aSollvp t’i 11 teti to of-’ me du titoz. 
Venous-Blood Tumors 
OF THE 
VAULT OF THE CRANIUM 
COMMUNICATING WITH THE 
INTRACRANIAL VENOUS SIROULATION, 
ESPECIALLY THROUGH THE MEDIUM OF THE 
SUPERIOR LONGITUDINAL SINUS. 
By WILLIAM MASTIN, M.D., 
OF MOBILE. 
REPRINTED FROM THE ANNALS OF SURGERY, APRIL AND MAY, 1883. 
ST. LOUIS, mo.: 
Annals of Surgery. J. H. Chambers & Co., Publishers. 
1883. ANNALS OF SURGERY. 
Contents for May, 1885. 
ORIGINAL MEMOIRS 
I. Chronic Peri-uterine Abscess, and its Treatment by 
Laparotomy. 3 Illustrations C. Fenger, M.D 393 
II. On a Peculiar Form of Fibrous Tumor, which 
Tends to Multiplicity and Indefinite Growth . J. Hutchinson, F.R.S. . . . 423 
III. The Cure of some Uterine Displacements by 
Shortening the Round Ligaments. 3 Illustrations W. Alexander, M.D., F.R.C.S. 426 
IV. Venous Blood Tumors of the Vault of the Cranium 
Communicating with the Superior Longitudinal 
Sinus. Continued IV. M. Mastin, M.D. . . . 439 
V. Case of Fracture of Femur Complicated with 
Sacro-iliac Dislocation F. J. Groner, M.D 463 
VI. Co-aptation Fork for Treating Fractures of the 
Patella. 1 Illustration L. A. Stimson, M.D. . . . 464 
EDITORIAL ARTICLES. 
I. Tuberculous Surgical Affections—The Conditions 
which Predispose Bone to Tuberculosis . . . Roswell Park, M.D. . . . 466 
INDEX OF SURGICAL PROGRESS. 
Wounds—Injuries—Accidents. 
Lister: Corrosive Sublimate as a Surgical Dressing 475 
Peabody: Toxic Enteritis Caused by Corrosive Sublimate as a Surgical Application. . 475 
Varick: Hot Water in the Treatment of Open Wounds 475 
Von Wahl: The Auscultatory Symptoms of Wounded Blood-vessels, and so-called Trau- 
matic Aneurisms . . 476 
Von Duhring: Auscultatory Phenomena in Vascular Injuries, and so-called Traumatic 
Aneurisms . . 477 
Haward: Rupture of Gluteal Artery 477 
Broume: Rupture of Axillary Artery 478 
Sands: Rupture of Veins, with Case of Rupture of a Deep Femoral Vein 478 
Bull: Gunshot Wound of Intestines, Laparotomy, Suture of Intestines, Recovery . . . 479 
Tumors—Abscesses. 
Kraske: Secondary Cancerous Deposits Originating by Inoculation 481 
Monod: Cancer of the Testicle in Infants 482 
Verneuil: Cystic Tumor of the Popliteal Space 483 
Gouley: Diffuse Aneurism of External Iliac Artery ; Ligature of Primitive Iliac; Pyae- 
mia ; Death 483 
Bones—Joints—Orthopedic. 
Vincent: Experimental Inquiries into the Osteogenetic Power of the Marrow of Bones . 484 
Lobker: Exsection of Bones in their Continuity Preparatory to Secondary Suture of Ten- 
dons and Nerves 484 
Volkmann: Arthrectomy of Knee 486 
Schuller: On Bacteria in Metastatic Inflammation of Joints 486 
Giiterbock: On Hereditary Syphilitic Diseases of the Joints 488 
Bidder: Expectant and Operative Treatment of Tuberculous Joint-diseases 488 
Allen: Simple Method of Treating Fractures of the Clavicle 489 
Allen: New Method of Reducing Dislocations of the Hip 490 
Fracture with Dislocation of the Astragalus 490 
Robson: Old Ununited Fracture of Spine of Scapula—Antiseptic Suture—Cure . . . 491 
Humphry: Spontaneous Fracture of Both Thigh Bones . 491 
Lynch: Result of Treatment of Fractures of the Patella by Wire Sutures ...... 491 
Kiisiner: Epiphyseal Fracture of Diaphysis of Humerus in the New-born 492 
Kleinmann: Supracondylar Osteotomy of Femur for Genu Valgum 492 
Gibney: Surgical Management of Rhachitic Deformities of Lower Extremities . . . 492 
Judson: The Management of the Abscesses of Hip-disease 494 
Von Meyer: Controversies on Subject of Flat-foot 494 
Gynaecological. 
Fehling: The More Recent Methods of Caesarean Section 496 VENOUS-BLOOD TUMORS OF THE VAULT OF THE 
CRANIUM COMMUNICATING WITH THE INTRA- 
CRANIAL VENOUS CIRCULATION, ESPE- 
CIALLY THROUGH THE MEDIUM OF 
THE SUPERIOR LONGITUD- 
INAL SINUS. / 
By WILLIAM M. MASTIN, M. D., 
OF MOBILE. 
INJURIES and diseases of the venous division of the 
blood-carrying system of vessels are found, upon attent- 
ive examination, to occupy a much more general and conspic- 
uous position in the extensive domain of pathology than 
lesions of their better-known arterial associates; for, exclud- 
ing their very manifest physiological importance, with those 
prominent disorders of which they are the evident and well- 
attested seat, the light of modern medical and surgical science 
has clearly demonstrated that the veins are intimately con- 
nected with, or play a most active role in, numerous maladies 
which, until recently, were classed among the obscurities of 
medicine. 
Not the least in this series are infarctions, metastases, and 
many forms of pyaemia and septicaemia, in which these con- 
duits are now recognized as furnishing the principal elements 
in the formation of, and ready channels for floating along, the 
embolic masses, or disseminating the septic material through- 
out the system at large. 
Notwithstanding this late acquisition to our knowledge, it 
must be conceded that clinical investigation, together with 
anatomical1 and experimental research, have not yet accom- 
1 Breschet’s Systeme Veineux, published in 1824, although elaborate, was far from being com- 
plete—leaving marked deficiencies; and it has not been followed by any \ ery extensive inquiry 
in this direction. 
A number of excellent and important papers on the venous circulation and distribution in 
certain regions have appeared, however, from time to time in various medical periodicals, all of 
which have been valuable topographical additions to our "-nlnmitnl infnrnntinn in this depart- 
ment. 2 
WILLIAM M. MAS TIN. 
plished in a full measure for the veins, ccetcris apribus, what 
has been obtained for other structures and tissues composing 
the human frame; and, therefore, even to-day there are many 
facts relative to this portion of the circulation, around which 
still hangs the veil of doubt and speculation; and especially 
so as to the degree and character of traumatism which can be 
sustained by or inflicted upon large venous branches, trunks, 
and sinuses, compatible with the preservation of their func- 
tional integrity or the health and life of the individual affected. 
Illustrative of this is the single example of the employment 
of ligation in the treatment of vein-wounds.1 This procedure 
was viewed in former days with such disfavor (witness, as a 
few among many distinguished authors, the cautions of such 
men as Langenbeck, Lisfranc, and Pirogoff) as to be declared 
always attended by dangerous, if not fatal consequences — 
either immediate or secondary; and, indeed, so deeply and 
firmly rooted in the professional mind of these times was this, 
which may be justly designated positive superstition, that it 
became a dogma which, upheld principally by a blind adher- 
ence to traditional doctrines, is still accepted with much of 
its original delusiveness, — largely pervading, as it does, the 
teachings, and governing the practice of some of the ablest 
surgeons of this decade. 
Of all the organs and regions of the body, the veins and 
sinuses of the brain and its enveloping tunics have been, per- 
haps, the most neglected.2 
Just at this period, therefore, when a surgical revision of the 
subject of head-injuries (fractures of the skull and cerebral 
injury) seems to be peculiarly called for, and to demand an 
examination of more than ordinary care, — and even such a 
reviewing is already passing through the hands of the profes- 
sion,— any marked point connected therewith, particularly if 
1 Mention must not be omitted of the papers of Dr. S. W. Gross (Amer. Jour. Med. Set.: 18&J) 
demonstrating the safety of the deligation of veins; and especially the statistical collections 
and experiments in lateral closure of incomplete vein-wounds by Nicaise, Braun, and more 
recently Pilcher, and others; includin' the published clinical details of many cases, by both 
American and European surgeons, where lateral ligation was practised successfully in wounds 
of large veins. 
2 The latest important contributions to the cerebral veins and sinuses with which I am ac- 
quainted are the admirable papers of Heubner, Duret, Langer, and Trolard with 
the recent brochure on The Veins of the Human Brain and its Envelopes (1884), by Wm. Brown- 
ing, of Brooklyn. VENOUS BLOOD-TUMORS OF CRANIUM. 
3 
associated with the intra-cranial circulation, should be of more 
than common interest; and, in this connection, the lesion 
which forms the theme of this essay presents features doubly 
attractive, since in it are involved both of the above mentioned 
conditions. 
Before entering into a full examination of the subject, I 
shall narrate briefly the history of the case which first engaged 
my attention and directed inquiry into the literature of the 
malady, as affording an appropriate prelude and explanatory 
introduction to a general consideration of the subject. 
This case is as follows : 
On September io, 1881, I had the opportunity of examining Mr. 
W. D. Penton, a native of Florida, who visited Dr. C. H. Mastin for 
professional advice relative to a tumor of the head, of several years’ 
duration, and which had become a source of considerable annoyance 
and solicitude. 
Inquiry elicited this history: He is a man 35 years of age, laborer, 
married, and the father of several healthy children. His own health 
has always been good, and, with the exception of frequent dull head- 
aches, is still excellent. In appearance, also, he is moderately robust 
and vigorous. There is no history or evidence of hereditary disease, 
nor is he cognizant of ever having sustained a severe fall, or any blow 
or wound upon the head. When a youth, he contracted a gonorrhoea, 
and also suffered from a venereal ulcer on the glans penis; but now 
the closest questioning and examination fail to discover the slightest 
indication of systemic infection. About five years ago he chanced to 
feel a small lump, or wen-like mass, equal in bulk to a common acorn, 
on the left and posterior portion of scalp. This was painless, com- 
pressible—disappearing entirely on pressure, but partially redilating 
with the removal of the compressing force—and gave so little trouble 
as to render its discovery the result of the merest accident. 
His attention being once called to the existence of the growth, fre- 
quent handling followed, and hence he is able to assert that the tumor 
gradually enlarged, until it attained its present dimensions of a large 
chestnut, although he is equally assured it has remained in statu quo 
for the past eighteen months. As mentioned above, his only incon- 
venience is an harrassing headache, which is fleeting in character — 
coming and going—and which he thinks is connected with the tumor, 
but he is unable to trace a positive or direct association therewith. 
He is confident, however, that the condition and size of the growth is 4 
WILLIAM M. MAS TIN. 
materially influenced by a hearty meal, the recumbent and stooping 
postures with the head below the level of the remainder of the body, 
and after muscular exertion; under all of which circumstances it 
becomes full, tense, and decidedly augmented in volume. 
A careful examination, whilst sitting upright, now reveals only a 
slight fullness of the scalp in the locality indicated, which readily, 
though somewhat slowly, disappears upon lightly-made pressure by 
the fingers or hand, and leaves in its stead an indentation or depres- 
sion in the skull, occupying the upper extremity of left arm of lamdoidal 
suture. This depression is quite perceptible, and is of a triangular, 
funnel shape, being wider at margins (large enough to admit the tip 
of the index finger) and gradually narrowing down, apparently, to a 
single small aperture where it penetrates the bone and emerges into 
the cranial cavity. When the sac is evacuated by compression, the 
tegumentary covering is regular, lax, movable, and moderately thin, 
and through which the surface of the bone is felt to be smooth, and 
devoid of all perceptible inequalities or roughnesses. Reversing this 
position, and causing the patient to recline or stoop, with his head 
hanging down, a round, distinct tumor is found to rise and expand 
steadily over the site of the indentation. It is soft, elastic, conveying 
to the touch the sensation of an ordinary haematoma or blood tumor 
of the scalp, not discolored, and is easily reducible, after the emptying 
of which, the osseous depression is again perceived. Dizziness and 
vertigo result if this posture, with the head lowered, is maintained for 
a short time. Pressure causes neither pain nor the least uneasiness— 
cerebral or otherwise. There is no pulsation or bruit; no appreciable 
effect produced by the respiratory act; but I find that any interruption 
to the blood-current through the jugulars increases the tension of the 
tumor. 
