do\vn\var(l. It was fastened in place by working the metal into the
indentations of the bone, and was packed loosely with gauze. The
scalp was so loosened on either side that the cup covered the opening.
One week later the wound was re-dressed : the metal was firmly Iield in
place, and there was no l)ulging nor escape of brain-matter. In two
weeks the wound was com])lctclv closed. The ])atient was kept under
observation for some time, and developed no unpleasant complication, in
spite of the remaining metal. Consetpiently, a new method of dealing
with cerebral hemorrhage and of prevention of ju'olapsus cerebri is
offered to us.^
The oprrolion for rvcwtudion of Ahscexx in the Brain has already
been sufficiently described under that heading. The opening may be
' See Med. Nevi<, Dec. .3 and 10, 1892. - Med. ^'eits, March 10, 1894, p. 267.
771) DISEASEf^ AXl) INJURIES OF THE HEAD.
made in any dt'sirabk' \v;iy, can be enlarged to any desirable extent,
and here, as elsewhere, one may feel that the instninients of the surgeon,
used jndiciously, will not do so much harm as will pus left unevacuated.
Sullieient directions for taniponinii', drainage, etc. have already been
given.
Opcrdfidii fur tiritliiili/e mid irr'n/dtioii <ij the iiuiiiiiyfiil cdrifi/ has
already lieen spoken of when dealing with the conditions \\hi<']i lead to
tile formation of pus in that situation. It needs but little further de-
scription here. The condition being a diffuse one, the oj)ening should
be so planned as to liest ])cnnit complete drainage. Consequently, at
least one of the openings should l)e made in the occipital I'egion, and
])r()l)al)ly on eitiier side of tlie falx. By these openings drainage will
be permitted, but if complete irrigation is to l)e practised, it will be
necessary to ni:ike t)]K'nings in the frontal region as well. These need
not be large, and may even be made with a guarded drill, extra care
being taken that it be not allowed to perforate the dura. There is more
danger of this, however, with tlic ordinary drill than with the small
trepliine. Scarcely any fluid could do so much harm as pus, but it
would ])ro!)al)ly be wise to use for irrigation Thiersch's l)orosalicylic
solution or else a not very strong sublimate scjlution.
Ojicrdtion iieccusitated for the removal of foreign bodies is to be based
entirely on the su])posed nature, extent, and location of the same. The
foreign substances most often calling for o])erative interference of this
kind arc bullets. While we have deliberately left most of the considera-
tions of gunshot injuries to be dealt with in another article, it will be
most pertinent to the subject to illustrate here the methods of detection
and removal of missiles. No matter how much a bullet may deflect in
its course licfore entering the brain, the presumption always is that when
once it has entered this viscus it will ]>ass straight through it ; conse-
cpiently, that it will impinge upon the skull at a point opposite tfi tliat
at which it entered. Here it may either ])t'rforate and pass out, may
remain attached to the bone, or may be reflected and drop into some
other ])art of the brain, where its presence may or may not be indicated
by fo(-al disturbances. It is now generally considered wise to trephine
not only at the ])oint of entrance, on account of the comminution of the
bone, but also at that point, above referred to, upon which it will im-
pinge. The (U'tectiou of this point has not always been an easy matter.
A probe passed into the bullet-track and allowed to And its own way
into the brain will seldom go to the complete extent desired without the
use of undue pressure or force. Tlie telephonic^ bullet-probe of Girdner '
will be reliable when its point comes in contact with the metal ; other-
wise, it will give no information which the ordinary probe will not.
Bryant has recently suggested a method of finding the second jxiint by
means of lines drawn meridianally, their common centre being the
point of entrance which is known and the point sought, whose location
is made known by the ))lace at Mhich these lines converge. Still more
recently Morgan of Indianajiolis has devised the method figured here-
with by the use of a trajector, of which the plate (' is a])plicd to the
])robe, already passed as far as it will easily go along the bullet-track,
' ]'i(lr papers by the writer ami others in Trans. Am. Ass'n of Mililury Surgeons, 1895i
vol. V.
OPERATIONS UPON THE CRANIUM AND BRAIN.
777
after wliich the point
the slidino; rod BF.
roviding
the desired point — will be indicated by
only that the original probe can be
safely introduced to a sufficient extent to give the proper direction, the
device is simple and, apparently, accurate. The desired, or second,
I'k;. 450.
point having been determined, the trephine is employed at this point,
and after removal of the button of bone the further procedure must be
determined by the condition of the parts. It may be possible now with
Nelaton's probe or the telephonic instrument of Girdner to follow the
bullet in its reflected path, locate, and remove it. Tliat too much inter-
ference is not necessary, and that it pays to stoj) after reasonable effort,
are illustrated by a case in tlie practice of my colleague. Dr. Parmenter.'
