which motion ceases-decelcrauon (see under concussion) Brain Injury by Rotation #blou to the head usually causes some rotator movement of the skull. The niotion of the shull is secondarily transmitted to the brain which may be contused or lacerated by bony projections or dual sepla at the onset or ler mination of rotation Holbourn belices that injuries due to rotatory movement are aused by shear strain **

·4
The Mechanisms of Head and Brain Injury
CONTUSION
VENTRICULAR SHIFT
TO RIGHT
a
LACERATION AND
INTRACEREBRAL
HEMATOMA
HERNIATION
OF UNCUS
PETECHIAL
HEMORRHAGES,
BRAIN STEM
Гіс 1 With the exception of the intracerebral hematom?
the lesions shown art nonsurgical (nonoperable)
that results when one type of tissue slides across an
other, thus stretching or pulling apart the cellular
structure Since the tissues of the brain itself are of
different densities, shear stiains also can take place
within the brain or brain stem as a result of rotatory
movement As with linear motion the injurious forces
wll vary with the rate of acceleration or deceleration
2 Injury of the Brain by Distortion of the Skull
This type of injury is less frequent in culian prac

·Brain Injuries
5
tice than those already discussed. However certain
traumas in producing general or local distortion of
the skull may cause general or local crushing, pulping
or brwing of the brain.
3 Brain Injury from Compresaon of the Thoran.
Injuria of the brain apecially in the form of pete
chual hemorrhages have been reported following blast
or direct compression of the thorax.
4 Injury of the Brun Due to Penetrating Objects
or Mignilci This aspect of trauma will be discussed
under surgical lauons of the skull and brain

·一 ·2 NONSURGICAL CASES OF HEAD INJURY In avlian practice over 97 per cent of all cases 2od about 90 per cent of severe cases of head injury suffer from a nonsurgical (nonoperable) craniocerebral Injury if open head wounds are excluded. A high percentage of those nonsurgical cases have an injury of the brain reversible or otherwise but the treatment us conservative. NONSURGICAL LESIONS OF THE BRAIN Concussion. The fundamental basis of concussion 11 still unknown When the term concussion is used dinically it usually implies an immediate traumatic loss of consciousness lasting for a variable period and unaccompanied by evidence of structural damage to the brain There is a wide diffance of opinion however as to whether prolonged unconsciouncu can occur in the absence of demonstrable organic brain , 03 injury 1, # Denny Broro and Russell * define experimental concussion as the occurrence of an immediate traumatic panalysus of reflex function, which occurs in the Se Chapter 3 for more detailed satisia. 7

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·9 Nonsurgical Lesions of the Brain cluded that concussion u the direct result of mechanı cal violence to cerebral cells Another cause of concussion as demonstrated by Scott," and Gurdjian and Ilebster * is that due to sudden brain compression This according to Denny Brown and Russell u much less common than that roulung from acceleration injury Compression con cussion may occur with severe penetrating hounds certain depressed fractura and other types of injury that are accompanied by a sudden rise in intracranial pressure. Walker et al 0 have provided evidence that experi mental concussion is the result of interse aratation of the central nervous system at the moment of the blow to the head, which is manifested by a marked electrical discharge and a temporary breakdown of the polarized cell membranes of many neurones in the brain. A review of many of the opinions held by aveti gatots regarding the nature and cause of concussion may be found in the article by Denny Brown and Russell Contusion local contusion of the brain is an area of traumauc bruuing in which there are varying de grees of swelling, perivascular hemorrhage duruption of cellular structure and even rupture of blood ves sels The latter may give rise to an intracerebral hematoma (discussed under surgical lesions) (Fig 1) Laceration. A laceration of the brain is an actual leanng of the neural and other tissue. There is no sharp dividing line between contusion and laceration and both leions are commonly found for instance at the site of the blok at the area of contrecoup on the under surface of the frontal lobe, or at the tem ·8 Nonsurgical Cases of Head Injury absence of visible lesions in the nervous system They regard concussion as a generalized reversible "molecu lar reaction" induced by physical stiess Subconcus sive blows, on the other hand, depiess but do not abolish these reflex functions They are of the opinion that pure concussion can account ſoi a prolonged period of cerebı al disturbance in man con esponding to the period of coma, semicoma and confusion which commonly follows a severe head injury Such an in jury they think may be associated with contusion and petechial hemorrhages in the biain stem, but these lesions are not responsible for the basic generalized cerebral disturbance of concussion Denny-Brown and Russell have shown that concus sion can be produced when an animal's head is sub jected to a sufficiently high rate of change oſ velocity The change of velocity may be positive or negative and accordingly results in what they term eithei an acceleration or a deceleration concussion Sudden acceleration sets up a complicated series of stains and distortions within the brain stem and cei vical cond and it is these forces that are responsible for concus sion as well as for hemorrhagic lesions when they These hemon hagic lesions are considered to occur immediately and are believed to be the result of direct injury and not due to prestasis, stasis and drapedesis Williams and Denny-Brown 108 have icported the electio encephalographic chinges in eypumental con They found an immediate diminution of electrical activity from the whole ceicbial hemispheres associated with concussion, folloned by the appear ance of slous Waves Refle activity iclined wlule the electical activity was sull diminished They con occur cussion ·11 Diagnosis of Nopturgical cases of Head Injury esses that cause a brief loss of consciousness and may rault in no permanent injury On thc other hand it may be that a prolongauon or extension of this initially reversible procesu might lead to secondary changes of a permanent nature A third possibility is that more gross changes such as contusion or lacera tion are in some cases contributing to the unconsaous state. It is often very difficult to gauge the severity of the brain lqion on the basu of the clinical symptoms For instance a neurosurgeon can remove the frontal or right tenporal lobe of the brain under local anesthala and have the patient carry on an intelligent conversation throughout the procedure. Postopera tively the patient may be up the next day and be essentially symptom free. Similarly the greater por tion of a frontal or temporal lobe u somctima de stroyed in an injury as with the jeep accident de scribed and yet the patient remains conscious and alert. On the other hand a blow to the movable head may ko jar it that a small hemorrhage occun in the brain stem and the patient dies no other pathology may be found In fact trauma can cause death without producing any definite evi dence of brain pathology at least of a gross natire At the autopsy DIAGNOSIS OF NONSURGICAL CASES OF HEAD INJURY All patients with a head injury should be under continuous observation and a description of the changing rigns and symptoms recorded from the earliest possible moment Diagnose rarely depends upon a single examination A detailed history is ·10 Nonsurgical Cases of Head Injury poial pole where the brain has been forcefully thrown against the sphenoid ridge of the skull Brain swelling may occur locally around a contusion or laceration on be more generalized as a result of tiauma The swelling oi edema in its milder form is piesumably due to an increase in intracellular or extracellular fluid, but petechial hemorrhages in the cerebrum and biain stem and even actual liquefaction of involved areas can take place As a result patho logic changes occur in the nerve and interstitial cells of the brain that may be permanent or transitory The cause of the swelling may be the direct result of trauma to the tissues or secondary to injury of the vessel wall, which esults in an increase in its peime ability with escape of fluid, and possibly blood corpuscles (petechial hemorrhage), or even rupture of the vessel 27 85, 00 Subarachnoid hemorrhage will occur when one of the vessels on the surface of the brain, or elsewhere is torn oi ruptures and empties into the subarachnoid space This will be true in laceration, frequently in contusion, and even as a result of severe edema Lum bar puncture in such cases will reveal bloody spinal fluid Comment Concussion may be brief or prolongea It seems likely that concussion of short duration can occur without any permanent damage to the brain just as consciousness may be lost temporarily in an epileptic seizure due to a generalized physiologic dis turbance 9- Whether a loss of consciousness pro longed for hours 01 days can occur without perma nent damage to the brain is morc questionable Un consciousness of long duration might be due to a continuance of the same physical and chemical proc ·11 Diagnose of Nonsurgical cases of Head Injury esses that cause a brief loss of consciouness and may rault in no permanent injury On the other hand it may be that a prolongation or extension of this initially reversible process might lead to secondary change of a permanent nature A third possibility us that more grous change, such as contusion or lacera tion are in some cases contnbuting to the unconscious state. It is often very difficult to gauge the seventy of the brain lesion on the basis of the clinical symptoms For instance a neurosurgeon an remove the frontal or right temporal lobe of the brain under local anes thena and have the patient carry on an intelligent conversacion throughout the procedure Postopera tively the pauent may be up the next day and be essentially symptom free. Similarly the greater por tion of a frontal or temporal lobe is sometimes de stroyed in an injury as with the jeep acadent de fcribed, and yet the patient remains conscious and alert. On tlie other hand a blow to the movable head may so jar it that a small hemorrhage occurs in the brain stem and the patient dies At the autopsi no other pathology may be found. In fact trauma can cause death without produang any definite cvi dence of brain pathology at least of a gross nature DIAGNOSIS OF NONSURGICAL CASES OF HEAD INJURI All patients with a head injury should be under continuous observation and a description of the changing signs and symptoms recorded from the carliat possible moment Diagnosis rarely depends upon 3 ungle examination A detailed history is ·case 12 Nonsurgical Cases of Head Injury essential and a complete examination, not only of the head but of the entire body, is required to rule out associated injury Signs and Symptoms and Their Pathologic Basis There is one important difference between the signs and symptoms in the nonsurgical and the suigical The patient with a nonsurgical lesion iaiely shows marked improvement followed by a 1101sening of his condition, although there may be some minor fluctuation in the severity of the symptoms When a major fluctuation in the clinical couise takes place in the mannei mentioned, an expanding intracranial blood clot should be suspected The nonsurgical cases of head injury may be di vided roughly into thee groups depending upon whether the injury is slight, moderate or severe (see Symonds 07) Slight Degree of Injury In the injury of slight de gree the patient may be dazed for a few seconds or perhaps ſor half an hour, with or without loss of mem ory for the accident and for a period thereafter On the other hand the slightly injuied patient may have a complete loss of consciousness for several min utes and may remain confused for a half hour or There is then an amnesia for the injury and rather frequently a so called retrograde amnesia (or events immediately preceding it With slight injuries the ncuiologic examination leveals a loss of ellexes while the patient is uncon In some cases there are abnormalities in the neurologic examination for a vauable time after the injury, indicating a mild, focal contusion of the bain and the electroencephalogram may confirm thus These findings are at times present in patients who more SCIOUS ·13 Diagaosis of Nonsurgical Care of Head Injury have been morely dazed and especially when a farly prolonged period of amnesia has followed the aca dent Some patients following a mild injury will com plain of headacho dizziness and perrouSess the cause of these symptoms is not clearly understood. They do not depend upon the severity of the trauma although the frequency of their appearance is greater in the more severe injuries (sce under post traumatic syndrome) Most cases of slight injury with loss of consaousness would be classed as examples of cerebral concussion with no permanent damage to the central nervous sy tem This conclusion cannot be applied to all mild cases horever and certainly not to those with evi dence of focal cerebral contusion Moderate Degree of Injury In this group there is loss of consciousness for perhaps five minutes to an hour or more The patient then goes through a stage of stupor during which he may be restless or violent followed by a period of drowsiness, confusion and disorientauon The whole course lasts anywhere from a few houn to several weeks. Somcuma a patent who is improving will become more confused or difficult to arouse This will cause concern and is the type of thing that happens with an expanding blood dot. Such a patient will have to be watched with extreme care but usually the down hill course is of short duration and improvement sets in again or at least the patients condition does not continue to be come more On admousion to the hospital these anses seldom show aidence of shoch unless there are 23sociated injuries or hemorrlage. There are usually rome aigns ·14 Nonsurgical Cases of Head Injury of injury to the head such as contusion of the scalp, periorbital hematoma, discoloration of an ear drum from blood in the middle ear, or bluish discoloration of the scalp behind one car There is frequently stiff ness of the neck The temperature may be moderately elevated and later may rise to 102° or higher There is commonly incontinence A convulsive seizure or even status epilepticus is sometimes seen Lumbar puncture in a fairly high percentage of cases will re veal blood in the spinal fluid The spinal fluid pres sure is moderately elevated in most cases but bears no definite relationship to the state of consciousness (see under subdural hematoma) The neurologic examination will vary depending in part upon whether contusion or laceration of the brain is present There is arreflexia immediately after the accident, but later there may be some inequality in the deep and superficial reflexes on the 1110 sides of the body The Babinshi may be positive bilat erally or unilaterally Any motor weakness which is present was usually there from the time of the injury as a result of direct brain trauma Il loss of motor poner appears later then one must suspect an intra cranial hematoma The pupils will vary in size and at times they are unequal A slight lower facial wcak ness is not uncommon Direct injury to one or more of the cranial nerves, of course, may occur The prognosis must be guarded in this group so far as residual symptoms are concerned portion will become completely asymptomatic within days to wechs Others will continue to complain for longer periods of headache, duziness and inability to concentrate The cause of the syinploms in these cases is bral concussion combined usually with varying se A good pro }((IC ·15 Diagnosis of Nonsurgical cases of Head Injury greo of brain contusion laceration edema and subarachnoid hemorrhage Severo Degree of Injury The clinical counc in this group is much the same as in the previous one except that the symptoms are more severe and the mortality high, especially in the fint fent day. The duration of unconsciousness is generally longer and about 20 per cent of patients although they may show some tem porary improvement, continue in a stupor whdı be come progressively dceper ending in death within about 48 hour Associated injuries of the face, long bones chat abdomen and elsewhere with their accompanying shock, arc higher in this severely injured group od must be diagnosed and adequately treated The patients who survive the injury for a few days will usually live if properly treated, but they frequendy have a stormy course Objective evidence of head trauma is nearly always present often with bleeding from the nose mouth or cars. Breathing is frequently difficult with accumula tion of tracheal secretions cyanosis and signs of pul monary edema Flude cannot be taken by mouth somcupies for days or wechs. The patients are in continent and may develop bed sore if not properly cared for their temperature rises and in many will reach 100 or more unless treated assiduously This u apecially truc in the dehydrated patient or the alcoholic with delirium temen. Epilepuc seizures occur and cause hemiplegua from ohauttion of corti. cal cells and death if not controlled. At timo the only manifestation of continuing seizures in an a hausted cerebral cortex will be a feeble twitching of onc extremity or perhaps only of the fingers. When a bemiplegia occur aller a seizure it is often dulfi ·16 Nonsurgical Cases of Head Injury cult to know whether or not the paralysis is the result of a hematoma All this is a clear indication of the importance of promptly controlling convulsive sei zures when they appear The general neurologic examination will be essen tially similar to that described for injuries of mod erate degree Stiff neck and bloody spinal fluid is the rule Focal neurologic signs due to brain contusion and laceration will be more common The effect upon the intellect, memory and disposition from gen eralized changes in the brain due to edema and perc chial hemorrhage will be greater Also in this gioup are seen those patients who remain unconscious in a more or less vegetative or decer ebiate state for long periods as a result of hemorrhage oi other damage to the brain stem The ultimate prognosis is more giave in these in juries of severe degi ee There is a loss of memory for the accident and usually for a period preceding it Post-traumatic amnesia or loss of memory for events following the injuiy may cover an interval of three months or more Many will show intellectual impair ment and emotional disturbance for a year or longer, but it is surprising how frequently patients will make an apparently complete recovery without disability This lack of disability is more true of persons doing manual work Individuals whose livelihood depends upon their intellectual capacity, however, may find themselves totally unable to carry on in their picvious jobs In the older age group even a minor head in jury may be followed by marhed intellectual impairment The patients who dic as a result of their head in jury as a rule shon diſſuse brain damage with con ·Conservative Treatment of Acute Head Injuries 17 tusion and lacerauon most commonly of the anterior temporal and inferior frontal regions In addition there is generally subarachnoid hemorrhage edema und scattered hemorrhages, commonly occuting in the brain stem. CONSERVATIVE TREATMENT OF ACUTE HEAD INJURIES There are a number of simple measure in the man agement of head injuries which if properly applied will appreciably lassen the mortality rate. A patient u best transported from the scene of the accident in the supine position to avoid flexion of a possibly fractured spine, any fractures of long bones sbould be splinted hemorrhage controlled and ample blankets used if there are signs of shock. On admission to the hospital a careful history us tahen concerning the nature of the acadent. Particu lar note is made of any loss of consciousness its dura tion and whetlier a luad interval followed. Such a history may have to be obtained from relauves or witnesses of the accident Shock, if present u treated with transfusions and other measures regardless of the head injury Injuries clsewhere to the body whether facial spinal thorac, intra abdominal to the extremities or elsewhere, must recente adequate care Caves of head injury uncom plıcated by shock will stand transportauon Hell and are best transferred to a hospital where neurosurgic treatment is available Specific Measures In Conservattro Treatment 1 A record of the blood pressure, pulse and respira ·18 Nonsurgical Cases of Head Injury tion is made every half hour A complete neurologic examination is done at frequent intervals 2 The nurse is requested to test the state of con sciousness and motor power every half hour (especially in the first 24 hours) by having the conscious patient hold his arms in extended fashion In the semistuporous patient some evaluation of motor power can be obtained by painful stimulation or by raising each upper extremity and dropping it on the patient's face If power is present the arm will usually avoid striking the face 3 The unconscious or stuporous patient is placed on his side with a pillow under the head to avoid lat eral flexion of the nech and compression of the jugu lar vein In this position he avoids swallowing the tongue, vomitus or secretions He should be turned every tvo to three hours When a stuporous patient is on his back his breathing often appears of the Cheyne-Stokes variety because of obstruction by the tongue 4 Oxygen should be given to the unconscious pa tient by nasal catheter or in a tent A tracheotomy may become necessary to enable adequate oxygen ex change 25 Frequent aspirations for mucus are used as indicated 5 The temperature inay rise to 1069 or more in the seriously injured and must be controlled if the patient is to survive In such cases the temperature regulating mechanism in the hypothalamus is dis turbed 61 The patients metabolism continues and heat is produced but cannot be lost unaided The temperature, therefore, should be recorded every half hour when elevated above 102° It must be hept below 102° with, if necessary, constant alcohol sponges, ·Conservative Treatment of Acute Head Injuria 19 multiple ice bags clectric fans, etc. Usually a few hours of vigorous treatment will get the temperature down to where it can be controlled with alcohol spongo alone, but the nurse must remain constantly on the alert for a further risc 6 In all head injuries 1500 to 2000 cc. of flud should be given every 24 hours by mouth or intra venously if necessary but it is probably best to delay intravenous fluids 21 hours in severe cases. The fluids should be nourishing if taken by mouth These cases do not tolerate dehydration any better than other sick patients. If the temperature is elevated or if the weather u hot another 1000 cc. of fluid are added Patients with delirim tremens require about 1000 CC. a day 7 Careful electrolyte balance must be maintained 8 Antibiotia are given routinely to the very sick as a prophylactic against meningius from say a pot sible fracture into the paranasal sinuses or middle ear Such treatment u also preventive against hypostatic pneumonia which is prone to develop 9 Sodium phenobarbital is used for convulsive sei zura, which are not infrequent following laceration or contusion of the brain The maintenance dose is gt i to gr u hypodermically three times a day If the patient has repeated sciura (status epilepticus) it may be necessary to give up to go yui of sodium phenobarbital in three or four hours If the seizura continue a full dose of lverun by rectum can be used Some employ intrai cnous sodium amobarbital or thio pental It is essenual to get the seizures under control promptly in these sich individualı. 10 Sodium phenobarbital gt 11 every four hours may be used if really necessary for restlessness If ·20 Nonsurgical Cases of Head Injury this is not successful paraldehyde can be added It is well not to use morphine or Demerol Sedatives are best avoided when possible The patient should be allowed to move about the bed and be restrained only when essential 11 When a patient has been improving and then becomes drowsy caffeine sodium benzoate gr vil ss every four hours is useful to arouse him If the drowsiness continues or deepens then one must be on the alert for a surgical lesion 12 Should a suspicion of meningitis appear, lum bar puncture must be done immediately and the spinal fluid examined, cultured and the sensitivity of any organisms present tested with the various antibiotics For a meningitis give immediately sodium sulfadiazine Gm v intravenously in 500 to 1000 cc of fluid, and then Gm îi in four hours folloned by Gm i every four hours thereafter for three to five days Large doses of antibiotics are also started immediately and later replaced by the antibiotic to which the organism is most sensitive 13 Lumbar puncture is useful in diagnosis It should be avoided during the first 24 to 48 hours, especially if the patient resists, as straining will raise the intracranial pressure and also the blood pressure and hence may cause intracranial bleeding After the first 48 hours lumbar puncture is indicated to determine the spinal fluid pressure when an expanding intracranial lesion is suspected Severe headache may be relieved by reducing the pressure by hall Other- 115e this method has not appeared of much value in treatment although there are opinions to the contrary 14 Drainage of blood and spinal ſuid from the car (otorrhea) is treated with antibiotics and by gently ·Conservative Treatment of Acute Head Injurios 21 sponging the outer car with alcohol and covering it with a dry senile dressing The cerebrospinal fluid and blood will be absorbed into the dressing Other rise it would run into tlie outer car become contam inated and then possibly drain back into the auditory canal and contaminate the cerebrospinal fluid. An Otoscope should not be inserted into the car canal when there is drainage of spinal fluid, but a large piece of wax or encrusted blood may have to be re moved with are The drainage will usually cease in about one lice with the above treatment 15 Drainnge of cerebrospinal fluid from the nose (rhinorrhea) may occur when there w a fracture into one of the paranasal sinuses plus a tear in the adja cent dura and arachnoid The treatment is conserva tive for about lour weeks unless complications arise. The patient is instructed not to blow hu nose under any arcumstances as lie might blow air and bacteria into the intracranial cavity Antibiotic and sulla drugs are given unul the drunage cases Surgery may become necessary (see under surgical treatment) 16 An indvelling catheter and tidal drainage is used for the patient who remains in prolonged coma and u not incontinent. Otherwise catheterization 4 done when indicated. 1, General Care is given to the skin and pressure point to avoid bed soros 18 Roentgen ray picturos of the skull are pot talen w an emergency and are contraindicated while the patient is seriously ull unless there are signs of an epidural bemorlage or of a compound fracture. Fre quends the patient is well enough to have roentgeno grams in 24 to 48 hours after admission to the liospital ·20 Nonsurgical Cases of Head Injury this is not successful paraldehyde can be added It is well not to use morphine or Demerol Sedatives are best avoided when possible The patient should be allowed to move about the bed and be restrained only when essential 11 When a patient has been improving and then becomes drowsy caffeine sodium benzoate gr vil ss every four hours is useful to arouse him If the drowsiness continues or deepens then one must be on the alert for a surgical lesion 12 Should a suspicion of meningitis appear, lum bar puncture must be done immediately and the spinal fluid examined, cultured and the sensitivity of any organisms present tested with the various anti biotics For a meningitis give immediately sodium sulfadiazine Gm v intravenously in 500 to 1000 cc of fluid, and then Gm īī in four hours followed by Gm ī every four hours thereafter for three to five days Large doses of antibiotics are also started immediately and later replaced by the antibiotic to which the organism is most sensitive 13 Lumbar puncture is useful in diagnosis It should be avoided during the first 24 to 48 hours, especially if the patient resists, as straining will raise the intracranial pressure and also the blood pressure and hence may cause intracranial bleeding After the first 48 hours lumbar puncture is indicated to deter mine the spinal fluid pressure when an expanding intracranial lesion is suspected Severe headache may be relieved by reducing the pressure by hall Otherwise this method has not appeared of much value in treatment although there are opinions to the contrary 14 Drainage of blood and spinal fluid from the car (otorrhea) is treated with antibiotics and by gently

