. Manual of operative surgery. starch bandage. CRANIAL TOPOGRAPHY. 15 HEMORRHAGE FROM THE MIDDLE VESSELS The middle meningeal artery enters the cranium through the foramen spino-sum, usually accompanied by two veins. It divides into an anterior and aposterior branch, which ramify in all directions over the dura. Meningealhemorrhage is usually accompanied by fracture of the skull, but as it sometimesis caused by violence which does not injure the bone, and even by contrecoup,the operative treatment of the latter class of cases must be considered separately. I. When focal symptoms per
. Manual of operative surgery. starch bandage. CRANIAL TOPOGRAPHY. 15 HEMORRHAGE FROM THE MIDDLE VESSELS The middle meningeal artery enters the cranium through the foramen spino-sum, usually accompanied by two veins. It divides into an anterior and aposterior branch, which ramify in all directions over the dura. Meningealhemorrhage is usually accompanied by fracture of the skull, but as it sometimesis caused by violence which does not injure the bone, and even by contrecoup,the operative treatment of the latter class of cases must be considered separately. I. When focal symptoms permit the determination of the site of the bleed-ing, the indications for treatment are exceedingly simple. Trephine the skullat the site of the hemorrhage. A tough, dark-colored clot will be found. Thismust be removed with forceps, probe, spoon, and stream of hot water. Prob-ably the trephine opening will require enlargement; possibly, a second openingmay be required, as extradural clots are frequently very extensive. If active. Fig. 16.—Exposure of middle meningeal artery. {Esmarch and Kowalzig.) bleeding continues, search for its source by enlarging the trephine opening withforceps or making another opening as may be required. Ligate the the dura carefully for signs of injury. If that structure is torn, cleansethe wound from blood-clots and close it with fine sutures. For suturing theauthor prefers fine silk or celluloid hemp to catgut, merely because the formerare so thin that they can be readily threaded on very small needles. If the durabe found distended and discolored, or pulsation is absent showing that subduralhemorrhage is probably present, carefully incise that membrane, remove blood-clot, stop bleeding, and close the dural wound. After the removal of extraduralclots the dura soon becomes pushed up against the skull in its normal position,and the external wound may be closed without drainage. II. In the absence of distinct focal symptoms the trephine
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