The surrounding integument is unimplicated, and there is no other 
lesion of the head. There is disturbed cardiac action, but both heart 
and lungs are without organic disease. The ophthalmoscope shows 
the papilla and general fundus of both eyes to be normal, although 
the vessels of the discs are rather small and narrowed. Hearing 
normal. 
Operative interference was deemed inexpedient; and hence the con- 
stant wearing of a small leathern pad over the tumor, to afford protec- 
tion and produce even and continued pressure ; the avoidance of all 
labor and excessive exertion; and the leading of an abstemious and 
regular life, was the treatment advised. VENOUS BLOOD-TUMORS OF CRANIUM. 
5 
These notes furnish an accurate and excellent clinical pict- 
ure, and, from a symptomatological stand-point, may be re- 
garded as typically descriptive of this singular pathological 
condition. 
I. LITERATURE. 
As far as I have been enabled to extend my researches into 
the history of this interesting lesion, it appears of compara- 
tively infrequent occurrence in surgical literature, and especially 
does this observation apply to surgical treatises of recent date; 
since, among the many late works on surgery, both special and 
systematic, with the vast number of journal publications, which 
I have examined, this affection seems to have escaped the 
notice of all except Dr. Gross, who is the only author referring 
to these formations; and even this reference made by him is 
exceedingly brief, and does not embody any of his personal 
observations. He classes the affection under the head of 
venous tumors of the cranial bones.1 
I have succeeded, nevertheless, in finding some scant men- 
tion of these tumors by a few writers, chiefly French, prior to 
twenty years ago, and which, among other less distinctive 
terms, are described under the several designations of: Vari- 
cose veins or venous varicosities of the skull (Chassaignac); 
Sanguineous herniae of the vault of the skull by communication, 
through openings in the bone, of the meningeal vessels with the 
exterior integument (Dufour); Reducible sanguineous tumors of 
the vault of the cranium (Azam); and, A new form of tumor of 
the vault of the cranium, produced by the blood in communication 
with the intra-cranial venous circulation (Dupont).2 
The last of these appellations I have adopted, with some 
modification, as the most fitting title for this monograph. 
1 A System of Surgery; by Samuel D. Gross, M. D., etc. 6th ed., vol. ii, p. 28, Phila., 1882. 
2 Essai sur un nouveau genre de tumeurs de la voute du crane formee par du sang en com- 
munication avec la circulation veineuse intra-cranienne,—par Emile—Pierre—Louis Dupont. 
74 pp., 4to, Paris, 1858. 
Note.—The above is a thesis, presented, for the Doctorate of Medicine, to the Faculty of 
Medicine, Paris, April 20, 1858, and is decidedly the most elaborate paper on the subject with 
which I am acquainted, and to it I must acknowledge my indebtedness for much of the material 
contained in this essay. In this connection, also, I desire to express my obligations to Surgeon 
JohnS. Billings for courtesies extended to me in the examination of works from the National 
Medical Library, at Washington. 6 
WILLIAM M. MAS TIN. 
Furthermore, there are cases reported by Busch, Nelaton 
and Richard, Hutin, Percival Pott, Azam, Middeldorpfif, Flint, 
Baron H. Larrey, Berard (senior), and Verneuil. 
These cases, not only on account of the total absence of all 
mention, and, I may say of, apparently absolute ignorance, of 
such formations by modern surgeons, but also, the interest which 
they present individually and collectively, are deemed of suf- 
ficient importance to bear a detailed repetition; and hence I 
shall not hesitate to' incorporate a sketch of each one of them 
in this section of my subject. I shall endeavor, however, to 
abridge and condense these histories as much as is consistent 
with their proper and connected presentation, and a correct 
elucidation of the different salient and important points which 
they offer. But several of them are of more than passing 
interest by reason of the careful and elaborate post-mortem 
examinations accompanying them, and these, of course, will 
receive a more extended transcribing. 
An attentive consideration of all the cases coming under my 
observation discloses such a difference in their etiology, that 
they are naturally and conveniently separated into the follow- 
ing groups, viz.— Class I. Cases of undoubted congenital ori- 
gin ; Class II. Cases arising spontaneously, or, at least, with- 
out presenting any manifest or tangible cause; and Class III., 
in which the cases are due to direct traumatism. 
CLASS I. CASES OF UNDOUBTED CONGENITAL ORIGIN. 
(1) Case of Busch} During the accouchement of a patient, after the discharge 
of the waters (which were thick, greenish, and fetid), and whilst head was still at supe- 
rior strait, a large, fluctuating tumor was distinguished on child’s head. The child 
was still-born; male; weight 7 lbs.; skin detached and macerated, and limbs flac- 
cid, showing conclusively that death had taken place some time prior to labor. 
On the head there was a rather large, fluctuating tumor, of a bluish color, which, 
in length, extends from the external occipital protuberance to the middle of the 
sagittal suture, and, in the other direction, from the point of ossification of one 
parietal bone to the corresponding point on the opposite side, and projects the most 
in the region of the small fontanelle. All the cranial bones were very mobile, and 
that which deserves especial note, from an etiological point of view, was the absence 
1 Heidelberger klinische Annalen, t. ii., p. 249, 1826: also Pigne, Memoire sur Us Cephale- 
matomes, dans Journal hebdom., Sept , 1833, t. xii., p.480; and These de M. Chassaignac, Sur 
Us tumeurs de la Voute du Crane, p. 125, 1848. Burchard, Reck, sur le Cephalem. (Journal 
VExperience, 1838, p. 292). Dupont, op. cit., p. 15. VENOUS BLOOD-TUMORS OF CRANIUM. 
7 
of a defined and prominent hard ring around the border of the tumor.1 The tumor 
was opened by a large transverse incision, extending from right to left, which dis- 
charged a quantity of dark-colored, viscous blood, and of an offensive odor. About 
two ounces was collected. This fluid was situated between the bones of the skull 
and the pericranium, and a careful examination of the line of incision showed that 
several vessels extending across the superior longitudinal sinus had been divided, 
and that the sinus was in communication with the tumor. 
The cranial aponeurosis over the site of the small fontanelle was thick and soft,— 
being infiltrated with a gelatinous lymph,—this thickness becoming less as the bor- 
ders of the tumor were approached. This thickness, also, was easily distinguish- 
able from an ordinary tumor of the head. There was no extravasation either on 
the brain or dura mater, although the cerebral vessels were engorged with blood. 
It should be remarked that in Pigne’s account of this case 
of Busch’s the lesion is regarded of traumatic origin, being 
due to the traction and pressure of the forceps employed in 
the delivery. But this, evidently, is erroneous, for the history 
given by Busch is so clear and explicit on this point that the 
intra-uterine death of the child, several days prior to time of 
labor, is not to be questioned; and hence I must consider the 
case, with Dupont, as one of congenital formation. 
(2) Case of Flint? He found in the occipital region of an infant, several days 
old, a tumor of considerable size. He opened it. It contained venous blood, 
which flowed out in such quantities that the infant speedily perished from hemor- 
rhage. Examination showed this tumor to communicate with the longitudinal sinus. 
(3) Case of Verneuil? In 1854, a young girl, aged 17 years, of a strong consti- 
tution and good health, presented herself to me for advice concerning a tumor on 
the forehead which had existed from infancy. She had some indefinite recollection 
of a blow received in early life, but it was entirely too vague to be relied on. No 
evidence of hereditary trouble in any of the family, and the tumor is, evidently, of 
congenital origin. The symptoms are as follows: Fluctuating, soft, and round; 
painless ; ordinarily it is of the volume of a large nut when she leans forward; and 
is situated on the right frontal protuberance. The skin is unaltered in consistency 
or color, and no vascularity of the surrounding parts. Pressure causes it to sink and 
disappear entirely, and after reduction one can definitely determine that there is no 
appreciable alteration of the bone, and only a little circular ridge around it (its lim- 
iting boundaries) is perceptible. This is rather resistant. The tumor is easily 
reduced by pressure, which must be steadily applied, and by this manipulation the 
sensation of a pouch partially filled with fluid, which empties itself, is experienced. 
The tumor bulges out under the influence of exertion and emotions, but there is 
neither bruit nor pulsation; and, again, cough does not affect it. When the head is 
lowered the tumor becomes voluminous, with the dimensions of 3 cm. in diameter 
1 Note—This reference (as remarked by Dupont) is to the very noticeable osseous ring which 
is so constantly found in the blood-tumors of the new-born. 
i Pigne and Chassaignac, loc. cit. Dupont, op. citat., p. 16. 
3 Bulletins de la Societe de Chirurgie, t iv., p. 414, et suiv., quoted by Dupont, p. 22. 8 
WILLIAM M. MAS TIN. 
by i cm. deep. In the dorsal decubitus the tumor attains a very large size, but it is 
largest when she sits in the sewing position with the head inclining forward. Dur- 
ing the menstrual epochs, however, the tumor assumes, perhaps, its greatest volume, 
and at these periods she suffers from decided headache, but to this she is, at any 
rate, subject. 
Later a cure took place, or, at least, the tumor subsided after a very prolonged 
examination with repeated palpations to which she was subjected at the Surgical 
Society. 
M. Verneuil announces the favorable termination of this case with 
caution and reserve, because of his inability to verify the permanence 
ot the cure by another examination at a more remote date ; as, imme- 
diately after the subsidence of the swelling, she disappeared, and was 
not again seen, 
(4) Case of Middeldorpff.1 Matilda H , set. 9 years; daughter of a peasant 
living at Carlowitz, near Breslau; well nourished and developed. From birth there 
existed in her forehead, a little to the left of the median line, a tumor covered by the 
hairy scalp. It is round, smooth, and does not pulsate. Shortly after birth it was 
the size of a cherry, but now (1851) it presents a diameter of an inch and a half, and 
one-quarter inch thick. Offers different degrees of tension—one time it is flaccid 
and then again much distended, but there is always a little fluctuation. 
Bending the head over towards the ground, excitement, etc., causes it to swell up; 
deep inspirations make it sink slightly; it quickly and without difficulty disappears 
under continued pressure, and this does not produce the least symptom of cerebral 
compression. After reduction the base of the tumor is found to be circumscribed by 
an edge or ridge three-quarters of a line deep, denticulated, and which is felt to be 
bony by the exploring needle. The base or floor of the tumor is formed by the 
cranial vault, almost flat, and without the sensation of any opening penetrating it, 
and is covered seemingly by a thin membrane. There are no cords or filaments to 
be felt in the tumor cavity except near the skin and hair line where an ovoid car- 
tilaginous button is perceptible, which is movable and about the size of a grain of 
rice. In 1856, at my clinic, I examined this tumor a second time, but, with the 
exception of being a little larger, it presented the same symptoms; the girl, also, 
continuing in good health. Pressure upon the tumor, after encircling it with an 
ivory ring, which closely fitted its base, and pressing the ring down sufficiently to 
cut off the skin circulation, also causes it to disappear, thus demonstrating conclu- 
sively that the blood flows from the direction of the osseous base, and not from 
circumference vessels. 
M. Chassaignac2 mentions having heard Professor P. Berard (sen- 
ior) relate, during a course of lectures on Anatomy, delivered in 1831 
or 1832, the history of an infant in whom there was a varicose dilata- 
tion communicating with the superior longitudinal sinus, and which 
swelled considerably when the child cried or made any exertion. 
1 Middeldorpff reports this case in a private letter to Dupont (vide op. cit., p. *6). 
2 Loc. cit. VENOUS BLOOD-TUMORS OF CRANIUM. 
9 
This is a simple statement without any careful or decided clinical 
details, and nothing to indicate its manner or degree of communica- 
tion with the intra-cranial circulation: and hence there is an element 
of uncertainty and obscurity associated with it. 
Dupont, however, in his reference 1 to the case, accepts and classes 
it among this order of tumors. 
There seems to be no reasonable doubt about its being of congenital 
formation. 
CLASS II. CASES ARISING SPONTANEOUSLY, OR, AT LEAST, WITHOUT 
PRESENTING ANY MANIFEST OR TANGIBLE CAUSE. 