·co
SURGICAL CASES OF HEAD
INJURY INTRACRANIAL
HEMATOMAS
All cases of head injury whether open" or closed"
are potentially surgical cases. They should be con
tinuously under expert observation. Until operation
becoma necaury the patient u treated like all other
individuals with a head injury by simple cominon
lense and conservative measures These conservative
masures already have been described in the diapter
on the treatment of nonsurgical cases
In this monograph surgical cases are divided into
three main groups Intracranial Hematomas Surgical
Loions of the Scalp Skull and Bram (Chapter 4)
und Other Complications Following Head Injury
(Chapter 5)
The problem of deciding n bether a case of acute
head injury 13 turgical or nonsurgical (nonoperable)
1 an important one There are three pe
polpu a knowledge of such will simplify the prob.
lera of diagnosis
| Surgical lesions of the scalp skull and brain in
adulu as delned in the following pages, an nearly
alwars be recognized with case by careful examina

·No text on this page.

·co SURGICAL CASES OF HEAD INJURY INTRACRANIAL HEMATOMAS All cases of head injury wliether open or closed" are potentially surgical cases. They should be con linuously under expert observation Until operation becoma necessary the patient is treated like all other individuals with a head injury by simple common sense and conservative measures These conservative measure already have been described in the chapter on the treatment of nonsurgical cases In this monograph surgical cases are divided into three main groups Intracranial Hematomas Surgical Loions of the Scalp Skull and Brain (Chapter 1) and Other Complications Following Head Injury (Chapter 5) The problem of deciding whether a case of acute head injury u ruigical or nonsurgical (nonoperable) 1 an important one. There are three pertinent points a knowledge of u bich will simplify the problem of diagnosis. 1 Surgraal lesions of the scalp shull and brain in adulis, as defined in the following page can nearly always be recognized with ease by careful examina ·24 Surgical Cases of Head Injury tion of the head in the great majority there is an open wound of the scalp A rather uncommon exception is a simple, depressed fracture, which can be revealed by roentgenogram of the skull 2 Intiacianial hematomas mahe up the gieat bulk of the other surgical lesions that must be diagnosed to save life and they are comparatively uncommon Statistics vary on the incidence of intracranial hema toma depending upon whiethei all degrees of head injury are included in the study oi only severe cases that might be referred to a neurosurgical center The incidence is much higher among those with sevcic head trauma Subdural hematomas constitute the largest group of intiaci anial hematomas and they have occuried in only about 1 per cent of all head injuries in some series, 24, 68 and in the neighborhood of 5 24 to 1000 pci cent of the seveic cases in other series The othei intiacranial hematomas are the cpidural and intra cerebral hemorrhages Their incidence has been ieported as much less than 1 per cent of all lead in juries and as about 2 per cent of the severely injucd by some observers 24 and as considerably higher by others (see below) 3 There are a few additional surgical complications following head injury, but apart from infection and arteriovenous aneurysm, surgery in then ticatment is usually elective In simple terms then it is estimated that iſ open wounds of the head are excluded, only about 2 10 3 per cent of all patients with a head injury, or about 8 to 10 per cent of the severly injured, develop an intracıanial hematoma or other less common lesion that requires surgical interi cntion ·Epidural Hemorrhage 25 Intracranial hematomas are either extradural suby dural or intracerebral and may occur following any head injury Whether this be of the "open" or closed variety FPIDURAL HEVORRHAGE An epidural hemorrhage u nearly always due to a tear of the middle meningeal artery cither at the formen spinosum in the middle fossa where it enters the skull or anywhere along its many branches (Fig 2A) The artery runs in grools on the inner table of the skull and a fracture which crosses the vessel can casily tear it (Fig 2B) Urually a fractwe must be present but, in rare cases, such a hemorrhage can occur without a frdure. When the bleeding tahos place it strips the dura away from the skull and in to doing tears many other little brancha of the artery and even may cause hemorrhage from pacchionian granulations near the longitudinal sinus. The larger the branch of the artery initially torn the more rapid and extensive the hemorrhage and the more severe and rapid the compression of the underlying brain and the development of clinical signs Occasionally an cpidural hemorrhage may be due of the large venous sinuses or may occur in the poste nor fona. The inadence of epidural hemorrhage was las then 0 25 per cent in 30 000 head injuries of all typos and about 10 per cent in 6000 sciere cases studied by Echlin et al but has been reported as 3 per cent by Munro and by Woodball et al The classic story of an epidural henorthage us as follows An individual us struck on the head with a a tear in one 2 ·gieat 24 Surgical Cases of Head Injury tion of the head in the great majority there is an open wound of the scalp A rather uncommon exception is a simple, depressed fracture, which can be revealed by roentgenogram of the skull 2 Intiaci anial hematonias inake ир the bulk of the other surgical lesions that must be diagnosed to save life and they are comparatively uncommon Statistics vary on the incidence of intracranial hema toma depending upon whether all degrees of head injury are included in the study or only severe cases that might be referred to a neurosurgical center The incidence is much higher among those with severe head trauma Subdural hematomas constitute the largest group of intracranial hematomas and they have occured in only about 1 per cent of all head injuries in some series, 24, 68 and in the neighborhood of 5 24 10 10 op pei cent of the severe cases in other series The othci intracranial hematomas are the cpidural and intra cerebral hemorrhages Then incidence has been icported as much less than 1 per cent of all head m juries and as about 2 per cent of the severely injured by some obser vers 24 and as considerably highei by others (see below) 3 There are a few additional surgical complications following head injury, but apart from inſection and arteriovenous aneurysm, sugery in their treatinent is usually elective In simple terms then it is estimated that iſ open rounds of the head are excluded, only about 2 to 3 per cent of all patients with a head injury, or about 8 to 10 per cent of the severly injured, develop an intiacranial hematoma or other less common lusjon that requires surgical intervention ·Epidural Hemorrhage 27 Jard object like a policemans club or falls hitting hus head on the paiement. He may be unconsaous for a few minutes but gets up and walks along There is a luad interval In a matter of minutes to an hour or more he develops a headacie usually on one side of the head and may vomit A convulsie suure sometna occurs The patient then becomes drowsy and often confused This is followed by a progressive hemiparesis to hemiplegia on the side opposite the hematoma the arm frequently being in volved first. The pupıl on the side of the lesion often Lecomes dilated. In a rapidly developing hemorrhage froin a tear in the main trunk of the vessel deep coma and decerebrate rigidity may take place within a few hours and operation u then frequently 100 laic to have lifc There are variations in the syndrome cases the course is not so rapid The hemorrhage is less and way actually stop A liemiparesis can be delayed for many houn and be relatively mild and III Sonic instances is on the saine side as the cpidural clot The motor scalness may only be recognized by the doctor on the day following the injury and the diagnosis not suspected until the lustory of a lucid interval is obtained In fact an occasional care may remai drowsy with realness of one side for a week or dioic before the diagnosis is made or 3 sud den worsening of the clinical condition taha place Cases with the history described in whom a lucid interial has occurred should all be suspected of hau ing an ez dural henorbage and explored as emcı gencia Unfortunately some patients following a head injun renain unconscious and during this inter al the cpidural hematoma develops and Lecps the In many

·1
MIDDLE MENINGEAL
ARTERY ON
DURAL SURFACE
A
GROOVES OF MIDDLE MENINGEAL
ARTERY ON INNER TABLE
OF SKULL
,تر
B
FIG 2
4 The location of the middlc meningeal ricry
explains why a hemorrhage from this vessel is on the outer
surface of the duri Bli is curent wy o fricture of the
shull may tear i branch of the middle meningeal artery is
It runs in a groove on the inner table of the skull
26

·Epidural Hemorrhage 29 dlc fossa anterior to the car it is usual to place the first burr hole aliout one inch anterior to the ear and a little above it. The head should be draped so that the inasion can be extended down to the zygoma and upward cien to the mid line Also it sliould le po sible to atend it backward in honahoe fashion to the mastoid process so that a skin and muscle flap can be turned and a large craniectomy rapidly arried out when needed. When through a burr hole an epidural clot is ex posed it should not be disturbed until the subtemporal decompression is enlarged to at least the size of a ulier dollar The enlargement should be as much as posible toward the center of the clot If the clot u disturbed before adequate exposure has been made active bleeding, which is often absent at this stage may be set up and cause serious damage before it can be controlled. On the other hand, after 2 sizeable coniectomy has been carned out which can be done in a few minuta, the clot can be rapidly attached with the sucher and spoon Bleeding may nou occur from a large branch of the middle meningeal artery or even the main trunk at the foramen spinosumn The sur geon an approach it immediately and cover it firmly with a piece of brain cotton or his finger until the field is cleared. Then the vessel can be coagulated clipped or tied and in addition the foramen spinosum may be plugged with bone wax and unun cotton if it 11 exposed Fortunately nature exposes the main bleeding point by having already stripped the dura away from the skull Hence when the arter) u torn for instance low in the middle fossa no stripping of the dura is required to bring the bleeder into yien It times there is additional bleeding from many tiny ·28 Surgical Cases of Head Injury patient in coma These cases are usually not diag nosed One should, however, be on the alert foi them and explore a patient who shows deepening coma and develops a piogi essive hemiplegia with a dılated pupil on the opposite side Nothing will be lost by operation in such a case and at times some thing may be gained The description of the rapidly developing signs and symptoms in epidural hemon hage should make it clear why head injury patients must be observed so closely, especially in the fust 24 houis aſtei trauma As pointed out under consei vative tieatment the ſic quent testing of the state of consciousness and motor ponei is most important if these cases are to be diag nosed Foi an excellent description of epidural hem orrhage sec McKenzie co and Munio and Maltby 0 Surgical Treatment of Epidural Hemorrhage In ei ploring for an epidural hemorrhage the same opera tive approach, positioning of the patient and method of anesthesia may be used as descubed in some detail under surgical treatment of subdural hematoma Before operating it is well to know if a fracture of the shull is present as it may give a clue to the point of tear in the middle meningeal vessel Sometimes the fracture line will pass entuely poster 101 to thc car and then it usually will be the posterior branch of the artery that is toin In such a case, a bun hole, in the usual position anterion to the car, may reveal no evi dence of a huge cpidural clot lying entirely oic the postenoi aspect of the occipitotempoioparietal 1egion Occasionally the hematoma may be located in tlic frontal region Then the fracture line traicises the side of the head from back to front or passes don nuaid unto the mud

·COMPRESSED BRAIN
WAY
SUBDURAL
HEMATONA
8
Fio 3 This is a common location of a subdural heritatoma,
but t frequently ext nds loner in the temporal region.
SI

