VENOUS BLOOD TUMORS 
OF THE CRANIUM 
In Communication with the Intra-Cranial 
Venous Circulation, Especially the 
Sinuses of the Dura Mater. 
BY 
WM. M. MASTIN, M.D., 
OF MOBILE, ALA. 
Read in the Surgical Section, at the Thirty-Seventh Annual 
Meeting of the American Medical Association. 
Reprinted from the Journal of the American Medical 
Association, Sept. 1S, 25, and Oct. 2, 1SS6. 
CHICAGO: 
Printed at the Office of the American Medical Association. 
1886 VENOUS BLOOD TUMORS 
OF THE CRANIUM 
Id Communication with the Jntra-Cranial 
Venous Circulation, Especially the 
Sinuses of the Dura Mater. 
BY 
WM, M. MASTIN, M.D., 
OF MOBILE, ALA. 
Read in the Surgical Section, at the Thirty-Seventh Annual 
Meeting of the American Medical Association. 
Reprinted from the fournal of the American Medical 
Association, Sept. IS, 2S, and Oct. 2, 1SS6. 
CHICAGO: 
Printed at the Office of the American Medical Association. 
1886. VENOUS BLOOD TUMORS OF THE CRANIUM 
in Communication with the Intra-Cranial Venous 
Circulation, Especially the Sinuses of 
the Dura Mater. 
Since the discussion of the subject of cranial ven- 
ous blood tumors communicating with the cerebral 
circulation, particularly through the medium of the 
dural sinuses, in an article which appeared in the 
April and May issues of the Annals of Surgery for 
1885, I have succeeded in collecting so much addi- 
tional data relative to this important pathological 
formation, that I have decided to embody the results 
of my entire research in a second and more complete 
monograph. 
This has seemed proper and desirable not only 
from the natural surgical interest which must attend 
all investigations and compilations leading to the 
clearer elucidation of an affection which, in both 
actual occurrence and literary records, constitutes a 
class of comparatively rare lesions, but also on ac- 
count of the necessity of a very material change in 
some of the conclusions and deductions arrived at 
in my preceding brochure, which this increased infor- 
mation now renders obligatory. It is to this enlarged 
and more comprehensive examination of the subject 
that I desire to invite your attention. 
With the simple explanation just made I shall not 
attempt to apologize for the numerous repetitions and 
dry details, especially in the references to clinical 
histories, which compose a certain part of these re- 
marks, and will remain content in the belief that the 
topic possesses attraction equally great for others as 
for myself. 4 
The infrequency of all reference to this interest- 
ing and uncommon form of sanguineous tumor 
in recent or modern surgical treatises, is a matter 
of considerable surprise and comment. Notwith- 
standing the occasional mention of the lesion, with 
the moderate number of clinical records which are 
to be found scattered here and there throughout 
the broad field of surgical literature, to say nothing 
of the manifest inherent importance of the formation, 
together with its relation to general surgery, I am 
unacquainted w’ith more than a half-dozen works, 
among the vast prolusion of surgical writings which 
have appeared subsequent to twenty years ago, that 
make the slightest allusion to the subject,—and espe- 
cially does this observation obtain of American and 
English publications. 
As representing the most prominent among those 
authors referring to the malady within this period, 
may be named MM. Follin and Duplay, who,in their 
admirable treatise on Pathology (Traite Elementaire 
de Pathologie Externe, Parts, 1868-9), devote a short 
but concise and instructive section to a consideration 
of the subject; Legouestand Servier in their valuable 
article on the Cranium contained in the Dictionnaire 
Encyclopedique des Sciences Midicales (ie Serie, Paris, 
1879), contribute an important and comprehensive 
chapter on these sanguineous tumors; Bergmann 
(Deutsche Chirurgie, 1880); and Dr. Gross (System 
of Surgery, Phila., 1882), who notices the lesion in 
a brief paragraph, and without the addition of any 
special or original observations. 
Prior to the date specified, however, surgical an- 
nals are not quite so barren of such allusions, as is 
amply indicated by the array of facts and clinical 
cases presently to be detailed, together with the bib- 
liographical collection appended to this essay, and 
the most important of which are the contributions of 
Burns, Demme, Dupont, Stromeyer, Duplay, Ver- 
neuil, Jules Dubois, Middeldorpff, Burchard, Dufour, 5 
Hecker, Michaud, Chassaignac, Melchiori, Azam, 
and Hutin, to which publications we are largely in- 
debted for much of the knowledge that we possess 
concerning these types of cranial blood-tumors. 
It is of interest to note, also, the various apella- 
tions given to the affection,—among other less dis- 
tinctive terms, it being described under the several 
designations of: Varix verus ■ cirsoideus and varix 
verus circumscriptus ; jistule osteo-vasculaire ; erectile 
tumors of the skull communicating with the superior 
longitudinal sinus; sinus pericranii; varix sinus 
verus extra-cranium con genitalis; 11 venous tumors” 
of the cranial bones; varix spurius circumscriptus 
vence diploicce frontalis; sanguineous tumors of the 
vault of the cranium in communication with the intra- 
cranial venous circulation ; sanguineous hernice of the 
vault of the skull by communication, through openings 
in the bone, of the meningeal vessels with the exterior 
integument; varicose veins or venous varicosities of 
the skull; a new form of tumor of the vault of the 
cranium, produced by the blood in communication with 
the intra-cranial venous circulation ; extra-cranial ven- 
ous tumors connecting with the intra cranial venous 
circulation; subpericranial venous tumors; and re- 
ducible sanguineous tumors of the vault of the cranium. 
These titles were based upon some salient or distin- 
guishing feature, and, at the same time, they furnish a 
fair insight into the individual opinions entertained 
of the pathology and origin of these formations by 
the authors respectively adopting them. 
Recognizing the scattered and, under existing cir- 
cumstances, often inaccessible condition of the liter- 
ature, it has seemed particularly desirable that some 
attempt be made to gather these fragments together. 
Therefore, having succeeded in collecting a sufficient, 
if not the larger, portion of these fugitive contribu- 
tions, from which, it is believed, some intelligent and 
decided inferences can be drawn, or, at least, enough 
to allow generalization, I shall endeavor in this sec- 6 
ond article to lay the collated material before the 
profession in a more compact and tangible form. 
Classification.—Considering all the pathologico- 
anatomical facts, combined with the various hypo- 
theses relative to the subject, to which I shall advert 
hereafter, these tumors should be divided, on account 
of the period and method of their formation, into the 
following classes: 
I. Congenital. 
II. Spontaneous. 
III. T raumatic, or cases resulting from direct 
traumatism. 
It appears warrantable, also, both from the etiology 
and special structures involved in each, to make two 
divisions of these three classes or groups, namely: 
1. The Simple or Diffused. 
2. The Venous or Vascular. 
1. The simple or diffused comprises those cases 
in which the blood effusion takes place immediately 
beneath one or all of the scalp layers—dissecting up 
these tissues and thus forming the tumor-walls—and 
which may be caused by spontaneous or other per- 
foration of the cranial parietes with opening into 
the sinus, as in rarefying osteitis, and from many 
traumatisms. 
2. The second division, the venous or vascular, 
covers those cases formed through direct implication 
of or morbid action in the venous coats—the walls of 
a sinus, an emissary vessel, or diploe vein—as in ecta- 
sia of the sinus wall through a normal or abnormal skull 
perforation, in circumscribed and multiple varicosi- 
ties and dilatations of the ven;e emissaria, in ruptures 
of these emissary veins, and in dilatations of the dip- 
loic vessels with loss of osseous substance. 
These two divisions again admit of still another 
division, dependent upon the particular features of 
the tumor, that is: 
t. The cyst or pouch variety, which may be further 
subdivided into: 7 
(a) Fusiform, 
(b) Sacciform, 
(c) False, and 
2. The varicose or erectile variety.1 
1. The cyst or pouch variety is that form of the 
lesion which is characterized by the formation of a 
simple (seldom more than one) cyst or cavity; and 
therefore includes circumscribed dilatation of a vena 
emissarium (fusiform); an ectasia or hernia of a 
sinus, and dilatation of a diploic vessel (sacciform); 
perforation of the skull and sinus followed by imme- 
diate exir.iv asation of blood beneath one or more of 
the scalp layers, and rupture of an emissary vein 
(false). 
2. The varicose or erectile variety is composed of 
tortuous and varicose veins—principally the emissa- 
ria Santorini—in fine or gross bundles, bound to- 
gether by connective tissue; and, occasionally, of 
a structure resembling true erectile or cavernous 
tissue. 
Each of these several divisions and varieties will 
receive additional consideration in the subsequent 
pages. 
A separate review of every individual case of the 
number collected, although requiring what would 
appear to be a needless detail and repetition, is 
really essential in an extended examination of this 
lesion, especially because of the several varieties of 
venous blood tumors communicating with the intra- 
cranial circulation, each of which appears to demand 
liberal illustration. It shall be my endeavor, how- 
ever, to make this notice as brief and condensed as 
CLINICAL RECORDS,2 WITH COMMENTS. 
1The varicose or erectile variety is not so distinctive of this class of 
tumors as the other forms, since it is very closely allied to the simple or 
superficial subcutaneous venous erectile tumor of the scalp. 
2 For several of these references I must acknowledge my indebtedness 
to Dr. William Browning, of New York, who very kindly directed my at- 
tention to them after the publication of my first paper. 8 
the proper and connected presentation of the histories 
will permit, with a correct appreciation of the differ- 
ent salient and distinctive points which they offer. 
The earliest record of any case belonging to the 
congenital group which has come to my knowledge, 
is that occurring in the practice of Moreau, and re- 
lated by M. Pelletan (Clinique Chirurgicale, t. 11, 
p. 76, Paris, 1810) as follows: 
A youth, 15 years of age, had located on upper 
part of forehead a congenital swelling the size of a 
pigeon-egg. It became larger and also of a bluish 
color when he stooped over the table at work, but in 
the morning upon first awakening it was much smaller 
and without discoloration. 
M. Moreau divided the tumor centrally, • and 
packed the profusely bleeding wound with lint, but 
this failing to arrest the haemorrhage, the surface of 
the wound was painted with butter of antimony, re- 
quiring very many of these cauterizations to control 
the escape of blood. Now, however, high fever, 
headache, convulsion, and paralysis of the corre- 
sponding half of the body followed, and finally death 
ensued on the fourth day. 
At the post-mortem examination were found 
three holes in the frontal bone through which en- 
larged and dilated veins passed on into the superior 
longitudinal sinus, thus placing the external varicose 
swelling in communication with the intra-cranial ven- 
ous circulation. For a large area around these per- 
forations the dura mater was inflamed and covered 
with pus. 
Bruns, who also details this observation in full, 
speaks of it under the heading of varix verus cir- 
soideus. 
The next case in point of date is that mentioned 
by Busch3 in Heidelberger Klinische Annalen, t. 11, 
p. 249, 1826: 
1. CONGENITAL CLASS. 
3 Reported also in my previous paper. 9 
During the accouchement of a patient, after the 
discharge of the waters (which were thick, greenish 
and fetid), and whilst head still at superior strait, a 
large, fluctuating tumor was distinguished on the 
child’s head. The child was still-born; male; weight 
seven lbs.; skin detached and macerated, and limbs 
flaccid, showing conclusively that death had taken 
place some time prior to labor. 
On the head there was a rather large, fluctuating 
tumor, of bluish color, which in length extended 
from the external occipital protuberance to middle of 
the saggital suture, and in the other direction from 
the point of ossification of one parietal bone to cor 
responding point on the opposite side, and projected 
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 of a defined and prominent 
ring around the border of the tumor. The tumor 
was opened by a long transverse incision, extending 
from right to left, which discharged a quantity of 
dark-colored, viscous blood, of an offensive odor. 
About two ounces was collected. This fluid was 
situated between the bones of the skull and the peri- 
cranium, 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 borders of the tumor were approached. This 
thickness, also, was easily distinguishable from an 
ordinary tumor of the head. There was no extravas- 
ation either in 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 trau- 
matic origin, being due to the traction and pressure 10 
of the forceps employed in the delivery. But this, 
evidently, is erroneous, for the description given by 
Busch is so clear and explicit on this point that the 
intra-uterine death of the child, several days previous 
to time of labor, is not to be questioned; and hence 
I must consider the case as one of congenital forma- 
tion. Dupont also regards it as congenital. 
M. Chassaignac (These snr les tumeurs de la route 
du Crane, p. 125, 1848) mentions having heard Pro- 
fessor P. Berard (senior) relate, during a course of 
lectures on anatomy, delivered in 1831 or 1832, the 
history of an infant in whom there was a varicose 
dilatation communicating with the superior longitud- 
inal sinus, and which swelled considerably when the 
child cried or made any exertion. 
'Phis is a simple statement without any careful or 
decided clinical details, and nothing to indicate its 
manner of communication with the intra-cranial cir- 
culation ; but there seems to be no reasonable doubt 
of its being congenital in formation, and composed, 
probably, of varicose venae emissaria. 
The case of Flint is thus briefly given by Pigne, 
Chassaignac, Dupont, and others: 
There was 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 haemorrhage. Examination showed 
this tumor to communicate with the longitudinal 
sinus. 
From the symptoms presented, and in the absence 
of contradictory data, this case may be regarded as 
an ectasia or hernia of the sinus through the poste- 
rior fontanelle. 
Mersemann records (Observateur Medicale Beige, 
1834) an example of considerable interest. Bruns 
also mentions this case, and includes with it that of 
Moreau’s under the head of varix verus cirsoideus, 
as before referred to: 11 
At birth a well-formed child had over posterior fon- 
tanelle a swelling the size of a pigeon egg, which in 
the course of six weeks had increased to three times 
that size. The pedicle was almost as large as the 
swelling itself; the skin covering it was thickened 
and wrinkled, although through it could be felt the 
fontanelle and edges of parietal and occipital bones. 
The tumor was uneven; no pulsation; color and 
temperature normal; but it became tense and bluish 
or even blackish-blue when child made any exertion 
whereby the blood return from head was interrupted, 
but not increased in size. Palliation being useless, 
as the growth continued to increase, and as the 
mother insisted upon its removal, strangulation of 
the tumor was undertaken. Hence, whilst child was 
at the breast, a ligature the thickness of a writing 
quill was adjusted about the base. Upon the first 
tightening the child screamed lustily and struggled 
with hands and feet, but as soon as it was fully tied 
the infant became quiet, sucked, and fell asleep 
without indicating further pain. Next day child 
equally well—the swelling remaining same in size 
and color. On third day the strangulation had in- 
creased without any bad effect, the surface being 
cold and bluish, with fetid discharge from around the 
ligature. By the fourteenth day, after repeated tight- 
enings of the ligature, the pedicle was reduced to 
size of a swan’s quill, and, after applying a second 
ligature thereto, the tumor was ablated without a drop 
of haemorrhage. There was now left a simple sore, 
of good appearance, at base of which the fontanelle 
could be felt, and in three days more the second liga- 
ture separated and the ulcer healed. On opening 
the tumor there was disclosed a mass of areolar tissue 
containing a bunch of greatly thickened veins in 
which were several spherical enlargements (dilata- 
tions). The scalp was quite thick, but beginning to 
shrink. 
Stromeyer (Ueber Sinus Pericranii, Deutsche Kli- 12 
nik, Bd. ii, S. 160; April 13, 1850) reports a case 
observed by Francke. This is classed by Bruns under 
the title of varix verus circumscriptus: 
Christian Brandt, a soldier, native of Wewelsfieth, 
20 years old, was born with a swelling over left eye, 
for the dissipation of which medical aid was unavail- 
ing. This swelling, according to report, is now, pro- 
portionately, of same dimensions as in early life; 
extends from the glabella two inches to' the left, and 
from the arcus supercilii to three lines above hair 
margin, covering about four inches square, and when 
distended is elevated about one inch. When patient 
is at rest the swelling does not stand out, but exer- 
tion, stooping, coughing, sneezing, compression of 
jugulars, warmth, and all conditions causing the blood 
to flow to head, or preventing its return, cause the 
swelling to fill, become tense, and elastic like a dis- 
tended gland-abscess. When Haccid the skin feels 
like the walls of a completely emptied abscess. On 
outer edge of arcus supercilii is felt, through the 
swelling, a depression in frontal bone, and in this 
depression towards the external side there exists, ap- 
parently, a pretty large foramen. The length of 
depression is three inches, breadth one and a half to 
three lines. No pain except when he wears a heavy 
head-gear, or when making great exertion, under 
which circumstances there arises swimming of head 
and a feeling as if tumor would burst. Color of skin 
unchanged, even under maximum distension. Easily 
emptied by pressure, and refills in one-half minute. 
When distended the tumor is equally elastic over 
entire surface, and clearly outlined. Curative treat- 
ment not employed because considered useless and 
dangerous. 
M. Verneuil presented, for M. Michaud, of Lou- 
vain, to the Socie'te de Chirurgie, a pathologico- 
anatomical specimen with this history (Tumeurs 
Erectile du Crane Communiquant avec le Sinus 13 
longitudinal Superior. L' Union Medicale, 8 Fe'vrier, 
n Sene, t. i, p. 254, 1859): 
A young man 28 years old with an erectile 
tumor of superior eyelid. This swelling was without 
bruit or pulsation ; its volume augmented upon 
compression of jugular vein or when patient stoops 
forward, but diminishes when head is erect. It is ir- 
reducible, and does not present characters pointing 
to communication with interior of skull; patient ex- 
periences sharp pains in tumor, and vision cut off by 
drooping of lid. Congenital in origin. Operation 
by cauterization with red-hot iron applied to three 
points. No trouble at first, but on seventeenth day 
patient seized with facial erysipelas, which was epi- 
demic, followed by meningitis and death. A few 
days after operation the patient announced that he 
had another similar tumor on his head. This pre- 
sented exactly same characteristics as first one. At 
the autopsy each tumor showed a cavernous tissue 
like ordinary erectile tumors; under them the bone 
was perforated by a multitude of little apertures 
which gave passage to the vessels penetrating into the 
interior of skull, thus putting each tumor into com- 
munication with the superior longitudinal sinus. 