(i) Case of Baron H. Larrcy.2 Val-de-Gr&ce, Ward 29, No. 10. O (An- 
toine), musketeer of the 8th Line; aet. 23. Entered, in September, 1856, with a 
varicose frontal tumor, the base of which, almost circular, was the size of a five- 
franc piece, situated on the forehead above the left eye, partly within and partly 
below the hair. He had no recollection of ever having sustained any blow or injury 
of any kind about the head, and he had not perceived its presence until one day, at 
the age of 11 years, his mother asked him the cause of the swelling on his forehead. 
Before the army examining board he was superficially examined, accused of possess- 
ing voluntary control over the swelling, and declared fit for service, but trial showed 
that it was impossible for him to wear the shako. 
At present the tumor is found slightly elevated above the skin-level when the 
patient is reclining or even standing, but it promptly increases in size when the head 
is lowered. There are a few ill-defined, deep blue spots on its surface; it is soft to 
the touch, but gives no sensation of pulsation. When sufficiently depressed to feel 
the bone beneath, there is discovered an irregular or stellated perforation of the 
cranium, and only the shape of which prevents the easy introduction of the finger 
therein. Compression causes no pain in the tumor itself, but does produce a little 
pain with a sensation of mistiness of vision in the eye of the affected side. Slight 
symptoms of cerebral compression are also produced by pressure upon the tumor. 
The day of his admission to the hospital, after a rather prolonged examination, he 
was seized with marked vertigo accompanied by vomiting, diarrhoea, etc. He was 
declared unfit for military service, and consequently discharged. 
At a meeting of the SociSte de Chirurgie, Paris, October 1, 1856, 
Middeldorpff referred very briefly to the case of a young girl in whom 
such a tumor was situated high up in the median line of the occiput, 
and emptied into the superior longitudinal sinus. This patient was 
also mentioned by him in a personal letter to M. Dupont (Op. cit., 
p. 26), in which he stated that, unfortunately, the clinical notes of the 
case had been mislaid, and hence he was unable to give, with any 
degree of certainty, from memory alone more than an outline of the 
case, with the correct diagnosis. 
1 Op. cit., p. 16. 
2 Gazette des hopitaux ; 14 Octobre, 1856. 10 
WILLIAM M. MAS TIN. 
(2) Case of Nelaton and Richard.* B , laundress; set. 19; female; moder- 
ate stature and strength; chestnut hair; born at Signier (Mauche); admitted Sep- 
tember 22, 1856, to Vhopital des cUniques, bed 4 of women’s pavilion, during the 
time that M. Richard had charge of the service of M. N6laton, in the absence of the 
latter. 
She gave the following history: No hereditary trouble in herself or any of her 
family. Never had but one serious attack of illness, and that when 4 to 5 years of 
age, and which was, evidently, some “ sweating fever.” In 1848, when 11 years old, 
she was seized with a violent, throbbing frontal headache, which lasted the entire 
night, and depriving her of sleep. The day following the pain still present, and 
greatly augmented when she assumed the recumbent posture. In arranging her 
hair on this day she lowered her head, and in doing so discovered that there was a 
soft point on the top of her head as large as a five-franc piece. In reply to ques- 
tions her mother informed her that it had existed ever since her sickness at the age 
of from 4 to 5 years, at which time she first discovered it. Thus it is probably of 
congenital origin. She is subject to headaches which appear two or three times a 
month and last about a day, but uninfluenced by the menstrual epoch. Tumor has 
been increasing since 1853. 
Examination now presents the following characters: It is situated at the summit 
of the occipital region over the sagittal suture—at superior angle of the occipital. 
When head is erect, as in standing or sitting, tumor not visible, and no projection 
evident to the touch, but when head is carried forward or backward the tumor 
appears immediately, and is found to be globular and voluminous, with a base of 
to 7 cm. in diameter. Any exertion causes the tumor to rise and become appar- 
ent, but it again subsides when the effort ceases. Uninfluenced by cough or respira- 
tion. When prominent it is soft, fluctuating, without pulsation or bruit. Natural or 
artificial reduction not followed by any cephalic symptom. Reduction very easy, 
and presents the sensation of a pouch full of liquid which empties itself steadily and 
rapidly. Compression of the internal jugular veins, even when head is erect, causes 
the tumor to rapidly fill and rise up. Again, the head being erect, a string tied cir- 
cularly around the head, and the internal jugulars compressed, the tumor appears 
quickly and to its full size. Border of tumor smooth and nearly regular. Carefully 
practiced palpation shows two or three depressions which might permit communica- 
tion through the cranial bone, but the curvature of the skull is unaltered. Cover- 
ings normal, without oedema or infiltration. 
The inconveniences of which patient complains are the following: Vertigo, which 
is produced by stooping or any sudden or extended movements of the head. After 
each examination drowsiness followed. Only treatment to be adopted was that 
which would control the increase of the growth. October 3d, patient left the hos- 
pital. November 18th, readmitted. Now complains of tension and stiffness about 
the head, with vertigo upon each and every movement. No explanation of this in 
the tumor itself, but, as she is probably enceinte, these phenomena probably due to 
nervousness of pregnancy. Patient now lost sight of until December 10, 1857. The 
supposition of pregnancy had proven correct; and after accouchement she had an 
attack of facial erysipelas, accompanied by intense fever and delirium. Local state 
of tumor and adjacent parts modified. She had taken no precautions to arrest prog- 
ress of tumor. Vertigo and other head symptoms had continued during first two 
1 This case was presented by M. Richard to the Societe de Chirurgie, October i, 1856; and 
was afterwards examined, and fully and carefully reported by M. Dupont (vide p. 28). VENOUS BLOOD-TUMORS OF CRANIUM. 
11 
months of pregnancy, and then all symptoms of malaise, etc., had entirely disap- 
peared. 
The following changes in the tumor are noted: Increased in all diameters as 
shown by careful measurements. The surface of the bone had no longer its normal 
curvature, but presented the appearance as if a chip or splinter of bone had been 
raised up from the cranial vault, especially at the anterior border ; and this portion 
(anterior), also, appeared larger, as if a collection of osseous particles had taken 
place at this point. The rest of the border indicated no change. 
In this general osseous depression the finger easily and manifestly demonstrates 
four smaller depressions in the bone, two of which are situated in the median line, 
and one on each side of that line. The median depressions are thus disposed: The 
first median depression is circular and placed immediately behind the anterior bor- 
der of the tumor; it has a diameter of cm., and admits only the tip of the pulp 
of the finger. The second median depression is located 1 y2 cm. behind the first 
one, and has a diameter of of a cm. only. The left lateral depression is directed 
from before backward and from left to right; it has the form of a cleft of less than 
cm. in width by 1 cm. long ; its posterior extremity extends to within 1 cm. of the 
median line, and to 1 cm. behind the first depression. The right lateral depression 
is on the same level with the left one, but it is circular and is less than '/2 cm. in 
diameter. The anterior median depression has thus modified the external appear- 
ance of the tumor, which is now not regularly globular, but resembles the hilus of a 
kidney. Placing a constricting band around the head with graduated compresses in 
the temporal fossae, the head being erect, and then causing the patient to bend for- 
ward, the tumor swelled up as usual, but there were no dilated veins along its cir- 
cumference, thus excluding a skin origin; and again closing the four osseous 
passages by the finger tips, and then inclining the head forward, the tumor expanded 
with some rapidity, showing that there were other unrecognized communicating 
orifices in the bone. 
January 24, 1858. Tumor now increased in size on its left side, and an examina- 
tion shows that at this locality a smaller tumor cm. in diameter) had formed in 
connection with it. This, it was easy to distinguish, communicated with the large 
tumor. 
This case of MM. Nelaton and Richard is considered by them of 
probably congenital formation (p. ince the tumor was discovered/ 
at an early age, and the history presented no evidence of direct trg,d- 
matism. When it is remembered, however, that the mother of the 
girl affirms that the growth was not present until after the attack of 
sickness experienced when her daughter was about 4 or 5 years old,— 
and had it existed prior to this event it is more than probable the very 
locality would have revealed its presence; that the patient suffered 
from a long period of serious illness, and immediately thereafter “ a 
soft spot ” in the head was discovered; and, again, that the history is 
devoid of any direct traumatism whatever, is regarded as quite suffi- 
cient to doubt, at least, the congenital origin of the growth, and to 
warrant the place which I have given it in this group of so-called spon- 
taneous cases. 12 
WILLIAM M. MAS!IN. 
To this division also belongs the case of Dr. C. H. Mastin, which is 
described in the first pages of this article. 
CLASS III. CASES RESULTING FROM DIRECT TRAUMATISMS. 
(1) Case of Azam.1 C , age 22 ; miller; robust; entered the HSpital Saint- 
Andr6, service of M. Hirigoyen, November 11, 1850. Situated on the top of the 
frontal region, a little to the right of the median line, was a tumor of the dimen- 
sions of a large nut. This was irregularly round, manifest fluctuation, but no dis- 
coloration of the skin. Gentle pressure with the palm of the hand reduces it 
completely in two or three minutes, after which the skin remains empty and flaccid, 
and is, also, very thin and soft. Hence one can easily recognize an irregularly cir- 
cular depression across it with salient and unequal edges. The patient reduces it 
easily himself, and it disappears when the head is thrown backwards and reappears 
with the forward inclination. The forward posture can not be maintained for any 
length of time on account of vertigo which accompanies this position. No bruit or 
pulsation, but seems a little more tense during the respiratory movements. I have 
thought that I perceived an obscure blowing sound in the tract of the superior lon- 
gitudinal sinus when the tumor was rapidly reduced by the patient, but my confreres 
could not verify it. No pain in or about the tumor, and were it not for the deform- 
ity, with the vertigo whilst bending forward, he would not be inconvenienced in the 
slightest by its presence. As to its origin he reported that, at 15 years old he was 
kicked by a horse in the frontal region. Did not lose consciousness, and even con- 
tinued to follow his occupation,—it being only several days thereafter that he dis- 
covered this tumor, which has always presented its present appearance. He had 
consulted another physician some time previously, who made an exploratory punc- 
ture, which was followed by a jet of blood. This, however, was easily arrested. 
Nov. 20th. M. Hirigoyen punctured it with a lancet. As on the first occasion 
blood spirted out, having all the characters of venous blood. A probe introduced 
through the opening discovered a depression in the bone and some roughnesses, 
although the bone is not denuded but covered by a thin, soft membrane. No orifice 
of communication with the interior of the skull is discoverable, but this communica- 
tion must exist, as the large quantity of hemorrhage could have originated only from 
some considerable source—probably the superior longitudinal sinus. Hemorrhage 
was easily controlled, and skin wound healed rapidly under simple protection by a 
bandage. Pressure over the tumor was employed for twenty days without result, and 
patient left the hospital in an unchanged condition. 
C was presented to the Society of Medicine November 27, 1854, by our col- 
league Dr. Dupuy ; and I saw him yet again three years afterwards, still finding the 
tumor unchanged. 
The avoidance of any operation and the use of local pressure was advised. 
(2) Case of Azam.2 Jeanne T , of the Bourg-sur-Gironde, age 60 years, 
consulted the “ charity committee ” of the Medical Society of Bordeaux in March, 
1854, about a tumor situated in the frontal region. She stated that about eighteen 
months previously, whilst at work in the field, she stepped upon a rake, which flying 
up, the end of the handle struck her with considerable force on the forehead. The 
1 Dupont, op. cit., p. 20; also Gazette Medicate, p. 411, 1854 ; L’Union Medicate, 1858, p. 49 ; 
and Gazette des hopitaux, 14 Janvier, 1858. 
