At this stage, it will be necessary to allude more fully to the general question of cerebro-spinal discharge from the nose, mouth, and ear. The symptom is an important one, though undoubtedly of far less frequent occurrence than stated in text-books. This was proved by Crandon and Wilson, who reported 27 cases in which there was a cerebro-spinal discharge out of a total number of 530 cases examined. Phelps mentions 13 in a series of 286 cases of fractured base. My experience coincides with these statements.
The escape of a slightly blood-stained fluid from the ear and nose does not necessarily imply that the fluid is cerebro-spinal in nature, for it has been proved on numerous occasions that fluid may escape in considerable quantities without the existence of a basic fracture. In such cases the fluid is derived either from the membranous labyrinth (the liquor cotunnii) or from the mucous membrane lining the ear and nose, the result of great vaso-motor dilatation of aural and nasal vessels.
If the fluid be cerebro-spinal in nature, the natural inference is that the subarachnoid space is opened up to the exterior, either directly or indirectly along the course of a cranial nerve. A chemical analysis of the fluid will determine the nature thereof, provided that the fluid be collected EARLY.
| Thus, cerebro-spinal fluid is rich in chlorides, contains little or no albumen, but shows a trace of a reducing substance, allied to pyro-catechin, | whilst | fluid derived from other sources contains chlorides, a fair amount of albumen, and no sugar. |
Certain factors, however, must be taken into consideration which diminish the value of these chemical tests, for, though the fluid be cerebro-spinal in nature, the admixture of blood at once interferes with the delicacy of the test. Furthermore, even in the event of a profuse discharge of cerebro-spinal fluid, the first part collected alone contains sugar, the discharge soon becoming nothing more or less than a serous exudation.
The fluid is almost certainly cerebro-spinal if the discharge begins within twenty-four hours of the accident, if it be practically colourless, fairly profuse, and continuing for two or three days, perhaps longer.
Though the discharge usually originates early, cases are recorded in which the flow commenced some weeks after the accident. The discharge may continue for hours or for weeks. Sir W. Savory recorded a case in which fluid escaped for one month from both ears. The quantity also varies greatly, usually a few ounces, but sometimes many pints. Sir W. MacCormac recorded a case in which 10 pints escaped within five hours. A profuse discharge is due to the fact that, as the original cerebro-spinal fluid drains away, its place in the subarachnoid space is taken by a serous exudation from the cerebral venous system. This exudation occurs as soon as the subarachnoid pressure is sufficiently reduced, the serous exudation progressing till the venous and cerebro-spinal pressures are again equal.
As regards the prognosis, it is interesting to note that the escape of cerebro-spinal fluid implies of necessity that the subarachnoid space is opened up to the exterior, with all attendant dangers of meningeal infection, yet that the prognosis is generally favourable. One might even go further and state that the prognosis in such cases is rather more favourable than under more ordinary circumstances. Thus, Battle records 36 cases with a mortality of 25 per cent., the general mortality of fractured base being about 44 per cent. My own experience tallies with these statistics. The more favourable result hinges no doubt on the fact that the prolonged outflow tends to wash away organisms existent in the aural and nasal passages.
With regard to any special points in treatment, it is obvious that syringing of ear or nose is absolutely contra-indicated. The cavities should be lightly plugged with gauze, the dressings to be renewed as soon as they are soaked. The patient must also be prevented from interfering with the dressings.
With regard to the routine use of urotropin to guard against the advent of meningitis, see p. 116.
This diagnostic symptom is of very rare occurrence. For its development the following factors are requisite:—
Great comminution and destruction of the anterior fossa.
Severe local laceration of the brain (frontal lobes).
A copious discharge of blood and cerebro-spinal fluid.
A general increase in the intracranial pressure.
One case only of this nature has come under my own observation, that of a man whose right nostril was blocked with brain substance. He died shortly after admission into the hospital, and at the post-mortem examination the above conditions were found.
When the fracture involves the frontal, ethmoidal, and mastoid sinuses, any sudden increase of the intrasinus air-pressure, such as is caused by sneezing, blowing of the nose, &c., may force air into the surrounding tissues. A distinction must be made between those cases in which the pericranium overlying the seat of fracture is torn and those in which it remains intact. In the former case, the escaping air may spread widely into the neighbouring loose tissues, leading to a condition of ‘surgical emphysema’. In the second case, the air remains confined to a smaller area, giving rise to a soft, more or less rounded swelling. Gentle palpation of this swelling imparts to the fingers that crackling sensation peculiar to the condition. Firm pressure results in diminution in the size of the tumour, the contained air being forced back into the sinus cavity. Such localized collections of air are known as ‘pneumatoceles’.