Middeldorpff gives the the history of the subjoined 
case4 in a private letter to M. Dupont (Essai snr un 
Nouveau genre de tumeurs de la voute du Crane for- 
mees par du sang en Communication avec la Circula- 
tion Veineuse intra-Cranienne, p. 26, Paris, 1858): 
Matilda H., aet. 9 years, daughter of a peasant 
living at Carlowitz, near Breslau; well nourished and 
developed. From birth there existed on her fore- 
head, a little to left of 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 flaccid, and 
4 Reported also in my previous paper. 14 
then again much distended, but there is always a little 
fluctuation. Bending the head forwards toward the 
ground, 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 compres- 
sion. After reduction the base of the tumor is found 
to be circumscribed by an edge or ridge three-quar- 
ters of a line deep, denticulated, and which 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 pene- 
trating it, and is covered seemingly by a thin mem- 
brane. There are no cords or filaments to be felt in 
the tumor cavity except near the skin and hair line, 
where an ovoid cartilaginous button is perceptible, 
which is movable and about 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 dis- 
appear, thus demonstrating conclusively that the 
blood flows from the direction of the osseous base, 
and not from circumference vessels. 
In the Bulletin de la Socie'te de Chirurgie (t. iv, p. 
414, et siav,) M. Verneuil reports the following case5 
of this malady: 
A young girl, aged 17 years, of a strong consti- 
tution and good health, presented herself to me, in 
1854, for advice concerning a tumor on the forehead 
which had existed from infancy. She had some in- 
definite 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. 
6 Reported also in my previous paper. 15 
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 skull is unaltered 
in consistency or color, and no vascularity of the 
surrounding paits. Pressure causes it to sink and 
disappear entirely, and after reduction one can defi- 
nitely determine that there is no appreciable altera- 
tion of the bone, and only a little circular ridge 
around it (its limiting boundary) 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 pulsa- 
tion; and, again, cough does not affect it. When 
the head is lowered the tumor becomes voluminous, 
with the dimensions of 3 cm. in diameter by 1 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. 
During 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 re- 
peated 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 of the cure by an- 
other examination at a more remote date; as, imme- 
diately after the subsidence of the swelling, she dis- 
appeared, and was not again seen. 
Case of M. Foucteau (Note pour servir it 1’ histoire 
des Kystes des Enfants Nouveau-nes; Gazette Med- 16 
icale de Paris, Novembre 2, i r i Serie, t. xvi, page 
695, 1861): 
A congenital tumor of the cranium, pediculated, 
situated over the posterior fontanelle. It was of a 
blackish color, fluctuating, and was divided by a ver- 
tical furrow into two unequal lobes. Greatest diam- 
eter was transverse; circumference measured around 
largest part Om, 40, and at smallest part, Om, 30; 
pedicle was Om, 12. The pedicle was strangulated 
by a thread, and tumor punctured in right half, from 
which 300 grammes of a serous liquid flowed out, but 
only the right half was emptied thereby. Another 
puncture in left side gave exit to about an equal 
quantity of a sanguinous fluid. The pouch was not 
tardy in refilling, and by the following morning it 
had acquired about one half of its former volume; 
but at the same time the child was steadily sink- 
ing; lips and surface pale. Death followed. The 
autopsy demonstrated a communication between the 
superior longitudinal sinus large enough to admit the 
little finger. In the principal cavity floated a little 
accessory pouch, the orifice of which was distinct 
from the main tumor opening. On right wall of large 
cavity there existed another opening, of oval shape, 
with a sphincter-like edge, communicating with a 
third cyst. This is the cavity from which only the 
serum flowed. The pouches emptied after death fur- 
nished 255 grammes of blood, which, added to the 
225 grammes extracted by the puncture, gives a mass 
of 480 grammes taken from the child in twenty-four 
hours, which is amply sufficient to explain its death. 
The pedicle was only incompletely strangulated. The 
little pouch in the middle was formed, apparently, of 
the vascular serous membrane. The two other com- 
partments were lined with a very vascular serous 
membrane, easily detached from the skin by simple 
traction, and is continuous with the serous membrane 
of the cerebral sinus through the occipital fontanelle. 
This, then, is a blood-cyst formed by a hernia of the 17 
serous membrane of the cerebral sinus through the un- 
closed posterior fontanelle. 
Under the designation of Varix Sinus Verus Extra 
Cranium Congenitalis, Herman Demme describes 
elaborately in his excellent monograph, “Ueber Ex- 
tracranielle mit den Sinus Dune Matris communici- 
rende Blutcysten” (Illustrated, VirchoiAs Archives, 
Bd. 23, fol. 48, 1862), a marked example, of which 
the following is a condensation: 
In February, 1861, I saw the infant son of W., a 
locksmith of Berne, nine months old, who was born 
with a swelling on the head, which had resisted all 
medical treatment. Other physicians had declared 
it cystic, and therefore benign, but the father was 
very uneasy on account of having previously lost a 
child with a very similar growth on back of head. 
Child’s health is poor, and often in his sleep he cries 
out and carries hand to head as if in pain. Pressure 
upon the swelling always makes him restless. He 
is a pale, weakly boy, with rickety thorax and large 
abdomen. Head rather small, covered with thick 
blonde hair, and located thereon in middle of sagittal 
suture, is a swelling the size of a small apple. It is 
roundish, upper surface smooth, its outer covering 
being the scalp, somewhat pale, and sparingly cov- 
ered with hair. No vessels visible; by transmitted 
light tumor is non-transparent; resistance equal in 
all portions; fluctuation in some places, w'ith firmer 
masses in others. Continuous pressure gradually re- 
duces swelling only in part on account of these firm 
masses—pressure, at the same time, causing face of 
child to become livid. Several large veins over up- 
per eye-lid are distinct. Crying, and compression of 
jugular veins caused tumor to increase in volume and 
expansion and tension of walls, with a blue color. 
No essential connection with extra-cranial veins 
could be demonstrated, circular compression around 
base of tumor producing no apparent change. No 
arterial pulsation, though there was a feeble and 18 
doubtful undulation movement. This was a syn- 
chronous rising and falling upon inspiration and ex- 
piration, which was more positively seen by the ex- 
cursions of an exploring needle inserted therein; and 
auscultation discovered occasionally and irregularly 
a rustling and whirring sound. Withdrawal of needle 
was followed by a few drops of dark-red blood. Base 
broad and without pedicle or constriction ; no appre- 
ciable alteration of bone surface, and hence no per- 
foration of skull could be perceived. Electro-punc- 
ture would have been employed, but the instrument 
was not available, and hence non-interference ad- 
vised. 
May, 1861, death from cholera infantum. Au- 
topsy: Body emaciated. The swelling, which is 
smaller (on account of absence of circulation), was 
incised lengthwise, discharging a dark bloody mass. 
Interior walls covered by different colored coagulum 
laminae, both firm and soft, as in an aneurismal sac. 
In the coagulum covering the base is a funnel-shaped 
depression into which a fine probe readily passes 
through an opening therein, for i inches into the 
cranial cavity. Removing the cranial vault with the 
cyst and that portion of dura mater which is adher- 
ent to the bone, the brain is found to be anaemic. 
The superior longitudinal sinus is distended and filled 
with coagulum, and is considerably dilated at point 
corresponding to the extra-cranial cyst, and in which 
the point of the probe, introduced through the cyst, 
is plainly felt. In right wall of sinus near its base 
there is discovered a long oval spacious opening, 
through which the probe projects. Old blood clot, 
size of a pea, found in cerebellum. The external 
cyst-wall consists of the normal scalp; and a closer 
examination of the other layers forming its walls de- 
monstrated seemingly the fact that k was formed by 
a hernia of the sinus walls through the osseous open- 
ing. The scalp moveable and easily raised, and pull- 
ing this forward showed that there was a hollow ped- 19 
icle to the tumor connecting the sinus with the cyst 
cavity. The pericranium did not enter into the com- 
\ osition of the cyst-coverings, but was intimately 
attached to the circumference of the bone opening 
and the pedicle. The bone was somewhat thinned 
throughout the space occupied by the tumor, more 
tiansparent and in a state of rarefaction. The walls 
of the superior longitudinal sinus were thickened, es- 
\ ecially the fibrous elements, but otherwise little 
altered. 
Demme also refers to a similar case, related by 
Bardeleben at a meeting of Naturalists, in Speyer. 
This was in the person of an adult in whom the cyst 
probably communicated with the sinus longitudinalis. 
in its treatment, JBardeleben successfully practiced 
electro-puncture. 
Finally, the last instance which I have to mention 
in the Congenital group is that of Dr. Acland, of 
Oxford, which is contained in a paper entitled Cases 
Illustrating the Formation of Morbid Growths, De- 
posits, Tumors, Cysts, etc., in Connection with the 
Brain and Spinal Cord, and their Investing Mem- 
branes, by John W. Ogle, M.D. (British and For- 
eign Medico-Chirurgicai Review, vol. xxxvi, p. 212, 
July, 1865): 
Case CXCVI—Blood-cyst beneath the Scalp, Commu- 
nicating with the Torcular Herophili.—The patient 
was a child, age three years, who died of chronic hy- 
drocephalus. 
Post-mortem.—Cranium : At the posterior part of 
the cranium, beneath the integument, was a venous 
capsule communicating as described below, with the 
cranial cavity. The brain was greatly enlarged, and 
the anterior horn of one of the lateral ventricles was 
distended with serum. The occipital tuberosity was 
perforated by a foramen, through which a tube of 
fibrous tissue passed from the torcular herophili, ad- 
mitting the blood into the subcutaneous venous cap- 
sule mentioned as existing at the back of the head. 20 
The morbid preparation illustrating the above his- 
tory is in the Pathological Department of the New 
Museum, at Oxford. 
IX. SPONTANEOUS CLASS. 
The first example of the Spontaneous Class which 
claims recognition on the score of priority, is from 
a specimen belonging to the anatomist Jacobi (or 
Jakobi), and described by Beikert (or Beyckert) in 
his Dissertate De Nervis Durce Matris, Argentorati, 
1772, S. 33; but concerning which all minute and 
descriptive data are wanting: 
It was a case where a large swelling was located 
on the occiput, which was composed of a cyst filled 
with a coagulum. Close examination demonstrated 
the existence of a rather long hole in the os occipi- 
tis through which the superior longitudinal sinus pro- 
truded as a hernia under the scalp; and this, from 
the examination of the preparation, is, without doubt, 
the result of a secondary perforation, and not the 
congenital protruding of the sinus through a fonta- 
nelle. 
Several authors refer to this example as an instance 
of congenital hernia of the sinus finding exit through 
the posterior fontanelle; but, as both Bruns and 
Demme (from the latter of whom I get my informa- 
tion, not being able to secure the original disserta- 
tion of Beikert’s) claim a secondary origin, and, there- 
fore, a probable non-traumatic perforation of the skull 
arising subsequent to birth, I have felt warranted in 
placing it in this division. 
In the Gazetta Medica di Milano, Nro. 1, 1843, is 
found the subjoined case by Giovanni Melchiori: 
In a girl, 14 years old, there was first discovered 
during an attack of fever with severe headache, a 
swelling on left side of head, beginning one inch 
above mastoid process and extending up to middle 
of parietal bosse. Transverse diameter below was 
12 lines, above, 9 lines; thickness below, 8 lines, 21 
above, 3 lines. Surface convex and smooth, but skin 
thinned in several localities, and of a transparent 
blue; base not movable; temperature normal; not 
sensitive to touch; consistency uniformly soft. Pa- 
tient complains of a deep continued pain, accompa- 
nied by a pulsation extending into ear, but ceases 
when lower part of swelling is compressed. Later 
there was observed at lower third a simple rising and 
falling of the tumor synchronous with cardiac pulsa- 
tions, with a blowing murmur. After death the swell- 
ing disappeared, there being in place thereof a net- 
work of empty veins, varying from the size of a thread 
to a pigeon quill, which intercommunicated freely, 
and finally ended in a common trunk the thickness 
of a goose quill. This passed through the galea 
aponeurotica capitis at lower and posterior edge of 
the parietal bone, piercing the bone, and finally open- 
ing into the transverse sinus, where it lies on inner 
surface of the temporal bone. There was meningitis, 
and all the cranial sinuses were filled with partially 
suppurating clots, although there was no disease of 
the sinus walls. 
The following record of Hecker (Varix Spurius 
Circumscriptus Vftnje diploicae frontalis, etc. Erfah- 
rungen und Abhandlungen im Gebiete der Chirurgie 
und Augenheilkunde, Ss. 151-155, with illustrations, 
Erlangen, 1845), especially illustrates the theory of 
slight traumatism in the production of osseous atrophy : 
H. G., set. 43 years; a factory hand; bileo-san- 
guineous temperament; of habitual good health, ex- 
cepting several attacks of pneumonia; had on right 
side of forehead a distinctly fluctuating swelling, ap- 
pearing gradually after certain movements and exer- 
tions, and which could be made to appear and 
disappear rapidly. It arose during the first year of 
life, after repeated blows received on head against a 
wooden floor in learning to walk. No effect resulted 
from remedies applied at that time. Notwithstanding 
the swelling increased with years the patient refused 22 
medical aid, because he had become accustomed to 
the insignificant annoyance which it caused— there 
being not the slightest mental trouble. For many 
years it remained in statu quo. In 1834 he received 
a stab in tumor with a pitchfork. Severe hemor- 
rhage lasting for half an hour followed, but stopped 
spontaneously; and with the exception of remain- 
ing scar there resulted no inconvenience. When 
fully distended the skin covering becomes dark blue, 
with little spots of capillary enlargement over surface; 
it is also painless on pressure, somewhat tense, plainly 
fluctuating, and can be caused to disappear at once 
by light pressure of the hand. No bruit. Transverse 
diameter of the fully distended tumor is three aid 
one-fourth inches; vertical diameter three inches; 
circumference at base eight inches; height two inches. 
It occupies almost entire right side ol forehead, 
slightly encroaching upon left side, and consists of 
two parts, one within the other as it were, irregularly 
separated by a circular shallow depression; the larger 
or main tumor being size of an apple, and of blue 
color; the smaller is less prominent and of normal 
color, and gradually passes out into surrounding 
healthy skin. All movements interfering with return 
of venous blood from the head cause the growth to 
enlarge, as coughing, sneez ng, straining, etc., but 
this enlargement is scarcely up to one-half its capac- 
ity, and subsides on cessation of the effort. No 
effect produced by holding breath. It augments to 
greatest extent and most rapidly by forward and 
backward bending of head, deep and continued ex- 
piration, pressure upon neck, and especially com- 
pression of jugular veins. The filling of tumor by 
bending head forward is accomplished in two min- 
utes; by pressure upon right jugular vein in one 
minute; and by pressure of both jugulars a little 
more rapidly. Although compression of left jugular 
causes the complete distension of the growth, yet 
only one-third of the tumor fills rapidly; and gener- 23 
ally one-half of the tumor swells faster than the other, 
which is notably slower in distending. Expansion 
begins by undulating movements a half inch above 
orbital rim at the lower and sloping edge of tumor. 
Only when distension is complete does patient com- 
plain of sensation of tenseness and dizziness. If 
head is now brought erect or if deep inspiration is 
taken, the swelling disappears spontaneously in the 
space of a minute, thus subsiding twice as rapidly as 
it developed. Light pressure effects reduction in 
ten seconds, and when reduced the walls form a 
loose, bagging sac, which hangs down one-half inch 
over brow; and above is distinctly felt, occupying the 
right half of forehead, a crescentic depression with 
horns looking downward. A pulsating vessel is also 
felt, corresponding to the supra orbital artery, and 
which causes pulsation of empty sac. More careful 
examination also discloses a circular opening in ex- 
ternal table, of the diameter of two and one-half 
inches, surrounded by a sharp osseous ring, but this 
absence of the outer table is not shown to be a com- 
plete perforation through the entire thickness of the 
skull. Therefore, just beneath the skin lies the dip- 
loic structure, on which is plainly felt nurfi'erous osse- 
ous projections from the size of a lentil to a pea, partly 
smooth and partly rough, together with depressions 
or real furrows—apparently the bony canals in which 
run the frontal diploic veins. About middle of this 
opening but nearer to supra-orbital ridge, there is a 
prominent osseous projection, in the point of which 
there is an apparent opening, and which is painful 
when roughly handled. Attempts at compression 
had no effect upon tumor. The growth is, therefore, 
a cutaneous blood-pouch which communicates by 
means of the frontal diploic veins with the intra- 
cranial venous circulation. Operative interference 
considered doubtful and hazardous. 
Hecker employed this term of “varix spurius cir- 
cumscriptus venae diploicae frontalis ” on the sugges- 24 
tion of Stromeyer, who chose the apellation from the 
analogy which the lesion seemed to bear to circum- 
scribed false aneurism. In a later work (Deutsche 
Klitiik, Bd. ii, S. 160, April 13, 1850), however, 
Stromeyer considers this title inappropriate, both on 
account of its length and the insufficient designation 
or description of the actual character of the growth 
which it conveys. Again, traumatism being, so evi- 
dently, a primary causative factor here, this case 
would appear to belong to the third or traumatic 
group; but it must be remembered that in the classifi- 
cation adopted, the traumatic class is composed alone 
of cases resulting from direct cranial fracture or su- 
ture separation. 
The following, which is the case6 of MM. Nelaton 
and Richard, was presented by Richard to the Soci- 
de Chirurgie, Oct. 1, 1856; and was afterwards 
examined and fully and carefully reported by Dupont 
(op. cit., p. 28): 
B., laundress, jet. 19 ; moderate stature and 
strength; chestnut hair; born at Signier (Mauche); 
admitted Sept. 22, 1856, to l’Hopital des Cliniques, 
bed 4 of woman’s pavilion, during the time that M. 