2 Loc. cit. VENOUS BLOOD-TUMORS OF CRANIUM. 
13 
pain was intense, but she did not lose consciousness. The apparent contusion was 
relieved by ordinary measures without the attention of a physician. Twenty to- 
twenty-five days afterwards she recognized the existence of a tumor at the point of 
contusion. This was soft, of the size of a small nut, and hardened and increased in 
volume when she lowered her head. No headache. Light pressure caused the dis- 
appearance of the swelling. Experiencing no pain, she did not consult a physician 
until after three months had elapsed, at which time the skin covering the tumor 
becoming thinned and of a violet color, she consulted M. Gaignerat, of Bourg, who 
punctured it; and, according to her statement, it bled most profusely. However, a 
bit of English taffeta sufficed to staunch it. She presented herself now at the 
Medical Society. At this time the tumor, situated on the median (frontal) line, near 
the root of the hair, was about the size of the half of an ordinary nut; soft and 
fluctuating; slightly violaceous in color; without either pulsation or bruit; and con- 
veying to the fingers the sensation of a pouch (the skin) containing a spongy 
substance. It becomes tense when the head is bowed down or lowered, and a 
continuance of this position causes dizziness It softens and slowly diminishes 
under pressure by the hand or fingers. It is very evident that the fluid passes into 
the skull. After reduction of the tumor there remains under the skin a soft tissue 
which prevents any close examination of the underlying bone. Taking her to my 
office for a closer and more careful examination, and making her bend her head 
forward so as to render the tumor tense, I punctured it with a small trocar. Only a 
small quantity of venous blood escaped. Manipulating the canula in different direc- 
tions, I recognized that the tumor was formed not of a single pouch, but of a spongy 
tissue composed of large cells. This explained the slowness with which the fluid 
trickled out, and which, also, evidently passed through a narrow passage in the bone- 
into the skull cavity. I could not discover this opening, not did I recognize any~ 
rugosities or denudation of the bone. 
(3) Case of Percivall Pott! A boy, eight years of age, son of a Jew merchant,, 
of this city, received a blow on his head with a stick. This made him giddy for a 
few minutes, but there was no bleeding, no external wound, and but little pain, and 
he concealed the fact of there being a swelling over that portion of his head until it 
was discovered by his barber. In the middle of the top of his head was a tumor,, 
about the size of a walnut; was indolent, had a dull kind of pulsation, and palpably 
contained fluid. In the presence of Serjeant Amyand and Mr. Shipton the tumor 
was divided with a knife, and a quantity of blood discharged ; but when the swell- 
ing was emptied it was found that the blood continued to flow, plainly not from the 
scalp wound, but from the bottom of the cavity. Examination now showed that 
the sagittal suture was fractured, and that a portion of the displaced fragment of 
bone was forced into the sinus, and by the sides of which the blood issued forth.. 
Attempts to extract this fragment failed. By the advice of the consultants, a small 
perforation was made on one side of the suture, but through this the point of the 
elevator could not be introduced so as to remove the broken piece, and so the tre- 
phine was applied on the other side of the suture, but with a like result. At last it 
was decided to risk the hazard of wounding the sinus (which was, indeed, already 
wounded by the broken bone), and enclose the suture within the circle of the 
trephine. This was done, but the button of bone came away in pieces, and left the 
original perforating fragment still piercing the sinus. This fragment being with- 
1 Chirurgical Works, first Amer. from last London ed., vol. i., p. 132; Philii., 1819: also- 
French edition, t. i., p. 151; Obs. 27, 1760: also Dupont, op. cit., p. 14. 14 
WILLIAM M. MAS TIN. 
drawn by means of forceps, a flux of blood followed, but a dossil of dry lint con- 
trolled it. The patient recovered.1 
(4) Case of Hutin (occurring in the service of M. Hutin, at I'hdpital ties Inva- 
lides.) Reported by Dr. Gustave Dufour.'1 
Achille Maximilien, Marquis de W , Comte d’l , born 1770, at Paris ; 
entered infantry service in 1792. In 1799, in charging a redoubt in the Piedmont, he 
received a blow from the butt end of a musket, in the hands of an Austrian, on right 
side of forehead about 3 cm. from median line. Stunned by the stroke, he was car- 
ried from the battle field, and remained unconscious for twenty-four hours. When 
he regained his senses perfectly, he was informed by the surgeon in attendance that 
there was a fracture of the skull, and the lesion was very grave. There was no 
wound of the integument, but a deep depression under the skin was quite perceptible 
to the touch. During almost the entire period of the next year he was an inmate of 
different hospitals, and received divers forms of treatment, especially pressure to the 
seat of injury. I he ultimate result of the wound was an infirmity which incapaci- 
tated him from following the profession of arms. When he leaned forward with the 
head inclined towards the ground, he would feel a swelling form on the site of the 
wound, having the volume of a nut, of a violet color, and which would disappear 
spontaneously when he again assumed the upright position. In 1814 he gained 
admission to the Hdpital des Invalides, and in 1847 M. Hutin, then becoming sur- 
geon in chief, was peculiarly interested in his case; and ordering his history care- 
fully recorded, he himself made the following notes: “Cicatrix not apparent; 
osseous depression very marked. The condition is, doubtless, the result of absorp- 
tion of the diploe and the approximation of the two tables of the frontal bone. The 
pouch is small, formed at the expense of the skin, and is not apparent when the 
soldier is standing, sitting, or reclining on his back; but when he bends forward 
with the head lowered, the pouch makes its appearance and attains the volume of 
half an egg. It is livid in color; is formed, evidently, as are cysts in contused 
parts; and is dependent on a communication with the superior longitudinal or some 
other sinus.” 
1 Note.—Very similar to this case of Pott are the following: 
A drag#on, receiving a wound of the trunk, fell from' hir horse, striking the summit of his 
l ead. He soon became cqmatose, and, when examined, a swelling of the scalp was discovered 
at the vertex, the point of injury. This being incised, a separation of the edges of the sagittal 
suture was discovered, and from which blood was seen to flow. Two buttons of bone were 
removed by the trephine on the twelfth day, to permit the ready exit of blood effused from a tear 
in the wall of the superior longitudinal sinus. The symptoms now rapidly subsided, and recov- 
ery followed (Vide Guthrie, Commentaries on Surgery, etc., p. 349, Amer. ed. : Internat. En- 
cyclopedia 0/Surgery, Ashhurst, art. “ Injuries of blood-vessels,” vol. iii., p. 208, 1883.) 
A parallel case is one mentioned by M. Mouton {Memoirs of the Royal Acad. Surgery of 
France, Sydenham Soc. Transactions, p. 8; also Internat. Encyclopedia of Surgery, Ashhurst, 
art. “ Injuries of blood-vessels,” vol. iii., p. 208, 1883), where trephining was practiced on a 
man, eleven days after a fall, in whom death was imminent from blood-extravasation coming 
from the superior longitudinal sinus, wounded by a separation of the edges of the sagittal suture. 
This operation furnished free vent, resulting in immediate cessation of the threatening symp- 
toms. 
Had it not been for symptoms of compression demanding speedy operative interference, these 
cases would have resulted, undoubtedly, in the variety of venous tumor which is the subject of 
this paper. 
2 G. Dufour, Comptes rendus el Memoires de la Societe de biologie, t. iii., p. 155 ; 1851 ; Du- 
> t t, Op. cit., p. 10. VENOUS BLOOD-TUMORS OF CRANIUM. 
15 
I learned that this old man, notwithstanding his age of 81 years, was in perfect 
mental and physical health, with the lull possession of all his senses and 
and of a lively disposition. He did not wear the silver plate which had been given 
him to protect the injured region, and easily and readily reduced this singular variety 
of hernia with his own hand. 
October 28th, 1851. Seized with erysipelas of neck and upper part of thorax, 
complicated with chronic bronchitis, and died November 3d. 
Necropsy, November 5th, thirty-six hours after death. Thorax—Double pleural 
adhesions, but no organic pulmonary disease. Heart hypertrophied, but otherwise 
normal. Aorta infiltrated with cartilaginous patches, appreciably dilated, and filled 
by an enormous fibrinous clot, which also extends into the carotids. Head—No 
visible traces of the erysipelatous action. Normal in size and contour. On the fore- 
head, 2 cm. below hair margin, and to right of median line, is seen a cutaneous 
space about 2 cm. in diameter, which is rendered distinct from surrounding skin by 
its rosy color ; and this corresponds to a clearly outlined osseous depression beneath. 
Lowering the head of the cadaver fails to produce the phenomenon which was so 
easily brought about during life in that part of the skull. Brain—Sound and with- 
out traces of old or recent apoplectic spots ; white and gray substances distinct; the 
vascular network of the pia mater is moderately injected, but without infiltration, 
and is easily separated and detached from the cerebral convolutions—even directly 
under the external wound. The visceral layer of the arachnoid, however, on the 
right side, 3 cm. from the middle line, is glued down to its parietal layer and also 
adherent to the dura mater, and any traction exerted upon these adhesions causes a 
few drops of blood to ooze out into its (arachnoid) cavity. The dura mater is, also, 
easily separated from the entire surface of the bone except at this locality of 3 cm. 
from the median line, where it is adherent to the osseous wall. Opposite to this 
attachment, the bone is perforated by several small openings. Injection of water 
and insufflation of air into the superior longitudinal sinus demonstrates the exist- 
ence of a pathological communication (through the bone) of the sinus with the 
blood pouch above. The caliber of the superior longitudinal sinus somewhat 
increased, and filled by a long, reddish, fibrinous clot. Skin over tumor thinned, 
and sends out from its inner fibro-muscular surface attenuated fibrinous prolonga- 
tions (trabicules, filaments, etc.) which attach themselves circularly to the periosteum 
on the circumference of the bone depression; and which depression is lined by a bit 
of cellular periosteum, and is 5 cm. in breadth by 2]/2 cm. in height. The circum- 
ference of the depression is formed by a notable thickness of compact bone tissue, 
•but its center is very thin and spongy. The floor of the depression is also divided, 
by a jutting out of compact structure, into two smaller depressions: the left one 
extends a little beyond the middle line of the forehead, is rugose, and is sprinkled 
with little dark openings ; the other on the right side is more extensive, and is rid- 
dled with minute apertures—entirely deprived of its vascular element (diploe), and 
corresponds to the thinnest portion of the cutaneous cavity, at which point both the 
skin and bone are translucent, so to speak. The frontal suture plainly seen above 
and below the osseous lesion, but especially apparent on the altered surface. Fin- 
ally, the tegumentary covering was thinned, being deprived of all muscular and 
adipose tissue, and composed only of skin re-enforced by a delicate lining of fibrous 
tissue. 
(5) Case of Hntin.1 K , born in 1771; entered military service in 1790; 
received, October 14, 1806, at the battle of Jena, two saber wounds on the head,— 
1 Memoires de Medecine Militaire, t. xiv., p. 232, 2e serie ; 1854. Dupont, p. 17. 16 
WILLIAM M. MASTIN. 
the first on superior and middle of forehead, the second on the top of the head. 
Did not lose consciousness; fragments of bone extracted; recovery after about 9 or 
10 months, without any grave symptoms. Forty years passed without his being 
troubled by any serious sickness, only he suffered from severe headaches. In March, 
1846, whilst intoxicated, he fell into a bed of rocks, fracturing thigh and ribs. A 
pleuro-pneumonia was not tardy in developing; and in ten days thereafter he was 
also attacked with erysipelas, which was epidemic in the wards. Delirium; parotid 
abscess. 
March 24th. Carries hand frequently towards summit of head to the right side of 
the most prominent cicatrix. Pressure here discloses circumscribed fluctuation and 
pain, which did not exist previously. Believing the existence of an abscess, a small 
incision was made into it, but only blood escaped. There was a blood pouch con- 
taining a black, semi-coagulable liquid, poured out between the osseous vault and 
the pericranium, thus detaching the latter. Attempts to detect a fissure failed. The 
day following the dressings were soaked with about 150 grammes of blood. At- 
tempts to find a fissure still futile. Extended the incision, which brought to view a 
slowT, continuous oozing of venous blood from the depths of the bony wall, and to 
the inner side of the wound. This was without pulsation, and uninfluenced by 
the respiration. A delicate blunt probe pressed upon this point readily passed on 
into the skull through a small opening which was covered over to about three-quar- 
ters of its extent by the soft tissues. Dry charpie and a bandage arrested the hemor- 
rhage. Dressing removed third day. Pleuro-pneumonia proved fatal April 7th. 
Autopsy. Head—Scalp puffed up and much injected from erysipelatous inflam- 
mation. Cicatrix on frontal bone adherent to the remains of the frontal suture, with 
marked depression of integuments in this locality. At 2 cm. beyond the fronto- 
parietal suture and within cm. of the sagittal, commences the other adhesions 
belonging to the anterior region of the second cicatrix, and which are equally resist- 
ing but of limited extent. None of these adhesions were touched by the knife until 
after the skull was opened. Below these is the pouch which was incised during life. 
