CHAPTER XI. Tumours of the Skull-Bones

TUMOURS OF THE SKULL-BONES

In this the last chapter of this work, I originally intended to deal with tumours of the scalp and skull-bones. With respect to tumours of the scalp there is, however, but little to say. The various conditions are well recognized, their pathology is known, and there is in general but little to relate. Tumours of the skull-bones come under a different category and require some consideration.

=Tumours of the skull-bones.= The more important of these tumours are as follows:--

Osteomata. Sarcomata, primary and traumatic. Secondary sarcomata and carcinomata.

OSTEOMATA

Exostoses of the skull, though by no means of frequent occurrence, occupy such definite positions that it would appear as if they were dependent on some local governing cause. They develop most frequently in the following positions:--

At the external angular frontal process.

At the frontal and parietal eminences.

In the region of the frontal sinus.

In the region of the external auditory meatus and mastoid process.

All pathological museums possess specimens illustrating the formation of such exostoses, tumours of a like nature in other parts of the skull being excessively rare.

In endeavouring to arrive at an explanation it would appear necessary to direct one’s attention to tumours of a similar nature occurring in other parts of the body, more especially in the long bones. There, it is well recognized that their development is dependent on irregularities of growth in the region of the epiphyseal lines, regions where activity of growth is long maintained.

On referring again to the skull, similar features appear. For instance, the frontal bone, besides possessing one primary centre for the frontal eminence, has secondary centres for the external angular frontal process, for the trochlear fossa, and for the nasal spine, and it is highly probable that those exostoses which develop in the region of the frontal sinus in reality arise from one or other of the secondary centres situated in that region.

Both frontal and parietal eminences are also sites of active and prolonged ossification, and the tumours there arising are to be explained on a like hypothesis.

Similar features are to be observed with respect to those bony tumours which develop in the aural region, the numerous centres of ossification for the periotic capsule accounting satisfactorily for their origin.

Whether originating in the region of the frontal sinus or in the aural area, the tumour naturally develops along the line of least resistance, filling up the frontal sinus and growing into the external auditory meatus and mastoid antrum.

More rarely, small exostoses develop on the inner aspect of the skull, chiefly from the frontal bone in the region of the crista galli. In some cases the inner aspect of the skull is studded with small bony tumours, more especially along the line of the superior longitudinal venous sinus.

These internal exostoses seldom give rise to pressure symptoms, although, according to Wilks and Moxon, they may push inwards the dura mater and even lead to idiocy and epilepsy. I have seen several cases of internal exostosis development, but in all cases their discovery was accidental.

=Clinical characteristics.= Exostoses vary greatly both in size and consistency. Some are densely hard--ivory exostoses--others possess a covering of compact bone, whilst their interior is made up of cancellous tissue continuous with that of the bone from which they arise. The denser variety seldom attain any considerable size, but the less compact, growing in the direction of least resistance, often attain such dimensions as to be both unsightly and dangerous. Thus, a frontal exostosis may invade the frontal air sinus and grow into the orbital cavity, obliterating the sinus, interfering greatly with ocular movements, causing protrusion of the globe and even destruction of the eye.

An aural exostosis may block up the external auditory meatus, compress the facial nerve, and lead to the development of a mastoid empyema.

It might also be added that there are a few cases on record in which a frontal exostosis, by reason of extensive inward growth, has produced cerebral symptoms--general compression and intellectual deterioration.

=Treatment.= In considering the question of treatment, it must be accepted that, although of slow growth, some of these exostoses are definitely progressive, tending to interfere with the character and functions of the region with which they are anatomically situated. There is also reason to believe that those secondary changes--sarcomatous, myxomatous, &c.--which are occasionally observed in the exostoses of long bones are also liable to develop in those cranially situated. The question of treatment hinges, therefore, to a large extent on the nature and position of the tumour.