Richard had charge of the service of M. Nelaton, in 
the absence of the latter. 
No hereditary trouble in either herself or family. 
No serious attack of illness except one when 4 or 5 
years of age, and and which was evidently some 
‘ sweating fever.’ In 1848, when 11 years old, she 
was seized with a violent throbbing frontal headache, 
which deprived her of sleep and lasted her the entire 
night. 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 so doing discovered that 
there was a soft point on top of head as large as a 
five-franc piece. In reply to questions, her mother 
informed her that it had existed ever since her sick- 
8 Reported in my previous paper. 25 
ness at the age above mentioned, at which date she 
first discovered it. Thus it is probably of congenital 
origin. She is subject to headaches, but which are 
uninfluenced by the menstrual epochs. Tumor has 
been increasing since 1853. 
Examination now presents the following charac- 
ters : It is situated at the summit of occipital region 
over saggital suture, at superior angle of the occipital. 
When head is erect tumor is not visible, and no pro- 
jection evident to the touch, but when head is carried 
forward or backward the tumor immediately appears, 
and is globular and voluminous, with a base of 
to 7 cm. in diameter. Uninfluenced by cough or 
respiration; but any exertion causes it to rise and 
become apparent, but again subsides on cessation of 
effort. It is soft and fluctuating; no pulsation or 
bruit, and artificial reduction not followed by cepha- 
lic symptoms. Reduction easy; sensation that of a 
pouch full of liquid which is emptied steadily and 
rapidly. Compression of internal jugular veins, even 
when head is erect, causes a rapid filling of tumor. 
Circular by string tied around the 
head, and the jugulars compressed, the tumor appears 
quickly and to full size. Border of tumor smooth 
and nearly regular. Palpation shows two or three 
depressions which might permit intra cranial com- 
munication ; curvature of skull unaltered; coverings 
normal, and without oedema or infiltration. Incon- 
venience complained of is vertigo, which is produced 
by stooping or any sudden or extended movements 
of head. Drowsiness followed manipulation of the 
tumor. Only treatment adopted was that which 
would control increase of the growth. Patient now 
lost sight of until December, 1857, when she stated 
that she had been pregnant and was then a mother. 
After accouchement she had an attack of facial ery- 
sipelas, accompanied by intense fever and delirium. 
She had taken no precautions to arrest progress of 
tumor, and hence it was now found to be modified. 26 
These changes are: Increased in all diameters; sur- 
face of bone no longer normal in curvature, but is 
irregular, as if a chip of bone had been raised up 
from cranial vault, especially at anterior border. In 
the general depression the finger easily demonstrates 
four smaller depressions in the bone, two in the me- 
dian line and one on each side of that line. The 
median depressions are thus disposed : The first is 
circular and placed immediately behind anterior bor- 
der of the tumor, has a diameter of cm., and 
admits end of finger pulp. The second median de- 
pression is located i)4 cm. behind the first, and has 
a diameter of cm. only. The left lateral depres- 
sion is directed from before backward and from left 
to right, has the form of a cleft of less than J4 cm. 
in width by i cm. long ; its posterior extremity ex- 
tends to within t cm. of the median line and to i 
cm. behind first depression. The right lateral de- 
pression is on the same level with the left one, but it 
is circular and is less than J4 cm. in diameter. The 
anterior median depression has thus modified the 
external appearance of the tumor, which is now not 
regularly globular, but resembles the hilus of a kid- 
ney. Circular compression does not prevent filling 
of the tumor; and again closing the four osseous 
openings with the finger tips, and then inclining head 
forward, the tumor expanded with same rapidity, 
showing that there were other unrecognized commu- 
nicating orifices in the bone. 
January 24, 1858. Tumor now increased in size 
on its left side, at which locality a smaller tumor (1J4 
cm. in diameter) had formed in connection with it, 
and communicated with the larger tumor. 
This case of MM. Nelaton and Richard is consid- 
ered by them of probable congenital formation, but 
a careful analysis of the history and symptoms given 
leaves no doubt of its spontaneous origin, and which 
was the result, in all probability, of a rarefying oste- 27 
itis, due to some trivial blow, about the time of the 
serious attack of illness in her infancy. 
Under the subdivision of “Varix Verus Circumscrip- 
tus,” already alluded to, Victor Bruns (Handbuch der 
Praktischen Chirurgie fur Artze und Wundartze, Bd. 
i, Abtli. i, S. 191, with atlas of illustrations, Tu- 
bingen, 1854), mentions an example met with in his 
own practice: 
A farmer, 36 years old, has observed for the last 
three years the gradual formation of a swelling on the 
forehead to left of median line, which is alternately 
larger and smaller, and sometimes even disappears. 
He can trace it to no cause. It is entirely painless, 
firmly located near the middle line in the course of 
the left frontal vein, which latter, when filled, together 
with its bifurcation over the swelling, is plainly visi- 
ble. The tumor is of size of one-half of a hen egg; 
becomes filled and distended when stooping, as, also, 
under all conditions interfering with return of venous 
blood flow from the head; can be instantly reduced 
by light pressure by the fingers, and when reduced 
there is distinguished in its site a perceptible depres- 
sion in the cranium, which on right side is bordered 
by a padded osseous rim. Pressure upon the venae 
frontales below the swelling does not cause its dis- 
tension, neither does pressure from above prevent 
tumor from being emptied. (Vide fig. 13, Abth. 1, 
Taf. iii, of Atlas.) 
In conjunction with this case Bruns details a sec- 
ond instance; but careful examination of this latter 
one shows it to be simply a cutaneous venous varix 
with no indication of intra-cranial communication, 
hence I do not consider it is entitled to occupy a 
place among the present order of tumors. 
In 1855 Dr. John S. Andrews reported a case of 
“ Tubercular Encephalitis with Pulsating Tumor on 
the Occiput” {New York Journal of Medicine, new 
series, vol. xv, pp. 356-361, November, 1855): 
Lamartine Bovay, born in 1848, of healthy pa- 28 
rents. Birth natural and head unusually symmetri- 
cal. Mind always active and very bright. Up to 
age of ten months he was very well, but at that date 
an eruption, following vaccination, appeared on his 
face and spread over surface; and as this subsided, 
dysentery ensued, followed by some pulmonary com- 
plication, which, in turn, was followed by glandular 
enlargements of neck and soreness behind ears, last- 
ing several months. In the ensuing February he was 
attacked with a so called intermittent neuralgia, char- 
acterized. by severe occipital pain, stiffness of neck, 
and fever, which continued for three weeks. Similar 
attacks followed up to 1854, when some lung affec- 
tion again manifested itself. This subsiding, the neu- 
ralgic symptoms again appeared, and were severe 
and erratic. The finale of this was the appearance 
of a pulsating tumor on back of head, attended by a 
gradual loss of sight in left eye. Under treatment, 
lasting from May to September, his health improved, 
the tumor disappeared, but no visual change. He 
remained in tolerable health, except headaches caused 
by excitement, etc., until May 7, 1855, when another 
neuralgic attack appeared with same previous symp- 
toms; and about the fourteenth day of this seizure 
there was slight unconsciousness. He now was ex- 
tremely prostrated, suffering agonizing pain in back 
and left portion of head. Veins of head full and 
enlarged, eyelids closed, pupils sensitive to light but 
eyes amaurotic. Hyperesthesia. There was an in- 
dentation in occipital bone where tumor had appear- 
ed. A few days later tetanic convulsions, lasting 
several hours, supervened, and shortly thereafter the 
tumor again appeared, and he died five days later by 
increasing coma. 
Autopsy—eighteen hours after death. On detach- 
ing scalp a number of large distended veins were 
observed about middle of occipital bone. Just be- 
low the external occipital protuberance was found a 
depression about one-third inch in diameter and one- 29 
fourth inch in depth. This was the location of the 
pulsating tumor, and corresponds with the intra cra- 
nial part known as the torcular Herophili. Covering 
this depression in the bone was a membrane which 
appeared to be formed of the thickened walls of a 
distended vein, and on incising it venous blood freely 
escaped. This opening proved to be a complete 
foramen piercing the bone, about size of a crow- 
quill, and there was no doubt a free communication 
between the sinuses of the brain and the enlarged 
external vein. Brain showed tubercular deposits, ef- 
fusion in membrane cavities and ventricles, in a 
word, tubercular encephalitis. 
At a meeting of the Surgical Society, held Nov. 
23, 1859, M. Verneuil reported the following case in 
behalf of M. le docteur Jules Dubois, Me'decin Ad- 
joint de l’Hotel Dieu d’ Abbeville (.Bulletin de la 
Societe de Chirurgie de Paris, t. x, p. 238, 1859) : 
Case of a Blood-Tumor of the Vault of the Cra- 
nium in Communication with the Longitudinal Sinus.— 
B. (Jean) born at Guer (Morbihan) April 8, 1833, 
of fine constitution, habitual good health, and with- 
out syphilitic manifestations. Belongs to 9th regi- 
ment Chasseurs. On May 8, 1859, he applied to be 
relieved of a wen situated on forehead between eye- 
brows. An ovoid tumor, about size of a hazelnut, 
very mobile, soft and pliable to the touch, non-fluc- 
tuating, of a slightly violaceous color, occupied the 
space comprised between the nasal eminence of fron- 
tal bone and border of true nasal bones on one side, 
and between root of brows on the other. No pul- 
sation, no expansion, no rising, no venous varicosi- 
ties in the vicinity. Light and moderate but contin- 
uous pressure caused complete disappearance of tu- 
mor, leaving nothing between the fingers but a little 
core-like substance about size of a lentil, soft and 
movable. A minute exploration after reduction dis- 
closes a thin pedicle which appears to spring from 
fronto nasal suture, but could not find any commu- 30 
nicating opening or appreciable fissure. Compres- 
sion being removed (patient in upright posture), the 
tumor returned gradually to its primitive volume. 
Reclining on back caused tumor to be diminished 
four-fifths in circumference; but it augmented and 
became distended, on the contrary, when the head 
was inclined forward. Compression and reduction 
produces no trouble whatever. Interrogated as to 
the cause and formation of the growth, he said that 
about five years before he received a blow between 
the eyes from a stone violently hurled. There was 
no other symptom besides a thrombus, which disap- 
peared by degrees, leaving, however, for quite a long 
time a slightly hard swelling, sensitive to pressure, 
with a heaviness of the head, but without pain. It 
was only at the beginning of this year (1859) that he 
felt for the first time a swelling which rolled under 
the skin. It was now of the volume of a pea, but 
increased gradually. It produced no trouble what- 
ever, and his only desire to have it removed was on 
account of its unfortunate location. Accurate and 
well applied pressure with a roller bandage was to- 
tally insufficient, and had to be removed the follow- 
ing day. On May 17 he was sent to the Hotel Dieu 
d’Abbeville, that my colleagues might see the case. 
He entered the service of Dr. Vdsignie', who also 
tried continuous pressure by means of forceps ap- 
plied directly to the tumor; but at the end of forty- 
eight hours the patient declared that he could stand 
it no longer; the skin was excoriated, and the tumor 
had pressed out on either side of the clamps, demon- 
strating the inefficiency, if not inutility, of such a 
method. June 18 he returned to his corps, and a 
few days thereafter I found that the coloration of the 
tumor was deeper, somewhat increased in volume, 
and especially that its reduction was not so easy— 
the dorsal decubitis having little influence over its 
volume. This was, evidently, the result of the for- 
ceps-pressure and the handling, for, at the expiration 31 
of a fortnight after being left undisturbed, the tumor 
presented all of its former characteristics. August 
7.—The tumor has progressively augmented in size, 
now equaling a pigeon egg, skin more thinned, and 
of a deeper violet color, and from time to time he 
experiences severe frontal headache, with a benumb- 
ing of the senses; tumor turgescent and less reduci- 
ble. My confreres at the hospital concurred in my 
diagnosis of a sanguineous tumor communicating more 
or less freely with one of the sinuses of the dura ma- 
ter, probably the superior longitudinal sinus. The 
pouch was evidently not single, but it contained, as 
shown after complete reduction by pressure, an elas- 
tic substance or areolar tissue communicating by a 
narrow opening with the sinus. 
A rarefying osteitis resulting from the contusion 
received five years prior to its appearance was, un- 
doubtedly, the cause of this formation. No further 
treatment was employed, because considered either 
useless or harmful. 
In the Gazette des Hopitaux, October 14, 1856, 
Baron H. Larrey reports this case :7 
Val de Grace, ward 29, No. 10.—O. (Antoine), 
musketeer of the 8th Line; aet. 23. Entered in Sep- 
tember, 1856, with a varicose frontal tumor, the base 
of which, almost circular, was the size of a five-franc 
piece, situated on forehead above left eye, partly 
within and partly below the hair. He has no recol- 
lection of ever having sustained any blow or injury 
about the head, and he had not perceived its pres- 
ence until one day, at the age of 11 years, his mother 
noticed the swelling on his forehead. He was super- 
ficially examined by the Army Examining Board, ac- 
cused of possessing voluntary control over swelling, 
and declared fit for service, but trial showed that it 
was impossible for him to wear the shako. At pres- 
ent the tumor is found slightly elevated above the 
skin-level when patient is reclining, or even standing, 
7 Reported in my previous paper. 32 
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, but gives no sensation of 
pulsation. When sufficiently depressed to feel the 
bone beneath there is discovered an irregular or stel- 
lated perforation of the cranium, and only its shape 
prevents the easy introduction of the finger therein. 
Compression causes no pain in tumor itself, but does 
produce a little pain, with mistiness of vision, in the 
eye of affected side. Slight symptoms of cerebral 
compression are produced by pressure upon the tu- 
mor. The day of 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 the meeting of the Societe' de Chirurgie, Paris, 
October i, 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. 
M. Giraldes, at the seance of July 27, 1864, of the 
Socie'te de Chirurgie, briefly related the clinical points 
of this case (Tumeur Vieneuse, Bulletin de la Societe 
de Chirurgie de Paris, 2 Serie, t. v., p. 357, 1864): 
He presented a child with tumor on frontal re 
gion. This growth seems to be formed by the super- 
position of two osseous fragments. Under the influ- 
ence of effort, as, for example, blowing into the hands, 
the tumor swells up; but lightly applied pressure 
completely reduces it. The consistency is soft; the 
bending-over posture augments it; and puncture with 
a pin is followed by the escape of a little venous 33 
blood. There is no pulsation. It communicates, 
probably, with the sinus of the dura. The tumor is 
of five years duration, and appeared after a fall on 
the forehead; other than this there is no assignable 
cause for its origin. A furrow is distinctly felt over 
the point occupied by the growth, and, the tumor 
being reduced, pressure by the fingers over this 
groove prevents its reproduction, notwithstanding 
those exertions, etc., on the part of the child which 
usually causes its increase in bulk. 
In the discussion which followed the presentation 
of this case, some doubt was expressed as to the com- 
munication of the growth with the superior longitudi- 
nal sinus; but the final result was a full concurrence 
in the opinion of M. Giraldes as to the existence of 
intra-cranial association. 
Again, the length of interval between the recep- 
tion of the fall and the appearance of the growth is 
not given, but it is presumable that it did not appear 
immediately upon, or even a reasonably short time 
after, the infliction of the injury. 
The next example is given by M. Simon Duplay 
(Tumeur sanguine de la voute du crane en commu- 
nication avec la circulation Veineuse intra-cranienne. 
Archives Generales de Medecine, vi Serie, t. 29, p. 
94, Janvier, 1877): 
A young girl, moderately well-developed, enjoy- 
ing habitual good health, and having menstruated 
regularly for the past eight months, presented herself 
to me at the Hopital Saint Louis in the month of 
last August. She was born at term, and delivery of 
head natural and without interference. At the age 
of four years the child received a severe fall from the 
second story, which fractured the right clavicle, but 
the mother declares that the head was not struck and 
hence there was no injury to this part. Three years 
later, however, the child struck her head violently 
against a table, but the precise locality of the contu- 
sion could not be demonstrated. About two and a 34 
half years after this second accident the mother dis- 
covered, in combing her hair, the existence of a small 
soft tumor, flattened, situated at the posterior supe- 
rior angle of the right parietal bone, in vicinity of 
lambdoidal suture. During last seven or eight 
months this growth has developed quite considera- 
bly, becoming modified in form, and increasing in 
depth. After shaving the scalp the following par- 
ticulars were demonstrated: On right side of cra- 
nium, in a line uniting the ears in passing over the 
vault of the skull, at about 10 cm. in front of occipi- 
tal eminence, there exists a rather projecting tumor, 
very irregular in contour, with poorly defined limits, 
of a deep violaceous color, skin-covering thinned, 
and measuring about i cin. from before backwards, 
and 7 cm. transversely. It continues outwards and 
downwards on the temporal bone as a prolongation, 
having the appearance of a large varicose vein, slight- 
ly tortuous and bosselated, and, becoming greatly 
lessened in size, terminates in a cul-de-sac behind 
right mastoid eminence. Its entire length is about 
2 cm. It is soft, non-resisting, fluctuating, easily de- 
pressed, and is incompletely reduced under the in- 
fluence of very light pressure. The contents are 
evidently fluid, can be pressed out of the varicose 
prolongation and vice versa; and when the compres- 
sion ceases the tumor and its prolongation gradually 
refill. Upon gentle palpation there is perceived a 
pulsation, very feeble, synchronous with the pulse. 
These are undulations rather than veritable pulsa- 
tions, and there is no appreciable expansion. Again, 
careful and repeated examinations do not discover 
the existence of any of these vague pulsatile undula- 
tions in the varicose prolongation. These undula- 
tions, on the contrary, are greatest at the principal 
centre of the tumor. At the first examination there 
was heard by means of the stethoscope a faint whirr- 
ing, intermittent bruit at the centre of tumor, but 
this could not be verified at subsequent examinations. 35 
Inclining the head forward causes the tumor to aug- 
ment in volume, becomes very hard, and the child 
complains of a vague sensation of pain in the head; 
and the same phenomena are produced with more 
intensity when the head is strongly bent backwards. 