This pouch (subpericranial) is about 4 cm. in extent from before backwards and 
2 cm. from right to left. The skull cap being sawn through, the membranes divided, 
and the brain raised, all was normal except a trivial injection of the arachnoid, one 
or two points in the brain, and a small quantity of serum in the ventricles. Dura 
easily detached over almost the entire vault, except at point corresponding to wound 
of vertex, and on each side of the closed sagittal suture, where it adhered closely to 
parieties, but without any visible scar. At a point corresponding to the external 
angle of wound dura mater intimately united with external tissues through a fissure 
of right parietal bone. The unclosed opening of the bone was about 2 mm. in 
width by 1 cm. long. On opening the superior longitudinal sinus it was seen to 
contain a small quantity of coagulated blood, which was partially dislodged by a 
stream of water,—after which was visible a very pronounced projection in the sinus, 
passing in a line from behind forward and from right to left; and corresponding 
exactly to the external cicatrix. This projection proceeded from the depression of a 
thick splinter of bone depending from the internal osseous table, and was produced 
evidently by the saber blow,—being partially detached and thus remaining fixed for 
many years. This spicula terminated in a spine which had perforated the longitud- 
inal sinus, and passing through into its lumen maintained patulous an opening into 
its wall of 4 mm. Through this opening a small quantity of blood had escaped 
from the sinps, and which, poured out between the bone and the dura, formed in this 
locality an oblong pouch of 3x2 cm. in diameter; but on the outside of the skull it 
had diffused itself between the bone (right parietal) and the periosteum, forming the VENOUS BLOOD-TUMORS OF CRANIUM. 
17 
collection which had been mistaken and opened for an abscess. This external effu- 
sion had passed through an opening existing in the left parietal, \ l/2 cm. in front of 
and to the right of the sharp end of the fragment, and resulting from the non-occlu- 
sion of that part of the bone divided by the saber blow. The extravasated blood 
between the dura mater and the skull was coagulated, and sent out a fibrinous clot 
into the open wound in the wall of the sinus. Another clot completely filled the 
osseous wound. Hence there was a direct communication between the superior 
longitudinal sinus and the wound in the integuments, for in this fracture there were 
no adhesions between the meninges and the pericranium as existed through the 
anterior fracture. By raising up the superior longitudinal sinus the perforated por- 
tion was displaced, and is thus seen to be a little to the right of the median line. 
II. ETIOLOGY. 
II. ETIOLOGY. 
In the etiological study of these venous formations are 
encountered marked difficulties and drawbacks; for, indeed, 
such obscurity surrounds this portion of the subject that, exclud- 
ing those cases resulting from direct traumatism, any examina- 
tion can be conducted alone upon an absolutely theoretical 
basis. 
I. In the grouping which, for apparent etiological reasons, 
I have found expedient to adopt, Class /, or Cases of congenital 
origin, comprises five examples (including the brief and unsat- 
isfactory one of Berard), and in two only (Busch’s and Flint’s) 
are there the slightest data to indicate, even approximately, 
the manner of inter-communication existing between the 
growth and the sinus. 
Therefore, with this exceedingly limited knowledge of their 
anatomical characters, nothing can be stated with positiveness 
“as to the cause or method of their formation, and the following 
theories, some of which have been advanced already, are only 
now proposed as being in the line of probabilities. 
(a) Of these hypotheses the most specious seems to be that 
of the absorptive action of the glandules Pacchioni upon the 
walls of the sinus and the cranial parietes. Dr. Gross (with 
others) asserts that, “ the most common cause of the abnormal 
communication is spontaneous, progressive absorption of the 
osseous tissue corresponding with the Pacchionian depressions, 
when, under the influence of slight traumatism, the bood es-/ 
capes beneath the pericranium.2 ” * * * A * ' 
1 Continued from p. 340. 
2 Loc. cit. 18 
WILLIAM M. MAS TIN. 
This assumption is strengthened when we consider the num- 
bers of these granulations or glands within the cavity of the 
longitudinal sinus and upon the dura mater in its vicinity (not- 
withstanding that their microscopical presence in infancy is 
denied by many physiologists), and the activity of all cell pro- 
liferation, especially in glandular structures, and under morbid 
influences, in early life. But in congenital cases it seems to 
be essential that the absorptive action which these bodies are 
supposed to produce be carried on to complete perforation, 
without the requisite agency of slight external traumatism, to 
effect the escape of blood from the sinus. 
In further support of these views I may refer to those ob- 
scure alterations and perforations occasionally met with in the 
petrous portion of the temporal bone, sometimes opening the 
tympanic cavity, which, according to Luschka, like the fova 
glandulares of the calvarium, are not improbably the result of 
pressure exerted by these villous-like vegetations. 
(b) Secondly, the aneurismal dilatation of a vein passing 
from the longitudinal sinus through the bone—many of which 
veins pierce the skull on each side of the tract of, and commu- 
nicate with, this canal,—suggests itself in this relation, and to 
which the case of Flint might be regarded as having some 
slight resemblance. But opposed to this, and, indeed, to any 
form of venous varix, is the extreme, if not absolute, rarity of 
of such a venous aneurism in this region, not to mention the 
absence of all aneurismal symptoms of a decided character. 
This method of communication, however, is maintained by 
Dupont to exist in some instances. 
(c) Certain constitutional or hereditary diseases should not 
be overlooked as very possible etiological factors. 
Hereditary syphilis or the rickety diathesis occasionally 
finds expression in the production of craniotabes, where areas 
or spots of softened and thinned osseous structure take place 
in the cranial walls, only requiring some slight internal or ex- 
ternal pressure to convert them into veritable skull perfora- 
tions. Although this condition is but seldom observed 
congenitally, occurring principally in syphilitic infants during 
the first year subsequent to birth, yet it is worthy of 
note that this sometimes does happen ; that the inner cranial VENOUS BLOOD-TUMORS OF CRANIUM. 
19 
aspect is usually the primary seat of attack; and that they are 
generally observed occupying the posterior parts of the 
parietal bones—about the position where the venous tumor 
under consideration is, perhaps, most frequent; and, too, in 
which neighborhood the Pacchionian bodies most abound. 
Parallel with this observation the so-called gelatiniform 
degeneration of the outer table of the skull (Parrot) must be 
referred to, as offering points for consideration in this study. 
How far the mere absorptive power of the Pacchionian glands 
alone, or stimulated by or associated with a systemic vice as 
above mentioned, or any of these individually, may act, is a 
question needing for its answer careful and painstaking 
research. 
(d) Finally, developmental arrests (of which the case of 
Busch is, at least, suggestive), including, also, absence of ossi- 
fication in the triquetral or Wormian bones, and abnormal 
fontanelles, must not be ignored in following out this inquiry. 
Against the latter, however, in those instances where the 
growth is situated centrally and anteriorly on the head, may be 
urged their extreme infrequence in the median part of the 
cranial vault; and here it may be remarked that in the congen- 
ital cases the tumor occurred equally in the frontal and occip- 
ital regions. 
II. An examination of the etiology of Class II., or Spon- 
taneous Cases, is met by equal if not greater obstacles than 
those characterizing the investigation of the first class, since in 
the present instance there are only the symptoms of the dis- 
order, and these largely subjective, which are available in 
furnishing any information whatever relative thereto,—again 
necessitating, of course, a resort to the uncertainty of specula- 
tion. 
These probable causes comprehend, in the main, those 
applicable to the congenital group, and have received already 
a sufficiently detailed notice. Therefore, beyond a simple enu- 
meration of them in the order of their greatest applicability or 
most probable tenableness, further reference is deemed un- 
necessary. 
Here again the most plausible theory, and the one deserving 
of first mention, is that of (a) the absorptive action of the 20 
WILLIAM M. MAS TIN. 
Pacchionian glands exerted upon the osseous tables ; and, for 
obvious reasons, is decidedly more applicable to the cases of 
spontaneous origin than to the congenital form of the disease. 
In this division is readily understood how slight traumatism 
can occur, which is considered essential to complete the break- 
ing through of those thinned points produced by the localized 
action of these glands; and here, also, can be found the asso- 
ciation of a certain degree of age and growth which anatomy 
has demonstrated to be favorable, at least, to the development 
of these bodies,—conditions non-existent prior to birth. 
(b) Coming next is the explanation proposed by M. Dufour.1 
He believed the abnormal communication was caused by an 
obscure form of osteitis, followed by interstitial resorption of 
bone, the probable consequence of a trivial contusion.2 Such 
an inflammatory process, however, to my mind, presupposes the 
presence of some constitutional taint which renders the osseous 
tissue peculiarly susceptible to the taking on or lighting up of 
this process upon the reception of the contusing force. 
(c) Aneurismal dilatation of a vein passing through the bone 
into the sinus. The same objections hold good here as in the 
congenital variety. 
(d) Localized diseased processes in the structure of the sinus 
itself, as in phlebectasia, or in phlebitis, followed by osseous 
absorption. But the absence of abundant and marked fibrous 
elements in the formation of the tumor, or phlebectasiac walls, 
are arrayed in opposition to such action. 
(e) Lastly, constitutional or systemic vices—more especially 
syphilitic or strumous—as manifested in those osseous changes 
already referred to. In this category should be included any 
systemic condition predisposing to bone alterations or degener- 
ations in general. And just here it must be remembered that, 
in the case of MM. Nelaton and Richard (case 2) the growth 
was not discovered until after a severe illness of the patient at 
the age of about five years. 
1 Loc-Citat. 
2 Note.—This theory might be regarded, at first glance, as pertaining to the trau- 
matic class, since slight traumatism in the form of a contusion is one of its essential 
elements. But whereas the traumatic group is composed of those cases only which 
are produced by severe and direct injury—in a word fracture of the skull,—it is seen 
that this really belongs to the division (spontaneous) to which I have assigned it. VENOUS BLOOD-TUMORS OF CRANIUM, 
21 
III. The same obscurity and difficulty, however, does not 
obtain of the traumatic cases, Class III., as of the two preced- 
ing groups, for in this are included only those instances where 
the lesion is directly traceable to some wound or blow applied 
immediately to the cranial vault. Traumatism, therefore, oc- 
cupies here a position so clear and well-defined in the relation 
of cause, that it becomes at once apparent without any dubious 
or speculative inquiry. 
There are several points, nevertheless, that should be brought 
into more prominent notice than the mere detail of the clinical 
histories have permitted, and to which, in this place, a brief 
reference, at least, is desirable. 
These points are the positive pathological characters fur- 
nished by the elaborate post mortem examinations accompany- 
ing two of the cases, and by the operative surgical measures 
adopted in another, together with the nature of the injury and 
the instrument or method by which the wound or blow was 
inflicted. 
Respecting the distinctive features of the injury I may as 
sert that, in each and every instance it was a severe one—a 
fracturing force—resulting in fracture of that portion of the 
skull receiving it. 
But among the five examples composing this class it is especial- 
ly interesting to note that four were characterized by the absence 
of all integumentary wound—being purely subcutaneous—and 
in one only (Hutin’s case) was the fracture open or compound.1 
In one of Azam’s cases, a boy, the tumor resulted from a 
kick of a horse, and appeared a few days thereafter, showing 
that the sinus must have been extensively wounded—probably 
a sharp fragment of bone puncturing or lacerating it,—as the 
time intervening between the injury and the appearance of the 
pouch was too short for absorptive changes to have effected 
any material alteration of the opening; whilst in his other the 
blow was produced by a heavy rake handle, but the swelling 
1Note.—Punctured and other compound fractures of the skull not infrequently re- 
sult in wounding of the underlying sinus, and, in illustration of this, numerous in- 
stances of such an injury have been reported, notably among which are the cases of 
Gagniere, Lassus, Hennen, and others. 
This class of injury, however, does not come within the limit of the present dis- 
cussion. 22 
WILLIAM M. MAS TIN. 
did not manifest itself until after the lapse of about twenty-five 
days. 
Here the tumor was tardy in visible development, and cer- 
tain osseous alterations may have modified the orifice between 
the skull and the sinus as originally produced by the trauma- 
tism. 
Neither of these afforded a necropsy. 
The lesion in Pott’s case was caused by a forcible lick with a 
stick, and which was followed by its immediate appearance. 
Being mistaken for an abscess by that distinguished surgeon, it 
was freely incised; but, when fracture was revealed, he tre- 
phined the skull over the sagittal suture, finding a splinter of 
displaced bone directly piercing the sinus. 