When of the ivory type and growing from the flat bones of the skull, but so situated that no marked deformity or pressure symptoms are likely to ensue, they may be left alone, but when definitely progressive and situated in accessible regions, they should be removed. Their exposure is carried out by the formation of a suitable scalp-flap--designed as far as possible so as to be subsequently hidden by the hairy scalp--and the exostosis removed by the application to its base of a Gigli saw. This method is greatly superior to the older procedures whereby the tumour was chiselled away with hammer and gouge.

Occasionally the tumour is so dense and presents so wide a basal attachment that it becomes necessary to attack from a more distant line, cutting out a trench, deepened to the diploic tissue, circumferentially around the tumour and levering away the central mass. When the tumour extends more deeply, involving nearly the whole thickness of the skull, it may be removed by the application of a small trephine immediately to one side of the tumour, followed by the use of de Vilbiss forceps circumferentially around the main mass, thus freeing it from its surroundings. The resultant gap in the skull may be protected by one or other of those measures enumerated in Chapter VI.

=Frontal and mastoid= exostoses often necessitate formidable operations insomuch as their size and anatomical relations present considerable difficulties (see Fig. 94).

The =indications for operation in the case of aural exostoses= are as follows:--

1. If there is middle-ear suppuration and signs of retention of pus.

2. When the pressure of the exostosis produces pain which cannot otherwise be relieved.

3. If the exostosis nearly blocks up the meatus of both ears, and there is prospect of each side becoming completely blocked in the near future. Here operation is carried out on the worst side.

4. If the meatus is nearly blocked by the exostosis and the patient going to a country where he cannot be within easy reach of a competent medical man.

The =indications for operation in the case of a frontal exostosis= are as follows:--

1. When the exostosis interferes with the actions of the ocular muscles, causes proptosis and threatens the integrity of the globe.

2. When associated with pain which cannot otherwise be relieved.

3. When the exostosis leads to blockage of the accessory sinuses of the nose, more especially when such blockage is associated with pus pent up within.

4. When very unsightly.

The accompanying figure illustrates the deformity and dangers associated with large frontal exostoses. The tumour developed from the inner angle of the orbital cavity, pushing the globe forwards and outwards, with diplopia and severe neuralgia.

It is barely possible to enter into the =operative details= suited to frontal and aural exostoses--the operations are so atypical. It is sufficient to say that the operation may be a very formidable one, that the details must be carefully thought out, and that every precaution must be adopted to avoid injuring neighbouring structures.

SARCOMATA, PRIMARY AND TRAUMATIC

Primary sarcomata of the skull, when compared to sarcomata developing in other situations, is undoubtedly a rare disease. Still, many cases have been recorded, and four have come under my own personal care, one of which is depicted in the figure.

The disease is equally prevalent in the two sexes, and, excluding chloromata (see p. 334), usually develops at or after middle life. The growth may originate in the diploic tissue (as a myelogenous tumour), or may spring from the pericranium. The cellular structure varies accordingly. More commonly the cells are of the large round or spindle type, and are proportionately malignant.

As regards site of development, the temporal bone (squamous portion) is most commonly involved, next to which comes the frontal bone.

In considering the ætiology of sarcoma in general, trauma must always be taken into account, for it is an undoubted fact that it plays an important part in the development of this dire disease. With respect to the skull similar factors come into play. For instance, Fröhlking, after collecting 48 cases of sarcoma of the skull, found a definite history of trauma in 9-21 per cent.

Ziegler lays down the following essentials in establishing the traumatic origin of the tumour: It must develop directly after the trauma on the basis of the swelling or directly in the scar of the wound.

The tumour must be palpable immediately after the acute swelling has diminished.

At the site of the trauma constant or intermittent pain must be present.

A considerable number of cases of sarcoma of the skull will fulfil even these arbitrary conditions. Such sarcomata may definitely be labelled ‘traumatic’ sarcomata.