Other foreign bodies which are occasionally driven into the brain
besides particles of bone are hair, pieces of hat or clothing, s]ilinters of
wood, or other substances which it is not necessary to catalogue. Be
they what they may, there is the greatest tirgcncy for their complete
removal, since one may be (pute sure that with them infectious germs
' Dr. Parmenter ha.'; fiirnislied notes of tlie case of a man of fifty-four with gunshot
wound of the external angular process on the right side, the orbit being shattered, the
bullet passing upward across the frontal lobes. The skull was trephined at the point of
entrance. A probe, passed along the course of the ball, impinged on the inner table of
the skull on the left side, aboiU two and a half inches above the middle of the left
superciliary ridge. Here the skull was again trephined, and on the under surface of the
button of bone was seen the mark of the ball, wliiih had struck here and glanced down-
ward, tearing a second hole in the <lura. Further attempts to locate the ball seemed
futile. The bnllet-track was draine<l bv a tube from one (ipening to the other. Seventy
hours later the man's temperature rose, and for five days his erudition was variable, but
with constant pyrexia. On the eighth day he was trephined again, just abuve the base-line
of the skull, one inch in fmnt (if the ear, to discover, if possible, the ball or any ab.seess
about it. After (ipening the (hu'a a slender knife was jiasseu inward and ujiward to the
depth of two inches. Ihi-* puncture was followed liv copious flow (if eerebm-spinal fluid,
showing that the lateral ventricle had been opened. Repeated ex|il(iration in every
direction, made with the needle, failed to discover the ball. Within a few hours his con-
dition improved in every resjiect. A day or two later he became conscious and rational,
and after about five weeks was removed to the jail. Here, again, after a few days, he was
seized with convulsions and was once more removed to the hospital. The convulsions
did not recur, however, and after a few days he was again transferred to the jail, tried,
and sentenced to five years in the penitentiary, where he is now serving his sentence.
778
DISEASES AND INJURIES OF THE HE All
liavc been also carried in, and tliat subsequent l)niin-absccssos ur puru-
lent meningitis may be caused if the source of infection be not com-
pletely removed and the cavity drained at least for a day or two.
Opcnillonst for cpUepxij (ind t/ie rcsii/fs iif ccrchrK/ irritatloii liave for
the most part found suttieient description un<ler their ap]ii'()priate head-
ings. The directions may be briefly summed up in tlie advice to detect
the cause witli the least possible amount ol' surface disturbance, to re-
move it with the least possible amount of deep injury, but to remove it
absolutely and thoroughly, and then to atone for such removal, so far as
one can, by accurate closure witii the use of gold-foil, to obviate as far
as one may the untoward effects of adhesion or of anehoring the brain to
the overlying dura and skidl.
Ojterdiions for the rcinoral of tiimorn must also be based upon general
principles, many of which have been already enunciated. The tumor
having been localized, one may be quite sure that a reasonably extensive
opening at least will be required. This would pr(>l)a])ly be made bv
means of some of the osteoplastic methods considered below. Should it
be necessary to remove a large area of dura, it would prol)ably be well
to substitute with gold-foil or some other material, in order that cor-
tical adhesions may be, so far as
Fig. 451. possible, prevented.' When exten-
sive removal of tissue has been
necessitated, the wound must be
tamponed for a reasonable time in
order that brain-pressure may be
e(|ualized, as has already been in-
sisted upon under tlie heading of
Brain-tumors. Tiie checking of
hemorrliage, the dressing of the
wound, provisions for tlrainage, etc.
have been treated of as fully as
space will allow under that heading.
Of late years (iKfop/aafir iiidhodx
have been so far improved on as to
include a certain phixtii- .•<iiri/cr_i/ of
the eraniuia itself. As a consequence
we have now a variety of so-called
" osteo])lastic " methods of opening
the cranium which have added very materially to the art of the surgeon
in cases of a character demanding intracranial ojieration. This has
been due to tiie combined efforts of a number of surgeons in various
parts of the world, and it is consequently ditticult to give any one man
the credit for this great improvement, though ])robably Wagner's name
is more prominent in this connection than that of any other individual.
