ARTICLE XIX.

TECHNIQUE AND AFTER-CARE OF
OPERATIONS UPON THE

CRANIUM.

BY CHARLES L. SCUDDER, M.D.,

AND

HARRY H. HARTWELL, M.D.

OF BOSTON.

HORSELEY, Wagner, Phelps, von Bergmann, Keen, vonFrey, Lauenstein, Gigli, Codivilla, Braatz, Treves, vonEsmarch, Senn, Macewen and König-these are the men who have recently contributed valuably to the literature of cranial surgery. The work of these men, as well as that of others, has been reviewed in the preparation of this brief communication.

We have been asked to present for your consideration the present generally accepted technique of operations upon the cranium following injury, and to state the method of caring for these operated cases.

OPERATION HAS BEEN DECIDED UPON.

Preparation of the patient.-The evening before the operation a laxative is given; the morning of the operation an evacuating enema is administered. One quarter of an hour previous to the operation gr. morphia is given subcutaneously. (We are of course supposing that the patient is an adult.) The whole head is shaved, including the eyebrows. It is washed with soap and warm water and scrubbed

with a nail brush. The soap is rinsed off with clean water and then with alcohol. The head is then washed with permanganate of potash (a saturated solution) with a saturated solution of oxalic acid, with a solution (1 to 2000) of corrosive sublimate. Care is to be exercised that none of these strong solutions enters the eye or the external auditory meatus. The corrosive sublimate solution is washed off the scalp with boiled sterile water. The face, neck and ears are protected by a sterile towel fastened snugly about the head. The patient is in the recumbent posture. The head is placed upon a firm surface. It is often convenient to support the head upon sand bags. The parts about the patient are covered with sterile sheets and towels. All instruments, sponges of gauze, sutures and ligatures are properly sterilized. The anesthetizer prepares himself for the operation as the surgeon does. The proximity of the anesthetizer to the field of operation demands that every precaution should be taken against his infecting the wound. He should wear cap, face mask and gloves, and use clean cones for ether or chloroform. If the patient be unconscious no anesthetic will be required. Chloroform or ether will be the anesthetic employed. There is less excitement and cerebral congestion associated with chloroform anæsthesia than with that of ether.

When a wound of the scalp exists, which possibly communicates with the brain, the same preparation of the head is made excepting that the scalp wound is carefully cleansed by means of small swabs of gauze wet with boiled sterile water, gently but firmly and searchingly introduced into all accessible parts of the wound. The wound is then thoroughly douched with boiled sterile water. It is unwise to use in the wound under consideration strong antiseptics. The bone is thoroughly exposed by enlarging the wound, as may be required.

When there is no wound of the scalp a semi-lunar flap

is raised, the convexity of the flap being toward the median line. The knife cuts directly to bone. The periosteum is removed from the bone by means of a very broad elevator at the same time that the skin flap is retracted. The flap should be ample. A small flap is difficult to work under. Bleeding from the flap is instantly checked by artery pressure forceps. The whole thickness of the scalp is grasped by the pressure forceps. It is a waste of time to attempt to compress each vessel singly. The flap is well retracted by vulsellum forceps (double hooks) or in the absence of these by a suture passed through the free edge of the flap and tied long.

There is a fracture of the cranium.—It is a fissure; there is no depression about the fissure. The fissure is followed a distance to determine its direction, its involvement of important cavities-the orbit, the nose, the frontal sinuses and the ear. Continuous oozing of blood from a fissure may mean a serious intracranial lesion. A fissure due to trauma must not be confused with one of the sutures of the cranium. Ordinarily blood can be wiped away from a suture, but it cannot be wiped away from a fissure. The situation of the supposed fissure is helpful in determining its identity. If it is at all likely that dirt has entered a fissure it can best be thoroughly removed by changing the fissure into a gutter by using a small bone gouge held at a great angle with the surface of the bone.

The fracture of the cranium is depressed.-In such fractures the inner table is usually more extensively broken than the outer. The problem presented therefore is not merely how to elevate the depressed fragment or fragments, but how can the depression be relieved without further damage to the underlying sinuses, dura and brain. Necrosis forceps may readily remove loose fragments. The bone may possibly be raised by the introduction of an elevator beneath it.

In a comparatively few cases it will be found necessary to use the trephine. A trephine one inch in diameter is the best for this purpose. The trephine is applied to the sound bone near to the fracture. Two-thirds of the circle of the trephine will be upon the sound skull and the remaining one-third will be over the fractured area. Moving any of the fragments of bone while trephining is to be carefully avoided for fear of injury to the parts beneath. Upon removal of the bit of bone access is had to the parts to be elevated; this is accomplished by the elevator introduced under the fragment to pry it into place. Hemorrhage from lacerated sinuses or other vessels, which perhaps shows itself first when the depressed fragment is ever so cautiously removed, is controlled ordinarily by gauze packing. It may be wise, in order to avoid damage to deeper parts when fragments of bone are much depressed and driven underneath the intact skull, to trephine over the deeply depressed end of the fragment and thus be enabled to remove such fragment more intelligently. The area from which hemorrhage occurs will then be opened to inspection. It is best to leave only those fragments of bone in the wound that are well attached to periosteum or dura. Completely detached fragments should be removed.

Suppose another case:

There is no evident fracture, and no wound of the scalp.-Intracranial hemorrhage is suspected. The previously mentioned systematic preparation is carried out so far as is possible. The scalp flap is reflected. The 14 inch or 2 inch trephine is placed 14 inches behind the external angular process of the frontal bone and 14 inches above the zygona in order to find the anterior branch of the middle meningeal artery from which hemorrhage is suspected. As soon as a groove has been cut throughout the whole circumference of the trephine, the trephine pin (if one has been used) is removed-it has served its duty of steadying the