Whether dependent on injury or not, the symptoms associated with sarcoma of the skull vary according to whether the tumour is extrinsic or intrinsic--whether, for instance, the growth develops in the inward direction and presses on the brain, or grows from the pericranium and is directed externally. Intrinsic tumours, with the exception of some local pain, œdema of tissues, and dilatation of superficial veins, give rise to symptoms closely resembling those observed in intracranial tumour formation. When extrinsic, the tumour varies in size, but is necessarily attached to the bone, the base being the widest part of the tumour. In the earlier stages the overlying skin, with the exception of a few dilated vessels, is more or less normal. Later on, the integument becomes adherent to the tumour, then red and inflamed, and finally ulcerated, the growth now fungating to the surface. The tumour itself is of variable consistency, first hard, then softer, and lastly semi-fluctuating.

Pain, though not very severe, is more or less constant--of a dull, aching character. The extrinsic tumours may, however, give rise to acute neuralgic pain in the event of implication of cutaneous nerves; whilst the intrinsic, in the later stages of the disease, lead to the more severe types of headache observed in intracranial tumour formation.

Secondary nodules appear in other parts of the scalp--all appertaining, in their clinical characteristics, to the primary growth; the cervical glands become infected, and death results from repeated hæmorrhages, pulmonary complications, &c., usually within one to two years from the date of primary development.

=Treatment.= The removal of an extrinsic tumour should only be carried out when the tumour is small and non-adherent to the tissues of the scalp. With respect to the intrinsic variety greater circumspection is required. The presence of cerebral symptoms and the inward extension of the growth--verified by symptoms and by X-ray investigation--may be regarded as implying that the conditions are beyond the reach of surgery. In both varieties of tumour, extensive glandular implication acts as a contra-indication to operation.

Under the more favourable conditions an attempt may be made at the extirpation of the growth. The operation should be rendered as bloodless as possible, for which purpose it is essential that the scalp-tourniquet should be applied as a preliminary measure. A scalp-flap is then framed, suited to requirements, and allowing of free exposure of the tumour and surrounding healthy tissues. The skull is then trephined to one side of the growth, and the disk removed. The dura is separated from the overlying bone, and by the circumferential application of de Vilbiss or other craniectomy forceps the central mass is isolated and removed. During these manipulations free hæmorrhage may be experienced from the numerous dilated diploic veins. For the arrest of this the surgeon should have ready to hand, ivory pegs, bone-wax, and other aids for the control of hæmorrhage (see Chapter II). The scalp-flap is then replaced.

The gap in the bone may be covered in, at a later date, if the patient’s condition is favourable.

The operation may be a formidable one, but records are to hand of 35 cases in which radical measures were adopted. Ten cases died from the operation, 13 were well for periods varying from six months to six years; and recurrence took place soon after the operation in 21 cases.

=Chloromata.= Chloroma, a peculiar type of sarcoma characterized by the pale green hue of the tissues, usually develops in the young. The cells are small and round, the pigment distributed in and around the cell elements. The colour, said to be dependent on the presence of a pigmented fat, is most intense immediately after the removal of the tumour, fading rapidly on exposure to light.

The tumour develops from the periosteum of bones, more especially from those which enter into the formation of the orbit and base of skull. In fact, nearly all the cases reported have originated from the temporal and orbital regions. Great rapidity of growth and early dissemination throughout the viscera are conspicuous features--no organ of the body can be said to be exempt from metastatic deposits. The meninges and brain are early involved by direct extension.

Proptosis, as the result of cavernous sinus thrombosis and orbital invasion, is a prominent and early symptom. Death results within six months. No treatment, surgical or otherwise, is of any avail.

=Carcinoma= can only involve the skull-bones as a metastatic deposit--more commonly in association with mammary cancer--or by direct invasion from an overlying epitheliomatous scalp ulcer. In the former instance, any radical treatment would be contrary to all surgical principles. In the latter case, presuming that the cervical glandular region is unaffected or capable of removal, the scalp ulcer should be freely excised together with the whole thickness of underlying bone. The resultant osseous gap may be covered in by means of a plastic flap derived from neighbouring healthy tissue.

Lectures in Pathological Anatomy.