One case of Hutin, was in the person of a soldier, who re- 
ceived a crushing blow dealt with the butt-end of a musket, 
producing skull fracture. A post mortem examination fifty- 
two years subsequently verified the presence of fracture, with 
an opening in the superior longitudinal sinus; but there existed, 
in addition, necessarily, certain osseous changes resulting from 
the length of time of the existence of this abnormal commu- 
nication. In his second patient the lesion was caused by a 
sabre stroke, producing a compound comminuted fracture of 
the cranial vault, with removal of loose bone fragments. 
Forty years afterwards death resulting from a pneumonia 
coming on after a fall, an autopsy disclosed a long fragment of 
bone perforating the wall of the sinus, and thus placing this 
canal in communication with the external blood-pouch. 
Thus the information gained from these cases, and particu- 
larly that obtained from the autopsic examinations, is sufficient 
to render safe the assertion that, in all traumatic cases fracture 
is invariably present, and in which the wall of the sinus is 
directly wounded either by (i) a depressed fragment or frag- 
ments of bone, (2) lacerated by the separated edges of the frac- 
tured bone, especially if the line of fracture passes across the 
suture, to which .the sinus is intimately attached, or (3) torn 
through by a disunion of the suture over the sinus,—particu- 
larly the sagittal suture.1 
1 of wounding of the sinuses of the dura mater by separation of VENOUS BLOOD-TUMORS OF CRANIUM. 
23 
III. MORBID ANATOMY. 
The classification of this lesion into the congenital, sponta- 
neous, and traumatic forms, is as essential in the study of its 
pathological anatomy as in the etiological division of the sub- 
ject ; but, our knowledge of the anatomical characters being 
derived almost exclusively from one class, it follows, necessa- 
rily, that we can speak definitely of that one group alone, leav- 
ing the others to be dealt with conjecturally or from an a pri- 
ori stand point. 
As previously remarked, all the direct light thrown upon the 
pathology comes from examinations conducted in three trau- 
matic cases, with scant and equivocal information supplied by 
two congenital instances, without a single gleam from the 
spontaneous group; and, therefore, all conclusions as to the 
morbid anatomy of this affection are based, almost solely, upon 
those cases which are due to trauma. 
The points of especial interest in this study, and which com- 
prise those of most importance, are, (1) the general character 
of the tumor; (2) the relationship of the tumor to adjacent 
parts, including the nature of the tissues limiting or bounding 
it; (3) the tumor contents; and (4)the connecting passage be- 
tween the cavity of the tumor and the sinus within the cra- 
nium. 
These I will examine separately, bearing in mind, at the 
same time, their association with each of the several groups 
individually. 
1.. The general character of the tumor. This tumor may be 
described briefly as an indolent swelling in the form of a pouch, 
external to the skull, composed of one or more cavities, con- 
taining vehous blood, and in communication, through the bone, 
with the cerebral venous circulation. 
In the congenital class the pouch was shown, by post mortem 
examination, to be single in two cases ; apd in the remaining 
two this same arrangement of its cavity was also pretty well 
the edges of a suture, especially the superior longitudinal by disunion of the sagittal 
suture, have been recorded. 
Among others I may refer to the cases of Guthrie and M. Mouton, which have 
been mentioned already. (Vide note, p. 14.) 24 
WILLIAM M. MAS7IN. 
assured by the sensation conveyed to the touch upon careful 
manipulation, both before and after its artificial reduction. 
Palpation with other physical conditions indicated very 
probably the existence of the single pouch or cavity in all of 
the spontaneous cases; although in the patient of MM. Nela- 
ton and Richard, the morbid action evinced a tendency to the 
production of multiple growths, for a second, distinct, tumor 
appeared near, and in communication with, the first or original 
one, alter the expiration of several years. Both these primary 
and secondary formations, however, were evidently of the sin- 
gle cavity variety. 
The only case of more than one or several cavities compos- 
ing the pouch was in one of the traumatic group, where the 
tumor was arranged, apparently, into cells or partitioned cavi- 
ties communicating with each other. This cellular character was 
demonstrated by both palpation and puncture with a trocar, 
combined with gentle exploration by means of a small blunt 
probe or stylet. 
Manipulation demonstrated a single pouch in another of this 
class, whilst the remaining three were found upon operative 
and autopsic examination to consist, also, of but one sac. 
Therefore, I may say, the single cavity is the most frequent, if 
not characteristic of this venous tumor. 
In every instance the tumor was external to the bone, except 
in one case (traumatic) where it was partly within and partly 
without the skull. And, again, all the examinations disclosed 
the presence of venous blood filling the tumor cavity, and 
which was in communication, either directly or indirectly, with 
the sinus. Upon these can be based substantially the opinion 
that such are the essential physical characters of the growth. 
These characters will be the subject of separate and more 
extensive inquiry as#we proceed in the consideration of the 
affection, 
II. The relationship of the tumor to adjacent parts, including 
the nature of the tissues limiting or bounding it. Taking the 
coverings of the cranium in their order from without inwards, 
I find the anatomical location of this tumor may be (a) between 
the integument and the cranial aponeurosis; (6) between the 
fibro-muscular layer (aponeurosis) of the scalp and the peri- VENOUS BLOOD-TUMORS OF CRANIUM. 
25 
cranium; (c) between the pericranium and the bone; (d) be- 
tween the pericranium and the bone, and extending internally 
between the skull and the dura mater. 
(a) Although not determined by actual dissection, the seac of 
the tumor between the skin and the epicranial aponeurosis is, 
at least, probable. Clinical observations alone, however, are 
inadequate to decide this exact seat, because the appearance 
and sensation of the pouch is not an index to the composition 
of its coverings, since both the skin and aponeurosis might be 
so extremely thinned or attenuated as to present to the touch 
the sensation of only integumentary thickness, and accompa- 
nied by a violet color as if the contained blood was imme- 
diately beneath the skin. 
I am unable to point out any conditions which would render 
this position or relationship of the tumor more prevalent in 
one class than in another, unless it be in certain instances 
where all the tissues of the scalp were originally torn through 
to the skin; or in those cases where absorptive action is 
especially prominent as an etiological factor, and in long stand- 
ing cases with a disposition to rapid tissue change, hastened, 
perhaps, by increased blood-pressure. 
(b) Probably, as it appears, the most frequent seat of this 
venous formation is its location between the aponeurotic layer 
of the scalp and the pericranium. This position was indicated, 
macroscopically, by two traumatic instances (cases of Hutin 
and Pott), and by puncture and exploration practiced in two 
others (cases of Azam); and is, doubtless, most often met with 
in cases of this class, as well as in those of all the groups. 
The congenital and spontaneous classes, although lacking the 
proof of direct examination, and even the uncertain evidence 
furnished by puncture and exploration of the interior of the 
sac, are, very probably, to a large extent, so situated ; and 
especially in their early stages, and where the growth is small 
and does not manifest a decided or rapid tendency to increase. 
(c) The situation of the tumor between the pericranium and 
the bone, and again (d) between the pericranium and the bone 
and extending internally between the skull and the dura mater, 
may be regarded as exceptional locations ; not only on account 
of there being but single examples of each of these among the 26 
WILLIAM M. MAS TIN. 
present collection of cases, but also from the 4 fact that the 
weight of probability, furnished by the general study of these 
formations, together with anatomical testimony, is against such 
relationships or positions. Furthermore, the etiological condi- 
tions of the two instances are diametrically opposed to each 
other—one being congenital and the other traumatic of long 
standing. In recent instances of traumatic origin, however, 
where comminution of the cranial tables has been produced, 
both the pericranium and the dura mater may be detached to 
a more or less extent from their bony attachments; and then 
one might expect to find the pericranium unglued or floated 
up by the blood, which had insinuated itself between the 
osseous tissue and this membrane, thus forming one of the 
layers of the tumor-wall, and even in connection with a second 
blood-pouch occupying a seat between the dura and the skull, 
although these seeming requisites of bone comminution and 
pericranial separation are not furnished by the histories of the 
above noted cases representing these locations. Should the 
coats of the sinus itself become dilated (phlebectasia) and pro- 
trude as a hernia through the osseous opening,—which might 
possibly occur where there was loss of bone substance without 
direct injury to the sinus; or again, if the tumor was of aneu- 
rismal production, as has been suggested, then, of course, there 
would exist a decided modification in the formation of the 
tumor; and, under such circumstances, naturally, the walls of 
the dilated sinus or aneurismal vein would be superadded to 
the constituents already enumerated as entering into the com- 
position of the tumor coverings. 
Each and all of these tunics forming the walls of the tumor 
may be normal in texture and in relationship to each other, or 
considerably modified or changed by diseased or natural 
processes,—even differing according to the age of the indi- 
vidual affected,— as is exemplified in several of the cases. 
Again this morbid or alterative action is not limited to the soft 
structures, but occasionally invades also the cranial surface,— 
altering it in both quality and configuration. 
III. The tumor contents.—From what has been said relative 
to the causes and formation of this growth it is almost need- 
less to remark that, the pouch contains invariably normal, 
liquid, venous blood. VENOUS BLOOD-TUMORS OF CRANIUM. 
27 
This was demonstrated by both ante-mortem examinations 
by means of puncture and evacuation, and autopsies, in con- 
junction with the histories and symptoms of all the cases. 
Moreover, solid elements may be found occasionally within 
its interior—as shown in one (spontaneous) of Middeldorpff’s 
patients, where a movable, ovoid, cartilaginous-like button, 
about the size of a rice grain, was distinctly felt,—and which 
may be formed (condensed) at the expense of the cellular 
tissue, or even, probably, as fibrinous deposits or concretions 
(phleboliths) from the blood itself. 
In addition the cavity of the tumor may be cellular in com- 
position with trabeculae and cords extending across it, and 
illustrative of this condition is one of the cases (traumatic) of 
Hutin. 
Finally, it is interesting to notice the difference in the tumor 
contents after death, revealed in the two cases of Hutin,—in 
one the pouch being empty, whereas in the other it was filled 
with a venous blood clot. Dupont endeavors to explain this 
difference in the contents of these tumors by the position of 
the head (hanging down) at the moment when life became ex- 
tinct, or according to the stage of the respiratory act (expira- 
tion) at the last moment, in congesting the tumor and thus 
facilitating the formation of a clot. 
IV. The connecting passage betzveen the cavity of the tumor 
and the sinus within the cranium.—That the blood of this tumor 
communicates with the intra-cranial venous circulation has been 
clearly proven, and it has been demonstrated, also, that the 
means or method by which this communication is effected, is 
through an abnormal opening perforating the bony parietes 
and emerging into the skull cavity; and, therefore, it is only 
left now to consider the character of this passage or commu- 
nication. 
With those etiological and pathological facts before us which 
the previous study of the lesion has rendered conclusive, it is 
to be expected that the cranial opening will differ in the several 
classes or groups, and vary to a like extent in each individual 
case; for, taking as an example the traumatic group, which is 
more conspicuous than the others, the size, shape, number, and 
direction of the orifice is absolutely dependent upon the extent 28 
WILLIAM M. MAS TIN. 
and character of the injury producing it. Hence no definite 
characteristic of this aperture can be noted besides its connec- 
tion or association with the sinus. 
It is well to revert, however, to the fact that the communica- 
tion may be either director indirect. The direct method, where 
the cavity of the tumor communicates immediately with the 
sinus through the cranium, is well exemplified in the traumatic 
cases of Hutin and Pott, and the congenital one of Busch, in 
each of which it was practically observed. But in the indirect 
communication the direction and extent of the passage is 
changed, or irregular—even tortuous,—and reaches the sinus 
only after traversing other tissues besides the bone, or it may 
form a distinct canal of some length. This is exhibited in one 
of the traumatic cases of Hutin, and, probably, in the congeni- 
tal instance of Flint; in the latter the connection with the 
sinus being, in all probability, through the medium of a men- 
ingeal vein. 
Taking the relative frequency of the direct and indirect 
methods of communication into consideration, although after 
eliminating the evidences of surgical and post-mortem dem- 
onstrations, an intelligent appreciation of the histories and 
symptoms presented by the cases speaks for the first or direct 
connection of the tumor cavity with the sinus. 
IV. SYMPTOMS. 
The symptoms can be divided into (i) general and (2) local. 