As regards the special treatment of these conditions, the patient must, in the first case, be warned against straining of all sorts. Pneumatoceles require no other treatment. The condition soon disappears if the patient recovers. In widespread surgical emphysema, an incision should be made over the injured sinus, thus allowing of the direct escape of the air expelled from that sinus.
The following nerves may be involved in anterior fossa fractures:—
The great majority of anterior fossa fractures traverse the cribriform plate, necessarily injuring the fine branches of the olfactory bulb. The bulb itself may be lacerated, with or without injury to the under surface of the frontal lobes. Sir Prescott Hewitt considered that anosmia, or loss of smell, resulted most frequently from blows applied to the back of the head, the frontal region being injured by contre-coup. From my own experience it would appear, however, that anosmia, whether uni- or bilateral, whether transient or permanent, generally results from direct injuries of the cribriform plate with associated lacerations of the olfactory nerves. It is difficult to estimate the presence or degree of immediate loss of smell on account of the general condition of the patient and because the nostrils are usually more or less filled with blood coagulum. Experience shows, however, that early loss of smell is the rule and total and permanent anosmia the exception. Anosmia is usually associated with some degree of loss of taste.
Many cases have been recorded in which visual defects resulted from blows applied to the head. The blindness may be partial or complete, immediate in onset or developing at some future date. In the latter case, the loss of vision is due to retinal changes or results from post-neuritic atrophy.
The occurrence of complete or partial blindness as the immediate result of the injury is, at first sight, difficult to explain, for the vast majority of anterior fossa fractures avoid the immediate vicinity of the optic foramina, passing by preference between the two foramina or diverging towards the sphenoidal fissures. Small fissured fractures not infrequently radiate through the optic foramina, usually, however, of so slight a nature as to be incapable of leading to any gross lesion of the optic nerves. Hæmorrhage into the sheath of the nerve is probably responsible for a certain proportion of cases, more especially those in which there is a peripheral concentric loss of vision, the more central fibres escaping. It is possible, also, that cases evidencing temporal or nasal blindness may be due, as J. J. Evans[17] thinks, to a contre-coup contusion of the nerve through it being forcibly driven against the bony boundaries of the foramen. Taking into consideration, however, the very frequent presence of a fracture through the anterior clinoid process (see p. 82), and the usual displacement of that process, it would appear probable that immediate and more or less complete loss of vision results from the compression and crushing of the optic nerve by reason of the pressure exercised by a displaced clinoid process.
The following statistics add confirmation to this view. Thus, Callen collected 17 cases in which the optic nerve was compressed by osseous fragments in the region of the optic foramen, whilst Holder observed injury to the bones entering into the formation of the foramen in 53 out of 86 cases of fracture involving this region.
The prognosis varies according to the cause of the blindness. When resulting from concussion of the nerve trunk or from hæmorrhage into its sheath, certain fibres may regain their function. In the majority of cases, however, that have come under my own observation, blindness of the affected eye was immediate and permanent.
The ophthalmic division of the fifth nerve is rarely injured to such a degree as to cause anæsthesia of all the regions supplied. Blood extravasation into the surrounding regions, or direct involvement of one of the branches of the nerve, often results in areas of anæsthesia, and some few cases have been recorded in which there was complete anæsthesia of both cornea and conjunctiva, with subsequent ulceration and sloughing. The nasal nerve may be implicated as the result of a fracture involving the cribriform plate, whilst the supra-orbital and supra-trochlear branches may be damaged by fractures of the vertical plate of the frontal bone.
The third nerve is similarly liable to injury, in any part of its orbital course. It is quite exceptional, however, for the whole trunk to be affected, some of the branches being taken, others left. The fourth nerve is also occasionally involved, generally in association with other orbital nerves.
When anæsthesia or paralysis of muscles results from pressure exercised on the nerves by extravasated blood, the ultimate prognosis is not unfavourable. When due to direct implication, in the line of the fracture, the prognosis is much more uncertain, partial or complete loss of function resulting.