Hunter Tod, Diseases of the Ear, p. 37.

Sarkomen des knöchernen Schädelgewölbes, 1895.

Über die Beziehung von Träumen zu den malignen Geschwülsten, 1895.

INDEX

Abbé’s operation for tic doloreux, 60 Abscess of the brain, acute traumatic, 247 chronic otitic, 249 multiple, 247 of cerebellum, 258 frontal lobe, 267 temporo-sphenoidal, 263 Acoustic tumours, 213 Adhesions, osseous and meningeal, 195 Alcohol injections in tic doloreux, 313 Anæsthesia in head operations, 12 Anosmia, 162, 220, 263 Aphasia, 142, 155, 221, 258 Apraxia, 221 Arachnoid cysts, 203 Arachnoid hæmorrhages, 158 Arachnoid œdema, 168, 186, 203 Aran’s theory of irradiation, 73 Archibald on birth-hæmorrhages, 53 compression, 168, 178 Ataxia, 164, 224, 259 Attitude in cerebellar lesions, 224, 262 Aural exostoses, 326, 329 Author’s operation for defects in the skull, 199 hydrocephalus, 64 subdural hæmorrhages, 156

Basal cephaloceles, 34 Base of skull fractures of, 73 symptoms observed in fractures of, 89 treatment in fractures of, 116 weakness of, 73 Basic foramina, their influence on basic fractures, 81 Basic fracture, the typical, 77 Bergmann (von) on cephaloceles, 36 laceration of the brain, 165 middle meningeal hæmorrhage, 143, 148 Bilateral cerebellar exposure, 240 Birth-fractures, 44 Birth-hæmorrhages, 50 Bland Sutton on dermoids, 56 Blood-pressure in compression, 174 concussion, 167 in middle meningeal hæmorrhage, 140 operations on the skull and brain, 11, 12 tumours, 219 Blood-cysts (subdural), 203 Bone-flaps in cephaloceles, &c. 39 (König-Müller), 196 (osteoplastic re-section), 25 Boullet on fracture of the mastoid bone, 108 Bowen on subdural hæmorrhage, 153, 158 Bowlby (Sir Anthony) on bullet-wounds, 297, 299 Brain abscess of, 247 compression of, 172 concussion of, 166 injury to, 159 irritation of, 171 tumours of, 210 Brain-matter, escape of in basal fractures, 93, 101 Broca’s area, 8, 221 Bullet-wounds of the skull and brain, 294 Burghard on Gasserian ganglion removal, 320 Bursting and compression theories, 74

Callen on injuries to the optic nerve, 95 Campbell on cortical motor and sensory areas, 7 Carcinoma of brain, 215 skull-bones, 334 Carotid artery, injury to internal, 148 Cavernous sinus injuries of, 150 thrombosis of, 288 Cephalalgia, traumatic, 187 Cephalhæmatomata, 49, 51 Cephaloceles congenital, 31 traumatic, 40 Cerebello-pontine tumours, 213, 238 Cerebral abscess, 256 compression, 172 concussion, 166, 177 decompression, 120, 129, 242 irritation, 171 laceration, 159 œdema, 168, 186, 191, 201 tumours, 223 Cerebellum abscess of, 256 decompression of, 120, 242 lesions of, 164 position of patient in operations on, 12 surface-marking of, 6 tumours of, 223 Cerebro-spinal fluid escape of from mouth, nose and ears, 91, 100 source of, 91 Cerebrum acute anæmia of, 167 surface marking of, 6 Chloroform as an anæsthetic, 12 Chloromata, 334 Chronic abscess of the brain, 249 Chronic encapsuled abscess of the brain, 268 Closure of the dura mater, 16, 236 gaps in the skull, 39, 196 Coma, traumatic and other forms, 179 Comminuted, complicated and depressed fractures of vault, 126 Compression, 172 Concussion, 166, 177 Contre-coup theory in basic fractures, 75 brain injury, 160 Control of hæmorrhage during operations on the skull and brain, 13 Cortical motor and sensory areas, 7 Cortical scars, 195 Cotterill on hydrocephalus, 67 Crandon and Wilson on hæmorrhages in basic fractures, 91, 99 Cranial defects, 196 Craniectomy, 19 Cranio-cerebral topography, 1 Craniotomy, 25 Crowe and Cushing on the use of Urotropin, 116 Cushing (Harvey) on birth-hæmorrhages, 52, 55 decompression of the brain, 121, 235, 242 epilepsy, 191 hydrocephalus, 66 pituitary tumours, 244 trigeminal neuralgia, 318 Cushing’s clips, 18 tourniquet, 13 Cysts of the brain, 215 the meninges, 203