The normal respiratory movements do not exercise 
any manifest influence in the volume and tension of 
the tumor, but these are slightly influenced by forced 
expiration with the nose and mouth closed. Upon 
pressure upon the prolongation, so as to press out 
its contents towards the principal tumor, causes it to 
disappear completely, and it is not reproduced upon 
exertion or forward inclination of the head whilst 
compression is maintained at its junction with the 
principal tumor. Whilst this prolongation is emptied 
in this manner gentle pressure upon the principal 
tumor by means of the hand easily effects its com- 
plete reduction. Circular compression by means of 
leaden strips, etc., demonstrates the non-connection 
of the growth with the vessels of the scalp. The 
cranial wall on which the prolongation rests seems to 
be absolutely normal. One is compelled to admit 
that the tumor communicates directly with the inte- 
rior of the skull or the diploic veins. When com- 
plete reduction of the tumor is produced there is felt 
on the cranial surface a sort of irregularity, which 
feels like an opening, but this is not certain; how- 
ever, it is seen that compression applied by two fin- 
gers to this locality which resembles an opening, ab- 
solutely prevents the refilling of the tumor. When 
reduction is complete the patient complains of a 
little pain in the head, but she experiences neither 
vertigo, giddiness, dazzling, nor roaring in the ears. 
Thetumor is indolent. Active treatment not ad- 
vised. 
The point of notable interest in this case is the 
peculiar venous prolongation terminating in a cul-de- 
sac behind the mastoid process, and which simulates 
a tortuous vein. The undulatory movements syn- 36 
chronous with the pulse-beat were clue, evidently, to 
transmitted cerebral pulsations. 
The last observation, which completes the series 
of cases belonging to the spontaneous class, is that 
of C. H. Mastin, in my previous paper (Annals of 
Surgery, vol. i, No. 4, p. 326, 1885): 
W. D. Penton applied for professional advice 
Sept. 10, 1881. He is a man 35 years of age, laborer, 
married, and the father of several children. His own 
health has always been good, and, with the exception 
of frequent dull headaches, is still excellent. In ap- 
pearance, also, he is moderately robust and vigorous. 
There is no history or evidence of hereditary disease, 
nor is he cognzant of ever having sustained a severe 
fall, or any blow or wound about 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 dis- 
cern 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 the scalp. This 
was painless, compressibleT disappearing entirely on 
pressure, but partially redilating on 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, frequent 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 re- 
mained in statu quo for the past eighteen months. 
As mentioned above, his only inconvenience is an 
harassing 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 
materially influenced by a hearty meal, the recum- 37 
bent and stooping postures with the head below the 
level of the remainder of the body, and after muscu- 
lar 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 local- 
ity indicated, which readily, though somewhat slowly, 
disappears upon lightly made pressure by the finger 
or hand, and leaves in its stead an indentation or 
depression in the skull, occupying the upper extrem- 
ity of left arm of lambdoidal suture. This depres- 
sion is quite perceptible, and is of a triangular funnel 
shape, being wide at margins (large enough to admit 
tip of index finger), and gradually narrowing down, 
apparently, to a single small aperture where it pene- 
trates the bone and emerges into the cranial cavity. 
When the sac is evacuated by compression, the tegu- 
mentary covering is regular, lax, movable, and mod- 
erately thin, and through which the surface of the 
bone is felt to be smooth, and devoid of all percepti- 
ble irregularities 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 hematoma 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 main- 
tained 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 surround- 
ing integument is unimplicated, and there is no other 
lesion of the head. There is disturbed cardiac action, 38 
but both heart and lungs are without organic disease. 
The ophthalmoscope shows the papilla and general 
fundus of both eyes to be normal, although vessels 
of the disc are rather small and narrow. Hearing 
normal. Operative interference deemed inexpedient, 
and hence only palliative measures of a protecting 
leathern pad and avoidance of excessive exertion 
was advised. 
Here was conclusively an example due to a rare- 
fying osteitis originating, in all likelihood, from the 
resorptive action of a Pacchionian granulation. 
III. TRAUMATIC CLASS. 
My researches in the traumatic group have been 
rewarded by the gathering together of several well 
authenticated and important records. 
One of the most typical, as well as the earliest, 
instances, is that related by Percival Pott8 (“ Chirur- 
gical Works,” first Amer. from last London edit., vol. 
i, p. 132, Phila., 1819; also French edition, t. 1, p. 
151, 1760): 
A boy, 8 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 centre of the top 
of his head was a tumor almost the size of a walnut; 
indolent, had a dull kind of pulsation, and palpably 
contained fluid. In the presence of Serjeant Amy- 
and and Mr. Shipton the tumor was divided with a 
knife and a quantity of blood discharged; but when 
the swelling 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 saggital suture was fractured, 
and that a portion of the displaced fragment of bone 
8 Reported in previous paper. 39 
was forced into the sinus, and by the sides of which 
the blood issued forth. Attempts to extract this 
fragment failed. By advice of the consultants, a 
small perforation was made on one side of the su- 
ture, but through this fhe point of the elevator could 
not be introduced so as to remove the broken piece, 
and so the trephine was applied on the other side of 
the suture, but with like result. At last it was de- 
cided 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 tre- 
phine. This was done, but the button of bone came 
away in pieces, and left the original perforating frag- 
ment still piercing the sinus. This fragment being 
withdrawn by means of forceps, a flux of blood fol- 
lowed, but a dossil of dry lint controlled it. The 
patient recovered. 
There are very many cases similar, if not exactly 
analogous, to this case, to be found in surgical liter- 
ature; and among the most striking of which are 
those mentioned by Guthrie (Commentaries on Sur- 
gery, etc., p. 349, Amer. ed.), and M. Mouton (Mem. 
Royal Acad. Surg. of France, Sydenham Edition, 
p. 8). 
M. Azam (Dupont, op. cit., p. 20) reports two 
cases of this accident which came under his observa- 
tion, as follows: 
C.,° age 22; miller, robust; entered the Hopital 
Saint-Andre, service of M. Hirigoyen, Nov. 11, 
1850. Situated on top of the frontal region, a little 
to the right of median line, was a tumor of the di- 
mensions of a large nut. It was irregularly round, 
manifest fluctuation, but no discoloration of 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 irregu- 
larly circular depression across it, with salient and 
9 Reported in my first article. 40 
unequal edges. The patient reduces it easily him- 
self, and it disappears when the head is thrown back- 
ward and reappears with the forward inclination. 
The forward posture cannot be maintained for any 
length of time on account of vertigo, which accom- 
panies this position. No bruit or pulsation, but 
seems a little more tense during the respiratory move- 
ments. I have thought that I perceived an obscure 
blowing sound in the tract of the superior longitudinal 
sinus when tumor was rapidly reduced by the patient, 
but my confreres could not verify it. No pain, and 
were it r ot for the deformity with the vertigo whilst 
bending forward, he would not be inconvenienced by 
its presence. 
As to its origin he reported that, at the age of 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 several days 
thereafter before he discovered this tumor, which has 
always presented its present appearance. He had 
consulted another physician some time previously, 
who made an exploratory puncture, which was fol- 
lowed by a jet of blood. This was easily ariested. 
Nov. 20, M. Hirigoyen punctured it with a lancet. 
Blood spirted out, having all the characters of venous 
blood. A probe introduced now discovered a de- 
pression in the bone and some roughnesses, although 
the bone is not denuded, but covered by a thick, soft 
membrane. No orifice of communication with inte- 
rior of skull is discoverable, but such must exist, and 
is probably with the superior longitudinal sinus. 
Haemorrhage easily controlled, and skin wound 
healed rapidly. Pressure over tumor was employed 
for twenty days without result, and the patient left 
the hospital in an unchanged condition. Saw him 
twice afterwards, the last time in 1857, and tumor in 
same condition. The avoidance of any operation, 
and the use of local pressure, was advised. 41 
The next is the second case10 of M. Azam (Du- 
pont, loc. cit.): 
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 consider- 
able force on the forehead. The pain was intense, 
biit she did not lose consciousness. The apparent 
contusion was relieved by ordinary measures without 
medical attention. Twenty to twenty-five days after- 
wards she recognized the existence of a tumor at 
point of contusion. This was soft, size of a small 
nut, and hardened and increased in volume when she 
lowered her head. No headache. Did not consult 
a physician until after three months had elapsed, at 
which time the skin covering the tumor becoming 
thinner and of a violet color, she consulted M. Gaig- 
nerat, of Bourg, who punctured it, and, according to 
her statement, it bled most profusely, but a bit of 
English taffeta sufficed to staunch it. She presented 
herself now before the Medical Society. At this 
time the tumor, situated on the median frontal line, 
near hair margin, was about the size of the half of an 
ordinary nut; soft and fluctuating; slightly violaceous 
in color; without pulsation or bruit, and conveying 
the sensation of a skin pouch 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 di- 
minishes under pressure by the hand or fingers. It 
is very evident that the fluid passes into the skull. 
After reduction of tumor there remains under the 
skin a soft tissue w'hich prevents any close examina- 
tion of the underlying bone. Punctured it with a 
small trocar; only a small quantity of venous blood 
10 Reported in my first paper 42 
escaped. Manipulating the canula in different direc- 
tions showed that the tumor was not formed of a 
single pouch, but of a spongy tissue composed of 
large cells. This explains 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 discern the opening, nor 
did I recognize any rugosities or denudation of the 
bone. 
The annexed case11 of M. Hutin, which occurred 
at the Hopital des Invalides, is reported by Dr. Gus- 
tave Dufour (Compt. rend, et Mem. de la Soc. de Biol., 
t- hi, p- iS5. i850 : 
Achille Maximilien, Marquis de W., Comte d’I.y 
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 on 
right side of forehead about 3 cm. from median line. 
He remained unconscious for twenty-four hours. 
When he regained his senses he was told by the sur- 
geon 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 the next year he was an inmate of different 
hospitals, and received divers forms of treatment, 
especially local pressure. The ultimate result of the 
wound was an infirmity which incapacitated him from 
following the profession of arms. When he leaned 
forward with 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 uptight position. In 1814 he gained 
admittance to the Hopital des Invalides, and in 1847 
M. Hutin, then becoming surgeon-in-chief, was pecu- 
liarly interested in his case, and added himself the 
following notes to the history of the case : ‘Cicatrix 
11 Reported in my previous paper. 43 
not apparent; osseous depression very marked. The 
conditon is, doubtless, the result of absorption 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 low- 
ered, 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.’ 
I learned that this old man, -notwithwithstanding 
his age of 81 years, was in perfect mental and physi- 
cal health. October 28, 1851. Seized with erysipe- 
las of neck and thorax, complicated with chronic 
bronchitis, and died November 3. 
Necropsy—Head.—No visible traces of erysipe- 
latous action. Normal in size and contour. On 
forehead, 2 cm. below hair margin, and to right of 
median line, is a cutaneous space about 2 cm. in 
diameter, which is rendered distinct from surround- 
ing skin by its rosy color, and this corresponds to a 
clearly outlined osseous depression beneath. Low- 
ering the head now fails to produce the phenomenon 
which was so easily brought about during life. Brain. 
—Sound and without traces of old or recent apo- 
plectic clots; white and gray substance distinct; 
vascular network of pia mater moderately injected, 
but without infiltration, and is easily separated and 
detached from the cerebral convolutions—even di- 
rectly under the 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. 44 
from the median line, where it is adherent to the os- 
seous wall. Opposite to this attachment the bone is 
perforated by several small openings. Injection of 
water and insufflation of air into the superior longi- 
tudinal sinus demonstrates the existence of a patho- 
logical communication of the sinus with the blood 
pouch above. The calibre of the sinus is 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 
prolongations which attach themselves circularly to 
the periosteum on the circumference of the bone de- 
pression, and which depression is lined by a bit of 
cellular periosteum, and is 5 cm. in breadth by 2 J4 
cm. in height. The circumference of the depression 
is formed by a notable thickness of compact bone 
tissue, but its centre is very thin and spongy. The 
fioor of the depression is also divided, by a jutting 
out of compact structure, into two smaller depres- 
sions : the left one extends a little beyond the middle 
line of forehead, is rugose, and is sprinkled with little 
dark openings; the other on right side is more exten- 
sive, and is riddled with minute apertures—entirely 
deprived of its vascular element (diploe) and cor- 
responds to the thinnest of the cutaneous cavity, at 
which point both skin and bone are semi-translucent. 
The frontal suture plainly seen above and below the 
osseous lesion, but especially apparent on the altered 
surface. Finally, the tegumentary coverings are 
thinned, being deprived of all muscular and adipose 
tissue, and composed only of skin re-enforced by a 
delicate lining of fibrous tissue. 
Hutin reports another case12 (Mem. de Medicine 
Mil., t. xiv, p. 232, 2e Serie, 1854): 
K., born in 1771; entered military service in 
1790; received at the battle of Jena, Oct. 14, 1806, 
two sabre wounds on the head—the first on superior 
and middle of forehead, the second on top of the 
12 Reported in my previous paper. 45 
head. Did not lose consciousness; fragments of 
bone extracted; recovery after about nine or ten 
months without any grave symptoms. 
Forty years passed without his being troubled by 
any serious sickness; only suffered from severe head- 
ache. In March, 1846, while 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 24. Carries hand frequently towards 
summit of head to the right of the most prominent 
scar. Pressure here discloses circumscribed fluctua- 
tion and pain which did not exist previously. Diag- 
nosing an abscess, a small incision was made into it, 
but only blood escaped. There was a blood-pouch 
containing a black, semi-coagulable liquid, poured 
out between the osseous vault and the pericranium, 
thus detaching the latter. Attempts to detect a fis- 
sure failed. The day following the dressings were 
soaked with blood; attempts to find fissure still futile; 
extended incision, which brought to view a slow, con- 
tinuous oozing of venous blood from the depths of 
the bony wall and to inner side of the wound. This 
was without pulsation and uninfluenced by the respir- 
ation. 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 bandage arrested haemorrhage. 
Autopsy.—Scalp puffed up and much iryected 
from erysipelatous inflammation. Cicatrix on frontal 
bone adherent to the remains of the frontal suture, 
with marked depression of the integument. At 2 
cm. beyond the fronto-parietal suture and within 
cm. of the saggital, commence the other adhesions 
belonging to anterior region of the second cicatrix, 
and which are equally resisting but of limited extent. 
Below these is the pouch which was incised during life. 46 
This pouch (subpericranial) is about 4 cm. in extent 
from before backwards and 2 cm. from right to left. 
On removal of skull-cap all was found 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 entire 
vault, except at a point corresponding to the wound 
of the vertex, and on each side of the closed saggital 
suture, where it adhered closely to the parietes, but 
without any visible scar. At a point corresponding 
to the external angle of the wound the dura mater 
intimately united with external tissues through a fis- 
sure in right parietal bone. The unclosed opening of 
the bone was about 2 mm. in width by 1 cm. long. 
Longitudinal sinus contained a small quantity of co- 
agulated blood, which was partially dislodged by a 
stream of water—after which was visible a very pro- 
nounced projection in the sinus, passing in a line 
from behind forward and from right to left, and cor- 
responding exactly to the external cicatrix. This pro- 
jection was caused by a depressed thick bone-splinter 
depending from the internal table, and was the result, 
evidently, of the sabre blow—being partially detached 
and thus remaining fixed for many years. This spic- 
ula terminated in a spine which had perforated the 
sinus, and passing through into the lumen maintained 
patulous an opening in its walls about 4 mm. in size. 
Through this opening a small quantity of blood had 
escaped from the sinus, and which, poured out be- 
tween the bone and dura, formed in this locality an 
oblong pouch of 3 X 2 cm. in diameter; but on the 
outside of the skull it had diffused itself between the 
bone and the periosteum, forming the collection which 
had been mistaken and opened for an abscess. This 
external effusion had passed through an opening ex- 
isting in left parietal, cm. in front of and to the 
right of the sharp end of the fragment, and resulting 
from the non occlusion of the bone divided by the 
sabre blow. Hence there was a direct communica- 47 
tion between the superior longitudinal sinus and the 
wound in the integument, for in this fracture there 
were no adhesions between the meninges and the 
pericranium as existed through the anterior fracture. 
The perforation in the superior longitudinal sinus is 
a little to right of median line. 
Stromeyer refers to two examples. The first (Ueber 
Sinus Pericranii, Deutsche Klinik, Bd. n, S. 160, 
April 13, 1850) is transcribed below: 
A boy, 6 years of age. He sustained a fall on 
his head from a considerable height in his second 
year, resulting in a depression of the right parietal 
bone, which extended along the greater part of the 
saggital suture. The point of greatest depression 
was lines. The entire depressed portion was 
covered by a blood-pouch of 2% inches square, which 
when filled was raised about 3 lines. On complete 
emptying the bone was felt, and the outer table was 
evidently poorly formed. Turgescence of the tumor 
is favored by each circumstance which is likely to 
produce congestion of the head, namely: crying, 
coughing, dependent position of the head, compres- 
sion of jugular veins, etc. When child was quiet no 
fluid was discernible in the pouch. 
The second case, of more recent date (Maximen 
der Kriegsheilhunst, note, S. 362, 1861), is thus briefly 
mentioned: 
A cavalryman in 1859 was dismissed from the 
army on account of a blood-cyst located on the fron- 
tal bone. When distended with blood it was the size 
of a pigeon-egg. 
The cause of the growth is not stated in this in- 
stance, but on account of the profession of the pa- 
tient, together with the connection in which it is 
referred to, I have been led to consider it as an ex- 
ample of the form due to direct injury, and thus class 
it as such. 
There are, in addition, cases belonging to the trau- 
matic division, mentioned by Schellmann (“Ueber 48 
Verletzungen der Hirnsinus,” Geissen, Inaug. Dis- 
sert.), and quoted by Bergmann (Deutsche Chirurgie, 
Lief. 30, S. 365, 1880). 
ETIOLOGY. 