·30 Surgical Cases of Head Injury vessels on the surface of the dura and these may be tedious to control Serious venous hemorrhage may also take place from the pacchionian granulations near the longitudinal sinus as mentioned Occasion ally this bleeding can be controlled only by gauze paching with perhaps, in addition, suture of the dura to the periosteum through burr holes placed over the convexities of the nemisphere It may even be necessary in a very acute case to leave this paching in for a day or longer SUBDURAL HEMATOMA ACUTE, SUBACUTL AND CHRONIC A traumatic subdural hematoma or hemorrhage is the result of bleeding into the space between the brain and the dura mater from a vessel situated on the surface of the brain, or running between the brain and the dura (Fig 3) The clinical course following a subdural hemorrhage may he acute, subacute or chronic Early reports of subdural hematoma nere concerned chiefly with the chronic form as this was the type seen in neurosurgical centers Wilfred Trotter in 1914 gave a classic description of chronic subdural hema toma and emphasized the traumatic origin of the le sion In 1925 Putnam and Cushing described the pathologic features in detail and alerted the neuro surgical world to the condition Since then many 11 15 22 24 28 32 35 19 50 JE P8, rd, 84, 102 hare estab papers lished chronic subdural hematoma as an important neurosurgical entity Descriptions of large series of acute subdural hema tomas began to appear with the advent of emergency ·Subdural Hematoma Acute Subacute Chronic 93 the basis of the findings reported by Echlın et al of 300 cases that the following observations on subdural hematoma have been made. Las than 5 per cent of 6000 patients with severe head injury were found at operation to have a subdural hematoma which is a lower inadence than that of Munro who found 10 per cent in a more selected group Etologic and Pathologic Condiderations in Subdurat Hematom. The most common cause of an acute or subacute subdural hematoma is a laceration of the surface of the brain with resultant hemorrhage into the rubdural space over the surface of the cerebral hernisphere or very rarely over the surface of the cerebellum When the injury is mild which is com monly truc in chronic hematomas, the source of the bleeding is probably rupture of one of the scids that bridge the subdural space Occasionally masive ar terial hemorrhage may occur bencath the dura when branches of the middle cerebral artery are torn or a lacerated middle meningeal artery bleeds through a tear in the dura. The formation of a collection of blood in the subdural space usually give rise to fent early symptoms unless the hematoma formos rapidly as in the uncom mon case of active arterial or massive venou hemor rbage. The bleeding generally stops soon after in jury and evidence of continued subdural bleeding rarely is seen at operation on subacute or chronic Gises. Delayed symptoms in subacute caso it is be lieved therefore, rarely are due to slon hemorrhage The fatal course of many patients with acute sub dural henuatonias us as stated, generally the result of associated bram injury and its complications and not of tlic hematoma Because the brain can adjust rapidly to a large sub- ·32 Surgical Cases of Head Injury TABLE 1 Operalıve Experience with 300 Cases of Subdural Hematoma24 TYPE OF SUBDURAL HEMATOMA ACUTE SUBACUTE CHRONIC Time from injury to operation 2 to 48 3 to 7 hours days 7 to 22 22 to 30 over 30 days days days Total number of 50 43 132 20 55 cases Lived 5 21 101 18 38 31 17* Died 45 22 2 Mortality 90% 51 1% 23 4% 10% 300% * 12 of these 17 patients were in coma at umg of operation Oicr all mortality 39 per cent (Froin Ichlin F A Sordillo S VR, and Carie, Thomas (), Jr Subdural licmatona acute, subacute and chronic, JAVA In press ) 68, r8 69 102 neurosurgical services in big city hospitals 23, 24, 36, 66, With time it became customary to de scribe all subdural hematomas as acute or chronic Later it was suggested that subdural hematomas be classed as acute, subacute and chronic A classificalion which includes only acute and chronic groups is misleading and fails to alert the profession to the fact that almost 50 per cent of subdural hematomas on a large emergency service are really subacute and require operation as a lifesaving procedure on the seventh to the twenty first day after injury 23, 24 (See Table 1) Incidence of Subdural Hematoma In a series of 30,000 head injuries reported by Echlin et al 24 there Kere 300 operated cases of subdural hematoma, an incidence of I per cent, which is in heeping with the findings of Laudig, Bronder and Watson 18 It is on ·35 Subdural Hematoma cute, Subacute Chronic CEREBRAL EDEMA FIG. 4 Cerebral edema duc to compression from a subdural hepatoma unau and this can lead to infarction in the occipital lolyc At the same time the third cranial neri e com inonly is subjected to prewure by the uncus with resulting lilatation of the pupil and less often a ptosis Acute Subdural Hernators. In this group are included all patients with a subdural hematoma who appear to require surgery as a lifesaving procedure during the first week after injury The majonty of these individuals have sustained a kevere head trauma raulting in fresh blood or blood clot in the subdural space and a seriously injured brun Because of the sciere brain injury the mortality in the acute group is high during the first week and extremely high in the first 18 liours after injury even though the hema toma be remorcd ·3*1, 114 34 Surgical Cases of Head Injury dural clot the patient may become asymptomatic or relatively so as he recovers from lus direct brain trauma Most hematomas then liquefy, if they are not already in such a state, and become larger as they acquire more fluid, presumably through the process of osmosis, ds demonstrated by Gardner´h and others It is this increase in sve of the hematoma orcr days to months with its resulting effect on the underlying brain, that causes progressive symptoms and death in the great majority of cases unless opera- Lion is carried out In the chronic state the hematoma is most often liquid hut may contain soft clot and usually is surrounded by a membrane at any time after the seventh day of its formation Occasionally the clot becomes organized to the consistency of liver or rarely is calcı fied Pathologic Changes in the Brain 27 00 TVhen a sub dural (or epidural) hematoma expands it compresses the underlying cerebral hemisphere and displaces it medially As a result there can occur a serious disturbance in cerebral circulation and even some obstruction of the flow of cerchrospinal fluid from the lateral ventricles Interfercnce with the scious outfou from the compressed hemisphere may lead to marled edema of the brain (Fig 4) and herniation of the medial portion of the icmporal lohe (uncus) over the free edge of the tentorium * 51, €* and herniation of the cerebellar tonsils into the foramen magnum Pressure from the herniated uncus may interfere with the senous circulation of the brain stcm and produce the equivalent of a deacrebiation through cdema or actual hemorrhage into the ston" » The posicrior cerebral artery at imes becomes compressed be the ·Subdural Hematoma Acute Subacute Chronic 97 a head injury usually consist of currant jelly or later milk drocolate clots with varying amounts of freslı or old fuid blood and cerebrospinal flud. Of 43 patients in this ategory operated on the third to the seventh day by Echlin et al 22 died m most ases prorunably as a result of their brain injury The mortality was 51 1 per cent which is much less than in those operated on within 48 hours following trauma The brief duration of the illness justifics plaung these cases in the group of acute hematomas. Subacate Subdural Hematoma Between the two ex tremos of the condition described as acute or chronic falls the group of subacutc subdural hematomas. In this group which in one series 14 included almost 50 per cent of all subdural hematomas the head injury is most often severe There is usually blood in the spinal fluid and frequently a fractured skull Recov cry from the brain injury occurs in the majority but u commonly incomplete and is followed in about one to three weeks by progressive signs of brain compres sion from the hematoma. Most patients reguin consciousness and about 25 per cent become mentally clear whereas the others con tinue to have some degree of drowsiness and disorien tation Many of the more alert patients complain of headache Before operation approximately 80 рет cent show progressive signs of brain compression eri denced by increasing drowsiness, usually fluctuating in nature and ending commonly in sem stupor stupor In most instances there are abnormalities in the nemologic examination (see later under dag nosis) Ibout 90 per cent of the more alert aves can be safely diagnosed with air studios or angiograns before or com ·36 Surgical Cases of Head Injury Early Surgery Patients with a subdural hematoma in whom surgery has seemed indicated in the first 48 hours after trauma are usually unconscious for varying periods and then show slight improvement to the state where they are stuporous They rarely have a lucid interval Most of them then become increasingly comatose and often develop "localızıng" signs such as a dilated pupil on one side and a pro gressive weakness of the opposite arm and leg Occasionally the clinical picture in the first 48 hours will be much the same as described for an epidural hemorrhage if the bleeding is severe and the direct brain injury slight Such cases, if they have a lucid intei val, are emergencies and must be operated promptly In the series reported by Echlin et al over 90 per cent of 50 patients operated on in the first 48 hours after injury died, despite adequate removal of a large hematoma Death in this group was attributed largely, if not entirely, to direct brain injury, the hematoma being incidental Survival in five cases was due to removal of the blood clot, the injury be ing less severe Later Surgery Palients with an acute subdural hematoma who present signs indicating operation on the third to the seventh day following injury usually regain consciousness but only occasionally are alert Most of them remain dronsy and disoriented and then become progressively dronsy or stuporous The onset of stupor may be sudden and not infrequently is precipitated by a convulsive seizure Neurologic signs of brain pathology are usually present and often indicate a "focal" lesion The hematomas removed during the first 11 cch aſter ·Subdural Hematoma Acute Sabacute, Chronic 37 a head injury usually consist of currant jelly or later milk chocolate clous with varying amounts of fresh or old fluid blood and cerebrospinal fluid. Of 43 patients in thu category operated on the third to the seventh day by Echlin et al 22 died, in most cases presumably us a result of their brain injury The mortality was 511 per cent which u much less than in those operated on within 48 hours following trauma The brief duration of the illnass justifier plaang these cases in the group of acute hematomas Subacurte Subdural Hematoma Between the two ex trema of the condition dacribed as acute or chronic falls the group of subacute rubdural hematomas In this group huch in one keria * included almost 50 per cent of all rubdural hematomas the head injury 3 most often severe. There is usually blood in the pinal Aud and frequently a fractured skull Recov cry from the brain injury occur in the majority but is commonly incomplete and is followed in about one to three weeks by progressive signs of bruin comprar sion from the hematoma Most patients regain consciousness and about 25 рег cent become mentally clear whereas the other con tinue to have some degree of drowsiness and disorien tation Many of the more alert pauents complain of headache Before operation approximately 60 per cent show progressive signs of brain compression evi denced by increasing drowsiness, usually fluctuating in nature and ending commonly in semistupor supor In most instances there are abnormalities in the neurologic examination (see later under dag nosus) About 20 per cent of the more alert cases can be safely diagnosed with air studies or angiograms before OS coma ·36 Surgical Cases of Head Injury Early Surgery Patients with a subdural hematoma in whom surgery has seemed indicated in the first 48 hours after trauma are usually unconscious for varying periods and then show slight improvement to the state where they are stuporous They rarely have a lucid intei val Most of them then become increasingly comatose and often develop "localızıng" signs such as a dilated pupil on one side and a pro gressive weakness of the opposite arm and leg Occasionally the clinical picture in the first 48 hours will be much the same as described for an epidural hemorrhage if the bleeding is severe and the direct brain injury slight Such cases, if they have a lucid interval, ale emergencies and must be operated promptly In the series reported by Echlin et al over 90 per cent of 50 patients operated on in the first 48 liours after injury died, despite adequate removal of a large hematoma Death in this group was attubuted largely, iſ not entnely, to direct brain injury, the hematoma being incidental Survival in five cases was due to removal of the blood clot, the injury be ing less seveie Laler Suigery Patients with an acute subdural hematoma u ho present signs indicating operation on the third to the seventh day following injury usually regain consciousness but only occasionally are alert Most of them remain diousy and disoriented and then become progressively drowsy oi stuporous The onset of stupou may be sudden and not inficquently is precipitated by a convulsive seizure Neurologic signs of biain pathology are usually present and often indicate a "local" lesion Thc hematomas iemoved during the first nicch aſter ·37 Subdural Hematoma Acute, Subacute, Chronic a head injury usually consist of currant jelly or later milk chocolate clots with varying amounts of fresh or old fluid blood and cerebrospinal fluid Of 48 patients in thus category operated on the third to the seventh day by Echlin et al 22 died, in most care presumably a roult of their brain injury The mortality was 51 1 per cent which is much less than in those operated on within 48 hours following trauma. The brief duration of the illness justifies plaang there causes in the group of acute hematomas Subacute Subdural Hermatoma. Between the two ex tremas of the condition desaibed as acute or chronic falls the group of subacute subdural hematomas. In this group which in one series included almost 50 per cent of all subdural hematomas the head injury u most often severe. There is usually blood in the spinal fluid and frequently a fractured skull Recov ery from the brain injury occurs in the majority but us commonly incomplete and is followed in about onc to three weeks by progressive signs of bruin compres 11on from the hepatoma. Most patients regain consciousness and about 25 per cent become mentally dear whereas the others continue to have some degree of drowiness and disorien tation Many of the more alert patients complain of headache Before operation approximately 80 per cent shou progressive signs of brain compression evidenced by increasing droutines usually fluctuating in nature and ending commonly in sem stupor stupor In most instance there are abnormalities in the neurologic estination (see latet under ding nosu) Ibout 20 per cent of the more alert aso an be uafely diagnosed with ur studies or angiograms before or coma ·38 Surgical Cases of Head Injury stupoi appears in the iemaining 80 per cent explora tory surgery becomes essential to save life at any time from one to three weeks after injury and cariics a very good prognosis in the majority of cases, providing the patient has not lapsed into coma beſoie operation Pathologically the subacute hematoma consists of currant jelly oi milk chocolate clots with different quantities of ieddish brown to black fluid Occa sionally the fluid is yellow or the hematoma may be organized Membranes may surround the clot at any time aſter the seventh day of its formation In the group of 132 subacute cases reported by Echlin et al, the mortality was 23 4 per cent which is considerably lower than in the acute variety Un like many of those with acute lesions, recovery from the brain injury had taken place or was occurring when the down-hill course was precipitated by com pression from the subdural hematoma Improvement clinically and from the brain injury was usually less complete and less prolonged than seen in the chronic group Pathologically the hematoma as regards its stage of liquefaction or membrane formation, occu pied in most instances a position between the acute and chronic types On the basis of time elapsed since the injury, clinical course, nature of the brain injury, and pathology of the hematoma, most of these cases are neither acute nor chronic and are well descubed as subacute 23 Chronic Subdural Hematoma Patients with chronic subdural hematoma usually have accovered from their head injury, ulich may have been severe but more often was mild, or there inay be no history of trauma Several nicchs to months later senious symptoms appear, often presenting a diagnostic piol a ·Subdural Hepatoma Acute Subacute, Chronic 39 len wuch may suggest brain tumor diffuse degen crative brain pathology or psychosis The history in the great majority of patients is one of mental de tenoration for many weeks with gradual disorienta tion and confusion leading commonly to fluctuating drotsine.. Headaches rather commonly precedle the appearance of mental symptoms Neurologic signs of organic brand disease often suggesting a focal lesion usually are procent but they may be slight or absent. The diagnosis is not infrequently made during the course of a ventriculogram for a possible brain tumor or other expanding laion Surgical evacuation of the hematoma, which as a rule is encapsulated, is curative in the majority of cases if the patient u not in coma at the time of operation Patienu operated on from the twenty first to the thirty first day after injury may present a clinical pic ture very similar to that described for the subacute cases and perhaps are better included with thu group After the thirty first day the clinical course of the chronic subdural hematoma corresponds well to that just dosarbed. Dlagnosis of Subdural Herrutome. If after a head injury a patient regains conscioumess and is relatrely alert (has a luad interval) and subsequently in liours to weeks becomes progresi ely drou sy or stuporous it u essential that an intracranial hematoma be ruled out Such a dinical course developing in the first 24 hours is usually due to an epidural hemorrhage from the middle meningeal artery and as a rule is accom panied by a herniplegia and a dilated purl but occa 310nally a masive nubdural or an intiacerebral hema toma will give a similar picture These case may be ·40 Surgical Cases of Head Injury saved by emergency operation The vast majoilla the other patients operated in the first 48 hours, w. have remained stuporous from the time of the ac dent, are suffering from severe brain injury and w not be benefited by surgery even though localızı signs are present and a subdural hematoma 15 : moved A rare exception is an epidural or large su dural hematoma unaccompanied by fatal brain traur that develops while the patient remains stuporous al is usually impossible to diagnose After the first 48 hours have elapsed since the : jury the most common and valuable symptom of subdural hematoma is progressive drowsiness, oſt with disorientation and generally fluctuating in chi acter Headache may or may not be present In t chronic lesion headache and a gradual mental terioration frequently precedes the drowsiness T clinical picture of an intracerebral hematoma or tun ſaction from local, traumatic softening? may close simulate that produced by subdural hematoma Abnormal neurologic signs, although they may minimal or absent, are usually present and often gra ually progressive These include papilledema whui is not common during the first two weeks followi injury Frequent findings are an inequality of t1 pupils, less often a dilated pupil, a slight loner faci weakness, unequal decp rellexcs, unequal abdomina and a positive, often bilateral Babinski Progressi liemiparesis even to hemiplegia as a result of a su dural hematoma occurred in 43 per cent of acute cas in one series,** 20 per cent of subacute and 42 per cei of the chuonic A slight driſt of one of the ou stretched arms is a frequent and very valuable sig ·Subdural Hematoma Acute Subacute, Chronic 41 Specially when it is inacasing in severity A con Tilsite kizure in any of these cases may preapitate a hemiplegia. Other lass frequent signs include aphasia, hopionymious henuanopsia a third or sutli nene paralysis, a hemisensory loss, and in chronic cases atatoniclike posture tremor and unsteady or shuffling gait. Some patients with a subacute or chronic subdural dot do not shon progressive drowsiness or mental change, at least at first but may complain of severe headache with or without neurologic signs. Papil ledema or an elevated spinal fluid pressure may be the only positne diagnostic signs that this group pre sents Headache of itself is of course by no means indicative of an intracranial hematoma Actually drowsy paucnus usually do not mention headache The diagnosis of subdural hematoma is not gen crally made on a single examination but on the pa uients clinical course It is the increasing severity of the signs and symptoms that are important since those present from the time of injury are usually due to laceration or contusion of the brain In summary it may be safely stated that if, after a 1 conscious patient at any time from hours to lechs or cien months begins to show a pro gressive down lll course in mental status or in neuro logic signs andicatne of an intracranial lesion he must be regarded as having a subwlural or other intrag anial bermatoma until it is ruled out onclinical iids Although the clinical piaurt provida the most valuable criteria in the diagnosis of subdural licmatoma there are certain nonclinical examinations that may be of great help These in haad injury ·42 Surgical Cases of Head Injury clude a shiſt of the calcified pineal body in the skull roentgenogiam, pneumo encephalography, ventiicu japhy, electroencephalogi aphy and angiography An studies or angiography are not well tolerated by the very sick patient with a subdural hematoma and bilateral temporal (and/or other) burr holes are safer and nearly always diagnostic Electio encephalography has not been of much help in acute cases but in the subacute and chronic ones has been of great assistance especially when repeated EEGs are done and seveal a progressive abnormality (see under electio encephalography) Localızıng Signs Abnormal neurologic signs due to subdural hematoma although indicative of an or ganic lesion are fiequently not of "localızıng" value 24 Localızıng signs of some degree occur in nearly 50 per cent of the cases, but correctly indicate the side of the hematoma in only about halſ this number In the other patients with localızıng signs these are either falsely localızıng or there is a bilateral hematoma An actual hemiparesis is present in almost a thud of the cases, but in about one quarter of these is on the same side as the hematoma An inequality of the pupils will be found in about half of all cases A slight to moderate enlargement of one pupil is oſ no localving significance A marhed dilatation of one pupil occurs in about 20 per cent and when present is correctly localizing in appioximately 60 per cent In the others it is either opposite to the hematoma or there is a bilateral lesion Convulsive Seizures A convulsive seizure occur ring before operation in patients with 7 subdural hematoma is surprisingly common, being recorded in Pre as lugh as 20 per cent of patients in one series 34 ·Subdural Hematoma Icute Subacute Chronic 43 sure sumably a lacerated or contuxed brain is the cause or 2 contributing factor Tlus high frequency of seizures in the presence of brain injury and subdural hema toma is a serious complicating factor and frequently precipitato a hemiparais or a continuing stupor in an already drowty patient. Pulse Cerebrospinal Fluid Pressure and Blood Pres Although Bronder and Meyers have shown that there is no constant relationship between pulse rate, blood pressure CSF pressure and state of con laousness in cases of subdural hematoma there are certain observations that deserve comment. A slow pulse u found in at least one third of the cases and an elevated CSF pressure in about tho-thurds A rise in blood prewure occur in approximately one third and in about 50 per cent of those who show a rapid down-hill course in the first 18 hours after injury (see Cushing s observations 1) A lughi CSF prasure is the rule in this latter group Vost individuals with a subdural hematoma who des clop a systolic blood pres sure orer 170 are likely to have an clevated lumbar puncture pressure (17 out of 18 cases where such com bined studies were done) A high CSF (lumbar punc ture) pressure, on the other hand in subacute or chronic cases us more often unassociated with a rise in blood pressure Causes of Death. The mortality in cases of subdural hematoma hen all groups are included ranges from 59 to 41 per cent in different series The cause of death in tliose operated in the fint week after injury and especially in those who come to surgery in the first 48 hours may be attributed largely to direct brain trauma A lugh per cent of the deaths among the subacute and chronic cases are in those ·44 Surgical Cases of Head Injury who have become comatose and who might have been saved by earlier operation It is very evident that if a patient is comatose or deeply stuporous before sur gery his chances of survival are greatly lesscued In the subacute and chronic cases coma only too frequently is due to irreversible changes in the brain stem and elsewhere resulting primarily from compres sion by the hematoma 27, 86 which explains the lack of improvement following operation in many of the un conscious patients At operation in some cases the compressed brain fails to "expand" after evacuation of the subdural clot and the mortality is high in this group Surgical Treatment of Subdural Hematoma The timing of surgical intervention is extremely important The acute cases are emergencies and may be indis tinguishable from epidural or intracerebral hema In the subacute and chionic group the drowsy patient must be followed with extreme care and op erated on before the appearance of coma which often, in a drowsy patient, comes on suddenly Local anesthesia supplemented with intravenous Pentothal Sodium, when necessary, is the most satisfac tory method of anesthetizing these patients, especially when they are irrational, drowsy or stuporous Perhaps the most satisfaciory operative approach in patients suspected of having a subdural hematoma is through the temporal region on each side with the patient supine, the head supported by a posterior neck rest (or sand bag), and the head of the operating table elevated (Fig 5) Both sides of the head are explored as about 18 per cent of these cases have a bilateral le The head should be draped so that a large sub temporal decompression and occipital burr holes for tomas SIon

