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sure, and downward and backward into the occipital lobe. The motor areas, which on the outer surface are adjacent to the fissure of Rolando, are shown in Figs. 166 and 167.

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The superior longitudinal sinus is overlaid by a line from the inion to the glabella. The lateral sinus is indicated by a line running from the occipital protuberance horizontally outward to a point one inch posteriorly to the external auditory meatus, and from this point by a second line dropped to the mastoid process. The suprameatal triangle of Macewen is bounded by the posterior root of the zygoma, the posterior bony wall of the auditory meatus, and a line joining the two. The mastoid process is opened through Macewen's triangle to avoid injury to the lateral sinus. Barker's point, the proper spot to apply the trephine in abscess of the temporosphenoidal lobe, is one and one-fourth inches above and one and one-fourth inches behind the middle of the external auditory meatus. Fig. 172 shows clearly the main points of craniocerebral topography, obtained by methods approved by many scientists.

FIG. 172.-Head, skull, and cerebral fissures: B corresponds to Broca's convolution; EAP, external angular process; FR, fissure of Rolando; IF, inferior frontal sulcus; IPF, intraparietal sulcus; MMA, middle meningeal artery; OPr, occipital protuberance; PE, parietal eminence; POF, parietooccipital fissure; SF, Sylvian fissure; A, its ascending limb; TS, tip of temporosphenoidal lobe. The pterion (to the left of B) is the region where three sutures meet, viz., those bounding the great wing of the sphenoid where it joins the frontal, parietal, and temporal bones (adapted from Marshall by Hare).

Diseases of the Scalp.-The scalp is composed of skin, subcutaneous fat, and the occipitofrontalis muscle and aponeurosis. The scalp is liable to inflammation from various

causes, and also to other diseases-namely, tumors, cysts, warts, moles (local cutaneous hypertrophies), cirsoid aneurysm (page 256), nevi, and lupus. Abscesses of the scalp are common. If an abscess forms beneath the pericranium, the pus diffuses over the area of one bone, being limited by the attachment of the pericranium in the sutures. If an abscess forms in the tissue between the occipitofrontalis and the pericranium, it is widely diffused. Treves calls this subaponeurotic connective tissue "the dangerous area' Abscess of the subcutaneous tissue is apt to be limited because of the great amount of fibrous tissue. Abscess is treated by instant incision at the most dependent part, antiseptic irrigation, and drainage.

Diseases and Malformations of the Bones of the Skull. The bones of the skull are liable to caries, necrosis, osteitis, periostitis, atrophy, hypertrophy, tumors, etc. (see Diseases of Bones).

Microcephalus. By microcephalus is meant unnatural smallness of the head due to imperfect development. Marked microcephalus is not a common condition, but it is an occasional cause or associate of idiocy. A child may be born with a skull completely ossified even at the fontanelles, or the ossification may become complete soon after birth, but in many cases of microcephalus ossification takes place late or not at all. In microcephalus the face is apt to be fairly well developed; the jaws are prominent; the forehead is flat; the cranium and brain are small; the convolutions of the brain are simpler than is natural; there is apt to be marked asymmetry of the two sides of the brain; internal hydrocephalus may exist; areas of sclerosis and atrophy are common; porencephaly is not unusual. Some patients have perfect motor power; others are slow and inco-ordinate. Epilepsy, chorea, and athetosis frequently complicate the case. Idiots of this type often present deformities such as cleft-palate, strabismus, distorted ears, hypertrophied tongue, deformed genitals or extremities, ill-shaped and irregularly developed teeth. They exhibit irregular muscular movements, are frequently paralyzed in childhood (infantile paraplegia or hemiplegia), and suffer from subsequent contractures. These idiots are active, destructive, excitable, and are liable to be violent and almost demoniacal. Clouston says they look impish and unearthly.

Treatment. Skilled training in a school for the feebleminded or in an institution for idiots is necessary in treating microcephalus. Idiots have but little power of attention,

and sensory impressions give rise to but few concepts, and these are feeble and fleeting. In order to educate the idiot it is highly desirable that speech be acquired, and “the more strongly the attention can be aroused the more perfect does speech become" (Kirchhoff). The principle of the education of idiots is to stimulate, co-ordinate, and guide sight, hearing, and feeling.

Lannelongue of Paris has suggested an operation in cases of idiocy with premature ossification (see Linear Craniotomy, page 577). In this procedure the author has no confidence. Idiocy is a general disorder and not a local brain disease. Soft parts mould bone, and bone does not mould soft parts. There is no evidence that the brain is being compressed; in fact, the simplicity of the convolutions suggests the contrary. In many typical cases of microcephalic idiocy there is no synostosis even years after birth. The operation has been much abused. It is sometimes fatal, and, although a fatality may gratify the family, a surgeon is not a legal executioner. The remarkable improvement which has been reported in some cases results probably from misconception; the new surroundings, the strange faces, the firm discipline, the effect of the anesthetic, and the shock of the operation attract the feeble attention and rouse the sluggish senses. Many cases are brought for operation because they are for the time being unusually intractable and excitable, and the return to the usual level of conduct after operation is regarded as a permanent gain when it is often but a temporary alleviation. We believe that scientific training is the proper treatment, and that the efficiency of training is not increased by the previous performance of craniotomy, and we follow the precept of Agnew, that a surgeon might as well cut a piece out of a turtle's back to make a turtle grow as to cut a piece out of the skull to make the brain grow.