The two principal varieties of this lesion recog- 
nized by M. Dupont were these: First, when the 
tumor communicated with the sinus of the dura mater 
through normal skull-openings or canals, as varicose 
venae emissaria passing through their respective fora- 
mina; and second, in which this communication with 
the intra-cranial venous circulation was effected by 
means of abnormal passages. This latter class might 
be due to fracture of the cranium and wound of the 
sinus; perhaps to a non-traumatic or spontaneous 
perforation of these structures; and, finally, to an 
ulceration of the osseous tissue and a vein in the 
situation where such a vein pierces the skull in its 
course to the sinus. 
M. Dufour suggests another condition, that is, in 
which the extra-cranial growth communicates with 
the sinus, either directly or indirectly through the 
medium of the diploic circulation. He considers 
this variety to be especially anticipated in persons of 
advanced years, in whom the diploic veins are greatly 
developed and frequently dilated into venous ex- 
pansions or lacunte. 
The etiological classification adopted by Herman 
Demme is as follows: (i) Rupture of the external 
cranial veins, without scalp wound, resulting in cysts 
which may communicate in various ways with the 
sinus. Thus, a vein emptying into the sinus may 
become torn, and, forming an epicranial or aponeu- 
rotic blood-collection, after the manner of traumatic 
aneurism, communicate with the sinus by this means; 
especially in the case of the large parietal veins which 
penetrate the bone thiough their foramina located on 
either side of the posterior portion of the saggital 
suture. It may occasionally happen, also, that, 49 
under the pressure of the extravasated blood, bone 
resorption takes place, leading to opening of the veins 
of the diploe and through these to a communication 
with the deeper venous blood conduit of the dura. 
Again, the injury producing such an external blood 
collection may itself excite absorption and perfora- 
tion in the position of a Pacchionian fossa or depres- 
sion, and by this method intercommunication between 
the sac arttl the sinus system be established. (2) 
Varices of the external cranial (emissary) veins 
forming cysts which unite directly, through their rel- 
ative openings, with the corresponding sinus. (3) 
Extra-cranial venous cysts resulting from enlarge- 
ment and dilatation of the sinus itself. These are 
produced either by gradual absorption and breaking 
through of the cranial parietes, or they are pushed 
forward and protrude through a normal or preexisting 
opening, like for example, a fontanelle. 
In closing a brief but interesting article on this 
character of formations, MM. Follin and Duplay de- 
clare that with the information before them they can 
admit only two varieties, namely: First, tumors 
produced by traumatic ruptures of the sinus; second, 
tumors resulting from atrophy and perforation of the 
bone in the region of the sinus or of the Pacchio- 
nian cavities. They add, however, that it may be 
possible, although an exception of extreme rarity, for 
tumors of this nature to be produced by a varicose 
dilatation of an emissary vein of the sinus. But, 
they continue, “we may be permitted to express 
some doubts as to the existence of this variety.” 
Bruns describes two forms of varices of the extra- 
cranial veins communicating with the dural circulation, 
under the description of (1) varix verus circumscrip- 
tus, and (2) varix verus cirsoideus. 
Stromeyer believes that these lesions are usually 
produced by a rupture of an emissary vein, resulting 
in blood extravasation and formation of a limiting sac 
beneath the pericranium. 50 
The theory of osseous atrophv—rarefying osteitis 
—first formulated and advocated,I believe, by Simon 
Duplay, is supported by Legouest and Servier, Azam, 
Follin and Duplay, and many others. The initial 
step in this process is claimed to be found in, (i) a 
trivial or even unnoticed traumatism, in the form of 
a contusion; (2) in the erosive action of the Pacchi- 
onian granulations alone; or (3) in both the first 
and second combined—the one being dependent 
upon the other. The final rupture of the rarefied 
osseous point may be accomplished either spontane- 
ously, or caused by some slight shock or blow. 
The se general etiological outlines, as applied to 
the several groups separately, call for a more com- 
plete elaboration. 
A. Congenital Group.—The points and theories 
to be examined relative to the etiology of the con- 
genital cases, mentioned in the order of their seeming 
prominence, are as follows: (a) Aneurismal or vari- 
cose dilatation of one or more emissaria Santorini; 
(b) Localized morbid processes in the structure of the 
sinus wall—a phlebectasia or true varix of the sinus; 
(c) Pathological enlargement and dilatation of the 
venae diploicae; (d) Certain hereditary vices, such as 
syphilis and struma; (e) Developmental arrests, as 
want of closure of a fontanelle, abnormal fonta- 
nelles, etc. 
a. Notwithstanding the questionable opinion ex- 
pressed by some authors as to the role played by 
varicose venae emissaria in the production of this 
form of sanguineous tumor, the preponderance of 
general evidence, clinical and anatomical, is most 
decidedly in favor of such a morbid association, and 
therefore I must claim conspicuous recognition for it 
in this position. In clinical proof of this union the 
cases of Moreau, Mersemann, Aclard, Michaud, 
Stromeyer and Verneuil bear ample testimony; and 
hence not only dispel any serious doubt as to the 
etiological office of such varicosities, but even ac- 51 
cord to this factor a high rank in the causal list of 
the present collection of congenital cases. In four 
of the cases intelligent and carefully conducted post- 
mortem sections, with surgical examination in the 
fifth, demonstrated the real character of the lesion. 
b. Diseased processes in the sinus-wall, producing 
hernial protrusion, or true ectasia, of the sinus itself, 
is upheld by the recorded examples of Demme and 
Foucteau, and probably that of Flint, in two of which 
a necropsy disclosed the extent and nature of the 
tissues involved. In Demme’s patient the micro- 
scope was employed in verifying the post-mortem 
appearances, and in the other (Foucteau’s) one or 
more of the coats of the sinus was clearly recognized 
by the unaided vision as entering into the composi- 
tion of the sac. 
Francke (Lehrbuch der Chirurgie, Bd. n, S. 49), 
expresses the belief that such blood-pouches formed 
at the expense of the sinus wall, can occur only in 
monstrosities and non-viable children; but the above 
instances, especially that of Demme, are fair evidence 
of the incorrectness of his views and statement. 
Furthermore, Velpeau (Gaz. des Hopitaux, t. viii, 
2e Se'rie, p. 87, 1846) mentions having seen in two 
instances (presumably congenital), extra-cranial 
blood-tumors caused by a phlebectasia or hernia of the 
dural sinus; once near the anterior fontanelle, and a 
second time in the region of the occipital bosse. 
c. Disease and enlargement of the diploic vessels 
is represented by the patient of Francke (and several 
others), in whom there was a blood tumor identical, 
apparently, with a frontal diploic vein, and associated 
with congenital resorption or absence of a portion of 
the outer table. 
d. Hereditary syphilis or the rickety diathesis oc- 
casionally finds expression in the production of crani- 
otabes, where areas or spots of softened and thinned 
osseous structure take place in the cranial walls, only 
requiring some slight internal or external pressure to 52 
convert them into veritable skull perforations. Al- 
though this condition is but seldom observed con- 
genitally, 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 aspect is usually the primary seat of 
attack; and that they are generally observed occu- 
pying the posterior parts of the parietal bones— 
about the position where one form of this venous 
tumor is most frequent; and, too, in which neighbor- 
hood the Pacchionian bodies most abound. 
Parallel with this observation the so-called gelatin- 
iform degeneration of the outer table of the skull 
(Parrot) must be referred to, as offering points for 
consideration in this study. 
e. The influence of certain developmental arrests 
suggests a field for inquiry. 
These may be shown in want of closure of the 
normal fontanelles, thus facilitating hernial protrusion 
of the dural sinuses; and in abnormal fontanelles, as 
absence of ossification in the ossa Wormiana. Against 
the latter, however, in those instances where the 
growth is situated centrally and anterioily on the 
head, may be urged their extreme infrequence in the 
median part of the cranial vault. 
Another condition having a possible, if not prob- 
able, relationship to the etiology of the congenital 
class, is to be found in traumatism from head press- 
ure during parturition. 
A wound or rupture of the sinus may occur at 
birth, as stated by Bergmann (Deutsche Chirurgie, 
Lief., 30, 1880), when the overlapping of the cranial 
plates, in the line of their sutures, exceeds a certain 
limit—an occurrence that, in spite of the great 
changes in shape and size to which the foetal skull is 
subjected in a narrow pelvis, must be considered 
rare. He mentions also that Litzmann (Ueber den 
Einfluss des engen Beckens auf die Geburt im Allge- 
meinen, in Volkmanris Satnmlung Klin. Vortrdge, 53 
Nr. 23, S. 191. 1871), saw the sinus longitudinalis 
twice torn during labor in cases of generally con- 
tracted and flattened pelves,where the pressure from 
the promontory upon the already compressed head 
was so great as to force the sharp j errated edge of 
the saggital suture through its tense coverings. Both 
children died shortly after birth. 
Similar cases are reported by Michaelis (“Das 
enge Becken, noch eignen Beobachtungen herausge- 
geben von Litzmann, Kiel, 1865), Weber {Beitrage z. 
pathol. Anat. der Neugebornen, Lief. 1, Kiel, 1851), 
Olshausen {DeutscheKlinik, S. 365, 1864) and C. Hen- 
nig (Die Kopfblutgeschwulst, in Gerhardt’s “ Hand- 
buch der'Kinderkrankheiten,” Bd. ii,S. 54). Again, 
the same injury of the transverse sinuses was met with 
by Weber (loc. cit.) and Breisky (Prager Viertel- 
jahrssclirift, Bd. 63, S. 178). 
Under such circumstances where there is a limited 
wound of the sinus, particulary if the external tissues 
or scalp escape implication, it is easy to appreciate 
how this character of tumor can be thus originated. 
Finally, it should be noted that in all the clinical 
cases belonging to the congenital group which were 
positively determined by post-mortem dissection 
(varicose vente emissaria, ectasia of the sinus, and 
dilatation of the diploic veins), the lesion had its ori- 
gin, apparently, in a morbid action of the vein-wall 
itself, namely : a venous hypertrophy and phlebectasis. 
B. Spontaneous Group.—The several explanations 
proposed as to the origin of the spontaneous group 
maybe summed up in the subjoined arrangement: 
(a) Absorptive or erosive action of the Pacchionian 
glands; (b) An obscure form of osseous resorption, 
or rarefying osteitis; (c) Varicosities of the venae 
emissaria; (d) Localized morbid processes in the 
sinus wall, producing bone absorption, and conse- 
quent hernial protrusion of the sinus; and (e) Cer- 
tain constitutional or systemic vices. 
a, b and c. As previously referred to, two forms 54 
of osseous implication were recognized, that is, bone 
resorption dependent upon two separate and distinct 
causes, namely: an osseous atrophy resulting from 
the absorptive or erosive action of the glanduke 
Pacchioni, and a, rarefying osteitis due to some re- 
mote contusion. Careful investigation, however, has 
determined me to include the two forms under the 
single title of rarefying osteitis, since it is very prob- 
able that the osteitic changes ascribed to the action 
of the Pacchinonian granulations are very similar 
to, if not identical with, those resulting from bone 
contusion, especially as the history of a blow or fall 
is often associated with the special individual action 
claimed for these glandular bodies. 
Furthermore, the bone resorption resulting from 
localized diseased processes in the structure of the 
sinus itself, followed by a true sinus varix or ectasia, 
is, doubtless, closely allied to the above forms of 
osteitis, and, hence, this should be comprehended, 
also, under the single form mentioned. Therefore in 
the following remarks I shall speak of one variety of 
osteitis only as produced by the three above named 
factors. The hypothesis of a rarefying osteitis with 
spontaneous perforation in the so-called spontaneous 
cases was suggested by M. Simon Duplay (vide Du- 
play, also Follin et Duplay), who formulated his theory 
upon the researches of Trolard upon the venous sys- 
tem of the skull and brain. This author (Recherches 
sur l’Anatomie du Systeme Veineux du Crane et de 
l’Encephale, Archives Gen. de Med., t. i, Mars, 1870) 
described as situated on the lateral parts of the supe- 
rior longitudinal sinus, certain areolar venous spaces 
or lacs sanguin13 corresponding to the fovea glandu- 
lares, limited on one side by the osseous surface, and 
which, bathed by the venous blood, communicate 
13 These structures were described, prior to the publication of Tro- 
lard, by Cruveilhier, Luschka, Henle and Meyer They are designated 
as lacunar lateralis sinus by Key and Retzius, and have received also 
from Browning the euphonious term of Parasinoidal spaces. 55 
freely with the superior longitudinal sinus and the 
venous canals of the diploe. 
A brief resume of the theory advocated by Duplay 
is as follows: The osseous lesion is the first degree 
or stage of the morbid formation. The bone is sub- 
jected to a blow or fall—a contusion—which produces 
a partial localized atrophy of the skull. This atrophy 
of the cranial bone is not extremely rare, occurring 
at all ages, and often taking place in limited areas or 
spots, particularly on the lateral parts of the superior 
longitudinal sinus over the fossae lodging the Pacchi- 
onian glands, and in which, also, are these spaces or 
lacs sanguins communicating freely with the sinus, 
and upon which anatomical disposition the theory is 
based. Thus, taking one of these points, atrophy is 
developed consequent upon a trivial blow and pro- 
gresses steadily, reducing the bone to an exceedingly 
thin lamina, until spontaneous perforation is pro- 
duced, or perhaps more frequently, a slight secondary 
contusion or shock may supply the rupturing force, 
and an opening into one of these venous spaces or 
lacunae is effected. By this means intercommunica- 
tion with the sinus is established, venous blood es- 
capes and is effused beneath the periosteum, the 
tissues are floated up, and this type of blood-tumor 
of the cranial vault is the result. “It is thus, prob- 
ably, that one would be able to explain the relation 
ascertained to exist in nearly all cases between the 
development of the tumor and the previous action 
of a blow or fall.” 
This theory of a rarefying osteitis in spontaneous 
cases is accepted in full by Legouest and Servier; 
and these authors even apply it to a more extended 
field than that claimed by Duplay, since they assume 
that the same theory is applicable to the pathogeny 
of analogous tumors developed in other portions of 
the cranium—first when occurring over the mastoid 
cells or the frontal sinus, a pneumocele resulting; 
or, second, even the diploic structure may become 56 
involved. In explanation of the latter involvement 
they refer to the existence in the diploe of ramifying 
cavities, lined with the internal venous coat (intima), 
communicating as freely with the dural sinus as vvith 
the extra-cranial circulation. These diploic canals 
constitute, especially in old persons, a continuous 
system which unites abruptly with four or five princi- 
pal confluents passing to the cavernous sinus, the 
ophthalmic vein, the middle meningeal vein either 
directly or through the intermediary of the posterior 
condyloid vein. It results, therefore, that the wear 
of the cranial table opposite to these confluents may 
give rise to the development of a sanguineous tumor 
in communication with the intracranial venous 
circulation without the longitudinal sinus being 
perforated. 
M. Azam believes that traumatism is always the 
point of departure of a rarefying osteitis; and Du- 
four also considers the abnormal communication to 
be caused by an obscure form of osteitis, followed by 
interstitial resorption of bone, the probable conse- 
quence of a trivial contusion. 
Many authors rather question the possible role as- 
cribed to the Pacchionian granulations of producing 
atrophy and skull perforation, among whom may be 
mentioned Meyer, of Hamburg ( Virchow's Archives, 
Bd. xix, p. 171), whose rich experience in this field 
of inquiry entitles his opinion to consideration. Not- 
withstanding very elaborate investigation and exam- 
ination of these bodies he has failed to encounter a 
single instance in which the fovea glandulares of the 
calvarium extended to actual perforation. 
But, on the other hand, some writers advocate this 
theory, giving it decided preference over any other, 
as shown by the opinion of I)r. Gross (System of 
Surgery), who asserts that “ the most common cause 
of the abnormal communication is spontaneous, pro- 
gressive absorption of the osseous tissue correspond- 
ing with the Pacchionian depressions, when, under 57 
the influence of slight traumatism, the blood escapes 
beneath the pericranium.’* 
Again, as a direct example of this character of 
perforation accompanied by a rupturing force or 
shock, the following case mentioned by Demme will 
be found of special interest and importance: 
A robust man falling from a high building scaffold 
received numerous severe injuries which proved fatal 
in ten hours. At the autopsy there was discovered a 
large blood effusion extending over the posterior part 
the saggital suture, and which was found to be, for 
the most part, beneath the periosteum. After care- 
fully washing the clot there was shown to exist, on 
the left side of the saggital suture, a sharp-edged 
opening the size of a cherry stone, through which 
protruded a Pacchionian granulation covered over 
by coagulated blood. On removal of the skull-cap 
a second coagulum was observed interwoven with the 
meshwork of the large Sickel sinus, and which (the 
sinus) communicated directly with the extra-cranial 
haematoma through this resorptive opening of the 
Pacchionian gland. My examination left no doubt 
in the matter that the intra-cranial haemorrhage 
arose from a rupture of one of the numerous venous 
vessels tearing through the fibrous walls of the 
sinus. 
In further support of these views I may refer to 
those obscure alterations and perforations occasion- 
ally met with in the petrous portion of the temporal 
bone, sometimes opening the tympanic cavity, which, 
according to Luschka, like the fovea glandulares of- 
the calvarium, are not improbably the result of press- 
ure exerted by these villous-like vegetations. 
Typical examples of this pathological process (rare- 
fying osteitis) are furnished by the cases of Bruns, 
Hecker, Dubois, Giraldes, and Duplay, for, although 
not positively demonstrated to exist by post-mortem 
sections, they have the history of a contusion fol- 
lowed after a delayed period by the appearance of 58 
the tumor, together with the subjective symptoms to 
be anticipated under such circumstances. 
The cases of Bruns, Dubois, and Duplay were re- 
garded as being connected with the sinus either im- 
mediately or through the medium of the diploic canals. 
But all the symptoms seem to indicate to my mindr 
that Bruns’s case was associated with the veins of the 
diploe, whilst those of Dubois, Giraldks and Duplay 
were,doubtless,in direct communication with the sinus. 
