The Surgery of the Skull and BrainRawling, Louis Bathe
Science
The Surgery of the Skull and Brain
Rawling, Louis Bathe
Brain -- Surgery; Skull -- Surgery
[Illustration: FIG. 30. PLAN OF THE BASE OF THE SKULL. _a_, _a_, The
transverse pre-condyloid line; _a′_, _a′_, The line pursued, in whole or
in part, by the ‘typical’ basic fracture.]
Any blow delivered at or near the basic level tends _primarily to
involve the weaker area, the base, passing secondarily upwards on to the
vault_. One may go even so far as to say that in most combined vault and
basic fractures, the vault fracture is a secondary development, the
basic fracture being the primary lesion.
There is, however, still another important anatomical feature bearing
on the mechanism of basic fractures, one that must necessarily come into
force in the greater number of such fractures. The base of the skull may
be said to consist of two parts, one lying anterior to the condyles of
the occipital bone, the other posterior to and including the condyles
with their vertebral attachment. These two segments are united to one
another by a weak chain--represented by a line drawn from one external
auditory meatus to the other, with, as a connecting link, the sphenoidal
sinus in the middle line.
When the base of the skull is viewed from below, it will be seen that
the weak line includes both Glaserian fissures, both petro-sphenoidal
sutures, both foramina lacera media, with the sphenoidal sinus again as
a connecting link. The two parts of the skull are, to all intents and
purposes, merely cemented together by the union of the basi-sphenoid and
basi-occiput. Consequently, if a blow be received on the antero-lateral
region of the head, the anterior segment tends to be split off from the
more fixed posterior part, the fracture following the weak line
previously indicated. This weak line occupies so important a position in
the mechanism of basic fractures that careful observation will show that
the greater number of middle fossa fractures follow that line, wholly or
in part. Such a fracture of the middle fossa may be termed ‘the typical
fracture of the base of the skull’ (see Figs. 30, 34 and 39).
=Summary of theories.= Aran’s theory of irradiation, with certain
modifications, accounts satisfactorily for about 30 per cent. of basic
fractures.
The contre-coup theory may be rejected entirely.
The bursting and compression theories are unsatisfactory, accounting for
not more than about 5 per cent. of fractures.
The majority of cases result from direct violence applied at or near the
basic level, the fracture passing across the base in the general
direction of the applied force, but not necessarily in the same straight
line.
Up to this point certain facts and theories have been discussed, such as
bear on the general mechanism of basic fractures. It now remains to
consider other factors that exercise influence on the general direction
of the fracture.
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