The Surgery of the Skull and BrainRawling, Louis Bathe
Science
The Surgery of the Skull and Brain
Rawling, Louis Bathe
Brain -- Surgery; Skull -- Surgery
_Its pathology._ A compression force--whether foreign body, blood
extravasation, abscess or tumour--must act on the brain substance or on
the fluid constituents of the skull. The brain, however, is itself
incompressible. It may be squeezed like a sponge, but its actual
structure is unalterable. Consequently, the compressing force exercises
its main influence on the fluid contents, driving out the cerebro-spinal
fluid, depleting the cerebral veins and emptying the arterioles,
producing in other words a state of brain anæmia.
Experimentally, it has been ascertained that from 3 to 6 per cent. of
the cranial capacity can be taken up by a foreign body without producing
compression symptoms--probably owing to the escape of cerebro-spinal
fluid into the spinal canal, and the recession of the medulla and
cerebellum into the foramen magnum. Furthermore, it would appear that
the incidence of compression symptoms is associated with depletion of
those cerebral veins which are in closest relation to the compression
force. As this force increases--for example, in middle meningeal
hæmorrhage--the pressure exercised on the surrounding regions increases
proportionately, to the level of the capillary pressure, and even to
that of the smaller arteries. A state of cerebral anæmia results, first
localized to the region primarily involved, then invading more widely
and finally affecting both supra- and infra-tentorial spaces.
With regard to the continuity of pressure between these three spaces,
there is but little pressure discontinuity between the two
supra-tentorial spaces, whilst, between the supra- and infra-tentorial
regions, there is less ready communication.
A slight degree of compression in the supra-tentorial space will act on
the corresponding space only, greater degrees will involve all three.
On the other hand, a rise of infra-tentorial pressure is not of
necessity associated with a corresponding elevation in the other two
regions. For example, a cerebellar tumour readily affects the medullary
centres, whilst the higher cortical regions are for the time being
totally unaffected. Again, a tumour situated in the frontal pole does
not necessarily produce any of those symptoms of cerebral compression
which are regarded as referable to an increase of subtentorial
pressure--slow pulse, vaso-motor disturbances, subnormal pressure, and
deep rhythmical respiration.
Public-domain text, read in full here on John Shaqi.
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