On the other hand, the patient described by Hecker 
was suffering clearly from a blood-pouch first com- 
municating with the diploe and then leading to the 
sinus—the result of extensive cranial loss. Hecker 
explains the origin and formation of this case (varix 
spurius circmnscriptus vence diploicce frontalis) about 
in this wise: In consequence of a fall on the head 
in infancy a separation of the outer cranial table was 
produced with tearing of the diploic vessels, which 
is easily explained from the thinness of the external 
table and the great vascularity of the infantile skull. 
The blood escaped now from the diploic veins into 
the adjacent cellular tissue under the skin, and as the 
repair of the vein-rupture (perhaps on account of 
anatomical conditions) wras not effected, the haemor- 
rhagic effusion continued until the cellular tissue be- 
came ipfiltrated and, as it were, consolidated. Now, 
however, this consolidation forming a barrier against 
further bleeding, a pouch with well-defined walls was 
finally formed, which, gradually but more or less com- 
pletely filled with blood, emptied its contents, by 
means of the supra-orbital foramen, into the external 
cranial veins, especially the vena supraorbitalis. Os- 
seous absorption rapidly supervened, and the tumor 
reached its present limits. 
Hernia or ectasia of the sinus is shown in only one 
instance, namely, the specimen of the Jacobi. There 
is considerable doubt expressed, however, by several 
authors, whether it was of congenital or spontaneous 
formation, but both Bruns and Demme are decided 59 
in their opinion as to its being spontaneous. Here, 
also, as before suggested, it is more than probable 
that osseous atrophy was the active element in caus- 
ing the skull opening. 
c. Varicosities of the vence emissaria is exemplified 
in the cases of Melchiori and Andrews, in both of 
which necropsies disclosed the morbid changes. 
Dr. Andrews gives this solution of his case: A 
small vein penetrated the skull (occipital emissary 
vein) communicating with the torcular Herophili and 
the scalp, and the protracted determination of blood 
to the brain produced enlargement and distension of 
the torcular,—this emissary vein also receiving a pro- 
portional increase in its calibre. Like the continued 
drop wearing a stone, so the oft-repeated vis a ter go 
expansion wore the bone, producing the pulsating 
tumor (in thus dilating the vein) and the large fora- 
men in the skull. 
In regard to spontaneously arising single or cir- 
cumscribed dilatations of the external cranial veins, 
Bruns (Op. cit., p. 191) expresses the opinion that 
they are extraordinarily infrequent. This assertion 
is based upon his personal experience of two cases, 
with one other which he had found recorded. 
e. Constitutional and systemic vices—more espe- 
cially syphilis and struma—deserve notice as occu- 
pying a possible causal position. Such is manifested 
in those osseous changes already referred to in the 
congenital group; but in this category there should 
be included, also, any systemic condition predispos- 
ing to bone alteration or degeneration. Further- 
more, it is quite possible that, in cases of rarefying 
osteitis, there is often some constitutional condition 
—a predisposition—which renders the osseous tissue 
peculiarly susceptible to the taking on or lighting up 
of this atrophic process upon the reception of a con- 
tusing force. Suggestive of this is the case of MM. 
Nelaton and Richard, in which the growth was not 
discovered until after a severe illness of the patient. 60 
C. Traumatic Group.—Direct traumatism is the 
essential element to be recognized in the etiology of 
this class, and the necessary conclusion deduced 
therefrom is that, in all traumatic cases fracture is, 
practically, invariably present, wounding the sinus- 
wall by, (i) either depressed fragments or detached 
spiculae, as in any comminuted fracture; (ii) by 
punctured fractures, the instrument used in such 
fractures also penetrating the underlying sinus; (iii) 
by the separated sharp edges of the fractured bone, 
especially if the line of fracture passes across the 
suture to which the sinus is attached; (iv) the sinus 
may be torn through by a disjunction or separation 
of the sutures over the sinus, particularly the sagit- 
tal suture. 
There is, however, another method by which this 
lesion may be possibly caused where fracture is not 
a necessary accompaniment, namely, rupture or tear- 
ing of the sinus without fracture or suture-separation, 
produced by certain decided changes in the form of 
the cranium resulting from heavy blows inflicted by 
some broad, flat instrument (Bergmann). I have no 
record of an example so produced, but the injury 
demands notice as standing in the category of possi- 
ble factors. 
From this last character of injury experience shows 
that the transverse sinuses tear more frequently than 
the longitudinal, which is explicable not only on the 
ground of their anatomical location and connections, 
them much more fixed and unyielding than 
the latter, but also in the fact that the cause resides, 
perhaps, in the direction of the rupturing forces, 
which commonly operate from above and behind. 
Thereby the cranium is compressed from above 
downwards, but expanded laterally,—an expansion 
which must cause great stretching of the transverse 
sinuses, and, as seen, a giving way, occasionally, of 
their walls. On the other hand, rupture of the torcular 
Herophili is, of all the sinuses situated directly be- 61 
neath the cranial walls, the most rarely met with. 
It should be noted, also, that in the analysis 
of the seven traumatic cases, six are characterized 
by the absence of external or integumentary wound, 
and in only one is the fracture open or compound. 
Hence this preponderance of subcutaneous or simple 
over compound fractures in association with this injury, 
must be mentioned as a point of special interest. It is 
necessary to remark, however, that investigation has 
shown that laceration of the sinus from cranial frac- 
ture with depressed bone-splinters, without simulta- 
neous scalp wound, is comparatively rare. Never- 
theless, in one of Stromeyer’s cases it is important 
to refer to the fact that it was a child who had his 
right parietal bone depressed, from a blow the result 
of a fall, without cutaneous wound, furnishing an- 
other instance of injury of the sinus from a simple 
fracture. 
Fortunately the collected cases represent a goodly 
number of authentic post-mortem sections, together 
with valuable surgical examinations; and consequent- 
ly, these furnish pathological data of a character suf- 
ficiently definite to enable, it is believed, the formu- 
lation of rational and decisive conclusions—conclu- 
sions which are also added to and strengthened by 
marked symptoms and conditions, as manifested by 
numerous clearly analyzed cases without post-mortem 
demonstration. 
A rapid rehearsal of the anatomical facts collect- 
ively, before entering into the examination and con- 
sideration of individual pathological points, seems 
advisable. 
Moreau’s Case.—There was a venous varix formed 
of congeries of veins, terminating in enlarged and 
dilated vessels which passed, by means of three per- 
forations in the frontal bone, into the longitudinal 
sinus. For a large extent around these osseous 
PATHOLOGICAL ANATOMY. 62 
openings the dura mater was inflamed and covered 
with pus,—a phlebitis and meningitis the result of the 
previous operative treatment. This is an example 
of venous varicose tumor. 
Michaud’s Case.—Two erectile growths, one over 
brow and eye lid, the other located on the head. 
They were composed of a cavernous tissue, under 
the seat of which the bone was perforated by a mul- 
titude of little apertures giving passage to the veins 
coming from these structures in their course to the 
superior longitudinal sinus. 
Foucteau’s Case.—Occupying the site of the pos- 
terior fontanelle was a blood tumor which communi- 
cated directly with the superior longitudinal sinus 
through a single opening in the fontanelle the size of 
the little finger, by means of a tubular pedicle of 
which the cyst appeared to be an expansion. The 
tumor was composed of two principal cysts with a 
small accessory pouch, which were lined by a vascu- 
lar serous membrane. This serous membrane was 
of the same character as, and continuous with, that 
of the cerebral sinus through the above-mentioned 
pedicle. Thus it would appear that this was a blood- 
cyst formed by a hernia of the sinus through the un- 
closed posterior fontanelle, in which only the serous 
coat of the sinus was recognizable by the eye alone. 
Demme’s Case.—Located on the top of the head 
(in the middle of the sagittal suture) was a tumor 
composed of a pouch the interior walls of which were 
covered by fibrinous laminations, of different color 
and consistence, according to their respective ages 
as in a true aneurismal sac. In the coagulum in 
contact with the bottom of this pouch was a funnel- 
shaped depression which proved to be the entrance 
to an opening leading to the cranium. The superior 
longitudinal sinus was distended and filled with a 
coagulum, and was considerably dilated at a point 
corresponding to the external tumor with which free 
communication was demonstrable. The external 63 
wall of the cyst consisted of the normal scalp, but 
the other layers were composed, very evidently, of 
the sinus walls protruding through the osseous open- 
ing. Traction upon the tumor showed that the open- 
ing in its base consisted of a tubular pedicle con- 
necting its cavity with the sinus. The pericranium 
did not enter into the formation of the cyst cover- 
ings, but was intimately attached to the circumference 
of the skull opening and the pedicle, showing that it 
had either ruptured or been absorbed. The cranial 
tissue was thinned throughout the space occupied by 
the tumor, rather transparent; and in a state of rare- 
faction. The walls of the sinus were thickened, es- 
pecially the fibrous elements, but otherwise little 
altered. The microscope was employed in the ex- 
amination. This presents a case of true ectasia of 
the superior longitudinal sinus through the anterior 
fontanelle, probably the anterior angle. 
Acland’s Case.—The growth was a venous capsule 
communicating through a foramen in the protuber- 
antia occipitalis, by means of a fibrous tube, with the 
Torcular Herophili, thus putting the cyst in commu- 
nication with the intra cranial venous circulation. 
Brain greatly enlarged, and anterior horn of one lat- 
eral ventricle distended with serum (hydrocephalus). 
Here is shown a circumscribed venous varix of an 
emissary vein (emissarium occipitale) passing to the 
Torcular. 
Bruns’ Case.—Located over posterior fontanelle, 
with a thick pediculated base. Surgical examination 
after strangulation and removal of the growth de- 
monstrated the structure of the formation to be a 
mass of areolar tissue containing a bunch of greatly 
thickened veins, in which were several spherical en- 
largements or dilatations. Beneath the cicatrizing 
ulcer left after removal of the tumor the underlying 
fontanelle was plainly felt. This is another instance 
of varicose emissary vein or veins passing to the 
sinus through the posterior fontanelle or below it. 64 
Busch's Case.—A large fluctuating tumor, occu- 
pying the superior occipital region, including the 
small fontanelle. Contained a quantity of dark, vis- 
cous blood. The fluid situated between bones of 
skull and pericranium, and was in communication 
with the sinus. Several vessels extending from the 
tumor to superior longitudinal sinus were divided by 
the post-mortem incision. Character of tumor not 
definite, but possibly a venous varix. 
Flint’s Case.—A tumor in occiput. Contained 
venous blood, and communicated with superior lon- 
gitudinal sinus. Probably an example of ectasia of 
the sinus. 
Jacobi’s Case (Morbid Specimen).—A large cyst 
filled with coagulum located on occiput. Perforating 
the os occipitis was a large and long opening or ca- 
nal through which the sinus protruded as a hernia 
under the scalp. The question arises, Was this not 
a varicose occipital emissary vein traversing its nor- 
mal but enlarged foramen? However, it is received 
by several authors as a true hernia of the sinus, and, 
with the unsatisfactory data at hand, I must now also 
accept it as such. 
Melchiori’s Case.—Located on left parietal bone. 
Tumor composed of a net-work of empty veins rang- 
ing in size from a thread to a pigeon-quill, freely in- 
tercommunicating, and finally terminating in a com- 
mon trunk about the thickness of a goose-quill. This 
trunk passed through the galea aponeurotica capitis, 
and piercing the skull at the lower and posterior 
edge of the parietal bone, emptied into the transverse 
sinus where this canal lies on inner surface of tem- 
poral bone. There was meningitis, and all the sinuses 
were filled with partially suppurating clots, although 
without disease of their walls. This was a case of 
varix of the external cranial veins communicating 
with the sinus. 
Andrews’ Case.—On removal of the scalp a num- 
ber of enlarged and distended veins were seen about 65 
middle of the occipital bone. Just below the exter- 
nal protuberance was found a depression in the bone 
of one-third inch in diameter and one-fourth inch in 
depth, and covering which was a membrane that ap- 
peared to be formed of thickened walls of a distend- 
ed vein, and upon puncturing this venous blood 
escaped. The depression was then found to be a 
complete perforation, about the size of a crow-quill, 
which led into the sinus. There were tubercular de- 
posits in brain, and serous effusion into both mem- 
brane and ventricular cavities. This was a case of 
circumscribed varix of the emissarium occipitale. 
Pott’s Case.—A blood collection on top of head. 
Operation disclosed depressed fracture with a sharp 
fragment piercing superior longitudinal sinus. 
Hutin’s Case.—Blood pouch on right frontal re- 
gion, communicating, through an old traumatic bone 
perforation, with the superior longitudinal sinus. Os- 
seous atrophy also evidenced. 
Hutin’s Case.—Fluctuating blood pouch on right 
side of summit of head, between osseous vault and 
pericranium. Perforation of under and right side of 
longitudinal sinus by a thick bone splinter, thus plac- 
ing the blood sac in communication with the sinus. 
Another blood collection internally between dura 
and skull, which also communicated with both sinus 
and external tumor. 
The individual points which call for consideration 
are these: I. The general character of the tumor; 
II. The anatomical relations of the tumor, including 
the nature of the tissues composing and limiting it; 
III. The contents; IV. The method of communica- 
tion with the intra-cranial circulation. 
I. 7he General Character of the Tumor.—This 
tumor may be defined as, an indolent swelling exter- 
nal to the skull, in the form either of (i) a cyst—sin- 
gle or compound—or of (ii) a varicose or an erectile 
growth, containing venous blood, and communicat- 
ing, directly or indirectly, bygone or many skull per- 66 
forations—normal or pathological—with the intra- 
cranial venous circulation. 
The indolent nature of the growth is too fully and 
prominently shown in the detailed history of the cases 
to necessitate further notice,—the only inconven- 
iences complained of in the large majority of in- 
stances being subjective, or due to the annoyances 
of its particular location. 
(i) The pouch-—or cyst—variety is, as its name 
implies, composed of a pouch or sac variously form- 
ed, and the character of this formation being depend- 
ent upon the cause in operation. It can be asserted, 
therefore, from an etiological standpoint, and largely 
sustained by necropsic evidences that this form is 
encountered in circumscribed dilatation of an emis- 
sary vein (fusiform); in ectasia or hernia of the sinus 
and in dilatation of a diploic vessel (sacciform); in 
cranial perforation the result of a rarefying osteitis, 
and in the greater number of cases produced by di- 
rect injury, including both skull fracture and rupture 
of an emissary vessel (false). These features mark 
this variety as being closely allied to aneurismal form- 
ations in general, and whereas these characters are 
met with in the majority of cases, at the same time 
they cannot be considered so characteristic of this 
division, as was formerly my opinion. 
Several post-mortem dissections, with every physi- 
cal indication in many other cases without the con- 
clusive proof of autopsic examinations, furnish suffi- 
cient demonstration for these conclusions. 
(ii) In the other form—the varicose variety—the 
tumor is composed of tortuous and varicose veins 
(chiefly the emissaria Santorini) with numerous dila- 
tations, or, occasionally, of a structure resembling 
true erectile or cavernous tissue (Michaud’s case). 
These varicose formations may be in both fine and 
gross bundles held together by a rneshwork of areo- 
lar tissue, and consisting of simple tortuous veins 
alone or combined with dilatations. Many cases in 67 
all three of the classes, the congenital, spontaneous 
and traumatic groups, illustrate this variety. 
II. The Anatomical Relations of the Tumor.— 
Taking the coverings of the cranium in their order 
from without inwards, I find the anatomical location 
of these formations may be, (a) between the integu- 
ment and aponeurosis; (b) between the 
fibro-muscular layer (aponeurosis) and the pericra- 
nium; (c) between the pericranium and the bone; 
and (d) occasionally extending internally between 
the skull and the dura mater. 
These conclusions, which were reached in my pre- 
vious paper, were then based upon the recognition 
chiefly of one principal variety of this formation, 
namely, the diffused, where the effused blood escapes 
beneath the scalp tissues; and even with a more ex- 
tended knowledge of the etiology and pathology, 
including the wider and more comprehensive classifi- 
cation now given to the lesion, these relational divi- 
sions are, in the main, still appropriate. 
(a) The situation of the growth between the skin 
and the epicranial aponeurosis, although not deter- 
mined by the positive evidence of actual dissection, 
can be considered as, at least, probable, especially 
in certain injuries where all the soft tissues, together 
with the bone, are torn through or divided except the 
skin, leaving that covering intact; or, again, in those 
cases where absorptive action is particularly promi- 
nent; and, also, in long-standing cases with a dispo- 
sition to rapid tissue change, hastened, perhaps, by 
increased blood-pressure. But clinical observations 
alone are not adequate to fix this exact seat, for, it 
must be noted that the sensation and appearance of 
the swelling are very deceiving in the impressions 
they convey of the composition of its walls. Thus 
in many instances both the skin and aponeurosis may 
be so extremely thinned or attenuated as to impart 
to the touch the sensation of only integumentary 
thickness, and accompanied, at the same time, by a 68 
violet hue as if the contained blood was immediately 
beneath the cutaneous covering. Furthermore, the 
probability of this position is re-enforced somewhat, 
if the first proposition of Demme be looked upon as 
tenable, that is, rupture of an external cranial vein 
from injury, producing an epicranial or aponeurotic 
blood-collection which results in a cyst, and finally in 
communication, by various ways, with the sinus 
through absorptive changes in the underlying tissues. 
Under such circumstances it can be readily appreci- 
ated how a venous blood-tumor of this description 
may be located between the integument and the 
fibro-muscular layer of the scalp. 
Again, in thickening and dilatation of the cranial 
veins, the diseased action may originate in and be 
confined to that portion of the vein lying between 
the skin and the aponeurosis, and thus the tumor be 
so situated, as is shown in the case of Melchiori, and 
some others. 