Diseases and Malformations Involving the Brain. -Meningocele is a congenital protrusion of the cerebral membranes through a bony aperture, the sac containing some extracerebral fluid. Meningocele feels and looks like a cyst (is translucent and fluctuates); it does not usually pulsate, it has a small base, it becomes tense on forcible expiration, and it may be reduced.

Encephalocele is a congenital protrusion not only of membranes, but also of a portion of the brain as well, the sac containing some extracerebral fluid. Encephalocele is small, opaque, does not fluctuate, has a broad base, does

pulsate, becomes tense on forced expiration, and attempts at reduction cause pressure-symptoms.

Hydrencephalocele is a congenital protrusion of membranes and brain-substance, the interior of the mass communicating with the ventricles and containing ventricular fluid. This is the most frequent and the most dangerous form. Hydrencephalocele is larger than a meningocele, is translucent, fluctuates, rarely pulsates, is pedunculated, is rendered a little tense on forced expiration, and cannot be reduced.1

Treatment. For hydrencephalocele nothing can be done, and early death is inevitable. In rare instances an encephalocele is converted into a meningocele, and the bony aperture closes, thus bringing about a cure. Among the expedients for treating meningocele and encephalocele are electrolysis, injection of Morton's fluid (gr. x of iodin, gr. xxx of iodid of potassium, 3j of glycerin), pressure and excision. In cases of meningocele, when portions of the nervecenters are not contained in the sac, Mayo Robson advises the performance of a plastic operation. He ligates the neck of the sac, cuts away the sac, sutures the skin-flaps separately, and leaves the stump outside the line of superficial sutures. It is usually possible to tell by palpation if nerve-centers are in the sac, but if in doubt, make an exploratory incision, and sweep the finger around inside of the sac."

Hydrocephalus.-In external hydrocephalus the fluid is between the membranes and the brain; in internal hydrocephalus the fluid is in the ventricles. Hydrocephalus may be acute or chronic, congenital or acquired.

Acute hydrocephalus, which results from meningitis (particularly tubercular meningitis), is usually internal, but may be external. The symptoms are headache, elevated temperature, delirium, stupor, convulsions, paralysis, and choked disk.

Treatment of acute hydrocephalus is of no avail. Tapping of the ventricles may be tried.

The cra

Chronic hydrocephalus is usually congenital. nium enlarges enormously and the bones of the skull are widely separated. The broad forehead overhangs the eyes. The child is an idiot, and very often does not learn to walk or to talk. Convulsions and palsies are common, and blindness is frequent. Such children usually die young. The treatment of chronic hydrocephalus is rarely of much

1 American Text-book of Surgery.
Am. Jour. Med. Sciences, Sept., 1895.

avail. tried.

Pressure by strapping with adhesive plaster has been Tappings through a fontanelle may be performed by means of a trocar (only 3ij or 3iij of fluid being drawn at a time). If much fluid is drawn, the head must be strapped afterward. If the skull ossifies, the lateral ventricles may be tapped. It has been proposed to drain by tapping the theca of the spinal cord (Quincke). This last operation is called lumbar puncture (page 595).

2. INJURIES OF THE HEAD.

Cephalhematoma (caput succedaneum), which is a collection of bloody serum under the scalp of a new-born child, results from the pressure of labor. No treatment is required.

Scalp-wounds are treated as are other wounds. Even a large piece of scalp with only a narrow pedicle may not slough; hence try to save any piece that has an attachment. Always shave a wide area and disinfect the wound thoroughly. Stitch the wound with silkworm-gut. The hemorrhage can, in most instances, be controlled by the sutures which are used to close the wound. If drainage is required, use a few strands of silkworm-gut.

Contusions of the Head.-Scalp-swelling from hemorrhage is usually considerable. The patient may be stunned or dazed. The swelling of hematoma must not be mistaken for fracture with depression. In hematoma there is a central depression, hard pressure on the centre finds bone on a level with the general contour of the bone, and the margin of a hematoma is circular, is not quite hard, and is elevated above the general contour. In depressed fracture the edge is on a level with or below the level of the general bony contour, and the margin is sharp and irregular. The treatment is by means of pressure and the use of lead-water and laudanum. If suppuration arises, at once incise.

Concussion or Laceration of the Brain.-For many years it has been customary to regard concussion as a condition produced by molecular vibrations in the nervous substance of the brain. Duret's classical observations have profoundly modified surgical thought, and have led to the opinion that in concussion of the brain there is injury to the brain itself, a rupture of cerebral vessels brought about by the advance and recession of a wave of cerebrospinal fluid. This wave first flows in the direction of the force. Keen says that there may be slight brain-injuries which can

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