The effect of _distance_:--When the bullet is fired from a distance, but

with full effect, the hole is clean cut and presents the characteristics

enumerated above. When the bullet is ‘spent’, the osseous injury at the

point of impact is usually of a more extensive character than when the

bullet possesses a higher degree of velocity. When fired at close

quarters the damage incurred from the impact of the bullet is increased

by the force of the forwardly driven air and gas. The skull suffers

proportionately, the scalp being severely lacerated, burnt, and

circumferentially ingrained with powder, the bone extensively

comminuted, and the brain severely lacerated.

The effect of _size and shape_ of the bullet:--The effects produced on

the skull in relation to the size and shapes of the bullet are so

obvious as to require no description. The nature of the bullet must also

be taken into consideration, whether of the soft-nosed variety,

expansile, &c.

The effect of the _angle of impact_:--The lesion produced by the bullet

varies according as to whether the bullet glances across the vault or

strikes the bone at right angles. In the former case a ‘gutter’ fracture

may result, varying in degree and associated brain complication

according to the angle of impact. In the latter case the skull is

penetrated or perforated.

The effect of the _position of the bullet_ at the moment of

impact:--The bullet, at the moment of impact, may be so changed in

position--head-over-heels, ricochet, &c.--that the skull may be struck

by its long axis instead of by its nose. In such cases, the wound of

entry will be more extensive than under ordinary circumstances.

It is obvious, therefore, that many factors require consideration in

estimating the extent of the osseous lesion and the nature of the

complications existent in any given case. Due allowance must also be

paid to other factors entering into the case, more especially in

relation to the weapon used--pistol, revolver, gun, &c.

=Injury to the bone.= The various injuries to bone may be classified as

follows:--

Fractures limited to the external table.

Fractures limited to the internal table.

Gutter fractures.

The complete fractures produced by a penetrating wound.

The complete fractures produced by a perforating wound.

=Fractures limited to the external table.= Fractures of this nature are

of exceedingly rare occurrence. They are produced by a bullet which

strikes the skull in such an oblique direction that the scalp and

external table are torn away (‘gutter’ fractures), or by a bullet which,

directed against the outer wall of the frontal sinus, possesses

sufficient force to comminute the outer wall of that sinus, but, from

loss of momentum, is incapable of penetrating further.

=Fractures limited to the internal table.= These fractures are even more

rare than those described above. Their occurrence is probably only

possible when the bullet strikes the skull in a markedly oblique

direction, and with greatly diminished velocity--‘spent’ bullets. I

believe I am correct in stating that only one instance of this

particular variety of fracture was observed in the South African War. In

any case, they are of such infrequent occurrence that they may be

practically disregarded.

=Gutter fractures.= Gutter fractures are almost invariably dependent on

the impact of a glancing bullet. They may be arranged in three groups,

according to the extent of the osseous lesion.

1. Where the external table is blown away, leaving the internal table

exposed, perhaps comminuted.

2. Where the internal table is driven in the inward direction, pressing

on, irritating, and perhaps lacerating the dura mater.

3. Where the whole thickness of the bone is blown away, leaving a gaping

wound from which brain-matter may protrude.

[Illustration: FIG. 87. DIAGRAMMATIC ILLUSTRATION OF THE THREE FORMS OF

‘GUTTER’ FRACTURE. (For further description, see text.)]

=The complete fractures produced by penetrating and perforating wounds.=

The general effects as produced by penetrating and perforating

bullet-wounds of the skull and brain are depicted in Fig. 88, and

described in the text associated with that figure.

=Injury to the brain.= Brain lesions vary ‘from a single track with

small points of extravasation in neighbouring areas to a condition of

hæmorrhagic pulp, which latter condition is the result of injury from

the projectile associated with bleeding, often extensive, into

neighbouring areas, disintegrating and pulping the brain-substance.

These latter cases are generally fatal, and are accompanied not

infrequently with meningeal and ventricular hæmorrhage’ (Bowlby).[59]

The worst degrees of brain-injury arise when the injury is inflicted at

close range, more especially at the site of emergence of a perforating

bullet, the damage to the soft parts being there magnified by the waves

and vibrations set up by the bullet during its passage across the brain.

In many cases also the brain is dashed as a whole against the opposing

osseous barrier (laceration by contre-coup).

The general effects produced on the skull and brain by a perforating

bullet of high velocity are shown in Fig. 88.

=Symptomatology.= It is unnecessary to enter into details with regard to

the symptoms arising from bullet-wounds of the skull and brain, for they

closely resemble those previously enumerated in the chapters dealing

with fractures of the skull and injury to the brain. There are, however,

a few special points to which attention should be directed.

1. External hæmorrhages are seldom profuse.

2. The escape of cerebro-spinal fluid is of infrequent occurrence,

probably due to the fact that the apertures of entry and exit are

blocked up with scalp, fragments of bone, and pulped and swollen brain.

3. Concussion and irritation are prominent symptoms, compression is

rarely seen in its typical form. As Spencer[60] says, ‘The dominant

feature is usually concussion. The extent of the paralysis depends on

the region injured, and there is often at first extensive temporary

paralysis from vibratory concussion of the brain substance suspending

its functions over a wide area around the bullet-track.’ Cerebral

irritation and Jacksonian fits are frequently observed.

=Indications for operation.= There is a great uniformity of opinion with

regard to the indications for operation as expressed by those who have

had considerable experience in wounds of this nature. One has only to

glance through the works of recognized authorities--Spencer,[61]

Bowlby,[62] Makins,[63] Lawford Knaggs,[64] &c.--to see that it is an

accepted rule that all bullet-wounds of the skull and brain call for

early operative interference, it being granted that the condition of the

patient is compatible with such treatment.

=Operation.= The operative details may be considered under two

headings:--

(_a_) The exploration of the wounds of entry and exit.

(_b_) The search for and removal of the bullet.

[Illustration: FIG. 88. TO ILLUSTRATE THE EFFECTS PRODUCED BY A

PERFORATING BULLET-WOUND. 1, The inverted scalp at wound of entry; 2,

Subaponeurotic hæmorrhage; 3, The wound of entry into the skull; 4,

Extra-dural hæmorrhage; 5, Lacerated dura mater; 6, Subdural hæmorrhage;

7, In-driven fragments of bone; 8, The passage through the

brain-substance; 9, Ventricular hæmorrhage; 10, The wound of exit

through the brain; 11, Subdural hæmorrhage; 12, The wound of exit

through the dura mater; 13, The wound of exit through the skull; 14, The

wound of exit through the scalp.]