(b.) I am inclined to consider the location of this 
formation between the aponeurosis and the pericra- 
nium as its most frequent seat,—an opinion, it should 
be remarked, that applies particularly to those cases 
arising from within outward or from the interior of the 
cranium. This position was demonstrated by post- 
mortem examination in a number of instances; and 
theoretically it may be looked for in the majority of 
these tumors due to spontaneous perforation of the 
skull, cranial fracture with sinus wound, ectasia of 
the sinus, and disease of the diploe veins, in which, 
especially the two first named, the periosteum is, in all 
probability, lacerated, and the blood extravasated in 
the cellular tissue beneath the more movable aponeu- 
rosis. Opposed to this view, however, is the opinion 
of Stromeyer, who expresses the conviction (Maxi- 
men der Kreigsheilkunst, S. 362, 1861) that the cyst 
is always beneath the pericranium. He declares that 
the case of Dufour’s in which the necropsy exhibited 
the bone covered by a thin periosteum is not opposed 69 
to his views, since all bone reproduces its periosteum 
when deprived thereof. But as evidence that the as- 
sertion cannot be applied unconditionally to all cases, 
it is only necessary to refer to the simple example of 
Demme’s case, where, with the aid of the microscope, 
in a hernia of the sinus through the anterior fonta- 
nelle, it was seen that the pericranium did not enter 
into the cyst coverings, but was perforated and inti- 
mately attached to the circumference of the skull- 
opening and to the pedicle of the tumor as it passed 
into the cranium. 
(c) Notwithstanding the assertion of Stromeyer 
and others, that the cyst (pouch-variety) is always 
seated between the pericranium and the bone, I am 
forced to regard this location as rare; or, at any rate, 
it is not the rule. This opinion is held not only from 
the fact that I have succeeded in finding but two ex- 
amples of such a location, but also from the anatomy 
of the periosteum and the associated tissue involved. 
Such, however, may sometimes occur, of which the 
testimony of Stromeyer with the illustrative cases of 
Busch and Hutin present sufficient proof. 
(d) The location between the pericranium and the 
bone and extending internally between the skull and 
the dura (vide Hutin’s case) is accidental, and con- 
sequently exceptional, and does not demand further 
consideration. It can occur, obviously, only in seri- 
ous injury to the cranium with both internal and ex- 
ternal haematoma, and is not particularly connected 
with this class or character of tumor. 
From the foregoing remarks it is very apparent that 
the coverings or walls of these venous formations of 
the head communicating with the intra-cranial circu- 
lation, are absolutely dependent upon the etiology 
and special form of the lesion. For example, the 
tunics of such a growth arising in diseased action of 
the coats of the sinus with protrusion through the 
bone, cannot be compared with simple blood effusion 
from skull and sinus perforation, under the scalp, 70 
and, therefore, its location and the composition of its 
walls must necessarily vary with the form and mode 
of origin of the tumor. 
Again, each and all of the tumor-coverings may be 
normal in texture and relationship to each other, or 
considerably modified or changed by diseased or nat- 
ural processes, and, indeed, even differing according 
to the age of the individual affected. 
III. The Contents.—Besides normal fluid venous 
blood, which is of course always present, this tumor 
may contain occasionally solid elements; but, as 
would be naturally anticipated, such substances seem 
to be confined to the cyst or pouch-variety, and, per- 
haps, in certain examples of the varicose form where 
gross dilatations with thickened walls exist. 
These solid elements may be of the character of 
condensations from the cellular tissue, or blood con- 
cretions (phleboliths) as indicated in one of Middel- 
dorpff’s patients, and also the case of Jules Dubois, 
where, after complete emptying of the sac, a “core- 
like ” substance about the size of a lentil was felt; 
or, again, the cyst may be lined by laminated fibrin- 
ous deposits identical in formation and composition 
with aneurismal coagula, and of which the case of 
Demme furnishes an excellent illustration. 
In the instance mentioned by Foucteau three cysts 
were present,—the third or accessory cyst being filled 
with serum. But this was, undoubtedly, of acciden- 
tal formation due to recognizable causes (witness the 
occasional formation of similar cysts in encephalo- 
cele and meningocele), and hence, although note- 
worthy, is without any associative significance. 
IV. The Method of Communication with the intra- 
Cranial Circulation.—The manner of communica- 
tion (direct or indirect), and the nature of the passage 
connecting the tumor with the dural circulation (nor- 
mal or abnormal skull-openings), are as different and 
various as the causes which originate the lesion, and, 71 
indeed, it may be considered as bearing a very inti- 
mate, if not constant, relation to the etiology. 
When the union takes place through normal or 
preexisting cranial apertures, as the emisary foramina 
and the fontanelles, the perforation partakes of the 
usual qualities and appearance of the natural and 
healthy tissues forming the opening, although in some 
cases they may be changed, in both size and contour, 
and, perhaps, with alteration in the quality of the 
bone. This method of connection is exemplified in 
hernia of the sinus through the fontanelles and in 
varicose dilatations and enlargements of the emissa- 
ria Santorini. 
When the communication is effected by means of 
abnormal perforations then the distinctive qualities 
and features of the communicating opening and pass- 
age must be largely influenced bv the causative agent 
in operation, that is, whether it be produced sponta- 
neously or by appreciable traumatic forces, together 
with the probable changes caused by the duration of 
the tumor. 
In the instance of the former where the glandular 
Pacchioni appear to be the exciting or active causes 
of the resorptive changes in the bone—a rarefying 
osteitis—an aperture may be looked for of moderate 
capacity, and presenting an irregular and uneven 
outline; whereas a rarefying osteitis the result of, 
possibly, extensive contusion, especially if located 
on the frontal region with involvement of the diploe, 
may be attended by a very extensive loss of substance, 
forming an opening with jagged edges, according to 
the extent of the osseous tissue subjected to the ex- 
citing cause. 
In the latter or traumatic cases, the orifice is di- 
rectly dependent upon the character and severity of 
the injuring force, that is, it may vary from a delicate 
crack or minute puncture with displaced spiculae to 
an extensive loss of the cranial wall; or, again, it 72 
may assume the features of a wide fissure, as in su- 
ture separation with displaced bone. 
The number of the apertures, also, is dependent 
upon the special features of the tumor, varying from 
one to a large number, but where they are numerous, 
or, at least, several in number, the tumor is prob- 
ably composed of an aggregation or bundle of fine 
varicose vessels, which penetrate the skull by ex- 
ceedingly small foramina. 
Again, the communication may be either direct or 
indirect—a condition which also stands in a certain 
ratio to the cause. Examples of the direct connec- 
tion, w'here the tumor cavity opens immediately into 
the sinus, are shown in spontaneous perforation 
through the fovea glandulares, ectasia of the sinus, 
and in some traumatisms. 
The indirect, where the bone perforation is sinu- 
ous, or, in other words, there is a medium, in addition 
to the perforated bone, through which the tumor is 
connected with the sinus, is illustrated in all dilata- 
tions and varicosities and ruptures of the external 
veins, or where the communication is through the 
intermediary of the diploic canals. 
Therefore, if any generalizations can be based on 
the revelations already made by clinical and post- 
mortem investigations, it can be safely affirmed that, 
First, in the simple or diffused class the cranial per- 
foration is usually of abnormal production or forma- 
tion, single, of moderate size, irregular contour, and 
direct; and, Secondly, in the venous or vascular class 
the communication takes, place more frequently 
through a normal skull opening, is variable in size 
and number, of a definite shape, and indirect in its 
course—but exceptions to this may exist, as seen in 
certain cases of rarefying osteitis with diploic in- 
volvement. 
SYMPTOMS. 
In the majority of cases the presence of the growth 
produces so little discomfort or uneasiness, and in 73 
some instances not the slightest inconvenience, other 
than that of location, is experienced by the patient, 
that it is scarcely possible to name any general symp- 
toms which may be regarded as characteristic of the 
lesion. 
Among such indefinite or variable symptoms en- 
countered, however, vertigo or dizziness is the most 
prominent and most constantly present. In many of 
the cases this symptom was complained of, 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, particu- 
larly such as to cause the rapid forcing out of its 
contained blood, although, on the other hand, once 
or twice it was noted that slight pressure or support- 
ing the tumor by the hand lessened or relieved the 
vertigo. But it may be stated that, as a rule, when 
dizziness is complained of it is the result of those 
causes which produce increased blood-pressure, or 
determination of blood to the head, such as com- 
pression of the jugular veins, position, muscular ex- 
ertion, mental emotions and so forth. 
Again, it is possible for pressure upon, or forcible 
reduction of, the tumor to cause serious cerebral dis- 
turbance, amounting almost to compression, as is 
vaguely referred to in one or two records; but such 
is rare, and must be regarded as a very infrequent 
attendant. 
Accompanying vertigo, although much less fre- 
quent, pain is sometimes met with, and finds expres- 
sion chiefly in the form of headache. It rarely arises 
spontaneously, and when present is usually associated 
with increased tension of the tumor, or, in other 
words, increased blood-pressure; and in some in- 
stances it was only produced by direct pressure ex- 
erted upon the swelling. Pain localized in, or confined 
to the vicinity of, the tumor is mentioned in one or 
two cases. 74 
The local symptoms are much more characteristic 
and reliable than the general or systemic ones above 
mentioned. 
The most conspicuous point in the examination of 
the tumor is its seat or location, which, in a general 
way, is nearly always in the tract of the superior 
longitudinal or some other sinus, or adjacent thereto; 
and, consequently, the proximity of a blood swelling 
to the course of any of the cranial sinuses, especially 
if presenting obscure symptoms, should be suggestive 
of this variety of sanguineous formation. But, as 
naturally anticipated, its actual or anatomical situa- 
tion is positively dependent upon the form or variety 
of the lesion. Thus it may be briefly stated that the 
diffused form the result of a rarefying osteitis, espe- 
cially erosion or resorption of the skull by the Pac- 
chionian bodies, is found in or near the median line 
on the upper and posterior part of the cranial vault, 
that is, on either side and along the course of the 
saggital suture (in which position the glandulas Pac- 
chioni are in greatest numbers), at its junction with 
the lambdoidal, and even extending a short distance 
on each side along the latter suture. 
In the second or venous variety the situation is 
again influenced by the special structures involved. 
First, if the growth be formed at the expense of an 
emissary vessel it will be located on that portion of 
the cranium where these exist, and particularly over 
the site of the parietal and occipital veins, which are 
the larger and most often implicated; Secondly, if a 
true varix sinus exist involving the coats of the longi- 
tudinal sinus, then the pouch is more frequently lo- 
cated over one of the fontanelles; whereas, thirdly, 
in involvement of the diploic system of vessels it is 
apt to be confined to the os frontis and ridges of the 
occipital bone, but particularly the forehead, in which 
localities the diploic structure reaches its most com- 
plete and highest development. In traumatic cases 
the location is governed, of course, by the portion of 75 
the skull receiving the injury, but Usually such forces 
are applied to the frontal and anterior-summit regions 
of the head. 
The moderate size of the tumor together with the 
direct influence exerted over its volume by certain 
conditions, are noticeable features. Even when dis- 
tended to its fullest capacity it is usually of medium 
dimensions, although several cases are mentioned 
where it attained the volume of a large apple; whereas 
when quiescent, that is when the swelling is relaxed 
or at its minimum enlargement, the growth is quite 
small and sometimes scarcely perceptible if not com- 
pletely indiscernible. 
These changes or alterations in the size of the 
growth are very characteristic, and can be seen and 
felt to take place under those conditions affecting its 
distension and relaxation: the tumor slowly rising 
and swelling up in the dorsal decubitus or any posi- 
tion with the head lowered; by interference with the 
proper return of venous blood from the interior of 
the cranium, as in compression of the jugular veins, 
forced expiration, crying, coughing, sneezing, and the 
like; occasionally by a full stomach, muscular exer- 
tion, or mental emotions; and, rarely, during the 
normal respiratory effort; however, under converse 
influences or those conditions lessening or reducing 
expansion or dilatation, the tumor recedes gradually 
to a lower level, and often entirely disappears. 
The color of the swelling in most instances is nor- 
mal and does not differ from that of the healthy skin, 
but this may be materially influenced by the consist- 
ency or thickness of the tegumentary coverings, and 
may also vary with the degree of distension of the 
tumor. Thus, when the walls are very thin it may 
assume constantly a purple or violaceous hue, or 
again the discoloration of the walls may be recog- 
nized only during distension, and fade away to a 
natural color with the relaxation of the tumor. Fur- 
thermore, changes in its color may be the result of 76 
coexistent disease of the skin of the tumor itself, 
namely, of a naevoid character, as was noted in sev- 
eral cases} but such a complication is infrequent,and 
when it does occur may be looked for, everything being 
equal,in congenital in preference to the other classes. 
The influence of head posture on the volume and 
resistance of the tumor is so apparent to both the 
touch and eye that, manifesting itself as it does al- 
ways, perhaps, in this affection, the symptom of 
dilatation and reduction produced thereby may be 
reasonably regarded as a pathognomonic character. 
Without an exception, I believe, this effect of posi- 
tion was decided and marked,—the tumor being felt 
to attain its 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 atti- 
tude, with the head fixed and erected, being attended 
by a diminution in both resistance and bulk. 
Similar results are produced by compression of the 
jugular veins. This was employed in a number of 
instances, producing unequivocal impression upon 
the growth, and its influence may be taken as a ra- 
tional symptom, and one of special value when asso- 
ciated with additional evidence; for, it is needless to 
remark, its range of applicability is much too wide 
and extended to be alone of diagnostic import in 
this type of sanguineous tumor of the skull. 
Probably next in importance to postural influence 
(in the pouch-variety) may be regarded the symp- 
toms of compressibility and fluctuation, which taken 
together furnish positive evidence of a fluid-contain- 
ing pouch or cavity with an intra-cranial outlet. In 
all the cases of the pouch—or sac—form these symp- 
toms were observed, and were among the chief dis- 
tinctions—the swelling readily, and nearly always 
completely, but slowly subsiding under continuous 
lightly applied pressure with the hand or fingers, and 
tardily redilating upon the removal of the compress- 77 
ing force,—and distinctly conveying to the touch the 
sensation of a sac filled with fluid, which was being 
emptied. 
The rapidity and ease with which pressure accom- 
plishes evacuation of the pouch is dependent, nec- 
essarily, upon the freedom and directness of the 
communication with the cranial cavity, but, as a rule, 
the reduction is rather slow and gradual. 
Another symptom of considerable weight is the 
ability in many instances to recognize by the finger, 
after reduction of the growth, somo. osseous alteration, 
or even depression or indentation in the skull, cor- 
responding to one or more openings leading to its 
interior, and which may be of considerable dimen- 
sions. 
Furthermore, puncture by means of a trocar and 
canula with direct exploration of the bone, may dis- 
close the existence of the aperture where it had 
eluded careful digital search. However, even such 
unsuccessful efforts to discover the communicating 
entrance should not be considered as conclusive evi- 
dence of its non-existence, for failure to detect the 
osseous perforation by this method occurred in sev- 
eral cases in which a subsequent incision or post- 
mortem examination demonstrated its presence. 
The sensation or feel of the tumor-walls, as con- 
veyed through manipulation, is to be taken into 
account in a description of the symptoms. In un- 
complicated cases of the pouch-variety, especially the 
simple diffused form, after being emptied, the sensa- 
tion is that of a loose, lax, movable covering of 
healthy skin tissue, of different degrees of thickness 
according to its constituents; whereas if partaking 
of aneurismal qualities, that is, with fibrinous deposi- 
tions on its interior surface, these are recognized as 
usually irregular but firm or solid masses occupying 
the substance of the walls, or, perhaps, the cavity of 
the growth. In the varicose-type there is readily 
discernible after evacuation or reduction of the swell- 78 
ing, a spongy mass or substance, varying according 
to the character of the varicosity, but which nearly 
always remains as an irreducible structure between 
the fingers. 
Pulsation and bruit require notice only because 
they are mentioned as occurring in several cases. 
They are to be regarded in the light of extremely rare 
accompaniments, and practically must be entirely 
eliminated from the list of symptoms. When met 
with they are explicable on the ground of contiguity 
to the cerebrum and a dural sinus or artery. 
Finally, a symptom of no indifferent significance 
is that attending the employment of circular compres- 
sion. This constriction may be applied either to the 
head, by means of a band or cord tightly drawn 
around the cranium with compresses in the temporal 
fossie, or to the tumor itself, as by a ring or similar 
apparatus closely encircling the base of the growth. 
By this means the external or superficial venous 
blood current is largely separated from the internal 
pr intra-cranial venous circulation, and the subse- 
quent manipulation of the growth now enables one 
to decide from which system of veins the blood sup- 
ply is derived. 
The method was employed quite a number of times, 
and in each instance fully demonstrated its utility 
and importance as a diagnostic measure. 
In uncomplicated cases, the history of the lesion, 
its location, want of marked elevation, and slow pro- 
gress; the usual normal color and texture of the 
integument of both the tumor and adjacent sur- 
face; the positive influences of posture coupled with 
those resulting from pressure of the jugular veins; 
compressibility of the growth—its easy and usually 
complete but slow evacuation; frequent fluctuation; 
the recognition by the finger or exploring needle of 
bone alteration; and very often of perforations in 
DIAGNOSIS. 79 
the cranium; the absence of bruit and pulsation; 
the effect of the application of a circular compres- 
sion; vertigo produced by certain positions and 
movements; and lastly, the demonstration by punc- 
ture of the presence of venous blood filling the tu- 
mor, constitute a symptom-group scarcely to be mis- 
interpreted. Hence, as a rule, the diagnosis should 
not offer specially confusing or obscure features. 