Dana’s syndrome, 209, 225, 259 Decompression cerebellar, 120, 242 cerebral, 121, 129, 242 Defects of the skull, closure or protection of, 39 Dental chair position in head-operations, 12 Depressed birth-fractures, 44 Depressed fractures of the vault, 126, 129 Dermoids, 55 Duchaine on middle meningeal hæmorrhage, 147 Dura mater hæmorrhage, external to, 133 hæmorrhage, internal to, 150 opening of, 19, 29 suture of, 16, 236 Duret on traumatic epilepsy, 193 tumours of the brain, 245 Dwight on fractures of the skull, 98

Eighth nerve, involvement of in basic fractures, 102, 106 Electric stimulation of brain in tumour exploration, 233 Elevation of depressed birth-fractures, 45 fractures of vault, 129 Endotheliomata of brain and dura, 213 English on remote effects of brain injury, 182, 187 adhesions between scalp and meninges, &c. 195 Epilepsy idiopathic, 190 Jacksonian, 189, 192 traumatic, 189 Escape of air from air-sinuses in basic fractures, 95 blood in basic fractures, 91, 96, 99 brain in basic fractures, 93, 101 cerebro-spinal fluid in basic fractures, 91, 99 Ether as an anæsthetic, 12 Exostoses of the skull, 325 Explosive fractures of the skull, 113 External table of skull, fracture of, 110, 133, 297 Extra-cerebellar tumours, 225 Extra-dural hæmorrhage, 135 suppuration, 284 Extrinsic sarcomata of the skull-bones, 332

Falx cerebelli, 4 cerebri, 1 Fibromata of dura and brain, 213 Fifth nerve, involvement of in basic fractures, 95, 101 Fifth nerve, neuralgia of, 306 Fissure of Rolando, 6 Sylvius, 6 Fissured fractures adult, 129 infant, 49 Foraminal occlusion in skull operations, 17 Fourth nerve, involvement of in basic fractures, 95 Fractures of base of skull, 73 external table, 110, 133, 296 internal table, 110, 296 mastoid process of temporal bone, 104, 108 skull, Teevan on, 110, 112, 294 vault (adult), 68, 109 vault (birth), 44 Frazier (Charles) on cerebellar tumours, 239 trigeminal neuralgia, 313, 321 Frontal exostoses, 329 Frontal lobe abscess of, 262 lacerations of, 162 tumours of, 219

Gaps in the skull, closure or protection of, 196 Gasserian ganglion, 310, 319 Gauze coverings in operations on skull and brain, 13, 16 Gigli saw in operation on skull and brain, 25 Gliomata of the brain, 211 Gowers on optic neuritis, 217 Grafts, muscle, 18 Grünbaum (and Sherrington) on cortical motor and sensory areas, 7 Gutter fractures, 296