_The exploration of the wounds of entry and exit._ Whether the skull be

penetrated or perforated, the wounds are investigated after similar

general principles. After careful shaving and cleansing of the whole

scalp, and after application of the scalp-tourniquet, a scalp-flap is

turned down, the centre corresponding as far as possible to the site of

entrance or emergence of the bullet. The under aspect of the flap is

examined for loose fragments of bone, hair, portions of headgear, &c.

These are removed and the flap cleansed. The bone is next examined. All

loose fragments are removed, both large and small. The smaller are

discarded, the larger are boiled (for ten minutes) and preserved in hot

saline solution for replacement at the termination of the operation, if

such a course should be deemed advisable (see p. 132). Those fragments

of bone which retain their pericranial attachments are merely elevated

and turned aside, to be again placed in position at the proper time.

Trephining is seldom necessary, the hole in the bone usually allowing of

the application of craniectomy forceps, if any enlargement should be

requisite.

A good view of the dura mater can now be obtained. If that membrane be

merely punctured or incised, the tear must be enlarged with

blunt-pointed scissors so as to allow of complete examination of the

underlying brain. Hæmorrhage from meningeal vessels is controlled by the

application of ligatures to all vessels that cross the line of dural

section.

The lacerated brain is _gently_ irrigated with saline solution (at a

temperature between 110° and 115° Fahrenheit), and all blood and pulped

brain matter washed away. The cortex is then lightly examined with the

finger and probe for any fragments of bone that may be embedded in the

brain substance. The removal of such fragments should be conducted with

all possible gentleness. The surgeon should be satisfied that no foreign

body remains. The bullet, when encountered, is removed. Needless to say,

the presence of a bullet and the existence of in-driven fragments of

bone should be investigated previous to the adoption of operative

measures by means of X-ray photography.

If the brain be penetrated or perforated a drainage tube is introduced

through scalp-flap and dura mater in such a manner that its distal end

lies in relation to the track through the brain or flush with its

lacerated surface. Elsewhere the dura is sewn up (fine catgut sutures)

and the scalp-flap replaced, the drainage tube being anchored to the

scalp with a single suture. The tube should be allowed to remain _in

situ_ for at least forty-eight hours and longer if necessary, the

surgeon being guided by the amount of discharge and by the general

progress of the case. In all cases of doubt the surgeon should err on

the side of leaving the tube in position for a longer period of time,

merely shortening it daily. Premature removal may lead to disastrous

results. There can be no question that ultimate success hinges to a

large extent on primary or early healing of the wound.

_The search for and removal of the bullet._ In the event of a wound of

entry only, it may be presumed that the bullet is within the skull.

Bullets, however, pursue such unexpected and devious courses within the

skull, and possess such a tendency to gravitate towards the base of the

brain, that no attempt should be made at removal except after full X-ray

investigation, stereoscopic if possible.

To this rule there are two exceptions:--(1) where the bullet lies

superficial in the brain substance, and (2) where there exists, at the

opposite side of the skull, what may be termed an area of attempted

exit, that is to say, an area of bone elevation and blood extravasation,

suggesting that the bullet has penetrated through the brain and impinged

against the opposite side of the skull. In both these instances

operative measures are not only justifiable but often definitely

indicated. On the other hand, it cannot be urged too forcibly that hasty

and ill-determined explorations usually terminate in failure. Even under

the most promising circumstances it by no means follows that the bullet

will be found at the site of counter-trephining, as it may have

rebounded to some more distant region of the brain, necessitating an

operation conducted over a totally different region. Thus, in a case

recently under my care, the bullet entered at the right temporal region,

penetrated the brain and produced on the left side of the head a

well-defined wound of attempted exit. The bullet, however, on striking

the opposing side of the skull rebounded, and was subsequently found in

the apex of the descending cornu of the right lateral ventricle. This

case affords a good example of the uncertain course pursued by bullets

entering the cranial cavity.

However, in certain cases of emergency and in others of expediency an

immediate search should be made for the bullet. The operation should be

carried out with a light hand and not unduly prolonged.

In order to find and remove the bullet various probes and extractors

have been invented. Perhaps the best of these is Sheen’s bullet-forceps,

probe, and telephone-detector.

‘The forceps are so constructed that they may be attached directly to

the telephone-detector and used as a combined probe and forceps, or they

may be used in combination with the specially designed graduated probe

attached to the detector in the following manner: The bullet having been

located with the probe, the forceps are introduced along the probe, the

jaws of the forceps being provided with an oblique groove for this

purpose. In both methods of use the telephone-detector is in

uninterrupted contact with the bullet during extraction, an advantage

which much facilitates the operation, and ensures the least possible

damage of tissue. In cases where the forceps are used as a probe and

forceps combined, the connexion attached to the forceps is composed of

silver wire, which can be readily sterilized, and while of sufficient

rigidity to avoid risk of accidental short-circuiting with the patient’s

body, is flexible enough not to interfere with the delicacy of

manipulation. The telephone-detector is placed on the head of the

operator, and the flat plate on the patient’s body, good contact being

secured by means of a damp roll of lint, or other material, moistened

with a saturated saline solution.’

[Illustration: FIG. 89A. SHEEN’S BULLET-PROBE AND FORCEPS.]

[Illustration: FIG. 89B. SHEEN’S TELEPHONE BULLET-DETECTOR.]

‘The probe is introduced, and when a metallic foreign body is touched a

fall of potential occurs, and the telephone buzzes. It is necessary to

point out that no mistakes can be made, as may be the case with a

battery in circuit. In using the “auto-telephone probe” the body

constitutes an electrolyte, the plate one pole of a voltaic circle, the

probe the other; on touching a metallic body different to that of the

probe, a difference of potential occurs, and the current ensuing flows

through the telephone and is recorded by the diaphragm in the usual

way.’[65]

If the bullet be not found it should be allowed to remain _in situ_ till

such time shall have elapsed as will enable the surgeon to determine

whether further operative measures are indicated, time being allowed

also for skiagraphy and for the evolvement of another plan of campaign.

It is of course a well-known fact that bullets in certain regions of the

brain--e. g. the frontal lobe--may exercise but little effect on the

individual. Further measures are also indicated when the want of

cleanliness of the wound and the anatomical situation of the bullet

demand secondary operative procedures. All remote operations are planned

according to the localizing symptoms, aided by X-ray photography.