·45
Sabdanl Hematoma Acute, Subacute Chronic
BURR HOLE FOR
VENTASCULOGU
SUPPLEMENTARY
BURIR HOLE
SLEDIRAL
WTORA
EXPLORATORY
BURR HOLE
SUBTEMPORAL
CRANECTOMY
Fio. 5 Popit on of the patient and opently approach used
lo renoving a pubdural or cpidural hemorrhage
ventrculography can be cared out if necessary The
great majority of gulxlural licmatomas can be found
and removed through the subtemporal approach al
though additional bur holes may be made when indi

·46 Surgical Cases of Head Injury cated Obviously if a hematoma is cxposed during the performing of occipital bu holcs foi ventriculog raphy it may be evacuated though such an approach if it is ſuid, oi fuithei bun holes may be icquired more antei 101 ly iſ there is any question of the exist ence of a solid clot Il a hematoma is not immediately cyposed on opening the dura in the temporal 1egion a cui ved instrument may be gently passed throughout the sub dual space over the lateral su face of tlic hemisphicie, hecping it close to the dua and avoiding the bridging vernis nicai tlie longiludinal sinus and low in the lem poial icgion TVhen a senusolid clot oi thich mem branes are present the subtemporal decompression can be crtended to any size desnied and a direction toward the center of the hematoma Iſ the clot is large and semisolid (cuant jelly type) it is often most easily removed by inserting the gloved fingci oi a curved isli umeni widely into the subdural space Some clous aie relatively fum and loculated and this method is then more satisfactory than migating the subdural space with salınc When membianics are encountered a large piece of both the outei and inner onc may be iemoved ſoi di unage though thic decom pression) Sometimes ſuid is picseni bencath the in nei membrane and lience it should always be opened It lias only occasionally been consideicd ncccssary to remove large portions of the subdmal membianos It is well to dian all cascs foi 21 hous with 1 solt rubbci diain iscited through a stab wound in the scalp The dicssing will usually be found soahcd with brown ſud on the fuse postoperative dny Among the advantages of the subtemporal opera ·Subdural Hematoma in Infancy and Childhood! 17 Lion is that when a large opening must be made the decompression Rill be adequately protected by tem poral muscle and fascia which is not true in open Lions in the posterior parietal region In addition with the patient supine and the head of the table clevated the contents of the hematoma will usually gravitate with case out through the subtemporal opening Fpidural and intracerebral hematomas subdural hydromas and areas of intracerebral softening in the temporal or inferior frontal region can also be evacuated through the subtemporal approach In the series of 300 operated subdural hematomas referred to throughout this section it was necessary to turn a bone flap in only a small number of casos and thus was usually to remove an organized liverlike clot or one with unusually thich menıbranes that appeared to prevent reexpanuon of the compressed brain, Certainly in the sick patient with a subdural bematona 2 cranotomy should be avoided it henever possible SUBDURAL HEM \TOMA IYI FANCY AND CHILDHOOD Subdural hematomas are common in infancy and childhood. A history of trauma u obtained in the minority of cases especially in infancy Malnutri uon and a deficiency of vitamin C is present in many with signs and symptoms of scursy in sonle patients. The bleeding and clotting time may be increased The symptoms appear at any time after birth The infant becomes irritable and listlas A convulsive suure often jacksonian in type occurs in a high, ·46 Surgical Cases of Head Injury cated Obviously iſ a hematoma is exposed during the performing of occipital buu holes ſoi ventuculog raphy it may be evacuated through such an approach if it is fluid, or further bun holes may be requned moie anteriorly if there is any question of the exist ence of a solid clot Il a hematoma is not immediately exposed on opening the dura in the temporal region a cui ved insti umcnt may be gently passed throughout the sub dural space over the later al surface of the hemisphere, hecping it close to the dura and avoiding the bridging veins near the longitudinal sinus and low in the tem poral region TVhen a semisolid clot or thick mem branes are present the subtemporal decompression can be extended to any size desued and in a direction toward the center of the liematoma If the clot is large and semisolid (currant jelly type) it is often most easily removed by inserting the gloved finger or a curved instrument widely into the subdural space Some clots are relatively form and loculated and this method is then more satisfactory than irrigating the subdural space with saline When membranes arc encountered a large piece of both the outer and inner one may be removed for diainage though thic decom pression Sometimes ſuid is present beneath the in ner membrane and hence it should always be opened It has only occasionally been considered necessary to remove large portions of the subdural membranes It is well to drain all cascs for 24 hours with a soft rubber diain inserted through a stab wound in the scalp The dressing will usually be found soaked with brown fuid on the first postoperative day Amoug the advantages of the subtemporal opera ·49 Subdural Hematomoa in Infancy and Childhood tolerate the performance of bilateral skull bunt holes which should be made it ſlud continuo to forn in the subdural space Such a procedure is also used for diagnosis in the older child where a subdural tap is not possible The burt holes are placed in such a manner that the subdural space can be drained and a bone Map turned later if necessary Il membranos are found bilaterally they are removed on only one side as thor oughly as possible through a bone flap About a week later a umuar procedure is carried out on the opposite side and the membranes there excised Connient Thc cuolog, and nature of many subdural hematomas in infancy and chudhood appears to be different from that in adults Some systemic factor as mentioned, is often prosent, for instance malnutrition or even scury This factor seem to account for findings rarely seen in adults, such as retinal hemorrhages and fresh bleeding in the subdural space and into the cerebrospinal fud eren in chronic cares Thc hematomas as stated, very often conust of yellow fluid In adults it is true, the subdural ſud may be yellow but these cases are in the munority and not the majority as is true in infancy Furthermore a fluid subdural heroatoma rarely reforms when removed in the adult even though the menubranos surrounding it are allowed to remain In infants and children the subdural space usually rapidly refills after drainage unles the membrane are excisel For this reason alone the membrane should be largely removed in the young pauent. In addition the rapidly enlarging bruin of the infant may be bampered in its growth if a menabrane which constricts it is left in place. In some infants luid ·48 Surgical Cases of Head Injury percentage of cases The patient may vomit and over a period of days or weeks become progressively drowsy The temperature is frequently elevated in part as a result of dehydration Examination may reveal a bulging or tense ſon tanelle with a large head and separation of the sutures in infants In older children roentgen examination may show separation of the sutures and other evidence of increased intracranial pressure Subconjunctival or retinal hemorrhages, are found in a considerable num ber of cases and internal strabismus when the intra cranial pressure is huigh Papilledema occurs in some children where the head cannot enlarge with ease The deep reflexes are commonly increased or unequal and a positive Babinski is not infrequent Hemi paresis or even hemiplegia may appear Lumbar puncture often reveals an elevated pressure and blood-tinged spinal fluid which is xanthrochromic on standing In other patients the spinal fluid is xanthochromic or clear The diagnosis in infants is confirmed by a subdural tap done through the most lateral aspect of the anterior ſontanelle This tap usually obtains a yellow fluid or a bloody one tiat is yellow aſter standing The subdural or spinal fluid as a rule has an elevated protein The majority of these subdural hematomas are bilateral Treatment of Subdural Hematoma in Infancy It is usually wise to remove no more than 15 cc of fluid from the subdural space on each side during the first tap Thereafter alternate sides of the head are tapped every other day removing 15 to 25 cc cach time for one to the neeks During this interval the inſanı generally improves and begins to take its nourishment much better The patient is then ucll cnough to ·Intracrrebral Hematoma 31 subdural one where motor seakness is generally less kevere. A common hátory is that following trauma to the head a patient regains consciousnas aod subsequently becomes drowsy and develops a progressive licmiparais. Exploration is carried out through the temporal regions for a suspected cpidural or subdural hematoma but neither lesion is found On the side opposite the motor weakness evidence of brain injury may be present in the form of swelling subarachnoid hemorrhage contusion or laceration In any case it is wise to enlarge tlie subtemporal decompression and examine the anterior portion of the temporal lobe and the inferior posterior portion of the frontal lobe Not infrequently an area of softened devitalized cere bral cortex will be found Application of the sucker to this arca may immediately lead one into a large intracerebral clot which can be removed with ease leaving a fairly smooth cavity At times it is necessary to colarge the cortical opening and insert retractors to evacuate the clot adequately for some of theiu may be buge, aspecally when a branch of the middle cete bral artery has been lacerated by an overlying de pressed fracturc. lo some patients, as devibed by Botterell 1 hen a portion of destroyed bran u removed with the suctor in the manner nentioned above an area is entered which u Dot hematoma but macerated at times lique fied brain perhaps mixed with a small amount of clot An arca of softening of this type may act like an intracerebral blood clot and gradually enlarge by the acquisition of fud and cause cerebral compression. When such an arca u entered any straining by the pa tient may cause the deritalized brain tissue to be ax truded like vomitus, again leaving a fairls smooth aar ·50 Surgical Cases of Head Injury does not reform following repeated tapping in these Cases it is questionable whether any further surgical procedures are indicated Of course where the etiology is traumatic and no complicating systemic element is present, subdural hematomas in inſancy and childhood are much the same as in adults and then a true blood clot rather than yellow fluid may be found in the subdural space An encapsulated collection of yellow fluid in the subdural space may also result from an inflammatory process such as a meningitis or an otitis media Treat ment of these cases is the same as outlined for sub dural hematoma SUBDURAL HYDROMA OR HYGROMA Occasionally a blow to the head will cause a tear in the arachnoid which allows escape of cerebrospinal fluid in ball valve fashion into the subdural space with little or no associated hemorrhage The fluid accumulates and may cause symptoms identical to those described for subdural hematoma 72 INTRACERLBRAL HEMATONA AND LOCALIZED INTRACERLBRAL MACERATION Traumatic intracercbral hematomas have been esli mated 10 occur in less than 1 per cent of severe licad injuries 24 The signs and symptoms of such a lusion may closely resemble those reported for an epidural or subdural hemorrhagc and diffcrential diagnosis us not usually made picopcraticly A hemiplegia is more common with all mitralichid clot than with a

·4
SURGICAL LESIONS OF THE
SCALP, SKULL AND BRAIN
LESIO\S OF THE SCALP
Hematoma of the Kalp in youth and in adults is
wually not much of a problem The blood as a rule
liqucfies and u absorbed.
A scalp hematoma in infants lilcwise will generally
be absorbed spontaneously Sometime it enlarge
temporanly and occasionally it persists for weeks giv
log invety to the parents.
It the hematoma is enlarging, unsightly or fails to
absorb it sometimes should be aspirated. Thu is done
carefully after proper preparation of the skin by
insetting a needle well to one side of the hematoma
and passing it through the periaanial tissua along
the outer table of the skull upul it enters the fluid
collection Do not tap directly over the clot u the
opening may penist and inlection enter Pressure is
applied to the needle track for many minuta after
withdrawing the neeille to be sure no bleeding occurs.
Cephalhematoma. Occasionally in the newbom a
hematoma kill Lonn under the pericranium and strip
it away from the skull Thu penganjal tissue may
0151fy forming a new outer table of the skull over the
55

·52 Surgical Cases of Head Injury
ity When no evidence of an expanding lesion is
ſound a ventriculogram is usually indicated if the
clinical picture has indicated the presence of such a
lesion (For an excellent paper on intracerebral hema
toma see Browder and Turney, 1942)

·Fractures of the Skull 55 galen und well tied so that the wound edges are firmly approximated. Thus tako all tension off the skin in a hich the sutures should never be tied tightly A dressing is applied and held in place with liquid adhaive or collodion about its edges A roentgenogram of the shull should be taken it there is any suspicion of a depressed fracture. Teta nus antitoun or toxoid 15 used as in all wounds. Afore extensive lacerations of the scalp are handled in the operating room in much the same fashion as described for the smaller wounds The head is shared widely and the scalp painted with antiseptic. Proaine, with epinephrine three drops to the ounce is used to cause a block anesthesia and prevent hem orthage The wound is then copiously washed with soap and water alınc and some merthio ate followed by saline During this stage bleeding u controlled with self retaining mastoid or thyroid retriaon. All damaged tissue is debrideu. Calea sutures of sill or catgut are very useful here to take all tension of the skin before the wound is closed (Fig 6) Actual loss of scalp tissue can make closure complicated and may require ingenious si inging of scalp flaps (sec under penetrating Hounds) FRACTURES OF THE SKULL In this section the important types of shull fnduro are discussed although some of them are not surgical laions. Simple hnear fractures of the skull are of little sig milicasce un diagnosis, prognosis of uraiment. They are evidence that a head injury has occurred, but give no indication as to whether or not there has been ·54 Surgical Lesions of Scalp, Skull and Biain surface of the clot and can be seen in a roentgeno gian In addition pressure erosion of the skull at times occurs beneath the hematoma Treatment consists of early aspiration and rarely oſ incision and removal of a solid clot When actual bone formation takes place this must be exposed and removed Laceration There is a popular belief that lacera tions of the scalp rarely become infected and that in a hospital they should be treated by the most junior interne, usually in the accident room Lacerations do become inſected and this is a serious complication if there is an underlying depressed fractuie, for then osteomyelitis, meningitis oi biain abscess may follow Should an operation for an intiacıanial hematoma become necessary, an inſected scalp intioduces a grave dangei Small lacerations of handled properly may be treated in the accident 100m, but extensive ones are moie saſcly cared for in the operating 100m In treating small lacerations, the scalp should be shaved for about two inches around the skin defect The scalp is then cleansed with meithiolate or a similar solution and may be anesthetized with pio The wound itself is washed with soap and water and then swabbed with meithiolate followed by saline The round is diaped with moist lowcls The depths of the wound wie now carefully ex amined, explored with the gloved ſinger, and gently piobed iſ necessary to rule out completely the possi bility of a depressed fidcture I he shin cdges aic debuded with scissors, the round is gaun washed with saline and closure carried out If there is active bleeding one or more sutures 11C used though the caine ·Fractura of the Skull 57 Simple depressed fractures are treated surgically in adults unlas the depression of the inner table is only a fer millimeters in depth (nically they may be palpated through the scalp but this method can be deceptive. A hematoma of the scalp rather commonly will have a soft center and fimm edges which to the palpating finger gives the definite impression of an area of depressed skull Roentgenograms are neces. sary for diagnosis and for deciding the type and loca tion of the skin flap that is to be turned down in ex posing the fracture. When the depressed arca u in the frontal region the skin inasion should be along the line of the coronal suture within the hair line The operative procedurc odieruise is as described below for compound depressed fractures of the skull The chief difference is that when the fracture is not compounded the bone fragments after being removed are usually thoroughly washed and replaced Deprewed Fractures lo the Newborn Simple de pressed fraaures are common at birth and are often associated with an extensive indentation of the lat eral aspect of the skull At times an indentation is present without any actual (racture and in some cases can be corrected by manipulation of the skull The depressed shull must be corrected promptly and thus requira surgery aspecially if a fracture is present. In these cases the area of depression unlike those in adults, inust be truly elevated. The proce simple burr hole is made in the skull and the bone elevated everywhere to its normal contour with a Mat director passed between the dura and the skull Compound Fractura. The ordinary compound dure is

