Surgery of Modern Warfare V. (töredék) [antikvár]

CHAPTER LXV INJURIES OF THE BRAIN AND SKULL The purpose of this chapter will be to describe primarily the methods in current use of handling cases of craniocerebral injury under optimum conditions, representing the ideal to be aimed at when practicable. In war such conditions are often impossible of realization, and therefore the procedures which have been found applicable under battle conditions are also detailed. Modern surgery implies much more than operative dexterity ; it involves accurate diagnosis, assessment and decision, operation when required and management until maximum recovery is attained. In brain surgery diagnosis is based chiefly on neurology; psychology and psychiatry also play their part. Assessment, decision and operations are based on these and on general surgical principles, operation being but an incident in the general management, which involves special nursing problems and continued neurological and psychological supervision. Experience in the Middle East has shown that a quite high percentage of the head-wounded can be returned fit to duty, in spite of the fact that wounds are as a rule grossly infected by the time they receive operative treatment. Two factors have probably been responsible for the satisfactory results, namely, early and heavy dosage of sulphonamide and, in the case of penetrating wounds, the removal of in-driven fragments of skull.^ SURGICAL ANATOMY IN RELATION TO INCREASED INTEACBANIAL TENSION The scalp, skull and dura mater are but envelopes of the brain, the dura being arranged to form the right and left supratentorial compartments and the infratentorial compartment (Fig. 868). The supratentorial compartments are separated by the comparatively rigid falx cerebri. They communicate with each other by the restricted archway beneath it and with the infratentorial compartment by the narrow incisura tentorii whose margins are sharp and rigid. The infratentorial compartment opens into the spinal theca at the foramen magnum. The dural partitions do not yield quickly to a higher pressure on one surface. Thus if pressure increases rapidly in one supratentorial compartment, the falx and tentorium resist it, and pressure becomes higher within this compartment than elsewhere. The result is a damaging dislocation or " basal shift " of the br.iin beneath the arch of the falx; and through the same side of the tentorial aperture—" tentorial impaction." Clinically the former is marked by impairment of consciousress ; the latter by signs of pressure on the cerebral peduncles—especially tremor and spasmodic rigidity in extension of neck, trank and limbs, and of press ire on the homolateral oculomjtor nerve—causing enlargement of the pupil. If, on the other hand, th;; rise of pressure is more gradual, the dural partitions yield considerably (Fig. 873), the increase of pressure is more equally distributed through them, and the local defi)rmitior.s are less in evidence. Eventually, pressure comes to bear at the unyielding foramen magnum. Impaction here causes neck rigidity, spasticity of lower limbs, and aggravation of hyper-tei.sion by secondary hydrocephalus, as the apertures of the fourth ventricle become blocked. Oerebro-spinal fluid is formed in the ventricles at a considerable secretory pressure, and obstruction of its circulatory pathway within the brain or subarachnoid space or at the venous sinuses into which it ultimately passes occasions hydrocephalus—an excessive accumulation of cerebro-spinal fluid under excessive pressure. 1 See review by H. Cairns. Bril. Med. Jour., 1944,1, 33. 83 717