After exploration for and removal of the bullet an extensive osseous

defect may remain. Opinions differ with respect to the time at which an

attempt should be made to remedy the deficiency and as to the operative

technique appropriate to the condition. The nature of the wound must

always be taken into consideration, for the application of any plate of

foreign material is doomed to failure in the event of the slightest

degree of suppuration. As a general rule, it may be accepted that it is

advisable to postpone such measures till after the primary or early

healing of the wound. Further delay, however, tends to allow of the

formation of such adhesions as will result in the development of

Jacksonian epilepsy, chronic headache, traumatic insanity, &c. The

operative features requisite to the interposition of plates between the

bone and the scalp, and other measures, are fully detailed in Chapter

VI.

‘The _after treatment_ consists in keeping the patient as quiet as

possible, and the administration of a fluid diet. In some cases,

recurring symptoms pointed to the continued presence of bone fragments;

these were usually indicated by signs of irritation, or often by local

inflammation, in the latter case infection taking the greatest share in

the causation. Such cases needed secondary exploration, and the

wonderful success of this operation, even when the wound was evidently

infected, was perhaps one of the most striking experiences of surgery in

general.’ (Makins.)[66]

=Complications.= The more important early complications are meningitis,

hernia cerebri, and brain abscess. For the Symptomatology and Treatment

of these conditions the reader is referred to Chapter VIII.

=Results.= The prognosis in any given case depends on the degree of bone

and brain injury, on the presence or absence of the bullet in the brain,

and on the ‘cleanliness’ of the wound. In the American Civil War 61·2

per cent. of all fractures of the skull terminated fatally, in the

Franco-German War 51·3 per cent., and in the South African War 33·1 per

cent. This decreasing mortality is undoubtedly dependent on the improved

methods of treatment.

When the injury is inflicted at short range the prognosis is undoubtedly

less favourable. ‘At short range, the characters of the wounds, and the

severity of the symptoms, rendered the immediate prognosis uniformly

bad, a very great majority of the patients dying, and that at the end of

a few hours or days.’ (Makins.)

The best results were obtained when the injury was received in the

frontal region. The occipital region comes second, and the cerebellar

last. Most injuries near the base of the skull were fatal. Longitudinal

wounds were more serious than transverse. However, the most surprising

recoveries were made, both with and without operative treatment.

The prognosis with regard to pistol wounds is absolutely bad. Phelps[67]

records the following results in cases that came under his own

observation.

Death occurred at once or within the first hour in 15 cases.

Death occurred within twelve hours in 7 cases.

Death occurred within fifteen hours to forty days in 10 cases.

Recovery in but 8 cases.

The more remote results are exceedingly difficult to determine, for it

is impossible to obtain an accurate account of the subsequent course of

events in all cases. With regard to the question of the after-history,

Makins[68] writes, ‘I feel certain that a long roll of secondary

troubles from the contraction of the cicatricial tissue, irritation from

distant remaining bone fragments, as well as mental troubles from actual

brain destruction, await record in the near future.’ In the experience

of the writer, this statement is fully justified. The hospital surgeon

continually meets with cases exemplifying the more remote effects,

varying from slight lesions associated with chronic headache to others

showing considerable deficiency in the vault of the skull with cortical

degeneration.

Some of these cases are still capable of being cured, others are

hopelessly inoperable.

In the consideration of the more remote results, it must be remembered

that the surgeon comes mainly into communication with those cases which

require further treatment. The more favourable are lost to view. Hence

the difficulty in estimating with certainty the absolute results

obtained after lesions of this nature.

[59] _A Civilian War Hospital._

[60] _Gunshot Wounds_, p. 170.

[61] _Gunshot Wounds._

[62] _A Civilian War Hospital_, p. 228.

[63] _Surgical Experiences in South Africa_, p. 293.

[64] _Lancet_, March 3, 1906.

[65] _Army Med. Corps Journal_, April 1905.

[66] _Surgical Experiences in South Africa._

[67] _Traumatic Injuries of the Brain_, p. 387.

[68] _Surgical Experiences in South Africa._

CHAPTER X

TRIGEMINAL NEURALGIA

Neuralgia of the fifth or trigeminal nerve is, in its varying degrees,

of frequent occurrence. In its cause, manifestations, and progress, it

offers so wide a field for discussion that the question must be focussed

down by means of some simple form of classification such as enables one

to include the majority of cases that come before one’s observation.

For all practical purposes, the following types will be sufficiently

inclusive:--

Neuralgia minor.

Neuralgia major.

Hysterical neuralgia.

NEURALGIA MINOR

This variety is almost invariably dependent in its development on some

exciting cause. In some cases this cause is readily demonstrated, in

others great difficulty may be experienced before the source is

discovered.

These secondary neuralgias may be regarded as resulting from the

following injuries and diseases.

Diseases of the tongue, fauces, and pharynx. For example, the pain

referred to the lingual nerve in epithelioma of the tongue.

Diseases and injuries of the maxillæ. For example, the neuralgia

associated with dental caries.

Injuries and diseases of the nose and its accessory cavities. For

example, the infra-orbital pain experienced in empyema of the antrum.

Injuries and diseases of the bones of the skull. For example, the pain

referred along the course of those nerves emerging through the basal

foramina involved in a fracture of the base of the skull.

Errors of refraction. For example, neuralgia of the supra-orbital

nerve.

Anæmia, influenza, alcoholism, Bright’s disease, cold, worry, malaria

(brow-ague), rheumatism, &c.

But slight allusion need be made to the _symptomatology_ of neuralgia

minor--the conditions are more or less familiar to every one. The pain,

though usually most intense in that particular branch of the nerve which

is most intimately related to the source of the neuralgia, is often

referred to other branches of the same nerve-trunk, and sometimes to an

entirely different nerve. Thus, in the case of an epithelioma of the

tongue, the pain, though perhaps most acute in the region supplied by

the lingual nerve, is nevertheless frequently referred to the ear along

the course and distribution of the chorda tympani.

The pain is more or less continuous, often associated with

exacerbations, but seldom paroxysmal. The patient frequently complains

of heat and tenderness over the areas supplied by the nerve in question

and, in almost every instance, there are points of special tenderness

corresponding as a rule to the emergence of the nerve-trunk through some

osseous foramen. Again, some relief may be obtained by the application

of pressure over the site of that foramen. For example, neuralgia

dependent on antral empyema is most acute in the region of the

infra-orbital foramen, and relief may be experienced by pressure applied

over that foramen.

In the event of failure to discover an exciting cause, some difficulty

may be experienced in coming to a correct conclusion as to whether the

case belongs to the minor types of neuralgia, or should be relegated to

the more serious group of neuralgia major (tic doloreux). In general,

however, the neuralgias minor may be distinguished from the major

variety by the following features:--

(1) The presence of some detectable forms of nerve-irritation. In the

neuralgias major there may be no such cause.