1. The general symptoms are few in number, inconstant 
and variable—some patients not experiencing the slightest gen- 
eral discomfort or inconvenience,—and are of that character 
which might be anticipated from the location and nature of the 
tumor. 
Of these vertigo or dizziness is the most prominent and most 
constantly present. 
In the majority of instances this symptom was encountered, 
especially when the tumor was at its maximum volume, but not 
always appearing spontaneously, and more often the result of 
posture with the head dependent or flexed ; or produced by 
compression of the growth, particularly if the pressure was VENOUS BLOOD-TUMORS OF CRANIUM. 
29 
such as to cause the rapid emptying of the pouch of its con- 
tained blood, although, on the other hand, in some cases sup- 
porting the tumor may lessen or relieve the vertigo. 
In one case (Larrey’s) compression of the pouch, in addition 
to vertigo, caused a mistiness or indistinctness of the vision of 
the eye corresponding to that side on which the tumor was sit- 
uated ; and in one or two patients these symptoms of dizziness 
resulted also from any cause whatever that would produce in- 
creased blood-tension, such as a distended stomach, muscular 
exertion, and certain mental emotions. In two instances again 
nausea and vomiting, together with “lightness” and swimming 
of the head, came on after repeated and prolonged manipula- 
tion of the growth. 
It is possible for pressure upon, or forcible reduction of, the 
tumor to produce symptoms of cerebral compression, as is 
vaguely referred to in the traumatic case of Hutin and the 
spontaneous case of Larrey. But, it should be added, this oc- 
curred only under certain circumstances, or in rare cases, and 
cannot be regarded as one of the symptoms ordinarily attend- 
ing this lesion. 
Pain is much less frequent than vertigo, and finds expression 
chiefly in the form of headache. 
When present it usually accompanies increased tension of 
the tumor, that is when largely distended ; but in some in- 
stances pain was only produced by pressure exerted upon the 
tumor. And in one case (Verneuil’s) headache was peculiarly 
severe at the menstrual epochs; however, in the face of the 
many and varied nervous phenomena and perturbations so often 
met with at these periods, this symptom is of no significance. 
Pain localized in, or confined to the vicinity of, the growth 
has not been recorded. 
2. The local symptoms are much more characteristic and 
reliable than the general ones, and, for convenience of study, 
may may be subdivided into, (a) symptoms furnished by in- 
spection, and (b) those elicited by palpation and manipulation 
of the tumor, including auscultation. 
(a) Symptoms furnished by inspection. The first point, and 
one of considerable importance, to be observed in an examina- 
tion of this growth, is its seat or location. 30 
WILLIAM M. MAS TIN. 
As would be naturally looked for, this is situated nearly al- 
ways in the tract of the sinus or adjacent thereto; and, conse- 
quently, the proximity of a swelling to the course of the supe- 
rior longitudinal, or, indeed, any of the cranial sinuses, especi- 
ally if presenting doubtful or obscure symptoms, should be, at 
least, suggestive of this variety of tumor. 
An analysis of the cases shows that the growth is encoun- 
tered in the frontal, parietal, and occipital regions, and these 
postions are distributed among the three classes as follows: 
The congenital group numbers four cases, two being in the 
frontal region—one to right and one to left of median line, and 
two in the occipital region ; the spontaneous group includes 
four cases, one occupying the left side of frontal region, and 
three the occipital—one on left side and two in middle line; 
and in the traumatic group there are five cases, of which four 
were situated in *the frontal—two to right of and two in the 
middle line, and one on the summit of the head or in the mid- 
dle parietal region. 
The size of the tumor, even when distended to its fullest ca- 
pacity, is usually of moderate dimensions, the largest size be- 
ing attained in the patient of MM. Nelaton and Richard 
cm. in diameter at its base by 2J cm. in height); and in the 
quiescent state, that is when the swelling is relaxed or at its 
minimum enlargement, the growth is quite small, and in some 
instances almost, if not completely, imperceptible. 
These changes or alterations in the size of the tumor are 
especially characteristic, and can be seen frequently to take 
place under those conditions influencing its distension and 
relaxation ;—the pouch slowly rising and swelling up in the 
dorsal decubitus or any position with the head lowered; by 
interference with the intra-cranial venous circulation, as oc- 
curred, for example, in two cases where the jugular veins were 
compressed, and in crying, coughing and sneezing; sometimes 
by a full stomach, muscular exertion, or mental emotions ; and, 
possibly, during the normal respiratory effort;—however, under 
converse influences or these conditions lessening expansion 
and dilatation, the tumor is observed to recede gradually to a 
lower level, and often entirely disappears. 
The color of the swelling is usually normal and does not dif- VENOUS BLOOD-TUMORS OF CRANIUM. 
31 
fer from the healthy skin in the region where it is located. 
But, in a measure, the color is influenced by the consistency 
or thickness of the tegumentary coverings, and may vary with 
the degree of distension, for when the walls of the tumor are 
very thin it may assume a purple or violaceous hue, or again 
being changed in color whilst distended this discoloration may 
fade away with the relaxation of the tumor. In one case it 
was of a deep red, and in another there were several dark 
bluish spots on its surface, giving it the appearance of a cap- 
illary naevus. 
As a rule the surrounding skin remains unimplicated, unless 
the lesion be complicated by the association of some disease 
of the integument—a complication much more likely to occur 
in the congenital than the other classes. 
(b) Symptoms elicited by palpation and manipidation of the 
tumor, including auscultation. The influence of head posture on 
the volume and resistance of the tumor is even more apparent 
to the touch than to the eye; and, as it is manifested always, 
perhaps, in this affection, the symptom of dilatation and reduc- 
tion produced thereby as furnished by palpation may be rea- 
sonably regarded as a pathognomonic character, and hence, 
should have assigned to it a position of prominence. 
Without an exception, as far as tested, this influence of posi- 
tion was decided and marked,—the tumor being felt to attain 
its greatest or maximum volume when any position with the 
head lowered was assumed, and even simply bending the head 
forward producing very evident increase of size and tension; 
whilst the reverse attitude, with the head fixed and erect, being 
attended by a diminution in both resistance and bulk, and in 
some instances the tumor subsiding so completely as to be 
positively indiscernible upon the most careful palpation. 
Palpation shows that a similar result is produced by com- 
pression of the jugular veins, or any interruption whatever of 
the cerebral venous circulation ; and, indeed, anything which 
materially or decidedly increases the blood pressure, as forced 
expiration in coughing, muscular exertion, crying, etc., etc., as 
enumerated in the preceding section, would at once impart to 
the hand a like sensation; the contrary, of course, taking place 
under opposite conditions. 32 
WILLIAM M. MASTIN. 
Although pressure upon the jugulars was employed in only 
two instances, the influence upon the growth was unequivocal, 
and may be taken as a rational symptom, and one of value 
when associated with additional evidences ; for, it is needless to 
remark, its range of applicability is much too wide and ex- 
tended to be by itself of diagnostic import in this form of 
sanguineous tumor of the skull. 
Probably next in importance to postural influences may be 
regarded the symptoms of compressibility and fluctuation, 
which taken together furnish positive evidence of a fluid-con- 
taining pouch or cavity, and the fluid of which having an intra- 
cranial outlet. 
In all of the cases, seemingly irrespective of cause, com- 
pressibility of the tumor was present and one of the chief 
characteristics,—the growth readily and completely but slowly 
subsiding under continuous lightly made pressure with the 
hand or fingers, and tardily redilating upon the removal of the 
compressing force,—distinctly conveying to the touch the sen- 
sation of a sac gradually being emptied of fluid. The rapidity 
with which this evacuation is accomplished must be dependent, 
necessarily, upon the freedom and directness of the communi- 
cating passage with the interior of the skull, but, as a rule, the 
reduction is slow and gradual. 
Notwithstanding the assertion of M. Dupont (op. cit.) that 
fluctuation was observed in only two cases in his collection, I 
am inclined to believe, after an attentive examination of these 
cases, that, on the contrary, it really did exist in all of them 
except the patient of Azam (traumatic), in whom the tumor 
had a soft and spongy feel; and, therefore, I must attach a 
significance to fluctuation far above that which he accords to it. 
Another symptom of especial weight is the ability in many 
instances to recognize by the finger, after the reduction of the 
growth, some bone alteration, or even the depression or inden- 
tation in the skull corresponding to one or more openings 
leading to its interior, which in several cases were of sufficient 
dimension to admit the tip of the finger. 
Furthermore, in a few instances puncture by means of a 
trocar and canula, with direct exploration by a stylet passed 
through the canula, disclosed the existence of these apertures VENOUS BLOOD-TUMORS OF CRANIUM. 
33 
where they had eluded careful digital search. However, even 
where this latter measure was employed, failure to detect the 
osseous perforation resulted in one or two cases, in which a 
subsequent incision or post-mortem examination disclosed its 
presence ; and hence such unsuccessful efforts to discover the 
communicating entrance should not be considered as conclu- 
sive of its non-existence. 
The sensation or feel of the walls of the pouch and adjacent 
integument are of value in considering the symptoms of the 
affection. In uncomplicated cases, after the pouch was emptied, 
this gave to the finger the sensation of a loose, lax, movable 
covering of healthy tissue, of different degrees of thickness 
according to its constituents, with a normal feeling of the sur- 
rounding skin; but in the one instance above referred to 
(Azam’s case) the sensation was that of a spongy mass within 
the skin sac. 
Pulsation, although noted as occurring in the patient of Pott, 
may be looked upon only as an exceedingly infrequent acom- 
paniment, and indeed, can be entirely eliminated from the list 
of symptoms. 
The very nature of the formation, together with the anatom- 
ical characters are, under ordinary circumstances, opposed to 
such a symptom, and in this instance of Pott I think the pulsa- 
tion was due either to a respiratory rise and fall, or, if synch- 
ronous with the cardiac action, to the’ cerebral pulsation 
imparted to it by contiguity through the fracture. 
The same observation applies to a bruit or aneurismal 
murmur. 
It is true that Azam claimed to have detected in one of his 
patients a blowing murmur; but this could not be verified by 
his colleagues ; and, moreover, it was audible only when the 
tumor was quickly and forcibly reduced, and seemed to be 
confined to the tract or line of the sinus. In no other in- 
stance was any blood sound discoverable. 
Finally, a symptom of no insignificance is the fact that, cut- 
ting off the external or superficial venous circulation, after the 
growth has been reduced, by means of a band or cord tightly 
drawn around the head, or by a ring closely encircling the base 
of the tumor, is followed by an immediate refilling and expan- 34 
VENOUS BLOOD-TUMORS OF CRANIUM. 
sion of the pouch when positions favoring or producing such 
expansion are assumed ; and again this circular compression 
being applied whilst the tumor is fully distended, complete re- 
duction is, as usual, produced by gently made pressure. 
By this means the external venous blood current is largely 
separated from the internal or intra-cranial venous circulation, 
thereby enabling one to decide with which system of veins the 
tumor is connected. 
This method was employed in but two cases. In the case 
of Middeldorpff it was accomplished by an ivory ring pressed 
down around the base of the tumor; and in the other, the 
patient of MM. Nelaton and Richard, a band encircling the 
head with graduated compresses in the temporal fossae effected 
the required constriction. 
V. DIAGNOSIS DIFFERENTIAL DIAGNOSIS. 
In the majority of instances the diagnosis should not offer 
features of grave doubt or obscurity. 
The history of the lesion, especially when the result of 
trauma; its location, want of marked elevation, and slow pro- 
gress ; the usual unchanged color and texture of the integu- 
ment surrounding it, and, more frequently than otherwise, of 
the tumor-wall itself; the direct influences of posture, coupled 
with those resulting from pressure exerted upon the jugular 
veins; compressibility of the growth—its easy and complete 
but slow evacuation ; fluctuation ; the recognition by the finger 
or exploring needle of bone alteration, and very often of aper- 
tures perforating the skull; the absence of both bruit and 
pulsation; the effect of the application of circular compres- 
sion ; vertigo produced by certain positions and movements; 
and lastly, the demonstration by aspiration or puncture of the 
presence of venous blood occupying the cavity of the pouch, 
constitute a symptom-group scarcely admitting of misinter- 
pretation. 
But, it must be remembered, this complexus of symptoms is 
representative of an uncomplicated or typical example of this 
formation, and since some cases do not exhibit them either in 
the prominence or clearness as here set forth, it is evident that VENOUS BLOOD-TUA/ORS OF CRANIUM. 