The extravasated blood may either be confined to the temporal region—temporal hæmatoma—or diffused throughout the subaponeurotic space. A temporal hæmatoma is always highly suggestive of a fracture involving the temporal fossa, especially in the event of marked outward bulging, with stretching and discoloration of the overlying tissues. In many cases also the hæmatoma pulsates, in which case it can be presumed that the fracture of the temporal fossa is associated with hæmorrhage from a lacerated middle meningeal artery (see Fig. 38). In such cases the application of pressure to the hæmatoma may lead to the development of fits on the contra-lateral side, originating in the face or arm regions and spreading to the higher cortical motor area.
A
B
Fig. 38. To illustrate the probable Source of Profuse Hæmorrhage from the Ear. A, The fracture the roof of the external auditory meatus. B, Comminution of the tegmen tympani, the fracture involving the groove for the posterior branch of the middle meningeal artery.
(b) Hæmorrhage from the ear and mouth. The great majority of middle fossa fractures involve the external auditory meatus, passing inwards across the roof and floor of the middle ear towards the body of the sphenoid. Examination will show that the fracture passes inwards towards the junction of the inner and anterior walls of the middle ear, that is to say, towards the tympanic orifice of the Eustachian tube. The membrana tympani undergoes a variable degree of destruction. In the lesser cases the membrane is torn in its upper and front part only—in the region of the membrane of Shrapnell—whilst in the more serious cases it may be completely destroyed. The blood that escapes from the ear is derived from those vessels that supply the lining cuticle of the external and middle ears, from the numerous tympanic vessels, from the lateral sinus, and from the middle meningeal artery. The amount of blood which escapes varies according to the source of the hæmorrhage. When hæmorrhage occurs from the smaller vessels, the blood either clots in the external meatus or trickles from the ear. In the most severe cases the hæmorrhage is profuse and long-continued. Some years ago a case came under my observation that threw light on the probable source of such severe hæmorrhages.
A man was admitted into the hospital, suffering from profuse hæmorrhage from the ear as the result of a fall down an area. The bleeding continued for fourteen hours, soaking the dressings and continuing so long as the man lived. At the post-mortem examination an extensive comminution of the tegmen tympani was discovered, the fracture being associated with great extra-dural extravasation of blood from a lacerated middle meningeal artery. The extra-dural hæmorrhage was enabled to escape through the tegmen tympani into the middle ear, and thence by means of the lacerated membrana tympani (see Fig. 38).
Profuse and long-continued hæmorrhage from the ear should always arouse suspicion as to the possibility of injury to the middle meningeal artery. Since meeting the case recounted above, many similar cases have come under my care, and, in several instances, guided by this symptom alone, operative measures have been carried out successfully.
The two following cases show, however, that the extra-dural extravasation may be derived not only from the middle meningeal artery but also from the lateral sinus.
‘A man fell down an area and suffered from continuous hæmorrhage from the ear. He remained in bed for a few days, and then, becoming tired of confinement, got up, walked some distance on a cold and frosty day, and visited a sage femme. On returning home he complained of feeling ill, the hæmorrhage from the ear ceased, and shortly afterwards he became unconscious and died. The autopsy showed an extensive fracture of the petrous bone with extensive extra-dural hæmorrhage from a torn lateral sinus and from a lacerated meningeal artery.’[18]
The man had remained fairly well so long as the extra-dural blood was permitted a free means of escape through the tegmen tympani and external auditory meatus, but, so soon as clotting occurred, compression symptoms developed and the man died in that condition.
‘A man, 50 years of age, fell down, striking his head against the kerb. On admission it was seen that blood was trickling freely through a torn membrana tympani. He rapidly became unconscious and died. The post-mortem examination revealed a fracture involving the middle ear and external auditory meatus, passing backwards across the lateral sinus, in which region there was a large extra-dural extravasation of blood.’[19]
The above statements are confirmed by Dwight,[20] who, in 146 autopsies, found that, in 69 per cent. cases of fracture of the middle fossa of the skull, there was bleeding from the ear, and that in 29 per cent. cases the fracture was associated with laceration of branches of the middle meningeal artery.
Although hæmorrhage from the external auditory meatus may be regarded as almost diagnostic of a middle fossa fracture, especially of that variety previously described as the ‘typical basic fracture’, yet the blood may be derived from a torn membrana tympani or from laceration of the lining cuticle of the external meatus. Aural examination will soon prove whether the blood is coming through a rent in the membrane, in which case the diagnosis is clear. Sometimes bleeding takes place from both ears, a symptom practically diagnostic of the transverse middle fossa fracture known as the ‘typical basic fracture’.