In a general way these consist in the more or less complete detachment
of a section of the cranial vault, with the formation of a window, as it were,
in the cranium, which is afterward closed l)y the replacement of the piece
of bone, which has not been completely severed from its vascular sup-
ply. In very young subjects the bone is so elastic as to permit it to be
sprung to a considerable extent, permitting a variety of manipulation
beneath. In the skulls of adults or adolescents it is necessary usually to
Osteoplastic resection after Wagner (Chipault).
i
OPERATIONS UPON THE CRANIUM AND BRAIN.
779
Fig. 452.
cut away a section of bone after incising the scalp in such a way as to
make a rudely horseshoe-shaped opening, the peninsula of hone left at
the base of this osseous Hap being broken tlirough with forceps or
divided witli saw and chisel. ^Ul of these measures are carried out
upon the principle that tiie soit parts are to be detached from the bone-
flap to only tiie sliglitest necessary extent, the subsequent nutrition of
the broken bone being su])plied
through vascular connections with
these soft overlying tissues. There
is scarcely any reasonable limit to
the extent to which tliis idea may
not be carried out in practice, cer-
tain fundamental princijiles, how-
ever, being observed. The first of
these is to provide for a ])roper
blood-su])ply to the bone. C'onse-
tpiently, the bony [lenin.-ula is made
on the lower aspect of the flaj) when-
ever possible, the lai'ger jiart of the
incision being carried up more or
less near to tlie middle line. Again,
the width of the basal portion of the
bone-section is preserved as great
as safely can be, especially when the
periosteal bridge is left undivided,
as it is usually intended to be. The
shape of the flap, both in the scalp
and the l)()ne, may be quadrilateral
or omega-like, as may best suit the
requirements of tiie case ; and when
it is desirable to resect an extensive portion these flaps may be made in
two pieces, as suggested by AVagner and shown in the accompanying cut.
Toison has even devised a very thin ril)bon-like saw which may be
passed in at one tre])liine (ipening and out througii another, and used as
a band or chain saw for cutting out through the bone. This of course
presupposes that a small trephine has been used at two or more j)oints,
making openings through which it can be passed. Could one only
ensure that the dura thereby wei-e not injured, it would be in many
respects a desirable method of opening the skidl.
The method, however, must be in large measure based upon the pur-
pose for which the opening is made. Wiien for the removal of tumor
it is not nearly so desirable to excise a wide margin of bone in order to
prevent sj)eedy ossification. In tumor cases, therefore, as in operations
for epilepsy, etc., we probably desire tlie speediest reunion, and it will be
at least tlieoretically wise to take away as little bone as is possible.
Here, then, such a saw may be used, or with the chisel a narrow groove
can be cut away, so that after thinning it the bone-cutting forceps can
be used to advantage. In cases wlicre the skull is opened for the pur-
pose of permitting expansion of the cranial contents, as in microcephalns,
arrested development, etc., we aim deliberately to take away a wide
section of bone ; and in this case, after making tiie preliminary trephine
liuuVile osteoplastic resection, as suggested by
Wagner (Chipault).
780
DISEASES AND INJURIES OF THE HEAD.
()j)('iiiii<;' at Olio or two ]ioiiits, the hone is bitten away to tiie full width
of tlio rongeur foree]).s. At oilier jilaees in this
article the olijei^tion lias heeii raised to the pro-
longed use of haiiiiiier and chisel, hy which
undoubtedly shock is increased. This is done
in spite of the fact that many Contiiu^iital sur-
ge(jns advise the use of the (•liisel. In the
liands of Ainericau or Knglish surgeons, how-
ever, its ])rolonged use is almost always de])re-
catt'd. Nevertheless, by the skilful use of the
chisel it may be ])ossible to so bevel the mar-
gins of the bone while cutting them away as to
form a trap-door of such charac^tcr tliat its sur-
I'aee cannot be depressed below the margin of
the surrounding bone by any [lossible pressure.
This is, in theory at least, an advantage. In
practice, however, e.xperience has taught that it
is scarcely necessary to ol>servc these theoretical niceties, and that when
it is necessary to make a trap-door operation it can be done with but
lemporarj resection (after
Chalot).
Flu. 4.34.