(2) The relief of symptoms on the successful treatment of the cause.

(3) The relative absence of those paroxysmal attacks which are so

typical of neuralgia major.

(4) The infrequence of severe vaso-motor, trophic, and sensory changes

in the regions supplied by the nerve affected. Such changes are more or

less constant in neuralgia major.

(5) The wide distribution of the pain and its reference to other nerves,

with no clear line of demarcation from neighbouring areas supplied by

totally different nerves. In neuralgia major the pain, though often

involving both second and third divisions of the fifth nerve, is

referred to the areas supplied by those nerves only, with a clear line

of demarcation from neighbouring regions.

In cases of neuralgia of doubtful origin one can only observe the effect

of treatment and be guided by the results obtained.

=Treatment.= The source of the neuralgia requires primary consideration.

When this has been rectified the patient should be treated after general

medical principles. In the event of failure at relief, we have two other

strings to our bow--alcohol injections, and neurectomy of the nerve

involved. Alcohol injections are dealt with later. Neurectomy--after

Thiersch’s method of avulsion--is greatly preferable to all the older

methods of neurotomy, nerve-stretching, and nerve-division. These older

methods brought about in their train but transitory alleviation of pain.

=Neurectomy of the inferior dental nerve.= A transverse incision is made

through the skin and subcutaneous tissues at the level of junction

between horizontal and vertical rami of the jaw, extending from the

anterior border of the vertical ramus to the posterior border of the

same. The tissues are retracted and the masseter muscle exposed. The

muscle fibres are split in the vertical direction and the bone laid

bare. A ¹⁄₂ inch trephine is applied, and a disk of bone removed so as

to expose the inferior dental nerve at its entrance into the inferior

dental canal. The nerve is freed from the corresponding artery, divided

at the centre of exposure, and the two ends seized with forceps, twisted

and avulsed in such a manner as to destroy and remove the maximum number

of nerve-fibres. The disk of bone is replaced, the muscle fibres brought

together with a few catgut sutures, and the margins of the skin incision

approximated.

=Exposure of the infra-orbital nerve.= A curved incision is made through

the skin and subcutaneous tissues parallel to and below the

infra-orbital margin, the tissues retracted, and the small muscles

overlying the infra-orbital foramen divided or retracted so as to allow

exposure of the foramen. The nerve is isolated and divided. The

peripheral end is seized with forceps and avulsed. The central end may

be treated after similar fashion, or, preferably, again exposed in the

infra-orbital groove or canal, the tissues being peeled away from the

floor of the orbit and the nerve sought for as it traverses the

infra-orbital canal. With this object in view, it may be necessary to

gently break away the osseous roof of the canal before the nerve can be

exposed. It is then lifted up with a small hook, drawn through the

infra-orbital foramen, seized with forceps, and avulsed in such a manner

as to be torn away somewhere in the region of the spheno-maxillary

fossa. The wound is then sewn up.

=Exposure of the supra-orbital nerve.= The nerve is exposed through a

curved incision parallel to the supra-orbital margin, and so planned as

to be concealed by the eyebrow. The fibres of the orbicularis

palpebrarum are separated and the foramen identified. The nerve is

separated from its artery, divided, the peripheral portion avulsed, and

the central portion again exposed as it courses along the roof of the

orbit. For this purpose the tissues of the upper lid are detached from

the supra-orbital margin, the nerve delivered with the aid of a small

hook, brought out through the foramen, and avulsed in such a manner as

to be torn away somewhere in the region of the sphenoidal fissure. The

wound is then sewn up.

NEURALGIA MAJOR

Neuralgia major originates most commonly in the third division of the

nerve, less frequently in the second, and rarely in the first. Whichever

division be primarily affected, there is a very general tendency for

other branches to become involved, and this in a very definite way--the

pain spreading centrally from the nerve first involved, radiating to

other nerve-trunks so soon as they shall be reached. Thus, pain

originating in the inferior dental branch of the third division spreads

to the lingual and other branches of that division and then involves the

second division. Fortunately, whether the trouble originates in the

third or second divisions, the ophthalmic tends to escape or to become

less seriously involved--a fortunate circumstance considering the

terrible conditions associated with neuritis of that nerve, the

disastrous results on cornea, conjunctiva, &c.

The disease is undoubtedly of a progressive nature, originating without

rhyme or reason. It seldom becomes evident before the ages of 45 to 55,

affecting both rich and poor alike.

Wilfred Harris[69] collected 265 cases, and showed that the disease was

slightly more common in men than in women--144 to 131. There appeared to

be some predilection for the disease to involve the right side in

preference to the left--179 to 80. In 6 cases the affection was

bilateral.

Trigeminal neuralgia does not in itself lead to fatal results, but the

continuous pain, the want of sleep, and the difficulty experienced in

taking sufficient nourishment soon reduce the patient to such a

miserable condition that, unless relieved by the surgeon, amelioration

is sought in morphia or release in death.

Before proceeding further it will be convenient to enumerate certain

points aiding in the differential diagnosis between the true and

hysterical forms of trigeminal neuralgia.

_True Neuralgia._ _Hysterical Neuralgia._

Patient old, probably over 50, Patient young, more commonly of the

and more commonly of the male female sex.

sex.

Pain paroxysmal. Pain severe for long periods

together.

Vaso-motor, trophic and sensory All these changes very rare.

changes common.

Pain strictly unilateral and Pain variable in distribution,

constant in site. radiating irregularly to the

opposite side of the face.

The =pathology= of tic doloreux is most obscure. The parts requiring

examination are the peripheral nerve-trunks, the ganglion, the sensory

root, and the central nervous system. The last two regions may be

excluded, not only on the ground that research has failed to show any

constant structural changes, but also because the removal of the

ganglion may be regarded as curative of the disease. The ganglion itself

and the peripheral nerve-trunks remain for investigation.

In the peripheral nerve-fibres no constant material changes have been

observed. The epineurium, on the other hand, is almost invariably

shrunken and sclerosed. Considerable stress might be laid on this fact

unless it were also taken into consideration that the nerves were

examined in patients who had suffered from major neuralgia for prolonged

periods of time. Similar changes have also been observed in patients who

have never exhibited neuralgic symptoms.

In the ganglion itself the following changes have been observed:--(1)

arterio-sclerosis; (2) alteration in the character of the nerve-fibres

traversing the ganglion; and (3) adhesions between the ganglion and the

surrounding parts. All these changes, however, are so inconstant that

but little importance can be attached to them.