The following statistics will supply further information as to the relative frequency with which hæmorrhage occurs from ears, nose, and mouth, and the proportionate mortality. The cases were collected and tabulated by Crandon and Wilson.
| Cases. | Lived. | Died. | Mortality. | |
|---|---|---|---|---|
| Hæmorrhage from the ear | 281 | 170 | 111 | 39 per cent. |
| Hæmorrhage from both ears | 47 | 16 | 31 | 66 per cent. |
| Hæmorrhage from the nose | 44 | 17 | 27 | 61 per cent. |
| Hæmorrhage from the mouth | 168 | 73 | 93 | 33 per cent. |
It is not possible to formulate any very definite prognosis when the hæmorrhage takes place from one ear only, though the mortality is about 40 per cent. When bleeding takes place from both ears the outlook is more grave, the mortality being about 66 per cent.
With regard to special treatment, two points are obvious: (1) that syringing of the ear is absolutely contra-indicated, on the ground that such treatment carries with it a considerable risk of bringing about meningeal infection; and (2) that plugging the external meatus with strips of gauze is an unsurgical form of treatment, insomuch as the escape of blood from the ear is an important factor in preventing compression of the brain, more especially in those cases where hæmorrhage is profuse. Under the last named conditions, operative measures—exploration for a torn meningeal artery or lacerated venous sinus—are to be carried out.
Hæmorrhage from the mouth may be slight or copious, according to the source from which the blood is derived. In the former case, the bleeding takes place from sphenoidal and pharyngeal vessels, in the latter from the cavernous sinus or from the internal carotid artery (see p. 148), the bone being shattered in the region of the sphenoidal body, with comminution of the walls of the contained air-sinus.
This condition was first investigated by Van der Wiel in 1727, and more completely by Langier in 1839. The majority of those middle fossa fractures which involve the petrous portion of the temporal bone pass immediately anterior to the genu of the facial nerve (see p. 102), and it follows, therefore, that the fracture cannot so involve the dural and arachnoid prolongations of that nerve in such a manner as to allow of the escape of cerebro-spinal fluid. This fact probably explains another fact, namely, that aural cerebro-spinal discharge is an infrequent symptom in middle fossa fractures. On the other hand, as a result of blows applied to the occipital region, a fracture originating in the posterior fossa may cut across the petrous bone, almost at right angles, in such a manner as to sever the seventh nerve in the region of the genu (see Fig. 41). This is the usual nature of a basic fracture associated with the escape of cerebro-spinal fluid from the external auditory meatus. More rarely, this particular class of fracture is unaccompanied by any injury to the tympanic membrane, in which case the fluid may escape along the Eustachian tube into the nose and naso-pharynx (see p. 91). Cerebro-spinal fluid may also escape from the nose and mouth in middle fossa fractures in the event of extensive injury to the basi-sphenoid with involvement of the overlying cisterna basalis. The following case exemplifies that condition:—
A man suffered from a severe fracture of the middle fossa. Three weeks later there was a sudden and profuse discharge of cerebro-spinal fluid from the nose. Meningitis developed and the patient died. The basi-sphenoid was extensively comminuted, the overlying membranes torn, whilst a probe could be passed readily from the cranial cavity into the naso-pharynx.
The question of cerebro-spinal discharges has been discussed previously (see p. 91). It is therefore merely necessary to lay further stress on the fact that syringing of the ear is absolutely contra-indicated, for reasons already stated. The ear should be cleaned out with wool and gauze and lightly packed with strips of gauze, these to be renewed when soaked with fluid. When the cerebro-spinal discharge is long continued, acute eczema of the side of the neck may develop as a result of the irritating effect of the fluid. Under these circumstances it is advisable to adopt precautionary measures, painting the skin with ‘new skin’ or collodion. Ointments are of but little use. The eczema will clear up so soon as the discharge ceases.
The conditions needful for the discharge of brain-matter from ear or nose have been enumerated previously (see p. 93). There are but few cases recorded in literature, and one case only has come under my own observation:—
A lad, 11 years of age, fell some distance out of window on to his head. He was admitted under the care of my colleague, Mr. Lockwood. On admission he was unconscious, and was bleeding freely from the right ear and nose. Shortly afterwards it was noticed that brain-matter was issuing from the right external auditory meatus, sufficient brain-matter being obtained to fill a teaspoon. The extensive nature of the brain-injury was confirmed by the fact that the left arm and leg were paralysed for some days. On the fourth day the boy regained consciousness and recognized his relations. From this period onwards he made an uninterrupted recovery. I have seen the lad on various occasions, the last time one year after the accident. At that time he was an exceedingly bright and intellectual boy.