Chipault's temporary osteoplastic resection : bone-edges bevelled.
little regard to the subsequent effects of pressure, since reunion and firm
cicatrization usually occur as rapidly as they could be desired. The illus-
trations of this subject will sufficiently describe the operation and obviate
OPERATIONS UPON THE CRANIUM AND BRAIN. 781
the necessity for much of verbal description at this point. I would wish,
however, to urge that tlie sculp incision and tliat in the bone be not made
in tiie same lines, but that tlicy be at least iialf an inch apart; also to
impress the general utility of not endeavoring- to get immediate reunion
throughout such a wound, but of inserting iodoform gauze, which I, for
my own part, prefer to saturate with a thoroughly sterilized ointment
contiiining some antiseptic which shall be laid in along tlie line of section
of l)onc, tlic scalp being closed over it by secondary sutures, the gauze
to be allowed to remain for al)out four days, after wliic li the secondary
sutures are untied, the packing removed, and the Mound then snugly
closed. I have done this in many instances, and have never regretted it,
while in some cases wiiere I have tried for more speed}- closure I have
been disappointed.
Tlie practice of rcpluc'uici the hulfonn of hone removed eifter treph'nting
has not found general fa\'or, and is now emjiloved by but few, since
results have not really justified such attempts. The following method
of opening the skull has been recently suggested by Cotterill,' and has
much about it whicli recommends it for general adoption. Epitomized,
the various steps of the operation are as follo\\s :
1. The base of the jiropostnl flap shoidd be a part of the seal]) carrying
large vessels.
2. Make two small V-shajied incisions, corresponding to the lower
ends of a iiorsesiioe flap, their angli's looking toward each other. Carry
these down to the bone, and strij) oil' the pericranium over a surface
half an inch in diameter.
.'». With a small trephine remove a disk of bone at each of these
points.
4. Pass a periosteum-scra])er from one of these to the other between
the pericranium and the skull.
5. With a line saw passed along tliis channel divide the neck of the
bone between the two openings, cutting only to the level of the inner
table ; which may be easily done, since the diti'crence between sawing the
diploe and sawing the iinier table is quite ])erceptil)lc. If necessary, pass
a curved director to protect the dura. By doing this first there is less
disturbance of relation of Hap and bone.
6. Complete the horseshoe incision, making it of any desired size.
Divide the pericranium all around this line of incision, not dislodging
the soft parts.
7. Use a semicircular saw around this line, applying it obliquely from
withdut inward at the expense of the inner table, so that when the fia])
is restored it shall not siid-: below the level of the skull. Although not
absolutely necessary, this will be easier if two small disks of bone be
removed at the upper angles of the flap, doing which does not materially
delay tlie operation.
8. Lift U|> the flap of bone with four elevators, when the inner table
will be found to crack across at the neck with absolute precision. In
doing this the <lura is exposed, and any jtroper jirowdure may be furtlier
carried out.
This form of operation is not applicable to all cases, but principally
to those wiiere large openings must be made for diagnosis or removal of
' Edinbtiryli Med. Juurn., Jan., lS9o.
782 DISEASES AND INJURIES OF THE HEAD.
tumors. It iiiiiy also be useful in dealing with hemorrhage. It is neither
tedious nor ditlieult.
In considering these osteoplastic methods it is of course taken for
granted that they are done for the jnirpose of exposing some lesion which
has already been considered, and that further directions for specific pro-
cedures have been given either above or in some other portion of this
article when dealing with the same.
Finally, osteoplastic methods are occasionally resorted to for the pur-
pose of covering traumatii' defects in the skull. They have indeed been
divided into homoplastic, heterojilastic, and autoplastic. The first is that
least often resorted to. Nevertheless, the experiments of Merwen ' and
of Oilier,^ as well as of others, show that it is ])ossible in selected instances
to accomplish a great deal by this method. For this purpose pieces of
bone taken after osteotomy or after fresh amjiutation have been used,
while Poncet once resorted to the bone removed from a new-born infant
dead of asphyxia. The heteroplastic method has been especially resorted
to since the reconmiendations of Koenig. Autoplastic methods include
the use of decalcified bone, celluloid, and other material.'
Decalcified bone has been recomuiended by Senn and by Kemmul:*
Le Dentu' and Keen" have reported success with this method. Hinter-
stoisser' has also had encouraging success with celluloid. Very thiii
plates of this material are made, and then so cut in shape as to be neatly
fitted in the margin of the bony opening and held there. In each case
we can insert a ])late, enclose it at once, and have primary healing.