·56
Surgical Lesions of Scalp, Skull and Brain
SKIN SUTURE
GALEA SUTURE
B
д
Tic 6
Galca and skin sutures used in closure of the scalp
intiaci anial injury
They require no treatment in
themselves and will heal in about six months in chil
dren and at a latei date in most adults Presumptive
but not absolute evidence of fracture is the presence
of a periorbital hematoma following a blow to the
bach of the head, ecchymosis behind the ear, blood
in the middle ear causing discoloration of the drum,
drainage of blood from the nose or ears, or edenia ex
tending in linear fashion over the lateral aspect of
the shull Escape of cerebrospinal fluid from the nose
or cars, of course, means that there is a fracture
Bleeding from the ear may occur in the absence of
fracture as a result of laceration of the car canal fol
lowing a blow to the jaw
What has been said of simple linear fractures ap
plies equally to simplc comminuted fractures If the
latier arc extensive one may surmise that the blow
has been quite severe but little more

·Fructure of the Skull 59 The head u ubaved and the wound prepared anet thelijed and draped as described for extensie lacera cons and for penetrating wounds. The lacerated area is cuced and the sound extended with a straight or curred incision to expose adequately the area of de pression (Fig 7) Self retaining retractor, Vichel clips or hemostats on the galca are enployed to con trol bemorrhage. With the common depressed frac ture seen in auian life that occurs from a blunt in strument like a hammer or larger object a small trough of bone is removed entirely around the periph ery of the depressed area To start this removal usu ally requires the making of a burt bole to one side of the depressed region (Fig 8A and B) but at times thu u unnecessary as a purchase with the rongeur may be possible on one of the bone fragment. After removing the trough of bone as described (Fig 8C) all the depressed fragments can then be extirpated almost aimultaneously Any underlying varsel on the dura or brain which bleeds when the pressure of the bone 13 removed can now be promptly controlled with silver clips (Fig 8D and E) coagulaung current Gel foam or Gbrin foam Do not elevate or withdraw ang bone fragments unul it u possible to remonc al most all the depressed area rapidly at the same time or bleeding may be started beneath this area and cause severe damage to the brain before the remaining frag dients can be rongeured anay and the offending vessel taposed It should be noted that except in children com pound depressed fractures are very rarely elevated." The bone fragments are removed and usually dis carded although they may be mashai and in some casos replaced Little concern need be given to the ·58 Surgical Lesions of Scalp, Skull and Brain LACERATION OF SCALP INCISION LINE A DEPRESSED FRACTURE B Tic 7 A and B Methods of debridement of 1 sculp laceration and exposure of a compound depressed fracture of the skull linear fracture of the shull passing beneath an area of lacerated scalp requires no treatment except cleans ing and debudement of the wound as descuibcd A simple linear or even slightly depressed fracture into the paranasal sinuses is best treated with sulla drugs and antibiotics, unless complications ause Compound depressed fractures occurring over the vertex or convexities of the shull should be treated surgically The hazards of meningitis, brain abscess, brain damage, and post-traumatic epilepsy are too great to handle them otheru ise The diagnosis is made by inspection of the wound and by roentgenogram The laceration of the scalp frequently lies at some distance from the underlying fracture and this must be considered carefully in plan ning the draping of the head and the scalp incision to uncover the depressed arca (Fig 7A and B)

·Cructuic of the Skull
61
LACERAT OD DUNA
ELVER CLIP ON
TORN DRAN VESSEL
SILVER AP OM
TORN DURAL ATTERY
LACERATED BANIN
FIO 8 Conl)
Illicn tlit undailymy dua and bain lave lxen
exposcul tlic first concern is couliol of hcmoulugc A
large piece of inoist galize or biram cotion (m 1xc
quickly placed over tlic cxposeel arca and licmorrhage
controlled with guitle pretulic l'lic gau/c is rc
moveel in stages and each blecier indlal will clip
or coagulation as it is cxjxner! Is mentione! Wien
bleeding is plcxent Veturcen lura and skull the dura
can Ixc situel to tlic perimtcum tlus timpoing it
Against thc muer table of the cranim If the dura
1 intad a tiny sila usually should Ixc openal cspc
cally if it appears blue to rule out a sulxluril lienia
tona
If tlic dua is alically lacciate thic cxlxonal
lorain is my metal carclully and any grossly macerata!
portion gently removal with the sucker Vacciatel
Lrain may be not only a source of inſection but ol
latcr kur formation Obviously subdural or intra
cerebral hematoma also slionld be evacuata! To

·60
Surgical Lesions of Scalp, Skull and Biain
fact that a shull delect will be left as this can be
covered by a plate at a later date
DEPRESSED
FRACTURE
д
w
BURR HOLE
TROUGH OF
BONE RENOVED
w
110 8 Stiges I Bind C un removing in area of do
pressed shull fruit Bonc Irigments should not be dis
urled until Suige Clics been completed Control of
bluding D from middle menige alicssel ud l. from
brun rosscl lucr vooral of depressed shull fragments

·Penetradag Wounds of the Brain 63 there are signs of neurologic deficit. In urcating more severe and possibly cobtamunated depressed fractura involving a sinus expert surgical handling us required. At least 1000 cc, of blood should be available. As described, in any deprased fracture fragments of bone should not be removed until the entire de prased area can be elevated at the tame time. If a tear in the sinus 1 encountered it should be covered immediately with brain cotton and compressed with the finger 10 present air entering Preparation is then made to close the opening If the size of the tear us small this may be sutured, or a piece of muscle can be futured over it. When a shelf of intact bone lies above the torn area muscle or Gelfoam an be placed over it and the dura futured to the pericranial tissues, thus tamponing the hole in the sinus done so often to control dural bleeding in any crani otomy When a dural sinus is tom completely across it should be securely ligated or closed with silver clips AS 13 PENETRATING WOUNDS OF THE BRAIN Our knowledge of the treatment of penetrating wounds of the brain has been derived chiefly from var experiences, 2.17 13, 14,4 although such in juries are not uncommon in peacetiine The basic principla involved in the handling of these cases as laid down by Cushing in World War I remain applicable today but the use of the sulla drugs, peni allin and emergency transfusions as well as carlier treatment of the round by the neurosurgeon in World llar II has led to certain changes in management and has lowered the mortality rate Chandication of Penetrating Woumdı. Vthough ·62 Surgical Lesions of Scalp, Skull and Brain the dura is then closed tightly using, if necessary, a periosteal graſt, temporal fascia or fascia lata Penicillin oi sulla powder should not be used on the biain for fear of causing convulsive seizures It is best to leave a thin rubbei diain through a stab wound in the scalp ſor 24 hours Compound Fractures into the Frontal Sinus A compound depi essed fracture of the frontal region in volving the frontal or ethmoid sinuses, iſ extensive, or if it includes the poster 101 wall of the frontal sinus where the dura may be lacerated, should be ticated surgically The area of involved bone can be ap proached under local or general anesthesia through the skin laceration oi, iſ this is small, though a long coronal incision luining the skin flap forward over the face The frontal sinus usually should be com pletely oblitcrated down to the frontonasal duct, re moving all mucous membrane and the entire posterior wall of the sinus The duct can be covered with a small piece of Gelſoam The dual and biain wound are handled as alieady descubed and the dura closed tightly A loose packing and steule catheter or soft rubber drain may be left in place and brought out through a stab wound to one side of the eyebiow Daily irigation with penicillin or baciliacin though the catheter can be used The packing usually is en tirely removed in several days Antibiolics and sulfa drugs are best continued for a weck or moic Compound Depressed Fractures Involving the Longitudinal or Major Venous Sinuses 11 Small slightly de pressed compound fractures over a venous sinus due to a blow from a blunt instrument are at times best left alone except for superficial debudement, unless ·If a Penetrating Wounds of the Brain 63 there are signs of neurologic defiat In treating more severe and possibly contaminated depressed fractures involving a sinus expert surgical handling is required. At least 1000 cc. of blood should be available As daanbed, in any depraised frađure fragments of bone should not be removed until the entire de pressed area can be cleated at the same time. tear in the sinus is encountered it should be covered immediately with brain cotton and compressed with the finger to prevent ur entering Preparation is then made to close the opening If the size of the car is small this may be futured, or a piece of muscle can be sutured over it TVhen a shelf of intact bone lias above the torn 2rca muscle or Gelfoam an be placed over it and the dura futured to the percranial Lusus, thus tampooing the hole in the sinus as us done so often to control dural bleeding in any otomy When a dural ainus u torn completely acos it should be securely ligaied or closed with silver clips PENETRATING TIOUNDS OF THE BRAIN Our Inowledge of the treatment of penetrating Hounds of the brain has been derived chiely from war expenences, 21,43 although such in junies are not uncommon in peacetime. The basic prinaplos involved in the handling of those cases as laid down by Cushing in Vorld lar I reun applicable today but the use of the sulla drugs, pens allin and emergency transfusions as well 2 earlier treatment of the wound by the neurosurgeon in World llar II has led to certain changes in management and has lonered the mortality rate Clanlfication of Penetrating Wounds. Although ·64 Surgical Lesions of Scalp, Skull and Biain there is an infinite variation in penctiating brain wounds they may be satisfactorily divided into four groups 1 Wounds in which an instrument like a knife or icepick is thrust into the brain 2 Wounds in which bonc ſi agments are driven through the dura into the brain as in the gutter type of bullet wound, or in the common depressed fracture resulting from a hammer blow 3 Wounds whicre in addition to pieces of bone, a bullet or shell ſragment has lodged in the brain 4 Wounds of through and through type, with a point of entry and of exit, where the missile passes directly through some portion of the intracıanial cav ity Signs and Symptoms and Indications for Treatment A practical classification of the early signs and symp toms is one based on the severity of the injury which, of course, will depend upon many factors in cluding the type of penetrating missile and the ſunc tion of the area of brain damaged A patient may be critically injured, seriously injured or less seriously injured An assessment of the severity of the condi tion will determine whether the patient can tolerate surgery and, if so, how urgently it is indicated The critically injured are those who appear more or less moribund ſiom associated wounds to other parts of the body damage to the vital centers of the brain, or brain compression from intracranial hemor rhage and brain maceralion In this group nice judg ment is required in selecting patients for surgery Those in shock, especially from hemorrhage or asso ciated injury, should be given immediate care At tention to fractures, chest or other sounds, may im 100 ·05 Penetrating Wounds of the Brain prove the patients condition to the point where the Intracranlal injury can be assessed and treated surgi cally when indicated. It seems established that there ve few operative neurosurgal emergences among cuses of penetrating wounds of the brain and that actually the citially or seriously injured may usu ally be benefited by 12 to 24 loun of conservative treatment. On the other hand 1 hen signs of severe brun compression from probable intracranial hem orrhage are present emergency surgery is indiaid provided the pauents condition does not appear hopeless. The seriously injured patient with a penetrating wound of the brain is one in wliom the wound is seri ous, but the general condition and vital signs do not sugget immediate danger to life. In these cases sur gery should be performed as soon as proper facilities are available They should be treated as emergences, especially if the condition begins to deteriorate ap parently as the result of intracranial hemorrhage The less seriously mjured are those with penetrat Ing brain wounds that bave not resulted in any senons neurologic or general physical abnormality Those patients are conscious and may be ambulatory Some of them will have insignificant scalp wounds through which a piece of sbarpnel has penetrated the brain without in some cases, causing a loss of consaowness Such casos illustrate how atential it is never to over look or underestimate tlie seriouness of the smallest scalp Hound Surgers may be postponed temporanly in many of thu group Surgial Treatment of Penetrating Wouds The present treatnient of penetrating wounds of the brain 13 well established Treatment at or near tbc ·66 Surgical Lesions of Scalp, Skull and Brain place of injury should consist of emergency care of shock and of hemorrhage, iſ necessary The head Hound must not be tampered with except peiliaps to shave and cleanse the surrounding scalp, control sur face bleeding and apply a dressing Tetanus anti loxin and antibiotics are given if there is to be some delay in definitive surgery It has been shoun that patients with penetrating wounds of the brain stand transportation very well unless they are in shock They should be taken to a hospital » here modern neurosurgery with all the nec essary equipment is available In wartime this was usually the evacuation hospital five to 20 miles be hind the front line These wounds must be treated as Cushing stated in an "all or none fashion " In complete operations must never be done The general management and surgical approach is much the same as described for the ordinary com pound depressed fracture Adequate stercoscopic, pre operative roentgenograms of the shull are taken and ample blood for transfusion must be available The head is completely shaved and operation carried out under local anesthesia if thc patient is cooperative Otherwise endotrachcal ether is used Before draping the head, the shin incision to be employed must be carefully considered The old tripod incision used in World War I has been largely abandoned Thc arca of lacerated scalp is excised and the incision either extended in linear ſashion or curied around the periphery of the area of involved shull so that a flap can be turned (Fig 7A and B) This flap can be rotated at the time of closure to cover an area of skin defect iſ necessary When a scalp defect is left it sliould be over a normal area of skull ·67 Penetrating Wounds of the Brain LIGHTED RETRACTOR LAISLE TRACT RUCTION TLP B WORVEX DONE FRAGMENTS KETALLIC PAGHEXT FC 9 and B Debridement in a case of penetrating wound of the brain. and this sliould be skin grafted immediately if possible usually with a split thickness graft Thorough débridement of the wound must be car ned out 411 devitalized soft tissno and all bone fragtoents are removed as described for compound depressed fractures. The cranial defect is enlarged unul normal dura is eteryu here exposed. The dura 15 débrided excising as little as possible. The brain itself is not carefully debrided removing all macer ated brain and bone fragments with the ud of gentle suction (Fig 94 and B) The tract into the brain 13 follored under direct vision to its depths. If infec cion u to be presented it is essential that all bone fragments be oblamed with if necourt the help of additional roentgenograms, and thus u truc also of all

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·ar OTHER SURGICAL COMPLICATIONS FOLLOWING HEAD INJURY TIOUND INFECTION Tlound inſection las always been one of the most dreadel compliations of head injury Fortunately this complication us nos not so comnion and usually not so serious since the introduction of modern neurosurgery and the line of the sulla drugs and antibiotia. In closed head injuries meningitis can occur as a roult of a fracture through a paranasal sinu or into the middle ear but braun abscess is rare. Very oca sionally after a contusion of the scalp an inſection sets in Icading to osteontyelitis of the skull which may be followed by an abscess in the cpidural or subdural space or within the brain Infection in open wounds of the scalp cranium or braid 15 more common Infection in a diplo laceration of the scalp is not usually a verious complication unless intracranial sur gen) through this area is contemplated 11 hen it oc curs and is maniloted by reddening and tenderness of the skin edges the head is shared rather widely 71