Hæmorrhage, control of from bone, 17 brain, 19 meninges, 17 scalp, 13 Hæmorrhage conjunctival, 89 extra-dural, 135 occipital, 90 ocular, 90 palpebral, 90 pia-arachnoid, 159 retinal, 90 subdural, 150, 153 temporal, 96 Hæmorrhage from ear, 96, 108 internal carotid, 148 middle meningeal artery, 135 mouth, 91, 99 nose, 91, 99 venous sinuses, 150 Hæmorrhage into temporal region, 96 Hæmorrhages at birth, 50 Hand-trephine, 21 Harris (Wilfred) on alcohol injections, 310, 314, 316 Hartley-Krause operation for trigeminal neuralgia, 316 Head-injuries, remote effects of, 182 Hernia cerebri, 291 Hernial protrusions, 291 Hill (Leonard) on brain compression, 175 Holder on injuries to the optic nerve, 93 Homonymous hemianopia, 222, 227 Horsley (Sir Victor) on the regional mortality of brain tumours, 246 pituitary tumours, 242 the ‘two-stage’ operation, 230 Horsley’s disk elevator, 23 dural separator, 24 gouge, 25 Hudson’s trephine, 21 Hutchinson (Jonathan) on trigeminal neuralgia, 310, 319, 323 Hutchinson pupil, 141 Hydrocephalus, 58 Hysterical neuralgia, 310

Idiopathic epilepsy, 190 Inco-ordination of movement in cerebellar abscess, 260 tumours, 224 Inferior dental nerve, neurectomy of, 308 Influence of air-sinuses in basic fracture, 79 basic foramina in basic fractures, 81 sutures in basic fractures, 78 Infra-orbital nerve, neurectomy of, 308 Injuries to the brain, 159 head, remote effects of, 182 internal carotid, 148 venous sinuses, 152 Intermusculo-temporal cerebral decompression, 121, 236, 267 Internal carotid artery, injury to, 148 Internal table, fractures of, 110, 112, 296 Intra-cerebellar tumours, 225 Intra-cranial birth-hæmorrhages, 52 Irritation of the brain, 171

Jacksonian epilepsy, 189, 192, 221, 262 Jacobson on middle meningeal hæmorrhage, 142

Keen-Hoffmann forceps, 23 Keith on pituitarism, 226 Koch and Filehne on cerebral compression, 167 Kocher on compression, 176 concussion, 166 epilepsy, 190 König-Müller flaps, 197 Krause on pituitary tumours, 243 Kredel’s hæmostatic sutures, 16, 21 Krönlein on middle meningeal hæmorrhage, 138

Lane’s forceps, 25 Latent period in subdural hæmatocele, 154 Lateral displacement of cerebellum, 238 Lateral sinus injuries of, 150 surface-marking of, 1 thrombosis of, 281 Line of basic fracture, typical line of, 78 Lines of basic fracture, 82 Little’s disease, 52 Luciani on cerebellar abscess, 260 Lucid interval in middle meningeal hæmorrhage, 139, 151 Lumbar puncture in hydrocephalus, 61 meningitis, 281 subdural hæmorrhage, 54, 120, 155 tumours, 227, 236 Lyssenkow on cephaloceles, 32, 39

Macewen on brain abscess, 290 pus evacuation, 266 Macewen’s suprameatal triangle, 5 Malar tubercle, 4 Mania (acute) after brain injuries, 201 Mastoid antrum operations on, 269 surface-marking of, 5 Mastoid process displacement of, 108 exostoses of, 329 Mechanism of basic fractures, 73 Meningeal cysts, 203 Meningitis, 273 Mental condition in abscess of frontal lobe, 263 compression, 176 concussion, 170 irritation of the brain, 171 lateral sinus thrombosis, 283 meningitis, 279 tumours of the brain, 216 Middle meningeal artery, surface-marking of, 5 Middle meningeal hæmorrhage, 135 Morphia before and after operation, 11, 30 in cerebral concussion, 178 cerebral irritation, 128 trigeminal neuralgia, 313 Motor areas of cortex, 7 Motor speech area, 8 Multiple abscess of the brain, 247 Muscle grafts, 18, 234

Neuralgia hysterical, 310 major, 308 minor, 306 of inferior dental nerve, 308 infra-orbital nerve, 308 supra-orbital nerve, 309 Neurasthenia after head-injuries, 185 Neurectomy of the branches of the fifth nerve, 308 Nicholl on birth-fractures, 46 Ninth nerve, involvement of in basic fractures, 106 Nystagmus, 224