35 
there must be instances where the diagnosis is not so easily 
determined as might appear, and in which the disease may be 
justifiably confounded with other tumors of the cranial vault. 
It will not be amiss, therefore, to refer briefly to the princi- 
pal lesions presenting symptoms in common with this one; or, 
at least, those which might arise for discussion in an accurate 
differentiation. 
Thus, in the congenital class of this affection there are found, 
as bearing a certain degree of similarity, the malformations of 
(a) meningocele, and (&) encephalocele, to the former of which 
the case of Middeldorpff offered many points of resemblance; 
(c) cephalhaematoma, as illustrated by Busch’s patient; (d) sub- 
cutaneous venous erectile or vascular tumor (including, possi- 
bly, the capillary variety), of which the patients of Verneuil 
and Middeldorpff are examples; (e) lymphatic vascular tumor; 
(/) congenital cystic tumors ; (g) venous aneurism, as evi- 
denced in the case of Flint; and, under rare circumstances, (k) 
an abscess, especially where skull-perforation has taken place. 
In the spontaneous class, the most conspicuous are, (a) sub- 
cutaneous venous erectile or vascular tumor of the scalp alone; 
or (b) the superficial naevus coexistent with meningocele and 
encephalocele,—exemplified in the patient of Larrey; (c) ven- 
ous aneurism ; (d) rarely, aneurism of the middle meningeal 
artery associated with bone erosion (Dupont); (e) fungus of 
the dura mater; and (f) circumscribed abscess. 
The traumatic class presents numerous symptoms in com- 
mon with, (a) haematoma, both within and without the skull,1 
of which an example is furnished by the case of Pott; (b) sub- 
cutaneous venous erectile or vascular tumor of the scalp, as 
seen in one of the patients of Azam; (c) venous aneurism, re- 
semblances to which were manifested in another case of Azam 
and one of Hutin’s; (d) traumatic cephalhydrocele ;2 and (e) 
circumscribed abscess of the scalp,—one of the cases of Hutin 
being mistaken for such a pus-collection. 
1 Vide cases of Guthrie and Mouton, to which reference has been made already. 
2 This interesting lesion is the subject of a communication by P. S. Conner, M. D., read 
before the Amer. Surgical Association, meeting of 1884, and published in the Amer. 
Jour. Med, Sci., July, 1884; and MedicalNews, July 19, 1884; also in Vol. II. of the 
Transactions Amer. Surg. Association. See also Dr. A. v. Winiwarter, Archiv fiir 
klinische Chirurg, 1884, B. 31, H. I,, who reported his case at the German Congress 
of Surgeons, April 19th, 1884. 36 
WILLIAM M. MAS TIN. 
A little care, however, should enable one to eliminate all 
questionable points; but in those instances where an individual 
case offers specially confusing difficulties, the demonstration of 
a fluid-containing-pouch, completely reducible under lightly ap- 
plied pressure without producing cerebral irritation, influenced 
by posture and circular compression, and of which tapping or 
aspiration shows the fluid to consist of living venous-blood, 
would be quite sufficient, against otherwise doubtful or oppos- 
ing symptoms, to establish the diagnosis. 
VI. PROGNOSIS — PROGRESS. 
As far as life is threatened, or even serious impairment of 
health is concerned, the prognosis is favorable, and equally so 
in all the classes of the disorder; but when a cure or perma- 
nent dissipation of the growth is considered, then the prog- 
nosis must be regarded in an unfavorable light, or, at least, is 
exceedingly uncertain. This conclusion is based upon the fact 
that, in all those cases where no active surgical treatment had 
been employed, and which were followed up for a longer or 
shorter period, the progress in each was slow,—there being 
but little tendency evinced to any increase in either bulk or 
symptoms. 
Examining these in their respective groups, it is found that 
in the congenital class, the case of Middeldorpff progressed 
slowly and was almost unchanged after the space of fourteen 
years ; and that of Verneuil also advanced tardily, and resulted 
in spontaneous cure after a long examination, including re- 
peated palpations, in the seventeenth year of its existence. 
This slow progress was also characteristic of the spontaneojts 
class. In C. H. Mastin’s patient there was only slight increase 
after five years; in Larrey’s case it had grown but little in the 
twelve years subsequent to its discovery; and in the patient of 
Nelaton and Richard the progress was slow for twelve years, 
then for the next four years it grew steadily and rapidly, at 
which date its dimensions were increased in all directions and 
with the formation of an additional or secondary tumor, but 
without a change or increase of the symptoms previously man- 
ifested. VENOUS BLOOD-TUMORS OF CRANIUM. 
37 
In the trawnatic class, this is again iDorne out by the two 
cases of Hutin, in both of which the lesion was under careful 
professional observation for forty years or more, and hence 
the slow progress is well authenticated. 
Among those instances where surgical interference was 
adopted are, first, the case of Flint (congenital), where death 
resulted from hemorrhage after free incision; secondly, the 
two patients of Azam (traumatic), upon whom repeated punc- 
tures were practiced for diagnostic purposes, and in which, after 
four years and eighteen months respectively, scarcely any 
change had taken place; and thirdly, the case of Percival Pott 
(traumatic), where incision and trephining, although attended 
by profuse hemorrhage, resulted in complete recovery. 
Thus it has been clearly shown by these examples that, the 
malady, per se, does not incline to a fatal termination ; that*the 
affection progresses slowly in the majority of cases even where 
no surgical measures for controlling or repressing its growth 
are resorted to, and without any marked interference with the 
health or comfort of the patient; and furthermore that sponta- 
neous cure is possible, and hope of recovery is held out by 
judicious operative interference, notwithstanding that in the 
case with this favorable issue the surgical procedure was 
undertaken without recognizing the true character of the 
lesion. 
VII. TREATMENT. 
The several methods which have been resorted to in the 
treatment of this variety of sanguineous tumor are to be 
classed into, first, the palliative, where protection of the part 
against injury or external influences, or even to limit or stay 
its progress, was afforded by a suitable shield or protector; and 
secondly, the curative, including (a) complete compression of 
the swelling by direct pressure, and (b) operative procedure. 
I. Palliative measures were instituted in all the cases with 
only a few exceptions. And in this connection, Dr. Gross re- 
marks : “ The treatment is entirely palliative, consisting in the 
protection of the part from accident by the application of a 38 
WILLIAM M. MAS TIN. 
compress and suitable straps.” 1 And Dupont,2 also, declares 
that the treatment consists only in palliation. 
It has been seen, however, that such methods have scarcely 
exerted any influence whatever over the progress of the 
growth. 
2. (a) Firm compression as a curative measure was em- 
ployed in three cases, but without success. 
M. Azam, in one of his patients, after puncturing the pouch, 
applied steady and continuous pressure for the period of twenty 
days, but no appreciable impression of any kind was made 
upon the tumor, and the patient was discharged in an unbene- 
fited condition. Hutin also used compression by leaden and 
silver plates without effect; and the efforts in the case of MM. 
Nelaton and Richard to dissipate the lesion by regulated pres- 
sure likewise proved futile. However, the fact must be 
referred to again, as being closely related to compression, 
that in Verneuil’s patient the tumor subsided spontaneously 
after a prolonged examination by several physicians, during 
which repeated manipulation and palpation of the growth was 
employed. 
(,b) Operative interference was resorted to in but two in- 
stances, although puncture as a diagnostic test was made in 
two others. In the little patient of Flint a free incision was 
made, largely dividing the tumor, and profuse hemorrhage and 
death therefrom was the immediate result; and in the case of 
Pott, under a misapprehension of its real character, incision 
and trephining were employed, but was followed by prompt 
and permanent recovery. These two cases represent the char- 
acter and extent of the operative treatment adopted; and the 
obvious reason why such procedures were scrupulously avoided 
in the management of this affection can be readily discovered 
in the dangers which formerly were anticipated and dreaded 
from the injury of any large venous trunk or branch, and 
especially when so intimately associated with the central 
nervous system as in the meningeal sinuses. Whilst these 
dangers must be still accorded surgical prominence in the 
wounding of a vein of the first magnitude,—and among the 
principal of these are, entrance of air, hemorrhage, phlebitis, 
1 Op. Citat., p. 28. * Loc. cit VENOUS BLOOD-TUMORS OF CRANLUM. 
39 
resulting in thrombosis and embolism, septicaemia, and, in the 
present instance, grave cerebral perturbations and meningeal 
inflammation,—the modern system of dealing with all traumat- 
isms' combined with our recent enlightenment of the tolerance 
of veins to surgical manipulation, has put quite a different 
phase upon many of these once feared complications. There- 
fore the risks of inflammatory and septicaemic manifestations 
do not require any special consideration in this discussion. 
The entrance of air is a peril which does not obtain to a 
greater degree in the wounding of the superior longitudinal 
sinus than of other important venous conduits,—those of the 
cervical region, for example,—and hence need not occupy us 
further than to mention that, in none of the cases was this 
accident encountered. 
Hemorrhage as a notable danger is, I think, more fancied 
than real, or, at any rate, greatly exaggerated. 
It is true that a fatal issue was speedily produced from loss 
of blood in Flint’s case, but this occurred in the person of an 
infant only a few days after birth, and the knife, evidently, was 
used recklessly. However, in the two cases of Azam, where 
frequent punctures were employed; in the patient of Hutin, 
where incision freely opened the swelling; and in Pott’s case, 
upon whom incision and trephining was practiced, although 
bleeding was profuse, it was easily and promptly controlled by 
simple compression. In confirmation of the comparative ease 
with which, as it would appear, hemorrhage from this source 
can be staunched, I may mention a recent paper1 of much in- 
terest, by Mr. Hector Cameron, in which he points out that very 
slight pressure is necessary to stop hemorrhage from a wounded 
cerebral sinus. Again, as pertinent to the subject of the oper- 
ative treatment, and just here to that of hemorrhage, I must 
refer to the unique and important case2 reported by Dr. 
Charles T. Parkes, of Chicago, where a compound comminuted 
and depressed fracture of the skull over the right parietal 
bone was sustained, accompanied by wounding of the upper 
wall of the superior longitudinal sinus to the extent of admit- 
ting the end of the little finger; and upon whom at first a 
1 Lancet, May 24, 1884. 
2 Annals Anat. and Surg., Vol. VIII., p. 118. 40 
WILLIAM M. MASTIN. 
compress arrested the terrific hemorrhage, and then later the 
removal of osseous fragments and the introduction of three 
fine cat-gut sutures permanently controlled all bleeding and 
entirely closed the rent. Furthermore, notwithstanding that 
by thus coaptating the edges of the wound, the “ calibre of 
the sinus was reduced fully one-third,” and a “well-marked 
bulging” of the sinus taking place at the anterior extremity of 
the closed wound, resulting from distention by pressure of the 
backward blood-flow, there was not the slightest indication of 
cerebral disturbance1 traceable to this marked interference with 
the natural movement of such a large column of blood,— the 
case terminating in recovery under antiseptic precautions. 
Hence, in addition to the valuable lesson here taught rela- 
tive to the ligation or suturing of the intra-cranial sinuses, we 
have positive demonstration that the brain will suffer a decided 
interruption in its vascular supply without evincing any appre- 
ciable alteration in its normal functions. Therefore, besides 
furnishing a response to several questions which naturally arise 
in considering the proper plan of treatment to be instituted in 
these venous tumors, this record of Dr. Parkes is a revelation 
in general cerebral surgery, and forms a strong link in the 
chain of facts and possibilities which continued experiment 
and investigation are disclosing in the surgical treatment of 
fracture of the skull, and diseases and injuries of its nervous 
and vascular contents. 
Consequently, whilst hesitating in the present state of our 
knowledge to declare the knife and the suture or ligature as 
constituting the character of treatment called for in this class 
of venous formations, I am justified, at least, in hazarding the 
prophesy that the day is not in the distant future when the 
surgeon will resort to the same methods of treatment* for 
wounds and diseases of the sinuses and arteries of the brain 
as govern him in like or similar lesions of the trunk and 
extremities. 
1 Nervous symptoms Were present immediately after the injury, and persisted for 
some time, but were uninfluenced by the suture, and reduction in calibre, of the 
sinus. Published Simultaneously in the United States and Great Britain. 
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