At the present time there is a disposition to regard trigeminal

neuralgia in the light of an ascending neuritis, originating

peripherally and ascending towards the Gasserian ganglion. Sir Victor

Horsley first pointed out that the ganglion acts as a barrier to the

further upward spread of the affection. This is proved by the success

obtained in the removal of the ganglion.

Symptomatology.

_Pain._ The onset of pain may be preceded by premonitory symptoms such

as tinglings, throbbings, and burning sensations in the parts

subsequently involved, whilst, in the earlier stages of the disease, the

pain may be more or less localized to the site of emergence of the nerve

from an osseous foramen.

In the earlier stages also the attacks, though severe, are paroxysmal,

of short duration, perhaps not lasting more than half a minute, and

definitely localized to some special nerve-trunk. During the periods of

remission the patient feels quite well. Gradually the pain increases in

severity, the periods of remission shorten, and the pain in its

distribution becomes more widespread, the neuritis--or whatever the

process may be--spreading centrally and radiating along the course and

distribution of such branches of the nerve as shall be encountered.

Paroxysms are a marked feature, occasionally of so severe a nature that

the patient falls to the ground as if struck by lightning, recovering

after a variable period of time.

In the later stages of the disease the pain may be almost continuous,

and the condition of the patient is truly miserable.

The attacks are often ushered in by the slightest stimulus--talking,

mastication of food, draughts, emotion, &c.--and, in order to avoid the

occurrence as far as possible, the patient abstains from talking, dreads

eating, &c. Dribbling from the mouth may be observed in those cases in

which the patient finds some relief in keeping the mouth open. It is

also frequently seen during the height of the paroxysm. At such stages

the patient is collapsed, with feeble pulse, shallow respiration, the

temperature subnormal, and the skin clammy. The attacks occur both

during the day and the night, sleep fails, and the body nutrition

suffers.

The site at which the pain originates can often be fixed by the patient

himself. Occasionally relief may be attained by pressure applied over

some particular part, by heat or by cold, or by some other method

discovered by the patient himself.

The attacks are often accompanied by twitchings of the muscles supplied

by the facial nerve, and, according to some investigators, by fibrillary

twitchings of the muscles of the region affected.

In the later stages, wasting of the muscles may be observed.

_Vaso-motor and trophic changes._ The skin and mucous membrane supplied

by the nerve involved become hyperæmic and hyperæsthetic, and, in the

more chronic cases, these changes may be associated with œdema of the

subcutaneous tissues--the clinical picture now closely resembling that

observed in some cases of angio-neurotic œdema.

Other symptoms of similar nature are herpes, increased salivation,

furred tongue (on the side of the lesion), sweating of the skin,

lacrimation, conjunctivitis, and keratitis.

_General decline in health._ This depends, not only on the difficulty

experienced in taking sufficient nourishment, but also on the moral

effect produced by the more or less continuous pain. In the more severe

cases emaciation is rapid.

Treatment.

1. _Therapeutic remedies._ The following drugs have been recommended.

Quinine, in large and increasing doses.

Arsenic, given in a similar fashion.

Gelsemium, in toxic doses, every few hours until tinglings in the

fingers and nausea show that the drug has been pushed far enough (Sir

Victor Horsley).

Methylene blue, in three-grain doses (Sir Watson Cheyne).

Iron, antipyrin, strychnine, cannabis indica, &c.

Morphia. This drug is undoubtedly beneficial in its results, but the

habitual use thereof is strongly contra-indicated, not only because of

the temporary benefit received, but also because of the necessary

increase in the quantity required to alleviate the pain. If persistently

used the patient gradually develops the morphia habit.

Some of these remedies suffice for the neuralgias minor, but with regard

to their action in cases of neuralgia major, their effect may be summed

up as follows: ‘True tic doloreux has been the therapeutic despair of

most physicians and surgeons,’[70] and ‘too often the operation is put

off till the patient is addicted to the morphia habit, depleted in

strength and vitality by drugs, sleepless nights, and years of intense

suffering’.[71]

Until quite recently, with the exception of these medicinal remedies,

the only other methods at our disposal in the treatment of trigeminal

neuralgia were Gasserian ganglion removal and other intracranial

operations on the three divisions of the fifth nerve. In 1906, however,

Schlösser[72] of Munich advocated the injection of alcohol into the

region of those foramina at the base of the skull through which the

nerve trunks emerged. As the result of these injections it was stated

that, although some slight degree of cutaneous anæsthesia frequently

resulted, yet that it was usually of an unimportant and transient

character, and that the pain subsided and finally ceased, remaining

absent for a variable period of time, usually about ten months. In the

event of recurrence the injection was repeated, each period of recurrent

pain being less intense and less prolonged, whilst the periods of

remission increased proportionately.

Whilst it is clear from the results obtained by those who have followed

in Schlösser’s footsteps, that alcohol injections are, as a rule,

reasonably satisfactory, yet it must be clearly understood that

beneficial results are not always observed, and that in the event of

failure the more radical intracranial operations must be carried out.

The technique of alcohol injections.

_Question of anæsthetic._ Freezing of the skin or other method of local

anæsthesia suffices to allow of the painless introduction of the needle.

A general anæsthetic should be avoided wherever possible, as the burning

sensation experienced by the patient when the nerve-trunk is encountered

greatly assists the accuracy of introduction.

_The needle._ The needle should be stout--10 cm. long, 1·5 cm. in

diameter, and graduated in centimetres up to 5 cm., and provided with a

blunt stilette.

_Introduction._ The skin is cleansed, the stilette slightly withdrawn,

and the needle introduced. After puncture of the skin the stilette is

pushed home, all further introduction being carried out with the blunt

advancing point. When in position, the stilette is withdrawn, and a

glass syringe, ready filled with alcohol, fitted to the needle and the

injection made.

_The solution._ Purves Stewart recommends the injection of 1-1·5 c.cm.

of the following solution:--

Beta eucaine, 2 grains

Absolute alcohol, 6 drs.

Distilled water to the ounce.

Wilfred Harris advises 90 per cent. alcohol, preceded by a 2 per cent.

solution eucaine. He urges that two or three drops should be injected

slowly, and if the needle be correctly placed a sharp burning pain will

instantly be felt over the area of the distribution of the nerve,

lasting fifteen seconds or so and then dying away. Two or three more

drops are then injected, and thus ‘a few drops at a time, from 1 to 1·5

c.cm. are injected, the pain produced with each succeeding push of the

syringe being less and less’.