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·Wound Infections 73 Dragnosis of Deep Infection Deep infection and even chronic brain abscess formation may talc place with few symptoms and signs aspecally when anti biotia bave been used Early symptoms include head ache and stiff neck. The latter may be absent Head acha are nearly always present but may be somewhat delayed and come on gradually The decompression mlry cease to pulsate und become tense Papilledema commonly is present accompanied by neurologic signs of an expanding brain losion Signs of mchingius an appear at any time, aspecially during the fint three weeks after injury through spreading of the in. fection into the ventricla or subarachnoid space. Treatment of Deep Infection It has been dernon strated in the past war that when deep infection occurs in a penetratiog wound debridement or re debridement should be came out without delay Truc abscess formation may not yet be present but it is deemed unwise to wait in the hope that a cap sule will form In most cases roentgenograms will reveal retained foreign bodies and those will be found to lie in 2 pochet of pus with varying amounts of necrotic brain along the missile tract. All pus for cign bodio and devitalized brain are removed with the sucher and the dura and salp closed without drainage. When unhealthy granulation usue is pres ent beneath the Kalp it is usual to drain the wound for a few days Chronic Brain Abscess In some patients a post traumatic brain absceu is treated in the same manner as used in nontnunatic asa. aally true if no foreign bodios remain within the brain If the abscess is chronic and a fairly thick capsule has formed the abscesi may be excised. " This is ope ·72 Other Surgical Complications the skin sutures removed and moist diessings applied If there is purulent drainage, the wound should be packed loosely open and local bacitracin, sulfathiazole or other ointment used The appropriate antibiotic can be given after testing the organism's sensitivity, if desired Infection Following Penetrating Wounds Superficial infection can be a very serious affair when it takes place as a complication following cranı otomy or craniectomy perſormed in the treatment of intracranial hematoma or of a penetrating wound Such an infection most often is due to improper scalp closure The infection may remain in the scalp and linger on for weeks causing one galea suture after another to slough out On the other hand, and espe cially if the dura is leſt open, the infection may ex tend inward causing an osteomyelitis, a meningitis or an intracranial abscess Treatment will vary with the circumstances Hot, wet dressings, antibiotics and removal of sutures may be sufficient if the infection is confined to the skin Low-grade infection in the extradural tissues inay persist In such a situation if a bone ſlap, shull plate or extradural bone fragment is piesent it usually has to be removed before healing will occur Deep infection in the epidural or subdural space or within the cerebral hemisphere may follow any inadequately treated compound compound depressed fracture with lacerated dura and brain In penctrating war wounds deep infection has been found to be icn times more frequent when a foreign body, especially a bone fragment, has been left within the cerebral hemisphere 63 ·Cerebrospinal Muid Rhinorrhea 75 The same injuries has been dacribed in Chapter 2 general treatment is used when meningits develops in a patient with a penetrating wound of the brain In addition the local source of the infectiop which is often a retained foreign body is generally created surgically Cerebral fungus or in other words a herniation of braun tissue through an opening in the skull may follow operation for an intracranial hematoma or penetrating wound. It can be of two types a benign fungus which is the roult of local cerebru wound inledion and an open dura, or a malignant fungus due to increased intracranial pressure caused by deep mlection brain abscess, hematoma or rarely necrotic brain issue In the lyoniga type hot wet dressings and antibiotic are used and the fungus usually will lical With the malignant form the hernia w progres sive until the cause is attached directly and cradicated Osteoing elites of lou-grade localued type may fol low any compound depressed fracture or jacracanal operation. It can usually be handled with case by removal with rongcun Only occasionally dod the disease process spread to involve a large area of skull CEREBROSPIN IL FI UID RIIINORRHEA Dramage of cerebrospinal flud from the nose or rhinorrlvea (sec (eman 1911) has been mentioned in Chapter' Nonsurgical Cases It niay occur as a result of a fracture insolung the frontal ethmoid, or occasionally the sphenoid sinus. For such drain age to take place there must be a copimunication be ineen the subarachnoid sue and the paranasal sidiu ·74 Other Surgical Complications If the lesion is less chronic the abscess can be diained by tapping and injected with 10 to 20,000 units of penicillin 105 on one oi more occasions and then ev. cised Antibiotics and usually sulfadiazine are used parenterally in all these cases, but as mentioned, there is a danger of convulsive seizures iſ penıcıllın is used on the brain aſtei excising the abscess I have seen a psychosis develop during migation of the brain with penicillin following excision of a temporal lobe abscess Meningitis Meningitis may occu as an occasional complication of a closed head injury when there is a fracture involving a paranasal sinus on the middle ear Meningitis is common in cases of penetrating wounds of the biain Diffuse infection of the subarachnoid space hias a habit of coming on suddenly This is particularly true in closed head injuries where the patient may become iapidly comatose over a period of 24 hours If the diagnosis is not made early it may be too late to save the patient Honevei, prompt treatment usually produces a diamatic iecovery The cardinal symptoms and signs are headache, diowsiness, high ſevei, stiff nech and othei signs of meningeal irita A case of meningitis can be overlooked in pa tients with acute trauma to the head since they so often have a stiff nech and high fever in the absence of meningitis However, when a patient who has been doing fairly well develops a sudden uise in ſever, meningitis should be immediately ruled out and especially if dionsiness or signs of meningcal irritation appear The treatment of meningitis in patients with closed tion ·Skull Defects and Their Repair 77 SKULL DEFECTS AND THEIR REPAIR Repair of skull defects or cranioplasty is frequently necessary in care of head injury following surgery or after treatment of compound fractures or penetrating wounds The skull defect may be covered with bone tantalum. or a number of other substances that cause little adverse tissue reaction Small defects ray the size of a 20cent piece, usually do not require repair except for cosmetic reasons and will become firmly covered by fibrous tissue Larger defects may bulge when the patient sloops over and if associated with headaches diziness or other incapacitating symptoms probably should be repaired. Somc patients develop apprehension and other psycho logical disturbances because of a skull defect which they believe renders their brain susceptible to injury il they cannot be reassured on this point repair 13 often helpful and of course is indicated when the patients occupation is such that the area of skull de feat might be injured On the other hand many pa uents will retpain well and asymptomatic with large cranial delects. There are many methods of making a shull plate and also of inserting 11.* The plate olay be made preoperatively say by the dental department as in the last har This method is useful in complicated plates where for instance a frontal bone with supra orbital ridges must be reproducer! The arcrage plate can be niade with ease by the surgeon Preoperativels * piece of paper 1 laid on the shared scalp and with a penal the outline of the defect is drant on the pa per making the drking meri here about one-quar ·76 Other Surgical Complications which implies a laceration of the arachnoid and the dura near or at the site of the fracture Because of this intracranial communication there is always dan ger of a meningitis In addition air may be driven in ball-valve fashion up through the nose and fistula and collect in the subdural space, within the brain, or even in the ventricles Such a collection of air is referred to as an aerocele, is visualized by roentgeno grams of the skull and at times produces signs and symptoms of an intracranial expanding lesion The initial treatment of rhinorrhea is usually con servative as ali eady described and most cases will clear up within about one month If the ihinorrhea per sists, oi iſ meningitis or aerocele appear it is then ad visable to obliterate the fistula by intracranial closure of the dura An endeavor is made to localize the site of the fracture roentgenographically and a rhinologist attempts by direct vision to see from which sinus the drainage is occurring The operative approach may be unilateral through a transſıontal craniotomy If the cribiſorm plate is involved a bilateral liontal ſlap The fistula can be approached either extra oi intradurally It is excised and the dura closed with, if necessary, a fascial graſt Gelſoam may be placed over the fracture site extradurally Any acio cele present will be spontaneously absorbed, but if it is under tension it can be tapped with a venticular needle When a compound depressed fracture of the frontal region with or without laceration of the overlying scalp is present and accompanied by a shinorrhea, im mediate surgical repair is indicated The compound fracture is treated as previously outlined and the fis tula closed is used ·Skull Defeats and Their Repair 79 merely laid over the defect and fixed in place with tantaluon wedges In certain regions to present slip ping, or where the skull is thin a portion of the plate can be sutured to the soft tissues or occasionally to bone after making drill holes This simpler method of inserung the plate usually avoids exposing Uic dura and stripping it from the skull which is necessary when drill holes are made for wiring Plates have been inserted at the primary open tion for depressed fractures and other contaminated Hounds but it is probably best to wait six months be fore performing cranioplasty in such casei. In clean operations a Ikull defect may be covered immediately Postoperaurely infection is uncommon after crania plasty but sterile fluid may collect around the plate, sometimes for weeks requiring aspiration and the application at times of an clastic bandage to the head. Arteriovenow Aneuryo Occasionally a fracture of the skull will cause a tear in the carotid artery us it passes through the cavernous sinus As a result the arterial blood is forcefully pumped into the venous sinus There follors venous congestion and back pressure with elema of the periorbital tissues on the involved side The cye is gradually and usually progressively pushed outward at times leading to extreme cophthalmos, swelling of the conjunctiva and even corneal ulceration The extra-ocular musclo become cieraatous and all or some of them cease to function. The patient may or may not hear a bruit with ach heart beat and careful inspection commonly recals a simultancous pulsation of the se. On auscultation 01er the cyc or temporal region a definite bruit is heard and this usually well disappear on compression of the carotid artery on that side When the sterbo ·78 Other Surgical Complications ter to one-half an inch larger than the actual defect A piece of tantalum is then cut with scissors to the size of the diawing Several newspapers or towels are laid on a haid surface and on this the piece of tantalum 15 pounded with a round-headed steel oi wooden hammer The metal is malleable and with a little practice can be beaten to any shape desired in a few minutes At intei vals it is laid on the patient's scalp ſoi comparison with the contour of the sur rounding skull and treated until it has the correct וורנfo At operation it is generally pieſe able to explore the defect by excising the old scar in the scalp if thuis lies over the defect The incision may then be ex tended to any length desnied oi cui ved about the mai gins of the deſect Adequate exposure is essential At times, especially in the fiontal region, it may be preferable to turn a skın ſlap There are several inethods of inserting the plate The bone edges may be exposed and a shell cut in the outer table so that the plate may be inlaid 39 The plate is then held in position until tantalumn wedges, used lihe glazier's points, are driven into the bone aiound the margin of the plate The plate may also be wired to the shull through drill holes in the bone about the periphery of the cranial defect A much simplei, moie rapid and highly satisfactory way of inserting the plate is as follows With a scalpel the periosteum is incised around the maigin of the defect and about one quarter inch way from it It is then brushed backward with a periosteal elevator ſoi a short distance The hand made plate, fashioned picoperatively or at operation as described, is then ·Pou-raumatic Epilepsy 81 Folloning ligation of the internal carotid artery the bruit may disappear only to return the next day After about 48 hours it may again disappear and this time permanently apparently as a result of tlirom. bosis within the internal caroud which extends up ward far enough to obliterate the fistula into the avernous sinus. With the disappearance of the bruit the signs gradually recede and the patient u cured. Unfortunately only too often the bruit persists and it is then necessary to ligate the carotid arter) intra Canually as well as in the neck. ARACHNOIDAL CYSTS Pauents who have sustane a fracture of the skull with an underlying laceration of the dura and brain Octasionally develop an arachnoidal cyst. Spinal fluid excape through the laceration and at time even extra Tubully In tune collections of fluid become sur rounded or encapsulated by outgrowing arachnoid forming a cyst Overlying the gu the bone along the fracture line sometimes atrophies leaving a skull deſect with unregular scalloped edges In the roent gen ray films the fraaure will be seen running into thu characteristic defect If symptoms are present or the condition is pro gresive operauon may be indicated at which time the gets are excised and the dura closed POST-TRAUMATIC EPILEPSY Vier a head injury a convulsi e semure may occur during the first few days or wechs or be delayed until Lometime in the future alien the brain ha recovered from the acute ellects of trauma Wien late Keizure ·DOSIS 80 Other Surgical Complications scope is placed over the eye the eyelid on the opposite side should be closed gently with the examiner's fin ger Otherwise flutter of the eyelid may simulated bruit Roentgenography of the skull may show a fracture Carotid angiography is useful in confirming the diag Usually the injected Diodrast is seen in the carotid artery up to the region of the fistula where it enters the venous system Treatment of Arteriovenous Aneurysm Belore per forming any surgery it is well to test and at the same time improve the adequacy of the collateral circula tion by compressing the involved carotid artery in the neck for gradually increasing intervals during about one week or longer This may be done digitally at first or with a mechanical apparatus that can be left in place Occasionally the fistula will heal spontane ously after a course of intermittent carotid compics sion ing fashion Usually surgery is carried out at the end of a weck, or sooner if the condition is piogressing in an alarm There are several ways of approaching the problem A satisfactory procedure is to obliterate the implicated common carotid artery in the neck with a home-made tantalum clip About one weck to ten days later the internal carotid artery on that side is also closed with a tantalum clip or Selverstone clamp The procedures are done under local anes thesia and the patient's motor power and state of con sciousness tested for a half hour or more before clos ing the wound During the next week similar testing is carried out at very frcqucnt intervals, so that the clamp may be removed immediately from the artcry if any sign of weakness appears The bruit should also, of course, be listened for ·Post traumatic Epilepsy 83 considered to llave an associated cerebral contusion as the probable cause of the seizures Braun injury during birth is a most important cause of epileps) ocaining later in life. In the process of delivery the brain can be injured by local trauma compression or ischemia Avanety of brain lesions may result frodi birth injury including meningocere bral acatrix areas of cortex where the gyti are small and shrunken (microgy ni) and more extensive lesions of a cerebral hero isphere One of the most important cpileptogenic lasions is scaring of the medial and inferior portion of a temporal lobe * apparently re sulting from berniation of this area over the edge of the tentorium on excessive molding of the hand dur ing birth Surplal Treatment. The problem of surgical treat ment in cases of cpilepsy is too extensive a one to be considered here except in a superficial manner The outstanding works of Pepfield " w and his associates would be consulted for an understanding of this mort important subject Surgery is used in the treatinent of certain carefully Kelected cases " that hare failed to respond satis- Cactorily to belial treatment and the appropriate usc of anticonvulsive drugs The selection of patients for surgery is a complı ated one and includes many individual factors in The usual basic criteria required before exploring a patient for an epileptogenic laion are evidence in the history and on observation that the attacks harc a focal ongin in the surgially approach able cerebral cortex or in the anterior or medial por tion of the teniporal lobe's and confirmatory eti dence in the electroencephalogram and in air studios each cause ·82 Other Sugical Complications appear they tend to be iecuirent Until further fig ures are available it is difficult to estimate with what frequency patients who have had seizures within sev eral weeks following a head injury will latei develop epilepsy The incidence of late epilepsy following penetrating war wounds of the brain is lugh, having been esti mated by Ascioſt as occurring in 23 per cent of pa tients in whom the dura semained intact and in 45 per cent of those with dual peneliation In gunshot wounds as a whole, the incidence of epilepsy reported in one series of 500 cases 31 from World War I was 98 per cent, but this rose to 18 9 per cent where the dura was penetrated, to 26 1 per cent with retained metallic ſiagments and 66 7 when bone was ietained The occurrence of seizures either carly or late is very low in cases of closed head injury in general, being reported as much less than 1 per cent by El On the other hand in a series of 300 sub dural hematomas with closed head injuries, 60 had a convulsive seizure before operation, an incidence of 20 per cent, 24 56 of the patients with seizures had acute or subacute subduial hematomas associated in most cases with iecent severe brain injury and cerc bral contusion or laceration It seems more than likely that the brain contusion or laceration lather than the subdural clot has the cause of the sei/i1 es in these cases If this is so then early convulsions may be as frequent in closed head mjuries as in pene trating wounds providing there is brain contusion or laceration These findings are in keeping with those reported in another series 60 of 71 patients with sub dural hematomas, 25 per cent of whom had one or more convulsive sciuics Most of this group were vidge -

·6
SPECIAL AIDS IN
DIAGNOSIS
TECHNICS
Lunbar puncture is a simple procedure and can pro
vide much valuable joformation of properly per
formed. When incorrealy used or carried out it can
be harmful and supply muleading data
The pauent should be on his ride near the edge of
the bed and his spine flexed by drawing the knea into
the abdomen and gently flexing the neck A pillow us
used under the head to avoid lateral Dexion of the
neck and compression of the jugular vein An un
sterile tonel is placed bencath the patient to protect
the bed from the colored antisepuc solution used on
the skin of the back. With the thumb nail the inter
space between the spinous processes of the third and
fourth lumbar vertebrae is marked with a cross di
rectly in the midline. Thu interspace lies just above
the pelvic brio The interspace immediately above
or the two below may also be used if desired.
Stenile gloves are not used and the back widely
painted at the level chosen with merthiolate or other
antiseptic. Do not lise drapes. A few drops of 1 to
2 per cent procaine can be used in the skin
A 19.
87

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·6
SPECIAL AIDS IN
DIAGNOSIS
TECHNICS
Lumbar puncture is a simple procedure and can pro
vide much valuable inforination of properly per
formal
When incorrectly used or carried out it can
be harmful and supply misleading data
The patient should be on lus side near the edge of
the bed and hu spine flexel by drawing the knets into
the abelomen and gently ſleting the neck A pillow us
1.sed under the head to avoid lateral flexion of the
beck and compression of the jugular vein
Anun
sterile towel u placed beneath the patient to protect
the bed from the colored antiseptic solution used on
the skin of the back. With the thumb nail the inter
space between the spinous processes of the third and
fourth lumbar vertebrae u marked with a cross di
rectly in the midline. This interspace lies just above
the pelvic brim The interspace immediately above
or the two belost may also be used if desired.
Sterile glove are now used and the back widely
painted at the level chosen with mathiolate or other
Antiseptic Do not use drapes. A few drops of I to
2 per cent procaine can be used in the skin 1 19
07