Heteroplastic attempts have also been made with l)ones of living animals,
as, for instance, by Jaks(!h,'* wiio used pieces of goose-bones, and Keen,
who tried small pieces from the skull of a sheep. Macewen has used
dogs for this pur])ose, and (lerstein has employed rabbit-bone. Kehr of
Halberstadt and Koenig have also suggested methods of raising a portion
of the external table with its overlying periosteum, a periosteal bridge
' Pniceedlnr/x lioijid Sue., 1831, Xo. '2\3. '' I'unoet, Cniu/rh fmni-nis de Chir., 1886.
' Tlie covering of recent or old skull-defects has lieen, for several centuries, a debated
subject among surgeons. In 1820, Walther replaced a resected portion of the skull, and
got partial healing of the rei)laced bone. Later a number of surgeons experimented with
the subject, and in 18liS, J. Wolf succeeded pretty uniformly with animals in reimplanting
bone. Macewen, Weir, and others later began to recommend the restoration of bone in
small fragments, whidi were sown, as it were, over the sutured dura. Then began other
transplantation experiments, while the investigations of Adamkiewicz ( " Ueber knochen
Transplantationeu," Berieht. der Amd.der WixxcnticJi., Wien, 1888) demonstrated the possi-
bility of healing the reiniplanted bone; (iuerin {Ball, dc I'.imd. de Med., 1888, No. 44)
transplanted bone from one living animal to another, usually with success; and, finally,
Seydel {Cintridhlat. /. Chir., 1889, No. xii. ) transplanted bone from the tibia of a patient to
the skull, and replaced that which hail been lost as the result of a comjinnnd fracture.
Since these experiments liave been made others have been tried with various other ma-
terials, living and dead — such as decalcified bone, ivory, aluminum, celluloid, etc. — to
cover in defects in the bone, and, though in a few instances such efibrts have been followed
by success, they have for tlie most part failed. Eiselsberg (Inter, klin. Biuuhehnu, 1891,
No. xxiv.) and Kriinkel (Bdlrdtli'K Fent.^ch., 1892) have been the most successful in this
regard. Probably the most reliable material for general use for this purpose is celluloid.
Beck has reported an apparent success with this — namely, a proper encapsulation of the
plate, but with spontaneous extrusion of the same three months later.
From all of which it would appear that the osteoplastic method of closing defects in
the cranial bones is the most successful of all which can be tried.
' Dmt. med. Woch., 1891, No. 11. = Gaz. des Hopilma, 1891.
' Am. Jourv. Mexl. Sci., Sept., 1891.
' Wiener klin. Woch., 1890, No. 43, and 1891, No. 16.
» Wiener med. Woch., 1889, No. 38.
PLATE IX.
Fic
rissura centralis.
/Fiss. occipilalia.
Topographical anatomy
of cortex. Localizatioq of functions. (Ziefjeq.)
Fig. 2.
iss. occipitalis.
Kerv.oV^' Hypupirysis.i
4'or[K»r;t cuutliciiutia. ^
Aperlura canal is cenlralis.
Anterior culuuiii of cord.
Posterior column of cord.
.Caualis cenlralis.
Topographical anaton^y of inner surface of right hemisphere, Localization of
functior^s. (Ziefien.)
OPERATIONS UPON THE CRANIUM AND BRAIN. 783
being made, and transferring this to cover the defect which it is intended
to protect. It will frecjuently be enough if, with the periosteum, a thin
layer from the external table be raised by the chisel.'
There remains only to indicate a suitable method for determining the
locatitjn of tlie various centres of the brain, since surgical procedures
must be guided by accurate anatomical data. The areas which most con-
cern the surgeon are mainly those which cluster about the fissure of
Kolando, and the proper determination of its locality is to the surgeon
what tiic l(ing base-line is to the geodetic surveyor." The reader's atten-
tion is called to tlie illustration from Macewen on page 70)S, wjiere are
outlined certain topngrapliical marks, as well as certain points in the
regional anatomy of the skull, which have been carefully described by
Broca. The principal landmarks of importance are the glabella, at the
root of the nose ; the external occipital protuberance, known as the inion;
the brrr/iiin, halfway between these ; the external angle of the ortiit ; the
tip of the mastoid ; and the lower border of the alveolar process of the
ujiper ja\\'. The tissure of liolando has its upj)er end about 5 cm. back
of the liregma, thougli not quite extending to the middle line. Its lower
end lies about a half a centimetre behind the auriculo-bregmatic line, a
little above an imaginary horizontal line parallel to the alveolo-condyloid
line. Thus the lower end of the fissure of Eolando will be found about
6 em. above, and a little behind the external auditory canal — /. c about
2^ cm. behind the bifurcaticm of the fissure of Sylvius. In the Lancet of