To reach the _foramen ovale_ (third division), the needle is introduced

through the cheek behind the last molar tooth, at the lower border of

the zygoma, at a point 2¹⁄₂ cm. in front of the descending root of the

zygoma. The blunt needle penetrates the masseter muscle and the

posterior part of the temporal muscle. It is then directed backwards and

slightly upwards till it impinges on the skull at the external pterygoid

plate. It is then pushed on, upwards and backwards, till it enters the

foramen ovale at a depth usually of about 4 cm. from the zygoma. In case

of difficulty in passing the needle through the sigmoid notch of the jaw

the mouth should be widely opened.

If the needle be directed too low it may penetrate the pharyngeal wall

or the Eustachian tube; if too far back, the middle meningeal artery.

To reach the _foramen rotundum_ (second division)--a rather more

difficult procedure--it is necessary to find the posterior border of the

orbital process of the malar bone, prolonging this line downwards to the

lower border of the zygoma and inserting the needle ¹⁄₂ cm. posterior to

this point. The needle is pushed horizontally inwards and the point

directed slightly upwards, the foramen being reached in the

pterygo-maxillary fossa at a depth of about 3 cm. from the zygoma. The

needle, for an average-sized skull, should never penetrate deeper than 5

cm. The structures pierced are the anterior fibres of the masseter and

the buccinator muscles. If directed too horizontally, the needle will

pass below the nerve and reach the spheno-palatine region; if too high,

the sphenoidal fissure may be reached and the branches of the third

nerve damaged, causing diplopia and dilatation of the pupil.

To reach the _sphenoidal fissure_ (first division), the needle is

introduced at the outer margin of the orbit, close within the

fronto-malar articulation, and passed along the outer wall of the orbit

to a depth of 3¹⁄₂ to 4 cm.

Needless to say, it is essential that these injections to the basal

foramina should only be carried out in the first instance after

experimentation on the cadaver.

In each case a single injection may suffice, but as a general rule it is

advisable to repeat the process after two or three days, and again at

longer intervals. It is not necessary that the nerve-trunks should be

pierced, but better results are obtained by so doing. The surface area

to which the particular nerve-trunk is distributed immediately becomes

anæsthetic, remaining in that state till the effect of the injection

shall have passed off. The masticatory muscles are paralysed. The

injection may be followed by paresis of the facial muscles, by œdema of

the lower lid, and by hæmatomata. These last-named results are, however,

transitory.

=Results.= Schlösser, who injects 15 to 20 minims of an 80 per cent.

solution of alcohol, reported in 1907 that he had treated 123 cases, the

average period of relief from pain being ten and a half months.

Wilfred Harris[73] reported on 38 cases, 31 of which were completely

relieved for periods varying from two to eleven months. In a more recent

communication he reports on 86 cases, in only 3 of which was no relief

obtained. In 7 cases the injection was made into the ganglion itself, in

anticipation of more permanent results.

=Operative procedures.= Intracranial procedures for trigeminal neuralgia

were formerly associated with so high a rate of mortality that they were

not regarded with favour. Of recent years, however, as the result of the

general improvement in technique, it has been clearly demonstrated that,

in experienced hands, ‘the ganglion can be readily exposed, hæmorrhage

and shock need no longer be considered elements of danger: the risks of

the operation are only those associated with every major operation.

Recovery from the effects of the operation is rapid; the patients are

frequently up and about on the third or fourth day, and the ultimate

results are, to say the least, most gratifying to the patient and to the

operator.’[74]

The following operations require consideration:--

1. Intracranial resection of the second and third divisions of the fifth

nerve (Abbé’s operation).

2. Operations for the removal of the whole or part of the Gasserian

ganglion (Hartley-Krause operation and its modifications).

3. Operations on the sensory root of the ganglion (Frazier’s operation).

_Intracranial resection of the second and third divisions of the fifth

nerve and operations on the ganglion itself_ resemble one another so

closely in their preliminary operative stages that they may be

considered together. After the usual preparatory treatment--in which

the shaving process may be confined to the temporal region--the

incision, commencing well above and behind the external angular frontal

process, passes backwards below the level of the temporal crest and

terminates immediately in front of the tragus of the ear. The front part

of the incision, as depicted in Fig. 91, is prolonged too far downwards.

It should not be carried further forward than the anterior margin of the

hairy scalp, any further downward prolongation tending to involve that

branch of the facial nerve which is distributed to the anterior belly of

the occipito-frontalis muscle.

The incision, carried out methodically, first involves the skin only,

pressure being applied by the surgeon on the one side and his assistant

on the other, so as to control bleeding. All divided vessels are at once

clamped. The operation may be a prolonged one, and in its later stages

bleeding from meningeal vessels and emissary veins may not be so readily

controlled. It is essential, therefore, that the earlier stages should

be as bloodless as possible.

[Illustration: FIG. 90. TO ILLUSTRATE THE OPERATIONS ON THE GASSERIAN

GANGLION. s.f., sphenoidal fissure; f.r., foramen rotundum; f.ov.,

foramen ovale; s.s., Frazier’s operation on the sensory root. The dotted

line = the line of section in removal of the lower two-thirds of the

ganglion (_Jonathan Hutchinson’s operation_). The shaded portions =

parts removed in intracranial resection of the second and third

divisions of the nerve (_Abbé’s operation_).]

The temporal fascia is next incised--slightly below the line of the skin

incision. Finally, the temporal muscle is divided--again at a lower

level than the fascial incision. Skin, fascia, and muscle are then

turned down to a zygomatic base. Some surgeons split the temporal muscle

in the direction of its fibres, a course, however, that tends somewhat

to cramp the operative field.

The trephine is applied to the bone, the surgeon aiming at striking the

angle between the anterior and posterior branches of the middle

meningeal artery. The bone-disk is removed. With the aid of craniectomy

forceps the bone is nibbled away, more especially in the downward

direction towards the base of the skull. It is essential that the

operator should get down as low as possible, for the lower the line of

attack the easier the approach to the ganglion and the less the damage

incurred by the brain (from retraction).

The opening in the bone, oval in shape, should present a diameter in the

vertical direction of about 1 to 1¹⁄₄ inches, and an antero-posterior

diameter of about 1¹⁄₂ inches.

The dura is stripped away from the base of the skull, partly with the

fingers and partly with the blunt dissector, and a flat, slightly

malleable retractor introduced along the floor of the middle fossa, the

dura and overlying temporo-sphenoidal lobe being gently lifted upwards.