·88 Special Aids in Diagnosis gauge lumbar puncture needle is inserted at the spot marhed, aftei checking the position of the spinous processes The point is inserted so that it just misses the tip of the spinous process below it Holding the needle so that the shaft can be well visualized it is slanted slightly upward, about 30 degrees, and advanced slowly and steadıly forward, Leeping it in line with the longitudinal aus of the spine and on the same plane as the spinous processes Advancing the needle in jerks is painful Usually the point can be felt to pop through the dura It is advanced another one eighth to one fourth of an inch The stilette is withdrawn and immediately replaced if fluid escapes If no fuid is obtained the needle is advanced a little furthei in stages, each time withdrawing the stilette, until Nuid escapes If the needle strikes the anterior wall of the canal it is withdianın in stages If still no spinal fluid is obtained the procedure must be repeated When fluid escapes from the needle be careful not to lose more than a few diops Apply the water manometer to test the lumbai punctue pressure Now ielax the patient's legs and extend them a little so that he is not suaming in any way Have the aims lie loosely on the bed Ask the patient to ielas completely, close his eyes, and breathe in and out with his mouth open Usually the cerebrospial ſud piesswe will be noted to fall gradually until it leaches the correct reading for that patient This may take The normal pressure is anywhere [rom about 70 to 160 Any stiaining whatsoever will give a false reading Now remove the desired amount of fluid slowly and take a final reiding If a lumbar puncture is done aluays take a pres many minutes ·Technia 89 sure reading Don t try to osumate the pressure by the rate of ccape of the CSF This is grossly in accurate Remove a few cubic centimeters of fluid into each of three tat tubes In this manner an eval uation an be made as to the origin of any blood whidi may be present. If the lumbar puncture itself has caused the bleeding the first tube will contain the most blood. If the blood camac from intracranially all the tubes will be the same color or the third one may be a deeper red Never do a lumbar puncture on a patient with an acute head injury if he struggles and resists and never compress has jugular teints to perform a Qucchenstedt test. Either procedure may produce a harmful rise in intracranial pressure and straiping may result in a rise in blood pressure and consequent innanul hemorrhage Pnoumo-encephalography was introduced by Dandy in 1919 In this diagnostic test the cerebrospinal Nuid is withdrawn and replaced by air or other gas The air fills the ventricles and subanchnoid spaces of the brun and will thus outline them in rocntgenograms Laken of the skull A pricumo-encephalogram is performed with the patient m the sitting position The head is flexed slightly forward and the arnis supported in front of the patient on a rost A sheet is tied around the thorax and bencath the mullas and then about the chart for support w ben an anesthetic is tised. Some use local anesthesia and sedation The patients have much less pain react better and have less shock if intravenous thiopental sodium is used I lumbar puncture needle is inserted at the third or founh lumbar intenspace and a pressure reading ·88 Special Aids in Diagnosis gauge lumbar puncture needle is inserted at the spot snarked, after checking the position of the spinous processes The point is inserted so that it just misses the tip of the spinous process below it Holding the needle so that the shaft can be well visualized it is slanted slightly upward, about 30 degrees, and ad vanced slowly and steadily forward, keeping it in line with the longitudinal axis of the spine and on the same plane as the spinous processes Advancing the needle in jerks is painful Usually the point can be fell to pop through the dura It is advanced another one eighth to one-fourth of an inch The stilette is withdrawn and immediately replaced if fluid escapes If no fluid is obtained the needle is advanced a little further in stages, each time withdrawing the stilette, until fluid escapes If the needle strikes the anterior wall of the canal it is withdrawn in stages If still no spinal fluid is obtained the procedure must be repeated When fluid escapes from the needle be careful not to lose more than a few drops Apply the water manometer to test the lumbar puncture pressure Now relax the patient's legs and extend them a little so that he is not stiaining in any way Have the arms lie loosely on the bed Ask the patient lo relax completely, close his eyes, and breathe in and out with his mouth open Usually the cerebrospmal fluid pressure will be noted to fall giadually until it reaches the correct reading for that patient This may take many minutes The normal pressure is anywhere from about 70 to 160 Any straining whatsoever will give a false reading Now remove the desired amount of fluid slowly and take a final reading If a lumbar puncture is done always take a pres ·Teclitilas 89 sure reading Dont try to estimate the pressure by the rate of escape of the CSF Thu is grossly in 2counte. Remove a few cubic centimeters of fluid into each of three test tubes. In this manner an eval uation an be made as to the origin of any blood which may be present. If the lumbar puncture itself has caused the bleeding the first tube will contain the most blood. If the blood came from intracranially all the tubes will be the same color or the third one may be a deeper real Never do a lumbar puncture on a patient with on acute head injury if he struggles and resuts and never compress lues jugular veins to perform a Quechenstedt test Either procedure may produce a harmful rue in intracranial pressure and straining may result in a nise in blood pressure and consequent intracranial bemorrhage Pneumo-oncepbulography 1-2 introduced by Dunely in 1919 In this diagnostic test the cerebrospinal ſud 13 withdrawn and replaced by air or other gas The air fills the ventricles and subarachooid spaces of the brain and will thu outline then in roentgenograms taken of the skull 4 pneumoencephalogram is perlomed with the patient in the sitting position The head is flexed slightly forward and thic arms supported in front of the patient on a rat A sheet is tied around the thorax and bencath the axillas and then about the char for support when an anesthetic is lised Some use loal anathara and sedation The patients have much leu pain react better und have less shock if intravenous thiopental sodium is used. I lumbar puncture needle is inserted at the third or fourth lumbar interipace and a prasure reading ·mm sterile gauze 90 Special Aids in Diagnosis taken When normal the fluid rises in the manometer to the level of the patient's nech, usually around 450 A three-way stopcock is leſt on the needle Be ſore removing any fluid 10 cc of air are injected after drawing it into a 10 cc syringe through a piece of Always before injecting any air be sure there is a very free flow of CSF under a fairly high pressure (ie, around 450) Now alternately withdraw 5 cc of CSF and inject 5 cc of air until about 90 to 110 cc of air have been used If there is some elevation of the spinal fluid pressure, or if a brain tumor is suspected, smaller amounts of air generally are used It is a useful practice to take one anteroposterior roentgenogram of the skull after 30 cc of air have been injected to obtain an estimate of the size of the ventricles and to determine whether air is entering them In cases of hydrocephalus or cerebral atrophy, more air may be used than usual, providing fluid is obtained Test the pressure at in tervals If it falls below its initial level small amounts of extra air may be injected to maintain the original pressure Following the injection of the air the patient's head must be kept in such a position that the gas cannot escape from the ventricles He is now taken to the Department of Roentgenology Proper manipulation of the head during the taking of the roentgen ray films is necessary to obtain maximum filling of the ventricles with air Pneumoencephalograms are not usually done on patients of the intracranial pressure is much above normal, on patients with more than one diopter of papil. ledema, nor on those who may have a posterior fossa tumor Ventriculograms are used instead in these ·Interpretation 91 In a patient suspected of haying an intra manial surgical lesion the air study is performed in the morning and the surgeon must always be pre pared to operate the same day if an expanding lesion is demonstrated Otherwise a chain of events may be preapitated leading to the patients death Ventriculography fint performed by Dandy in 1918 is done by injecing air directly into the lateral ven tricos through occipital burt bola INTERPRETATION OF PNEUVO E\CEPIT VIO) GRAMS AND VENTRICUI OGRAMS Air studies are of value in nonsurgical cares in in In dicating the presence of brain atrophy or injury surgical case these methods are very useful in diag losing certain cases of intracranial hematoza or ab scos formation (Fig 10A-D) Patamo-oncephalography in Nonsurgical Cars After a sere trauma to the head an air study not in frequently reveals some dilatation often asynunetnici of the venuidia (Fig 100) In addition there Day be increased amounts of air in the subarachnoid spaces over the cerebral hemispheres Those findings are usually interpreted as evidence of brain atrophy which may be more marked in the cortex or in sub cortical arcas lf injury to one cerebral hemisphere severe the lateral ventricle on that side may be Larger than the opposite one and the enure ventricu lar system shifted toward the atrophic hemisphere At tlmas a collection of alr will be seen filling a ** within the cerebral hemisphere, shich com municates with the ventricle or subarachnoid space. Such an abnormal collection of air is due to thic de ·92 Special Aids in Diagnosis 1 NORMAL VENTRICLES A B FOURTH VENTRICLE THIRD VENTRICLE с D VENTRICULAR SHIFT TO LEFT DILATED VENTRICLES THIRD VENTRICLE Tic 10 Appearance of ventricles after ventriculograplıy or pneunio encephalography A und B normal ventriculai system C Ventricles are shuſicd to the Icſt by i right sided subdural hematoma D The ventricles art cnlarged duc to Irun atrophy following a severe closed licad injury struction of all died of brain and is referred 10 as porencephaly Pneumo-encephalogram and Ventriculogram in Surgical Cases Subdural Hematoma A unilateral subdural hiema toma will almost always be revcaled in a satisfactory air study The hematoma causes a shiſt of the ven tricular system to the opposite side, just as does ans expanding lesion (ig 10G) It IS not necessary to ·Ingography 93 tale roentgen ray films with the patient in the up nght position for diagnosis However with the pa tient uprglit, occasionally a characteristic air aidois may be present between the inner surface of the clot and the brain near the midline When the subdural hematoma u bilateral there may be no ventricular shiſt and the diagnosis can be over looked. Usually the clot on one side u larger and hence displaces the ventncles Intraceneural liematomas also can be demonstrated by adequatc air studies. A lesion of this type du place the sentricles to the opposite side and often in an 29)mmetrical fashion. The resulting distortion of the ventricular system appears much the same as with any other intracerebral maus such as brain tu mor or chronic brain absces. ANGIOGRAPHY Carotid angiography or arteriography 1 neful in the diagnosis of subxlural or intracerebral hematoma Thu method was first used by Monut in 1927 It consuts of injecting 35 per cent Diodrast (introduced by Gross 1999) into tlie carotid artery under local or general anestboia Serial roentgenograms are taken at about half second intervals as the contrast medium arculates through the arteries and then the veins of the brain and sullrounding tissues This method is of particular value when the patient is in good gencral condition Tric acute and early subacute casos of subdural hematoma, or tlost patienu who are quite drons or slupojous, do not stand the procedure at all well nor do soule elderly patients with arteria sclerosis ·94 Special Aids in Diagnosis Angiography in Subdural Hematoma A subdual lieinatoma in displacing the underlying cerebial hemi sphere creates an avascular zone (in the angiogram) throughout the area occupied by the hematoma In addition the vessels in the compressed brain imme diately beneath the blood clot aic to some extent oblitciated and the deep lymg, large arteries like the middle oi antei 101 cerebral may be pushed to vaid the opposite side of the lead Angiography in Intracerebral Hematoma An intia cerebral hematoma displaces and obliterates the Dio diast filled cerebral blood vessels m much the same mannei as do certain biam lumois THE LLECTRO-ENCEPHALOGRAM ASSOCIATED WITH HEAD TRAUMA 11, 10, 107 Lleclio encephalography, discovered by Beiger" and placed on a sound scientific basis by Aduan and Matthews, is of value in the study of brain injury Considerable caution must be used in mici picling electio encephalogiams on paucnts with a hustory of head trauma Generalizations concerning the find ings in a large group of post traumatic cases should not be applied to the individual patient There are many rcasons for thuis caution in intci pretation The LEG findings following trauma alle not specific and could have been present before the patient was injuicd About 15 per cent of normal people have some abnormality in then EEG l'o determine whether an abnormality is the icsult of a specific injury, icpcated ECGs must be taken over a long period Improvement in the accord may take ·9j Electro-encephalogram lace or there may be a marked Quduation in the degree and 15pe of abnormality before the pattern stabilizes. Presumably such a fluctuating abnormal ity w due to teroporary cellular vascular and clema tous changes in the cortex sub.contex basal ganglia and brun steid The degree of abnormality of an EEG is judged on the slowness, uregularity and amplitude of the waves the presence of focal abnormalities the relaure wym metry in the activity from the two hemiphetes and whether or not there is suppression of the normal alpha rhythm In head injuna with severe clinical manifestations alow waves at four to seren per second are usually prescat diffusely throughout the record During tlic first few days after the injury irregular and less ofien rhythmic delta wave at iko to three per second at time of high voltage occur These della waits are more common in youthful patients With 10 levert trauma generalized theta waves, cithet random rhythmic at four to mien per second and instally nl moderate voltage (40 V) are seen Waves at a irc quency of four to seien per recond can apparently be caused by traumatic changa in the brain slot) In the mild case of concussion there may tre little or no abnormality by one to two days alte the are dent. Some of these cases have what a rars to 1* norinal record with an alpha frequency at way righus per second Days in kocke later in mr jatjesta the alpha frequency may rise to ienis mier Int's it! ond shoping that the previous tracing has an unal Tlie amount of abnormality usually lewens with the clinical improvement of ilic patient but vir times the recrse occun, at least ieintury 10 11 ·When pres 102 Some Nonsurgical Complications rotation of objects or of the individual, is not very often encountered as a result of trauma ent vertigo is the result of pathology in the vestibular apparatus in the middle car or its connections in the posterior ſossa A form of mild dizziness akin to vertigo, described as a movement of objects or of the patient, but not usually as a violent whirling, is not uncommon These sensations may come on spon tancously or be precipitated by movement of the head or eyes and their origin, like true vertigo, is probably in the middle ear or brain stem Post-traumatic Nervousness Nervousness occurring with headache and dizziness is quite frequent The patient complains of easy fatigue, that he is irritable, more sensitive to minor annoyances, anxious and often depressed These symptoms are more commonly pres ent in the emotionally unstable, in compensation cases and in the financially insecure, but they are by no means confined to these groups Treatment of post-traumatic headache, dizziness and nervousness will vary with the degree of injury, type of individual and many other factors In general, as soon as the physical condition permits, these cases seem to do better with a resumption of mental and physical activity and the use of mild sedatives and analgesics for headache Psychiatric care may be required in Certain localued post-traumatic headaches have been relieved by spinal subarachnoid injection of air in the manner described by Penfield 70 some NEUROSES FOLLOWING HEAD INJURY It is beyond the scope of this book to describe the neuroses which may be associated with head trauma ·Pos choses Tollowing Head Injury 103 It is rulhcient to pote that a post traumatic neurosis either acute or chronic, may follow a head injury regardless of whether or not organic brun pathology u present. The organic diangos hotever are not the basis of the neurons PSYCHOSES FOLLOWING HEAD INJURY As already discussed organic brain injury may be directly responsible for intellectual impairment and emotional disturbances. To what degree trauma may aggravate an alcoholic, luetic, arteriosclerotic or other organic psychosis depends upon many facton and the utitings of psychiatrists should be consulted With regard to any posible relationshup between trauma and the functional psychoses such u manic-depressive Psychosu or schizophrenia, the reader is referred to the opinion of psychiatrists

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·8 REHABILITATION Under thus headlag consideration is given to early convalecent treatment as well as to later rehabilita tup In the past it was fairly generally accepted that a patient should remain in bed for at least three weeks following a head injury of moderate or severe degree. Opinion is now divided on this poiot but many au thorities agree that such a rule should not be applied indiscriminately Each case should be evaluated sepa rately If an individual is symptom free within a few dast after a moderately ste head injury there appears to be no contraindiation to allowing him to be up. In fact he will regun hus vasomotor and mur cular topt more rapidly and will be low likely to have postural dizinas, On this point Penfield " quotes Dr KG Mchenzle who has stated "I may say that my praaice for some years now has been to allon patients up touch earlier than we used to 105 rulc nos u to let them up day after the patient feels like getung up for instance, I would not hai tate about letung a compound deproued fracture case get up a day or two after operauon if he feels like it. On the other hand if the patient continues to have simptoms and apecially if these have followed a sesere injury lxed rat should usually be more pro 105 In genel