The brain-matter should be gently wiped away from the ear, and the meatus cleansed and lightly plugged with gauze. Operative measures are required in the event of the development of symptoms pointing to brain compression. The prognosis must necessarily be unfavourable, but, as the conditions are almost entirely confined to the young, the most astonishing recoveries are reported.
The second and third divisions of the fifth nerve pass respectively through the foramen ovale and the foramen rotundum, two foramina which lie anterior to the petro-sphenoidal suture, a suture traversed by the majority of middle fossa fractures. These two nerves are therefore seldom involved.
In all the cases of fractured base which have come under my observation I have never seen the foramen rotundum implicated, and in one case only was the foramen ovale involved.
In certain rare instances, a fracture, passing in the antero-posterior direction, may cut across the apex of the petrous bone in close relation to the cavum Meckelii—the bed of the Gasserian ganglion—in which case all three terminal divisions of the fifth nerve may suffer. Thus, a case was reported by Lee in 1853 in which, seven weeks after the accident, the following symptoms were present:—anæsthesia of the left face and forehead, anterior two-thirds of tongue, and left nostril, together with weakness of the left masticating muscles, and an opaque left cornea.
The sixth nerve may be involved either by itself or in conjunction with other cranial nerves. In the latter case the paresis is due to blood extravasated in the sphenoidal fissure or in the orbital cavity. In the former case the nerve is injured where it grooves the lateral aspect of the dorsum ephipii, a process frequently fractured in lesions of the middle fossa. Fractures tend to pass obliquely across this process, one nerve usually escaping. The prognosis as to functional recovery is very problematical.
There can be no doubt that the seventh nerve, on account of its complicated intrapetrous course, is more frequently involved than any other cranial nerve. Köhler records 22 cases in 48 middle fossa fractures. My own experience coincides closely with Köhler’s, facial paresis or paralysis being noted in nearly 50 per cent. cases of middle fossa fracture.
The question of facial nerve implication is so intimately associated with involvement of the eighth nerve that the two subjects must be considered together. Thus, cases may be classified as follows:—
1. Cases of paresis of the facial nerve with a variable degree of deafness.
2. Cases of complete facial paralysis with complete deafness.
The greater number of middle fossa fractures involve the middle and external ears, as is evidenced, amongst other symptoms, by hæmorrhage from the ear. Some degree of facial paralysis is frequently existent, not always evident at first sight, but requiring careful examination and comparison between the two sides of the face. The fracture involves both roof and floor of the external ear and passes inwards towards the junction of anterior and inner walls of the middle ear, the membrana tympani undergoing a variable degree of destruction whilst the ossicles may also be injured. Thence, the fracture passes inwards towards the petro-sphenoidal suture in such a manner that the geniculate ganglion of the facial nerve is exposed and laid bare on the anterior aspect of the posterior portion of the skull.
The facial nerve, therefore, escapes direct injury except in so far that the ganglion may be compressed by blood-clot or fragments of bone. Partial loss of function results. In most cases the blood is absorbed and a complete recovery may be anticipated. The degree of deafness is directly proportionate to the damage incurred by the membrana tympani and ossicles.
Fig. 39. To show the Relation of a Typical Basic Fracture to the Middle Ear and its Adjuncts. A, Malleus; B, Middle ear and aditus; C, Geniculate ganglion (facial nerve); D, Groove for great superficial petrosal nerve; E, Canal for tensor tympani muscle; F, Processus cochleariformis; G, Eustachian tube; H, External auditory meatus; I, Membrana tympani; J, Mastoid cells.
In the second group of cases a different picture is obtained. Usually the result of blows applied to the occipital region, the fracture traverses the thin cerebellar fossa towards the outer angle of the jugular foramen, thence cutting across the petrous bone, external to the internal auditory meatus, and terminating, usually by comminution, in the tegmen tympani. It is in the transpetrous part of the fracture that the damage is done, for, not only is the facial nerve cut across in the region of the ganglion, but the auditory apparatus is also severed into two parts. The exact line of the fracture is shown in Figs. 40 and 41.