The surgeon should take upon himself the responsibility of retracting

the brain, holding that instrument with the one hand and working inwards

with the other, directing his course towards the foramen spinosum

(middle meningeal) and foramen ovale (third division of the fifth

nerve).

During this stage hæmorrhage, derived mainly from the branches of the

middle meningeal, is often troublesome. It may be controlled by the

insertion of dry or wet gauze--in the latter case the gauze is soaked in

saline solution or sterilized water (at a temperature of about 110°

Fahrenheit)--or by the introduction of cotton-wool plugs to each of

which a silk thread is attached, for the purpose of facilitating their

final removal.

The middle meningeal artery acts as a guide to the foramen spinosum, a

foramen that lies immediately posterior and external to the foramen

ovale. In many cases the position of this artery so hampers the operator

in his manipulation that ligature is demanded. For this purpose

Cushing’s silver ‘clips’ will be found most serviceable. One clip is

applied to the artery immediately after its entry into the skull, the

other a short distance above, the vessel being divided between the two

(see Fig. 6).

The foramen ovale is then identified, the dura being stripped away from

the nerve trunk by blunt dissection. The surgeon then works inwards and

forwards to the second division of the nerve and its foramen, the

foramen rotundum. Hæmorrhage, in this case derived from emissary veins,

may again be troublesome. Considerable perseverance is required, and,

although each attempt at further separation of the dura from the bone

entails more oozing, the difficulties--except in the most exceptional

cases--may be overcome.

The _second and third divisions may now be resected_. For this purpose

it is essential that the two nerves should be exposed from the point of

their exit from the skull right up to the margin of the ganglion. Their

dural coat seldom requires to be incised with the knife, the membrane

being readily stripped away with the blunt dissector. When fully

exposed, the nerve trunks are picked up with a blunt aneurysm needle and

divided in two places, flush with the basal foramina and close up

against the ganglion. The intermediate parts are removed.

To prevent regeneration of nerve fibres--with consequent return of

symptoms--the basal foramina are blocked up with small ivory pegs--well

driven home--or with amalgam.

All gauze plugs are removed, the field of operation well dried, and dura

and brain allowed to fall back into position. The wound is closed, if

possible without drainage. In the event of considerable oozing a

cigarette drain should be inserted for twenty-four hours. The scalp-flap

is sewn up, skin, muscle, and fascia being united separately.

_Removal of the Gasserian ganglion._ There is some divergence of opinion

as to whether it is necessary to remove the ganglion entire or whether

it suffices to resect the lower two-thirds--that part through which the

fibres of the second and third divisions course--the upper third being

left intact. This latter course is advocated by Jonathan Hutchinson on

the grounds that (1) the first division is but rarely involved in the

neuralgic process, (2) its inclusion in the process of removal entails

some risk to the eye--conjunctivitis, keratitis, and sloughing of the

cornea, and (3) resection of the lower two-thirds of the ganglion, when

carried out in suitable cases, is but rarely followed by the development

of neuralgia in the first or ophthalmic trunk. Added to these facts, it

must be admitted that the complete removal of the ganglion is associated

with added operative risk--wounding of the cavernous sinus and injury to

the third, fourth, and sixth nerves.

The Gasserian ganglion lies in the cavum Meckelii, a depression on the

anterior aspect of the petrous portion of the temporal bone, and is

situated between the two layers of dura mater, the stronger on the upper

or cerebral side, the weaker between it and the bone. Under the

pathological conditions often existent in cases of trigeminal neuralgia,

considerable adhesion may be present between the ganglion and its

enveloping coats. Consequently, its complete exposure is often a matter

of considerable difficulty. The dura must be stripped away from the

outer aspect of the ganglion, firstly by dividing the membrane along the

border of the ganglion between the site of emergence of the second and

third divisions, and then by blunt dissection.

The ganglion and its efferent branches being exposed, _resection of the

lower two-thirds_ may be carried out. The second and third nerve trunks

are severed flush with the basal foramina, traction applied, and the

lower portion of the ganglion resected.

During the final stages, the manipulations of the operator are again

likely to be obscured by venous oozing and by the discharge of some

cerebro-spinal fluid. Patience, careful application of gauze plugs, and

good illumination of the field of operation are required to overcome

these difficulties. In some few cases the bleeding has been so profuse

that the operation has had to be abandoned for the time being, a fresh

attempt being made some days later. This course should, however, rarely

be necessary.

Similarly, if the operator should deem it necessary to remove the whole

ganglion, this procedure may now be carried out. The posterior part of

the ganglion is exposed, together with its sensory root. This root is

hooked forward with a small blunt-pointed hook and then divided.

Traction is applied to the ganglion and it is turned forwards, the three

terminal divisions being divided one after the other with the minimum

risk of injuring the cavernous sinus.

=Modifications of the Hartley-Krause operation.= With the object of

obtaining further manipulative room, some surgeons recommend the

formation of an osteoplastic flap. This method should never be adopted.

It is quite unnecessary, it prolongs the operation, and entails more

deformity. Others advise division of the zygoma, both in front and

behind, with downward displacement of the intermediate portion.

Burghard[75] recommends division and downward displacement of the zygoma

together with section of the coronoid process, this process being

turned upwards together with its attached temporal muscle.

From my own experience, I should regard all these modifications as quite

unnecessary, the Hartley-Krause operation permitting an adequate

operative field. The deformity resulting from all these more extensive

procedures must also be taken into consideration. The lines of incision

in the Hartley-Krause operation are more or less concealed by the hairy

scalp.

[Illustration: FIG. 91. TO ILLUSTRATE THE OPERATIONS FOR EXPOSURE OF THE

GASSERIAN GANGLION. _e_, The incision for Frazier’s operation; _f_, The

incision for the Hartley-Krause operation (in its most recent

modification, the front part of this incision is not carried so far

downwards, thus avoiding _b_², that branch of the facial nerve which is

distributed to the anterior belly of the occipito-frontalis muscle);

_c_, The intra-osseous portion of the anterior division of the middle

meningeal artery; _b_¹, The branches of the facial nerve to the

orbicularis palpebrarum, &c.]

=Operations on the sensory root (Frazier’s operation).= Charles Frazier

advocates the ‘physiologic extirpation’ of the sensory root of the

ganglion. The advantages claimed over other methods are as follows:--

1. _Control of hæmorrhage and avoidance of risk of injury to the

cavernous sinus_. The ganglion receives its main blood-supply from

below. Division of the sensory root leaves the base of the ganglion

undisturbed, and this cause of free bleeding is removed. With respect to

the cavernous sinus, the operation is confined to the root of the

ganglion and consequently the sinus is in no wise concerned.