Occipital cephaloceles, 33 Occipital lobe lesions of, 164 tumours of, 222 Occipital sinus, surface-marking of, 4 Olfactory nerve, involvement of in basic fractures, 94 Opening of dura mater, 29, 119 Optic nerve, involvement of in basic fractures, 95 Optic neuritis in abscess of the brain, 254 lateral sinus thrombosis, 283 meningitis, 279 tumours of the brain, 216 Orbital aneurysm, 204 Orbital hæmorrhage, 90 Osteomata of the skull-bones, 325 Osteoplastic re-section of the skull, 25, 229 with decompression, 235

Pachymeningitis, 274 Palliative treatment of cerebral and cerebellar tumours, 241 Palpebral hæmorrhage, 90 Parietal prominence, 4 Parieto-occipital fissure, 7 Parsons on the pupil in middle meningeal hæmorrhage, 143 Pathology of brain abscess, 251 tumours, 210 Paton on optic neuritis, 217, 218 Percussion of skull in fractures of vault, 112 Phelps on brain laceration, 160, 162 bullet-wounds, 304 middle meningeal hæmorrhage, 142 Pia-arachnoid hæmorrhage, 159 Pituitary tumours, 225, 243 Plating of skull in traumatic and other defects, 198 Pneumatoceles, 93, 108 Position of patient in head-operations, 12 Powell on traumatic insanity, &c., 202 Precautions against the development of shock, 11 Preparation of operative field, 13 Preparatory treatment, 10 Pringle on percussion of the skull, 112 Prognosis after decompression, 243 in brain abscess, 290 cavernous sinus thrombosis, 290 lateral sinus thrombosis, 290 meningitis, 290 Proptosis in basic and brain lesions, 90 cavernous sinus thrombosis, 289 orbital aneurysm, 206 Protection of gaps in the skull, 196 Pulsating exophthalmos, 205 Puncture of the ventricles, 61, 236 Punctured fractures, 132 Pupillary changes in middle meningeal hæmorrhage, 142

Radical treatment of cerebral and cerebellar tumours, 229, 237 Reading, cortical area concerned in, 9 Regional mortality in basic fractures, 133 brain tumours, 245 Reid’s base-line, 6 Remote effects of head-injury, 182 Results after operation on abscess of the brain, 290 alcohol injections for tic doloreux, 316 basic fractures, 133 brain tumours, 245 bullet-wounds, 304 Gasserian ganglion removal, 323 middle meningeal hæmorrhage, 147 subdural hæmorrhage, 158 traumatic epilepsy, 200 insanity, 201 Retinal hæmorrhages (Fleming on), 90 Retraction of the head and neck in cerebellar abscess, 260 tumours, 224 in meningitis, 280 Rivington on pulsating exophthalmos, 204 Rolando, fissure of, 6

Safety-valves in middle meningeal hæmorrhage, 96, 139 Sarcomata of bone, 330 brain, 211 Scalp-tourniquet author’s, 15 Cushing’s, 13 Schlösser on alcohol injections for tic doloreux, 313, 316 Sensory cortical areas, 7, 8 Serous meningitis, 273 Seventh nerve, involvement of in basic fractures, 102, 106 Shaving of scalp, 10 Shaw (Claye) on general paralysis, 203 Sheen’s bullet-forceps, &c., 301 Sherrington and Grünbaum on cortical areas, 7 Shock (cerebral), 166 Shock, precautions against, 11 Sincipital cephaloceles, 34 Sinus pericranii, 150 Sinuses (air), influence on in basic fractures, 79 Sinuses, thrombosis of, 281, 288 Sinuses (venous), injuries of, 150 Slow cerebration, 140 Smell, registration of, 9 Speech areas, 8, 163 Stage of depression in concussion, 168, 170 Stage of reaction in concussion, 168, 170 Stereognosis, 9 Sterilization of skin, 11 Stewart (Purves) on tic doloreux, 314 Stromeyer on sinus pericranii, 150 Subconjunctival hæmorrhage, 89 Subdural hæmorrhage, 150 Summary of theories re basic fractures, 89 Superior longitudinal sinus injuries of, 150 surface-marking of, 1 Supra-meatal triangle (Macewen), 5 Surgical emphysema, 93, 108 Sylvian point and fissure, 6 Syphilomata of brain, 214