A
B
Fig. 40. To show the Relation of Basic Fractures to the Petrous Bone. A, The basic fracture, resulting from a force applied to the left occipital region, follows the course depicted in Fig. 36. B, The inner half of the petrous bone, being loose, is thrown forward so as to show the relation of the fracture to the integral parts of the petrous bone.
In this class of fracture, though facial paralysis and deafness are both immediate in onset and permanent in duration, there is, in many cases, no bleeding from the ear as the membrana tympani may be uninjured.
The facial nerve may also be implicated in that rare type of basic fracture which was described by Lèon Boullet in 1878, under the title of ‘Fracture of the Mastoid portion of the Temporal bone’. This fracture is fully described on p. 108. It will suffice to mention that the mastoid process may be torn away from the base of the skull, the facial nerve being lacerated as it descends the aqueductus Fallopii.
Bilateral facial paralysis is exceedingly rare. Two cases were described by the late Professor von Bergmann. Its occurrence is pathognomonic of the typical basic fracture (see p. 84).
A
B
Fig. 41. To show the Relation of Basic Fractures to the Petrous Bone. A shows the course pursued by an antero-posterior fracture of the petrous bone. Note that it lies external to the internal auditory meatus. B shows—enlarged—the inner aspect of the outer fragment. Note the relation of the fracture to the semicircular canals, and that the membrana tympani and ossicles are quite uninjured.
Complete facial paralysis may be associated with the following symptoms:—
Epiphora, conjunctivitis, and keratitis (from paralysis of the orbicularis palpebrarum).
Loss of taste (from involvement of the chorda tympani).
Impaired nasal air-entry (from paralysis of dilator alæ muscle).
Impaired acoustic sensibility (from paralysis of the stapedius).
Impaired mastication (from involvement of the buccinator muscle).
Impaired secretion of saliva (from the cutting off of the secretory and vaso-dilator fibres of the chorda tympani).
Lastly, it is necessary to add that facial paralysis developing some days or weeks after the accident, though sometimes dependent on degeneration of nerve-fibres as the result of pressure in the region of the geniculate ganglion, may also arise from an ascending neuritis or from meningeal infection.
In fractures of the posterior fossa, blood effused into the deeper tissues of the scalp has considerable difficulty in coming to the surface and thus making itself evident. Furthermore, the resistance offered by the nuchal muscles tends to confine the blood to the subtentorial region, thus adding to the already grave prognosis of fractures in this region. On careful palpation, however, it will be noted that the nuchal tissues present a doughy or boggy condition, whilst ecchymosis becomes evident after twenty-four to thirty-six hours. A peculiar ecchymotic patch is occasionally observed, appearing in front of the mastoid process and travelling upwards in a curved direction, concavity forwards, following the outline of the ear. It is said to result from the tracking of blood along the course of the posterior auricular artery. Whether this is the case or not, the hæmorrhage usually implies a separation along the line of the masto-occipital suture.
Escape of cerebro-spinal fluid. |
- | Neither of these symptoms are present. |
|
Escape of brain-matter. |
When dealing with fractures of the middle fossa, allusion was made to the implication of the seventh and eighth pair of nerves as the result of a fracture traversing the posterior fossa of the skull towards the outer angle of the jugular foramen and cutting across the petrous bone (see p. 104).
The ninth, tenth, and eleventh cranial nerves may be injured in the same variety of fracture. These three nerves are, however, so protected by their dural sheaths that they generally escape injury.[21]
In the following cases the nerves were involved:—
The patient was admitted suffering from a fracture resulting from a blow on the posterior parietal region. During the next four days no special symptoms developed. On the fifth day, during a sudden attack of dyspnœa and dysphagia, death occurred. A fissured fracture was found which extended into the jugular foramen, a region occupied by blood-clot.
A man committed suicide by means of a pistol-bullet fired through the mouth. The bullet lodged against the under surface of the petrous bone, tearing the jugular vein and lacerating the nerves passing through that foramen.
In another case the patient was admitted with a fractured base. He progressed favourably until the tenth day when, on sitting up suddenly in bed, he was seized with rigors, dyspnœa, and dysphagia, dying shortly afterwards. A basic fracture was found, practically dividing the skull into two parts and involving the jugular foramen. Displacement had occurred with consequent compression of the ninth, tenth, and eleventh nerves.
The anterior condyloid foramen is most favourably situated with respect to the course pursued by posterior fossa fractures. No instance of its involvement has come under my own observation.