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·Billiography 113 4. Kuhn, EA The treatment of enapsulated brin abscess with Auallation by colloidal thorium di ovide Michigan Unit Hosp Bull 4 17 1938 55 Kennedy F and H Wartis Acute subdural hema toma and care epidural hemorrhagt. A study of Litty-two cases of hematoma and Heicntcen cases of beroorthuage Surg Gynec & Obstet 63.52-412 1936 56. King J J The treatment of brain abscess by unroofing and temporary hernlation of abscess carlty with the avoidance of usual drainage methods Surg Gyec. & Obstet, 39 554 1974 57 hing JEJ Hematomas extradurel, subdural and subcortal Am. J Surg D4 39948 71 1943 58. Laudis, H.] Browder and R. A Watson Subdural hematoma. A study of one hundred ſony three cours encountered during a five year period. Ion Surg 113 170-188 1841 59 Leary T Subdanal hemorrhagch. J A A A 103 897-903 1934 60 LeBeau J Radial surgery aod penicilin in brain abscess. J Neurosurg 3 359 1946. 61 L Grot Clark, 11 Em Benttie GR ddoch, and N Dont Hypothalamus Oliver and Blod, Edin burgh 1938 Go Maltby G L Penenating maniocerebral injunch. Evaluation of the late rcaulus in a group of 00 con kecutive pencunung canul war wounds. ] Neurosurg 346 1946 63 Alartin, Joho, and CH Campbell Early complia Lions following penetrating wounds of the skull J Neurosurg 358, 1946 64 Klawon D D ad j llomin Hematomas asociated with penenung wounds of the brain I Neuro uurt 3 16 1940 65 Vuon D The Treatment of Acute Cranio-cerebral Injurko Due to Ausilo. Am Lecture Serich Charlos C Thomas, Springfield, 1919 (6 \ Асле к с Lxindural biomotthage. Sutt 26 316 1938. 67 Voniz, E Lencephalographie antrielle son impot Bril J ·a 112 Bibliography 40 Holbourn, A H S Mechanics of head injuries Lancet, 145 438, 1943 41 Holmes, G, and P Sargent The injuries of thic su perior longitudinal sinus Brit MJ, 499–500, Oct 2, 1915 42 Horrax, G Observations on series of gunshot wounds of the head Brit J Surg, 7 10, 1919 43 Horrax, G, and J L Poppen The frequency, recog nition and treatment of chronic subdural hiematomas New England ] Med , 216 381, 1937 44 Hutchinson, J Lectures on compression of brain, clinical lectures and reports London Hosp, 4 20, 1867 45 Ingraham, F D, and O T Bailey The use of prod ucts prepared from human fibrogen and human thrombin in neurosurgery Fibrin foams as hemo static agents, fibrin films in repair of dural defects and in prevention of meningo cerebral adhesions J Neurosurg, 1 28–39, 1944 46 Ingraham, I D, and H W Heyl Subdural hematoma in infancy and childhood J AM A, 112 198–204, 1989 47 Ingraham, F D, and D D Matson Subdural hema toma in inſancy J Pediat , 24 1-37, 1944 48 Jasper, H, and J Kersbman Electroencephalographic classification of the epilepsies Arch Neur & Psych , 45 913, 1941 49 Jasper, H, J Kershman, and A Chudge Llectro encephalography in head injury Res PublA Nerv & Ment Dis , 24 388–420, 1943 50 Jasper, H Electroencephalography and Llectrocorticography Chapters XV and XVII in "Epilepsy and the Functional Anatomy of the Brain" by Pen field, w, and Jasper, H Little, Brown & Co, Boston, 1954 51 Jefferson, G Tentorial pressure conc Arch Neur & Psych , 40 857–876, 1988 52 Jefferson, G The physiological pathology of gunshot wounds of the head Brit J Surg , 7 262, 1919-20 53 Jefferson, G The nature of concussion Brit M J 11, 1944 ·Bibliography 119 54 Kahn, E A The treatment of enapsulated brun abscess with violination by colloidal thonum dioxide. Michigan Unlı Hosp Bull, 4 17 1938 55 Kennedy F and H Wortba Acute subdural hema tana and acute epidural bemorrhage. A study of seventy-two cases of hematoms and seventeen cases of hemorrhage Surg Gynec. & Obstel, 0332-742 1936 56. King. J E J- The treatment of brain abscess by un roolog and temporary herniation of abscess cavity with the avoidance of urual drainagc method. Surg Gynec. & Obstet. 39 554 1924. 57 hing J J. Hematomas extidural, ubdural and subcortical Am. J Surg ns 59 248–271 1913 58 Laudig G H EJ Browder an R A. Watson Subdural hematoma. A study of one hundred ſorty three casos encountered during a five year period. lon. Surg 113 170_188 1941 59 Lean T Şubdural bemor bages. I A. VA 103 897-903 1934. Radlal surgery and penlolllo in brala abscer. J Neurosurg 3 359 1916 61 LeGros Clark. "E I Beatle G Riddock and N 11. Dort Hypothalamus. Oliver and Blyd. Edinburgh 1938 Co Valtby GL Penetraung craniocerebral injuries Evaluation of the late rrults in a group of 900 conkecute penetraung moal wat wounds. J Neuro- HUT 346 1946. 63 V nin John, and E H Campbell Early compliartlons following peacoating wounds of the tull. \eurosury 358 1946 64 Vacon DD und ) lolkia Hematomus associated with penetriung rounds of the brain J Neurourg 3 16 1940 65 Vatron D The Treatment of Acute Cranio-cerebral Injung Due to Almila. Am Lecture Series Cha la C Thomas, Springfield 1919 86 Wichenzieh. G Exindural hemorrhage Surg 26 446 1938 67 Vonte E Lencephalographic antrielle son impor 60 LeBeau J Bril 1 ·114 Bibliography tance dans la localisation des tumeurs cerebrila Rei Neurol 272 1927 6S Munro, D Cranio-cerebral Injuries Their Dia nosis and Treatment. Netr York Ofon Unire Press, 1938, XXVIII 412 pp 69 Munro, D Cerebral subdural hematomas it studi of three hundred and ten renfied cases Nen Eng land J Med., 227 87-95 1942 70 Munro D, and G L Maltby Extradurl hemorrhage study of 44 cases Ann Surg 113 192-20S 1941 71 Munro, and H H Merritt Surgical patolog of subdural hematoma based on a study of one hundred and fire cases Arch Neurol Psychiat. 35 6+78 1936 72 Naffziger, H C Şubdural fluid accuniuliuons follow ing head injury JAM 4,82 1751 1924 73 O'Connell, J E A Trumatic cerebral fungus. Brit J Surg , 30 201, 1943 74 Peet, MD E\tradurl hematoma, subdurl hem? toma, subdural hy droma In Injuries of the Skull Brain and Spinal Cord 3rd Ediuon Ed by Broch S, 1949 The Williams and Wilkins Co, Balumore 75 Penfield, W The mechanism of cicatriail contriction of the brain Brain, 50 499, 1927 76 Penfield, TN Chronic meningeal (post-traumatic) headache and its specific treatment bi lumbar air insufflation encephalography Surg Gynec & Obst, 45 747, 1927 77 Penfield, WG Military Neurosurgery Canad Arms Manual Department of National Defence Goi Printing Bureau Ottawa 78 Penfield 1, and R Bucklei Punctures of the bruin The factors concerned in gliosis and in caatrical contraction Arch Neurol & Psich, 2.1, 1925 79 Penfield W and T C Erickson Epilepsi ind Cerebral Localization Baltimore Charles C Thomas, 1941, 302 PP SO Penfield, W, and J Jasper Epilepsi and the Functional Anatomy of the Human Bruin Little Brouin & Co Boston, 1951 si Perlstein, M C L Gibbs and F 1 Gibbs The ·Bibliography 115 electroencephalogram in infanule ccrebral palss Am J Phys. Ved 34 417–496 1955 2 Pudert R. H The repair of cronal defects with uplalam JAVA 121 478 1945 B. Putnam, T j and 11 Cushing Cluronic rubdural hematom. Its pathology iu relation to pachymen ingitis bernotthagica and its surgical treatment Arch. Surg Chicago 11 329-393 1925 M. Rand, C. Chropic subdural hematoma. Report of seven csen. Arch Surg Chicago 14 1136–1165 1927 8 Rand, C. & Reeves D and CB Courville Histologic studies of the brain in cases of fatal Injury to the head Arch Neurol. & Psych. 36 1277–1293 1936 Crudioplasty American Lecture Series, Charles C Thoman, Springfield, 1919 37 Reld, L and w' v 'Cone The mechanism of fured dilatation of the pup 1 resulung from ipse Lateral cerebral compression. I AM A 112 030 204, 1919 8. Rowbotham, GF Acute lojuria of the Had. DI agbok, Treatment Complications and Sequela 3rd Ed, ELS Lningstone Lid Edinburgh, 1919 89. Russell, 1 R The after effects of herd injury Tnn M Chu Soc., Edinburgh, 113 199 1953–34 90 Schenker IM Neurosurgical Pathology Carla Thomus Sp sogfield Ill 1918 91 Schilda P Me roses following head nd brain in furla in Injuries of the Brain and Spinal Cord ud Their Lopetings 3rd Edt on Ed ted Brock S 1919 The 11 Viams & Wilkins Co Bultmore 92. Schwartz, il 6 and G E Roulhac Cranlocerebra) kar round Obser tion on delayed treatment Ann Surg 121 149-151 1915 95 Scotc, il 11 Phytolog, of con us on. Arch. Acurpl & Psych 43 70 1910 91 Small J V nd E \ Turner surgical experience of two hundred cases of penetrating I rain wounds battle All Eu ope 1911-15 Bril J Surg Har Suppl No 1 6 1917 9, Spurl ng RC Craniocerebral trauma. In Surgical ·116 Bibliography Treatment” [d by Bancroft, F W, and Pilcher, C, 1946 J B Lippincott Co, Philadelphia 96 Symonds, CP, and WR Russell Accidental head injuries Prognosis in service patients Lancet, 17, 1943 97 Symonds, Sir Charles Concussion and contusion of the brain and their sequelae In "Injuries of the Brain and Spinal Cord and Their Coverings Ed S Broch, 1949 The Williams & Wilkins Co, Balti more 98 Trotter, W Chronic subdural haemorrhage of trau matic origin, and its relation to pachymeningitis hemorrhagica interna Brit J Surg, 2271-291, 1913 99 Turnbull, I E tradural cerebellar hematoma, case report J Neurosurg , 1 321–324, 1944 100 Vance, B N Fractures of the skull Fractures of the skull Arch Surg. 14 1023, 1927 101 Vincent, C, M. David, and H Ashenasy Method of therapy of subacute and chronic abscesses of cerebral hemispheres in ablation en masse without drainage, with or without preliminary decompression Cases J de Chir, 49 1, 1937 102 Voris, H C The diagnosis and treatment of sub dural hematomas Surgery, 10 447, 1941 103 Walker, A L, J J Kollros, and T j Case The physiological basis of concussion J Neurosurg, 1 103, 1944 104 Walker, AC, and H C Johnson Surgical treatment of epilepsy Am J Surg , 75 200, 1948 105 Walker, AC Personal communication, 1956 106 Weaver T A, and A J Trishman A report on the treatment of craniocerebral wounds in an evacuation hospital J Neurosurg, 3 148, 1946 107 Williams, D Clectroencephalogrım in acute head in juries J Neur & Psych , 4 107, 1941 108 Williams, D, and D Denny Brown Cerebral clectri cal changes in experimental concussion Brain, 64 223, 1941 109 Windle, WF, RA Groat, ind CA Tox Lxperi mental structural altcrations in the brain during and ·Bibliography 117 after concussion Surg Gynec. & Obst., 79 561-572, 1914 110 Il olf, H Headache and Other Head Pain Oxford Uair Pran, New York, 1918 111 Woll, G L and A L Halker Canoplasty Collec the ICVICK Inter Abst. Surg 81 1 1915 112. lioodhull B J + Davine, and D Hart Homolul eral dilatation of pupil, homolateral paress and br lateral muscular rigidity in dignou of extrıdural hemorrhage Surg Gynec. & Obst 72 391 1J11 115 loodball, B and R. G Spurling Tantalum cranioplasty (or war rounds of the skull Ann Surg 191 644 1945 114 Zollinger R and R. E. Gross Traumatic rubdural hematoma An explanation of the Late onset of presure symptoms J AM A. 103 245-49 1934

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·INDEX ·120 Index Caffemnc sodium benzoite therapy, drowsiness nftc head injury, 20 Coplallıcınatoma, scalp, 53 54 Cerebrospinal fluid, picssic, cleva uon, with hematoma, sub dural 40 hematoma, subdural, 43 Olorrlici in fractuic of shwl, 56 treatment, 20 21 rhinori lica in fractuc of skull, 56 aſtei head injury, 75 76 Licitment, 21 Complications aftei bcad mju), neuroscs 102 103 Bonsurgical, 99 103 duziness, post (mumalic, 99 102 ucatment 102 licidachie post-traumalic, 99 101 licalment, 102 NcIvousness post lipumilic 99 100 102 post 11mmatic syndrome 99 102 psychoscs 103 surgical 71 85 inelliysin irtcrioiculous, 79 8) cysts 117chnold i 81 dclects of shull rep ur 77 81 epilepsy, post li humilic Sce rpilepsy, post limitic palsy ccicbral, 84 85 hunonci, cerchiospinal flud 715 76 wound infection Sec Infection Hound Concussion 7 9 cicchio encephalography 97 cuiology ugh all of cliuge oſ vclocity 8 intense cautation of contial nervous system al moment of blon to hicid 9 sudden brain compression 9 experimental 79 electro cnccphilogi zpluic, 8 9 Contusion brain injury from, 3 4 9 Convulsiic seizine, with hem tomi, subdural 10, 12 13 treatment 19 Cysis, nachnoda vici (null}l of shull 81 Death See Mortality Debrideincnt brun sound peniciating 69 70 Diagnosis special uds 87 98 angiography Sci Angiography ·Index 121 ·122 Index Hemitoma(s), subdural, acutc-(Continued) surgical treatment, cail), 36 Jatcr, 36 37 classification, 32 chronic, 38 39 definition 30 descriptions 30, 32 diagnosis, 39 43 ingiography, 94 cerebrospinal flud pressure, 13 convulsiic SCI/UCS 42 43 drowsiness or slipoi, incrcising, 39 11 clcctro encephalography, 96 98 Jocalızıng signs, 12 neurologic signs, abnormi 40-41 nonclinical uds, 41-42 pneimo chcephalography and senisiculographs, 1293 pulse and blood pressure, 43 cliology 33 34 incidence, 24 32 33 in infancy and chuldhood, 17 70 diagnosis 48 surgical treatment 48 49 winploms 47 48 location, 31 inortalıly, causes 43 41 operibile cxpcricucc WU 300 (ascs 32 pathology 33 31 chinges in brun 31 35 subacuc 37 38 surgical treatment 44 17 anesthesia 41 operatie ipproach 47 position of pauult 44 17 Hunianopsii liomonymous with him itom i subdural, 41 Hemiparesis with heindtoin i suludura 12 18 progressie with licuitom? subdwul 10 Hemiplegia with hematom i subdural 18 Heinorrlagc (5) cpidural 2:3 30 clinical picture, 25 27 28 cuolog), 27 incidence 24, 25 surgiul treatment 28 30 intriccrcbril cience 21 pcicchu 4 10 ·Index 123 Il Tourage (Hlonunued) retinal Ith her togu bulurl 18 ubarachnoid, 10 wbconjunctis IIth hematoma subd al, 19 Herniation funcurs, 4 Lory taking concerning nat r of accident 17 Ilydroma pubil nal 50 Flygtoma subdural 30 Infection deep after penetrating woul, 7" 3 dlarnon 73 tratment 75 superficial after penetrating wounck, Olin l, 71 73 complication abacon of brala chronic 73-71 fungu cerebral, 73 meninglih, 74 75 vermydlus 3 incidence 71 Luceration of Kalp 71 7" perctrati g. 273 I wantlon of bral 9-10 dintrictebral bogat mm 4 Kalp. 31-56 In ſection mond 71 72 iment 51 % diagnod Tead hty cute 20 hematoma subdural 49 toeningith technic, 87-89 1 Lurabu P t 1 canks of 1 rio Iraun 3 01 posto of thor diu rtion of II 1 moment of b real or (01 Il lina monement 3 sot t on 3 f om periinat & Tjects of m Rules, 5 her 1 duirert 1 nill att Viong lagin1 baru tim 90 f tamau 1713 piph la ani Lot 1997 1 Inent ·122 Index Hemnuloma(s) subdural, achtc-(Continucl) surgical treatment, cul), 36 17tci, 36 37 classificat101, 32 chronic, 38 39 definition 30 descriptions, 30, 32 dignosis 39 43 angiography 01 ccicbrospinal llud pressure, 13 coni ulşnic seizues, 12 43 dronsiness or stupoi mcrcising 39 11 clcctio encephalogi?phy 96 98 localizing signs, 12 neurologic signs, abno mil, 40 41 nonclinical uds, 41-42 pneumo cncephalography ind venusculograplıy, 9203 pulse ud blood pressure 43 ctrology, 33 34 incidencc 24 32 33 in infancy and childhood 47 50 duguosts 48 surgical ticruncii, 48 19 symptoms, 47 48 location, 31 moitality cruscs 4941 opcrlic cypericnice w 300 (75CS 32 pitholog) 33 31 clienges in bu 31 35 Sunculc 37 38 surgical ticumeni 14 47 111cstler 11 opcratic ipprouch 45 position of patient 1115 Temuinopsii liomonymous with hematoma sundmal li Hemipaicsis with hematomi subdural 12 18 progressive wt hem itomi subduru 10 Hemplugin with limitom i subium 18 Ilumori bage(s) cpidul 25 30 clinic il picturc 27 27 28 ctiology 27 incidence 21 23 surgical 11cament, 28 30 miricerchi incidence 21 petcchul 1 10 ·Index 125 Paky cerebral afta head injury 81-83 Ppilledema with hematoma subdural 40 41 48 Paraklehyde thermpy rouesnan, 20 Prahdı, deri third or u thith hematoma subdural, 40 Pealalla therapy contnindications uter endson of brain b- 100 1 Pantothal Sodium Itna ou with loal nouala, for harda TOTDA subdun! 44 Phicobarbiul sodion therapy con ukl e kelture 19 ratcmnc 19 Pneumo-encephalograms interp stattoo 81 93 Pneumo-cı cephalognphy duagilosti ald ham toma Intra CCTebal, 93 rubdural, 42 92 03 norreurglalara, 91 92 Harglal asc 92 99 technic, 89-01 Ineumonia hypostatic. p ophyla 1, 19 Honltion of patieot, surpal tralment hernatom subd 14-15 Procaine as local aneuheul font with opinephrine lactation of Kalp 55 15ychowcy after had i jury 103 Pulse I hematom wuldurl 3 Pupib diluauon Iney ality I with hem torna dural 40 12 Rehabil tatlon 105-107 Rattlewo treatment 19-20 Rhinorrha cerebroy nalflukl fta fragt e fshuti 50 after bead I Jury 736 tresuncit 21 Roentgen inauon cut had I suresi fract of all, ckpreneul 53 Corpoxi 458 Hmple 57 hematoma wibd 1 in f my n childhood 18 Scalp surgiul locoon, 53-55 plulhematom 1-31 hematoma 33 fact on fou 1 I Lertxoa 118 tan es tment 51 37 FH it atment in Herent 30 - ·124 Index Missiles, penetration of bıyın by, 5 Morality, caniscs, in hematoma subdual, 43 44 statistics, biall), 1 ounds, penetraung, 68 69 Nerve, third or sixth, pırılysis, with hematoma, subduril, 40 Nei vousness, post-traumatic, 99 100, 102 Neuroscs afici licad injury, 102 103 Nonsurgicıl lesions, acute, dingtiosis, 20 21 lumbur puncture, 20 rocntgenograms, 21 ircitment, 17 21 antibiotics, 19 21 convulsivc 90101 es, 19 drowsiness, 20 Nud and clecuolyte balancc, munten ince 19 meningitis, 20 otorilici, ccicbro spinal ſud, 20 21 ogen administration, 18 restlessness, 19 20 rhinonhoi, ccicbiospul ud, 21 shoch, 17 specific meisies 17 21 ching history of accident, 17 tempcratic contiol, 18 19 iransportation (10m score of .ccicieni, 17 unconsciousness 18 brun, 711 concussion, 79 contusion, 3, 4 I hemorrhage, petech.nl, 10 subiraclinoid 10 laceration, 4, 9 10 swelling Tround contusions or licciition on from 119011197, 10 diagnosis, 1 17 degree of injury modcratc 13 15 Scicrc, 15 17 siiglic, 12 13 symptoms and their pathologic basis, 12 hend, 721 incidence, 7 signs and Osicomyclius, milli inſection of wound 77 Otorrhca cerchrospinal fund, in fractic of skull, 56 trcitment, 20 21 Oxygen therapy unconsciousness, 18

·Index
127
und contindor 1 eration or for traim
Swelling brain
10
Tanperature ontrol arlourly injured patient 18-19
Tetin anttorin prophyla 1 lacci t n of valp 5
Thcopent 1 odium thet Py con ulsi Ken 19
Thora
compraloa, brala Injury for 5
Transportation of patient from Kene of acadent 17
Uncon dounen trainent 18
Urxur, herniatlon, 4
lentriculognmı, interpretation OI 13
Teatrkulography in diagnosti id hornatoou intracerebral 03
rubdural 1 41-43 92 93
Harglal cases, 92 93
ttch Se 91
Wounds, brain Sre Brain wou de

·126 Index Suuics, whilsuse Sec Convulsi e sci/uses Shoch, treatment, 17 Sign Babenshi, possuise, with hunatom i, suludwal, 40 Sinus(cs), frontal, fractures of shull into, 62 Icnous, major, or longitudina), moliement in compound de pressed fractures of shull, 62 63 Skull deſculs, rcpair, 77 81 plice, 77 79 distortion, injury of brain by, 1.5 fractures, 5 03 alicurys arterioscholls, 79 83 coinminute, pl, 56 coinpound, 57 58 depressed, 38 62 diagnosis, roentgenog aplıy, 38 molimg longitudinal oi mujor SCIOUS suures 62 63 surgical irtaimcui 58 62 into frontal snus, 62 clcpressed, 21 Inculojn 57 roentgcii (dmiti ilion, 77 sinple 57 Jucar, simple, 57 50 Thmorhea, ccrobrospia) lud 75 76 Suupor with hematomi subdural 39 11 Sulladsazne therapy, abscess, 1951, chionic, 74 MICIngilis 20 Sulfonamides theripy ſuictures of shull, compound imo fronti SuS 62 unorrla witbrospmal fluid, 21 Surgical lesions 23 32 bain, pencriting sounds Sre Brain, wounds peniciraning differential diagnosis from nonsugical (nonopcable) 29 23 fractuit, depressed 24 luciatomas intracranial 21 23 fractures, shull See Shuli fractures Junaiomni intraccrubril 50 32 subdural Scc Hematoma sulduril licmorihage cpidural See Honorrhage pumil Indioma suldurii 50) lisgroma subdural, 30 mausiuon intraccrcbrul locului 1072 scilp Sor Scalp surgical lesions Suturo laceration of scalp 53, 36

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