2. _Simple technique._ The operation of division of the sensory root is

complete before the difficulties common to extraction of the ganglion

have commenced.

3. _Avoidance of injury to adjacent structures._ The cavernous sinus is

not touched; the sixth nerve, which is intimately related to the

ophthalmic branch, is not exposed; and the motor-fibres which, passing

beneath the ganglion, join the third division outside the skull, and

which are almost necessarily injured in the ganglionic operation, may,

in division of the sensory root, escape implication.

4. _Reduction in the rate of mortality._ The operation is said to be

more economical of time, to entail less hæmorrhage, and therefore to be

less dangerous.

5. _Absence of ocular changes._ After division of the sensory root

ocular changes are absent, due in part to the fact that the ocular

nerves are left intact, and also to the probability that ‘sympathetic

fibres pass to the eye after entering the trigeminal nerve through the

Gasserian ganglion’ (Spiller).

In the consideration of these advantages it should be noted that they

are mainly directed against procedures in which complete extirpation of

the ganglion is attempted, and are of less weight when contrasted with

the partial excision advocated by Hutchinson.

=Frazier’s operation[76] on the sensory root.= ‘A horse-shoe shaped

incision is made, beginning at the middle of the zygoma and terminating

a little below the apex of the lobe of the ear (see Fig. 91). The

musculo-cutaneous flap is made purposely a little larger than the

opening in the skull. An opening is made in the skull with a diameter

not exceeding 3 cm. and extending down as far as the infra-temporal

crest. The dura is separated from the base of the skull with a blunt

retractor as far as the foramen spinosum. The middle meningeal artery is

ligatured and the dura mater incised directly over the third division at

the margin of the foramen ovale and separated from the upper surface of

the ganglion as far back as the sensory root. The latter is picked up

with a blunt hook, grasped with forceps and divided or avulsed. It is

necessary only to expose the posterior portion of the ganglion; the

second and third divisions of the fifth, the structures on the inner

side of the ganglion, and the cavernous sinus, are left undisturbed.’

=Choice of operation.= There are both advantages and disadvantages to

each of the various operations enumerated. There are also other

operations. From my own experience I have come to the conclusion that

the two operations of choice are resection of the second and third

divisions of the fifth nerve and division of the sensory root. The

former of these two operations is carried out when the general condition

of the patient is not altogether satisfactory, presuming, of course,

that the neuralgia is limited to those divisions of the nerve. Under

more favourable circumstances excellent results are obtained by exposure

and division or resection of the sensory root, with, I think, the

minimum risk.

=The results obtained by operation.= The prevailing impression that

these operations are associated with a high mortality is totally

incorrect. From my own experience and from numerous recorded cases, the

mortality may be estimated at not more than 5 per cent.

The extent of anæsthesia resulting varies according to the nature of the

operation. Thus, if the upper part of the ganglion be spared or the

operation confined to the second and third divisions, the upper lid,

conjunctiva, cornea, and forehead escape. In any case, taste is but

little impaired, the posterior part of the tongue being supplied by the

glossopharyngeal and the tip and sides by the chorda tympani. In all

cases, except perhaps in Frazier’s operation, the motor fibres which

accompany the third division are almost always divided, with consequent

paralysis of the corresponding masseter, temporal, and pterygoid

muscles. The degree of discomfort and deformity resulting from such

anæsthesia and paralysis is, however, not very considerable, and in

contrast with the relief from the terrible pain, of very little import.

It is, as Jonathan Hutchinson says, the price which the patient has to

pay for the cure of the neuralgia.

With respect to recurrence of pain, there is every reason to believe

that the resection of the sensory root and the complete removal of the

ganglion are never followed by recurrence of pain. With respect to

Jonathan Hutchinson’s and Abbé’s operations, there is some divergence of

opinion. There would appear to be some cases recorded in which the

symptoms have recurred--often many years later. With regard to

Hutchinson’s operation I have no personal experience, but it is stated

that in some few cases the pain has recurred in the first division. I

believe, however, that I am correct in stating that this is denied by

Hutchinson from the experience based on his own cases. As regards Abbé’s

operation, recurrence may take place if the basal foramina are not

completely occluded, some few nerve fibres growing through the foramina

on either side of the occluding medium. Such complications have not

taken place in the cases in which I have carried out this operation.

Besides experiencing immediate and complete relief from pain, the

patients sleep well, eat well, and rapidly convalesce. For some two or

three days they may suffer from some headache, presumably due to the

necessary manipulations of the brain, but this, besides being relieved

by drugs, soon passes off. Frequently, the patients are up and about

within a few days.

Whatever the nature of the operation, the greatest care must be taken to

protect the eye on the affected side--the conjunctival sac is washed out

daily with a mild boracic solution and the cornea guarded from exposure

to air and dust by means of a glass covering fastened round the

forehead. This appliance should be worn for two or three weeks.

The =main difficulties and dangers of operation= are as follows:--

1. Hæmorrhage (from middle meningeal artery and cavernous sinus).

2. Infection.

3. Shock.

4. Ocular complications.

5. Later after-results--insomnia, restlessness, impairment of memory,

aphasia, and hemiplegia--all of which are dependent either on rough

handling of the brain or lighter handling of an already diseased brain.

[69] _Lancet_, November 27, 1909.

[70] Purves Stewart, _Brit. Med. Journ._, June 11, 1910, p. 848.

[71] Frazier, _Univ. of Philadelphia Bulletin_, April 1909.

[72] _Berlin. Klin. Wochenschrift_, No. 3, 1908.

[73] _Brit. Med. Journ._, June 11, 1910.

[74] Frazier, _Univ. of Philadelphia Bulletin_, April 1909.

[75] _A System of Operative Surgery_, vol. i, p. 437.

[76] _Univ. of Pennsylvania Medical Bulletin_, April 1909.

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.

[Illustration: FIG. 92. IVORY EXOSTOSES OF THE SKULL.]

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.

[Illustration: FIG. 93. THE DEVELOPMENT OF THE FRONTAL BONE. A, Metopic

suture; B, Primary centre for frontal eminence; C, Secondary centre for

external angular frontal process; D, Secondary centre for trochlear

fossa; E, Secondary centre for nasal spine.]

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.

[Illustration: FIG. 94. AN EXOSTOSIS OF THE ORBIT.]

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.

[Illustration: FIG. 95. AN EXTRINSIC SARCOMA OF THE SKULL.]

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.

[Illustration: FIG. 96. AN INTRINSIC SARCOMA OF THE SKULL.]

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

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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”