The Surgery of the Skull and BrainRawling, Louis Bathe
Science
The Surgery of the Skull and Brain
Rawling, Louis Bathe
Brain -- Surgery; Skull -- Surgery
Moreover, the fundamental points on which the bursting and compression
theories are grounded are based on erroneous principles. The skull
cannot in any sense be regarded as a sphere, nor does it possess the
requisite elasticity to bulge and allow of compression in the manner
that the theory demands. The skull, in reality, forms rather less than
two-thirds of a sphere, the base passing inwards from the lower limits
of this partial sphere in a more or less horizontal plane. This can be
readily verified by placing the skull on a table so that its base
corresponds to the surface of the table. The elastic properties of the
skull have also been greatly exaggerated, and far too little attention
has been paid to the peculiar anatomical formation of the base.
(_c_) =The contre-coup theories.= Fractures of the base occasionally
occur in which evidence is conclusive that the blow was received on the
vault, the vault itself remaining uninjured. Such cases have given
origin to this theory, one stating that ‘from the point struck a wave is
transmitted through the semi-fluid brain, producing a fracture at some
more distant point’. Helferich, for instance, maintains that isolated
fractures of the orbital roof, and more rarely of other parts of the
base, are produced by the influence of hydrostatic pressure. There can
be no question that waves are transmitted through the brain and
cerebro-spinal fluid, but that such waves should be capable of producing
a basic fracture is, in my opinion, beyond the bounds of possibility.
The theory is opposed to all my experience of basic fractures, and the
cases brought forward in support are capable of a much more probable
explanation. The base is undoubtedly the weakest part of the skull, and
a blow on the vault may fail to produce a local lesion and yet, when the
force is transmitted to the weaker base, may there bring about a more
definite result. For instance, it is by no means uncommon to find that a
blow on the frontal region fails to fracture the vertical plate of that
bone and yet suffices to produce a fracture, often comminuted, of the
orbital plate of the frontal bone or of the cribriform plate of the
ethmoid, two fragile plates, either of which may shatter like a plate of
glass from the effect of forces transmitted across them. In further
support of this theory, the following case, recently under my care, may
be cited. The patient received a heavy blow over the left occipital
region. A fracture passed inwards across the left cerebellar fossa
towards the posterior border of the foramen magnum, and a second
fracture, entirely distinct from the first, passed across the right
orbital plate of the frontal bone. In this case, the force conducted
across the base, from behind forwards, failed to fracture the strong
basi-occiput, but succeeded in producing a more definite lesion on
reaching the fragile orbital plate.
Public-domain text, read in full here on John Shaqi.
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