Taste, registration of, 9 Technique of operations on the skull and brain, 10 Teevan on fractures of the internal table, 110 bullet-wounds, 294 Temperature in relation to head-injuries, 114 Temporal crest, 4 Temporal hæmatomata, 96 Temporo-sphenoidal lobe abscess of, 256 injuries of, 164 tumours of, 222 Tenth nerve, involvement of in basic fractures, 106 Thiersch’s method of neurectomy, 308 Third nerve, involvement of in basic fractures, 95 Thrombosis of cavernous sinus, 288 lateral sinus, 281 Tod (Hunter) on abscess of the brain, 249 aural exostoses, 329 lateral sinus thrombosis, 283 Traumatic cephalalgia, 187 defects in the skull, 196 epilepsy, 189, 192 insanity, 201 mania, 201 neurasthenia, 185 orbital aneurysm, 205 Tuberculomata of the brain, 214 Tuberculous meningitis, 275 Tumours of brain, 210 skull-bones, 325 Twelfth nerve, involvement of in basic fractures, 107

Urotropin Crowe and Cushing on the use of, 116 routine use of, 118

Vault birth-fractures of, 44 fractures of, 109 Venesection in cerebral compression, 119 Ventricular puncture, 62, 236 Ventriculo-abdominal drainage, 66 subdural drainage, 63 Vertigo in cerebellar abscess, 259 tumours, 224 Vilbiss (de) forceps, 25 Visual impressions, registration of, 9 Vorschütz’s safety-pins, 16, 17, 21

Wagner on osteoplastic re-section of the skull, 25 Walton on middle meningeal hæmorrhage, 143 Weber (Parkes) on hydrocephalus, 58 Wiesman on middle meningeal hæmorrhage, 139, 141, 147 Writing, cortical area concerned in, 9

X-rays in bullet-wounds, 294 fractures of the skull, 112 tumours, 228

Yawning in abscess of the cerebellum, 262 lesions of the cerebellum, 165

Ziegler on traumatic sarcomata, 331 Zygoma, 4

Transcriber’s Notes

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Figs. 18 and 71, as well as Figs. 3, 58 and 68 and their respective captions and references in the List of Illustrations are identical in the source document.

Page 39, Ssamoylenko: more commonly transcribed Samoylenko.

Page 99, table, bottom row: the data do not add up to the total; the data and the total do not result in the percentage given.

Page 115, van Benedin: possibly an error for van Beneden.

Page 134, table: mortality with 59 survivors and 29 fatalities is 33%, not 37%. Some other calculated percentages elsewhere in the text are erroneous as well.

Page 196: the Intersection symbol ⋂ is used to indicate the shape only, it is not used in its operator sense.

Page 252, two-saced: as printed in the source document; possibly an error for two-faced.

Page 312, 1. Therapeutic remedies: this is the only numbered sub-section in this section.

Changes made

Illustrations have been moved outside text paragraphs; footnotes have been moved to the end of the respective chapters.

Some obvious minor typographical errors have been corrected silently.

Page 68: “see Figs. 29 and 50” changed to “see Figs. 29 and 30”

Page 146: “(see Fig. VI)” changed to “(see Fig. 6)”

Page 174: “mesencaphalon” changed to “mesencephalon”

Page 280: “tâche cérèbrale” changed to “tâche cérébrale”; “Treatment.” changed to “=Treatment.=”

Page 321, Fig. 21 (caption): closing bracket added after “the anterior belly of the occipito-frontalis muscle”