Chapter XI: 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,[77] 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[78]:--

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,[79] after collecting 48 cases of sarcoma of the skull, found a definite history of trauma in 9-21 per cent.

Ziegler[80] 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.

[77] _Lectures in Pathological Anatomy._

[78] Hunter Tod, _Diseases of the Ear_, p. 37.

[79] _Sarkomen des knöchernen Schädelgewölbes_, 1895.

[80] _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

Depending on the hard- and software used and their settings, not all
elements may display as intended.

Inconsistent spelling, hyphenation, capitalisation, formatting and
lay-out have been retained, except as mentioned below.

The heading hierarchy has based on the contents and/or lay-out of the
text due to the inconsistent formatting and lay-out in the source
document. Consequently, this hierarchy (and any auto-generated tables
of contents based thereon) do not necessarily reflect the author’s
intent.

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”