Stierlein records a case in which the tenth and twelfth nerves were injured, with inability to speak or swallow, paralysis of the right half of the tongue, soft palate, vocal cords and pharyngeal constrictions. Death resulted in seven weeks.
The late Professor von Bergmann[22] mentions a case of hypoglossal paralysis together with paralysis of the sterno-mastoid and trapezius muscles (eleventh nerve).
For treatment of basic fractures, see p. 116.
Fracture of the Base of the Skull: Summary of Symptoms
| Anterior Fossa. | Middle Fossa. | Posterior Fossa. |
|---|---|---|
| Hæmorrhages. | Hæmorrhages. | Hæmorrhages. |
| Subconjunctival. Palpebral. Peripalpebral. Orbital. Retinal. From the nose. From the mouth. |
Into the temporal region. From the mouth. From the nose. From the ear. |
Into the nuchal region. Into the occipital region. Into the post-auricular region. |
| Cerebro-spinal fluid. | Cerebro-spinal fluid. | Cerebro-spinal fluid. |
| From the nose. From the mouth. |
From the nose. From the mouth. From the ear. |
None. |
| Brain-matter. | Brain-matter. | Brain-matter. |
| From the nose. | From the ear. | None. |
| Air-escape. | Air-escape. | Air-escape. |
| From the frontal sinus. From the ethmoidal cells. |
From the mastoid antrum. | From the mastoid antrum. |
| Nerve-involvement. | Nerve-involvement. | Nerve-involvement. |
| Olfactory. Optic. Third. Fourth. Fifth (first division). Sixth. |
Fifth (second and third divisions). Sixth. Seventh. Eighth. |
Seventh. Eighth. Ninth. Tenth. Eleventh. Twelfth (?). |
Fractures limited to this region are of rare occurrence. Our knowledge of the condition is obtained from the researches of Lèon Boullet, who first described the fracture in 1876, reporting at the same time 26 cases.
The fracture usually results from sharp blows delivered along the posterior border of the mastoid process, the force acting obliquely from above downwards and forwards. More rarely, the process is detached as the result of a blow delivered immediately above the ear, that organ sharing in the displacement. In either case the detachment is usually of an incomplete nature, mainly on account of the muscular and pericranial attachments in the region involved.
According to Boullet, the following symptoms result:—
Air escapes from the mastoid cells and antrum into the overlying tissues, either spreading widely through the subaponeurotic space of the scalp and cellular tissues of the neck (surgical emphysema), or remaining localized and forming a tumour of inconsiderable size (pneumatocele). In either case palpation reveals that peculiar crepitation which is pathognomonic of tumours of this nature.
Hæmorrhage takes place into the middle ear, and, as the tympanic membrane is usually lacerated, the blood escapes from the external ear. In the event of the tympanic membrane being uninjured, the blood may escape along the Eustachian tube into the naso-pharynx.
Boullet also pointed out that certain complications may be associated with the mastoid lesion. These are as follows:—
Immediate.
Wound of the lateral
sinus.
Laceration of dura
and brain.
Injury to the aqueductus Fallopii and paralysis of the seventh nerve.
Remote.
Deafness.
Otitis
media.
Caries and necrosis of the petrous bone.
The displacement of the mastoid process is of so incomplete a nature that the question of replacement by open operation seldom arises. In the event, however, of intracranial complications, operative treatment must be carried out. Under ordinary circumstances the treatment consists mainly in the prevention of suppuration. When suppuration occurs, frequent cleansing of the ear must be carried out in order to prevent accumulation of pus in middle ear and antrum. This object is to be attained, not by syringing, but by gentle irrigation and light packing. Later on it may become necessary to carry out the complete mastoid operation.
Fractures of the vault of the skull may be restricted to the vault or associated with a basic fracture. Evidence has been brought forward previously to show that many vault fractures may be regarded as mere upward extension from a primary basic lesion. The limitation of a fracture to the vault depends on the nature of the productive force, the degree of violence used, the site of application, and the direction of the force. Thus, the smaller the weapon, the greater the violence, the nearer the site of application to the vertex, the more direct the blow, the greater is the tendency to vault limitation. Again, compound fractures are much more liable to vault limitation than simple fractures, as is proved, for instance, by the reports of Sir Prescott Hewitt—20 compound fractures in which the fracture was restricted to the vault of the skull, and 56 simple fractures in which the base was involved in all but one.
Fractures of the vault may involve:—