THE SKULL. 



attachment of the dura mater in children, the meningeal arteries are more liable to 

 be torn and cause hemorrhage than is the case in adults. For the same reason the 

 blood pressure is not sufficient to dissect the dura from the skull, therefore epidural 

 clots are rare. If there is a fracture, blood may collect beneath the scalp, and if an 

 external wound exists, the blood will find an exit through it. 



Bleeding from the Venous Sinuses. Bleeding may occur from the sinuses of the 

 base as well as from those of the vault. In severe injuries of the vault detached frag- 

 ments frequently penetrate the superior longitudinal and lateral sinuses. In these 

 cases profuse bleeding occurs as soon as attempts are made to remove the loose pieces 

 of bone, and it is necessary to use a packing of gauze to control it. Fractures passing 

 through the petrous portion of the temporal bone wound the petrosal sinus and 

 this no doubt contributes to the blood which flows from the ear. 



Emphysema is most likely to occur if the frontal air sinuses are involved, partic- 

 ularly if the patient blows his nose in the 

 attempt to relieve it of blood clots. Em- 

 physema is not so liable to occur in cases 

 of fracture involving the mastoid cells. 



Cerebrospinal fluid may escape when- 

 ever the meninges are torn and the sub- 

 arachnoid space is opened. It is most fre- 

 quently seen in the fractures involving the 

 middle fossa and passing through the in- 

 ternal auditory meatus. The meninges are 

 prolonged into the internal meatus, and the 

 clear fluid is not infrequently seen coming 

 from the ear of the injured side. Although 

 the normal amount of cerebrospinal fluid 

 is only about two ounces, much greater 

 quantities can escape. A serous discharge, 

 perhaps of several ounces, is indicative of 

 a rupture into the subarachnoid space. 



Injuries to Nerves in Fracture 

 of the Skull. The nerves most often 

 disturbed in injuries of the skull are the 

 first, second, third, seventh, and eighth. 



The first or olfactory nerve may be 

 injured directly in the line of fracture, or 



by concussion. I have had under my care two such cases in women who struck the 

 occiput on an asphalt pavement in getting off backward from a moving trolley car. 

 These patients left the hospital after several weeks with the sense of smell still lacking. 



Injuries to the second or optic nerve are apt to be accompanied by such severe 

 injuries to other parts as to cause the death of the patient before the loss of sight is 

 discovered. If the optic nerve is injured at the optic foramen, there may be impair- 

 ment of sight without any intra-ocular changes to be seen with the ophthalmoscope. 

 Inside of two weeks, however, the pinkish color of the disk gives way to the gray-white 

 color of atrophy, and this progresses until complete. The nerve never resumes its 

 functions and the patient remains blind. 



Injury of the third or oculomotor nerve has also come under my notice. In this 

 the pupil of the affected eye is moderately dilated and does not respond to light. 

 The ciliary muscle is supplied by the third nerve, as well as the circular fibres of the 

 iris, so that the accommodation is paralyzed and, if the eye has been normal in its 

 refraction, the patient will be unable to read or see objects clearly at close distances. 

 The extrinsic muscles of the eye, with the exception of the superior oblique and 

 external rectus, are also supplied by this nerve and the eye is therefore pulled outward 

 and slightly downward, and diplopia, or double vision, may be produced. The patient 

 is unable to move the eye either upward, inward, or downward. The levator palpe- 

 brae muscle is also paralyzed and there is ptosis or drooping of the upper lid. The 

 orbicularis palpebrarum muscle, being supplied by the seventh nerve, has its func- 

 tions unimpaired, and the eyelids can be closed. 



FIG. 26. Paralysis of the facial nerve from fracture 

 of base of skull (author's case). 