There are, however, a number of lesions present- 
ing symptoms in common with this formation, which 
might claim consideration in a nice or accurate dif- 
ferential diagnosis, and, therefore, the principal of 
these affections call for a brief reference : 
Thus a certain degree of resemblance is borne to 
(i) meningocele and (2) or (3) su- 
perficial nsevus coexistent with these; (4) cephal- 
hfematoma; (5) simple subcutaneous venous erectile 
or vascular tumor (including, possibly, the capillary 
variety); (6) lymphatic vascular tumor; (7) certain 
cystic tumors; (8) venous aneurism; (9) rarely an- 
eurism of the middle meningeal artery associated 
with bone erosion; (10) fungus of the dura mater; 
(11) pneumatocele; (12) traumatic cephalhydrocele; 
and, under rare circumstances, (13) circumscribed ab- 
scess, especially where skull perforation has taken 
place. 
In those instances, however, where an individual 
case offers specially confusing difficulties, or, at least, 
where questionable points prevent a definite conclu- 
sion, the demonstration of a tumor containing fluid, 
completely or partially reducible under lightly ap- 
plied pressure Avithout producing cerebral disturb- 
ance, directly influenced by posture and circular 
compression, and of which puncture or aspiration 
shows the fluid to consist of living venous blood, 
would be quite sufficient, against otherwise doubtful 
symptoms, to confirm the diagnosis. 80 
PROGNOSIS—PROGRESS. 
Analysis of the cases collated shows that, this class 
of sanguineous tumors if left to nature and not dis- 
turbed by treatment, does not incline to a fatal ter- 
mination ; and, therefore, the prognosis may be looked 
upon as favorable in all the types of the lesion as far 
as life is endangered or even serious impairment of 
health is concerned, and, indeed, spontaneous cure 
is said to have resulted in one recorded instance. 
Where, however, surgical interference is resorted 
to with the view of a radical cure or permanent reso- 
lution of the growth, then the prognosis becomes of 
very different import—assuming an important, if not 
serious, phase—and being materially influenced by 
the special type or variety of the tumor involved, with 
also the particular operative method adopted. 
In the large majority of those instances where no 
active surgical treatment was employed, and which 
were kept under observation for a longer or shorter 
period, there was not only no marked change in the 
attending symptoms, but the progress was noticeably 
slow—there being but little tendency evinced to ex- 
tension or any decided change whatever. Thus, in 
illustration of the general stationary tendency of 
these tumors after a certain size is attained, it may 
be mentioned that of twelve cases, embracing all the 
classes and the several types, which were followed 
up, eight were noted as remaining unchanged after 
five, twelve, fourteen, twenty, forty, forty-three, forty 
and seventeen years, respectively; and in the latter 
instance the growth disappearing spontaneously after 
a long examination, including repeated palpations. 
But in two other instances moderately rapid growth 
was reported,—in one of which the progress being 
slow for twelve years, and then in the succeeding 
four years rapid increase took place, with the devel- 
opment at the same time of a second tumor or sac 
communicating with the first. 
Whereas, on the other hand, among seven patients 81 
upon whom operative measures were practiced, com- 
prising free incision, strangulation by ligature of the 
base, the actual cautery, and electro-puncture, there 
were four deaths, two each from immediate haemor- 
rhage and suppurative phlebitis with meningitis. The 
three successes which resulted were respectively from 
strangulation by ligatilre, incision, and electro-punc- 
ture. It must be referred to, also, that the two cases 
of M. Azam were unaffected, apparently, in their 
symptoms and progress by the repeated punctures of 
the pouch which were practiced for diagnostic pur- 
poses. 
Notwithstanding the fact that palliative or protect- 
ive measures have received the strong endorsement 
and recommendation of the larger number of writers 
upon this subject, and by some is regarded as the 
only treatment to be adopted (v. Gross, Dupont, and 
others), and although almost universally employed, 
with but few exceptions, in the collected cases, the 
histories of these prove that such methods exercise 
hardly any, if, indeed, not being wholly without ap- 
preciable, effect over the progress or course of the 
affection, and hence must be declared not only fruit- 
less, but, in some instances, positively harmful. 
This can scarcely serve as a matter of comment 
when the anatomical and pathological characters of 
the lesion are considered, and, therefore, beyond the 
mere statement of the results of palliative treatment, 
this portion of the subject does not demand further 
consideration. 
Measures having a radical or curative object in 
view, were of two forms, namely, direct compression 
of the growth, and certain operative procedures. 
The former, or the application of direct compres- 
sion to the tumor, occupies a very similar position to 
that of palliation, as far as exerting any retarding or 
inhibitory influence over the course of the disease; 
TREATMENT. 82 
and, at the same time, on account of the effect pro- 
duced in several trials of the method, it should be re- 
garded also in the light of a dangerous or hazardous 
operation when indiscriminately employed, and espe- 
cially so in certain varieties of the lesion. Thus, in a 
case of probable varicose emissary veins, M. Azam 
punctured the tumor and practiced steady and con- 
tinuous pressure for twenty days, but not the slightest 
benefit whatever was obtained, and the patient was 
dismissed in an unchanged condition. 
Hecker applied compression for a considerable 
time without effect, in a case of frontal diploic tu- 
mor with loss of osseous tissue; continued and care- 
fully regulated pressure proved equally useless in the 
patient of Nelaton and Richard; and the efforts of 
Hutin to cure by compression, with leaden and silver 
plates, a blood-pouch resulting from cranial fracture 
and accompanying sinus-wound, were likewise inef- 
fectual. Again, Dubois, in a case of frontal tumor, 
probably of the diffused variety, first attempted com- 
pression by bandages, but without benefit or change; 
then later forceps-pressure was employed for forty- 
eight hours, but such excessive pain associated with 
cerebral symptoms of an ominous character, and de- 
cided reactive or inflammatory changes both within 
and without the sac, were provoked, that the attempt 
was necessarily abandoned. This was also devoid 
of beneficial result. 
In Verneuil’s patient spontaneous subsidence of 
the growth took place after repeated and prolonged 
handling and palpation of the tumor. Such manip- 
ulation should be reckoned as a form of compres- 
sion, but in this instance the observation loses its 
value because of the inaccuracy of the history, fail- 
ure to follow up the case for a sufficient length of 
time, and the consequent doubts expressed by the 
reporter himself. . 
The nature and extent of the operative interference 
employed, are represented by the following methods, 83 
viz.: free incision, and incision combined with caut- 
erization; constriction or strangulation of the base; 
the actual cautery; and electro-puncture. 
The operation of laying open the tumor by free 
incision was resorted to in four instances. 
Pott, mistaking a diffused form of the lesion fol- 
lowing direct wound of the sinus from fracture in the 
person of a lad, employed incision and trephining 
with a favorable result. 
In the case of an adult suffering from a growth 
composed of varicose venae emissaria, Moreau di- 
vided the tumor directly across, and, in order to 
staunch the alarming haemorrhage which ensued, he 
made frequent cauterization of the wound with anti- 
mony. Death took place on the fourth day from 
suppurative phlebitis and meningitis. 
Flint’s patient was an infant with a probable ecta- 
sia of the sinus through the fontanelle, in whom im- 
mediate dissolution from haemorrhage was the con- 
sequence of an extensive incision. 
The last instance is the patient of Hutin, who had 
an old blood-tumor of the cranial vault produced by 
injury. During a subsequent attack of erysipelas, 
in which he became unconscious, this swelling was 
taken for a pus collection and freely incised. Venous 
blood flowed abundantly, but pressure easily con- 
trolled it. Pleuro-pneumonia caused a fatal termi- 
nation. 
In two other cases of probable varicose emissaries, 
small punctures were made to aid diagnosis, but with- 
out observable effect. 
There are two examples of constriction or stran- 
gulation. Mersemann’s patient was an infant at the 
breast, with a venous tumor of the varicose type. 
Complete strangulation effected a cure. Foucteau 
encircled the base of a large tumor on the head of a 
child, which proved to be a sinus ectasia, with a stout 
ligature and then punctured the growth. A large 
quantity of blood was withdrawn, and the child sue- 84 
eumbed on the following day, from haemorrhage, he 
believes. 
The actual cautery was employed by Michaud ini 
a varicose formation. Erysipelas and meningitis fol- 
lowed the application, and death took place there- 
from on the seventeenth day. 
But one case, also, represents the use of electro- 
puncture. This was in an adult upon whom Bardel- 
eben successfully punctured the tumor, which was- 
probably a varicose formation, communicating with 
the longitudinal sinus. 
Summing up the evidence furnished by these sev- 
eral cases of operation, it is seen that incision gives 
one cure in four, and that one being of the traumatic 
diffused form; strangulation gives one cure in two, 
the successful issue being of the varicose type; the 
only instance in which the actual cautery was em- 
ployed—-a case of varicose emissary veins—ended 
fatally; and the single use of electro-puncture in a 
similar form of the lesion was attended by gratifying 
results. 
The causes of death in these cases brings up the 
question of the dangers to be apprehended from sur- 
gical or operative measure, and which may be em- 
braced by phlebitis, attended by thrombosis and 
embolism, meningitis, septicaemia, haemorrhage, air- 
embolism, and serious cerebral disturbances. 
Phlebitis, meningitis and septicaemia are so closely 
connected in the present relation that they may be 
properly discussed under the same heading. From 
this cause two deaths took place out of seven opera- 
tions, and therefore on this account and for apparent 
anatomical reasons such a danger assumes an im- 
portant and just significance. This is furthermore 
borne out by well-known clinical examples, and also 
by the experiments of Schellmann (v. Bergmann, 1. c.) 
who found that the chief danger resulting from sinus- 
wound was the formation and subsequent disintegra- 
tion of the thrombus—leading to septicaemic infec- 85 
tion. However, the aseptic management of wounds 
which characterizes modern surgical practice, asso- 
ciated with our increasing enlightenment concerning 
the tolerance of the venous system in general, and 
especially, in the present instance, the veins of the 
brain and its enveloping tunics, to operation wounds 
and accidental injuries, not only marks a great sci- 
entific advance in surgery, but has reduced in a won- 
derful degree the risks and dangers to be apprehended 
therefrom; and consequently revolutionized our ideas 
of the once dreaded inflammatory and septicremic 
processes. 
Although two fatal results are reported in our col- 
lection from immediate haemorrhage, I cannot regard 
this danger from sinus-wound in the same light as it 
is evidently looked upon by many authorities. 
Wounds of the dural sinuses if extensive are, un- 
doubtedly, attended by profuse and even alarming 
loss of blood, but the methods at our disposal for 
controlling such haemorrhage are both trustworthy 
and easy of application. 
Thus the efficiency of simple pressure in arresting 
haemorrhage is exemplified not only in the special 
lesion under consideration by the cases of Pott and 
Hutin, with those cases which were simply punctured, 
in which pressure sufficed to permanently staunch 
all bleeding, but also in different injuries and wounds 
of the sinuses, as illustrated by the patients of Reid 
(.Edinburgh Med. Jour., April, 1864), Sands (Anna/s 
of Anat. and Surg., vol. viii, p. 100, 1883), Hopkins 
(.Annals of Surgery, July, 1885, p. 67), and other 
easily cited instances, and more recently by the ex- 
periments of Senn, contained in an admirable article 
on the subject of Air-Embolism, read before the 
American Surgical Association, April, 1885 (v. So- 
ciety Transactions, 1885, also Annals of Surgery, 
June, July, August and September, 1885). 
Numerous other authorities might be adduced in 
confirmation of the efficiency of pressure, but, be- 86 
yond the additional mention of the paper of Hector 
Cameron (Lancet, May 24, 1884), in which is shown 
that in many, or the majority of, instances only the 
gentlest pressure is required to stop blood-flow from 
a wounded sinus, further citations would be super- 
fluous. 
If I have spoken in commendatory terms of press- 
ure as a haemostatic measure in sinus injuries, I be- 
lieve that I am warranted in speaking in an equal, if 
not more positive, manner of the ligature and suture, 
especially applied laterally. It is true that Senn 
(l. c.). and he is not alone in this opinion, considers 
suturing the sinus (including, evidently, lateral lig- 
ature) as unreliable and in most instances anatom- 
ically impossible, but the successful instances where 
such measures were adopted are sufficiently numer- 
ous to justify my expressions of confidence in the 
proceeding; and, as furnishing clinical and physio- 
logical support to. the practice, the experiments of 
Schellmann, already referred to, demonstrated the 
important fact that wounds of the sinuses heal with- 
out causing obliteration of the sinus,—the wounded 
wall becoming thickened in the reparative process 
but the lumen of the vessel remaining unobstructed. 
Such successful employment of the lateral suture 
and ligature in the cases of Brinton (.Philadelphia 
Med. Times, vol. xii, p. 577, 1881) and Parkes (An- 
nals of Anat. and Surg., vol. viii, p. 118, 1883), are 
by themselves adequate testimony of its practical 
application and reliability. 
Proximal and complete double ligature of the sinus 
has been shown to be largely devoid of serious re- 
sults, and calls for adoption when othef less severe 
methods have failed or proved incompetent to meet 
the indications required. 
Besides other important facts shown by Schell- 
mann, he has indicated also, by both experiment and 
collated cases, that contraction in the calibre or 
even complete obliteration of the lumen of the large 87 
dural sinuses need occasion no constant disturbance 
in the brain, but, on the contrary, that such obstruc- 
tions may and do exist for an indefinite time without 
the manifestation of any grave cerebral symptoms. 
Additional evidence of the immunity with which these 
venous channels may be reduced or lessened in their 
calibre, is seen in the case of Parkes (/. r.), where 
the sinus longitudinalis was diminished at least one- 
third by lateral suture, and also that of Kuester 
{BerlinerKlin. Wochenschmft, Nov. 14, p. 673, 1881), 
Avho, in the extirpation of a sarcomatous growth from 
the dura mater of the frontal region, successfully 
practised prophylactic double ligation of the exposed 
longitudinal sinus. 
This subject of deligation of the sinus has been 
particularly studied by Senn, and, as a result thereof, 
he considers it a safe measure for the arrest of hjem- 
orrhage, and believes that preliminary ligation will 
become an accepted procedure in the removal of 
dural and other tumors involving this structure. Cer- 
tainly the subject is an important and interesting one, 
and with me fully maintains the feasibility of ligation 
of the sinus in specially severe cases of ectasia or 
hernial protrusion of the sinus-wall, and also of the 
diffused variety, demanding surgical action. 
The aseptic tampon (Senn), cold (Abel), position, 
and styptic substances as means of arresting bleeding 
from this locality need not be discussed. 
Air-embolus or aspiration of air into the sinuses is 
a danger which, although having but one known re- 
corded instance of a fatal occurrence to demonstrate 
its possibility, namely, Volkmann’s case (reported by 
Geuzmer ( Verhandlungcn der Deutschen Gesellschaft 
fur Chirurgie, vol. vi, p. 32), must be recognized 
and borne in mind in all operations implicating these 
venous reservoirs; and, indeed, the assertion of 
Franck {Sur la transmission de laspiration thoracique 
jusqiiaux canaux Veineaux des os du Crane, etc.; Ga- 
zette Med., No. 25, 1881) that he has witnessed more 88 
than once after trephining the entrance of air into 
the diploic veins, should admonish us that the so- 
called danger zone is not limited to the cervical 
region, and to exercise due precaution in dealing 
with all operations and injuries implicating the cra- 
nial tissue. 
It is unnecessary to examine any farther this dan- 
ger of air-aspiration in these localities, and for more 
accurate information of the subjec,. generally I can- 
not do better than direct you to the literature of the 
entrance of air into veins, and in particular the valu- 
able and elaborate paper of Senn, which has been 
already several times referred to and quoted from. 
The occurrence of serious brain perturbations and 
disturbances attending operative measures upon the 
sinuses, rests almost entirely in an interference with 
the delicate equipoise of the cerebral circulation. 
This question has been clearly answered in the neg- 
ative by the observations of Schellmann, and the 
cases I have referred to, to which may be now added 
the patient of Schiippel (Ziemsscris Handbuch, Gnlle 
and Pfortarder, p. 324, mentioned by Browning, /. c.) 
in whom the superior longitudinal and both trans- 
verse sinuses were found obliterated by an organized 
thrombus, and with compensatory anastomosis. 
In conclusion, after this brief sketch of the treat- 
ment of this class of sanguineous formations, I must 
express myself as favorably inclined towards curative 
operative measures—especially by the suture and 
ligature, electro-puncture, and strangulation of the 
base—in certain extieme instances, the particular 
method chosen to be governed by the type and form 
of the individual case involved. 
RECAPITULATION. 
As a result of the foregoing study the following 
summarized conclusions are reached : 
i. Cranial venous blood tumors communicating 
with the dural circulation are to be classified into 89 
three divisions, namely: the congenital, spontaneous, 
and traumatic. 
2. These classes are divided, upon both anatomical 
and pathological grounds, into two species or varie- 
ties : a, the diffused, produced by a perforation of the 
cranial plates and the wall of the subjacent sinus, re- 
sulting in a limited extravasation of blood beneath 
the scalp and thus forming a blood-cyst in direct or 
immediate communication with the affected sinus; 
and b, the venous or vascular, in which the tumor is 
directly formed at the expense of the venous coats, 
and includes in its scope the sinuses, the venae emis- 
saria, and the diploic vessels. 
3. The venous type is the commonest in point of 
occurrence, and of this type, varicose involvement 
of an emissary vein is the most frequent form; whilst 
the diffused is the rarest of all the varieties. 
4. The diffused variety is especially characteristic 
of the spontaneous and traumatic groups. The ven- 
ous or vascular type occurs most frequently in the 
congenital class, but at the same time is often met 
with in the spontaneous division. 
5. The medium of communication with the intra- 
cranial circulation is, in the very large majority of 
instances, represented by the superior longitudinal 
sinus, particularly its central and posterior portions. 
The emissaria Santorini most often implicated are, 
probably, the superior or posterior parietal emissaries, 
which pair, also, are the most constant and uniform 
in their existence. When the diploe is involved the 
frontal region is the usual seat—no instance of a 
similar occipital formation having been observed. 
6. In a causal relation, some morbid action in the 
venous walls is notably prominent in the congenital 
class; in the spontaneous group, atrophic or rarefying 
osteitis ranks first as a cause, and venous disease sec- 
ondly; and in the traumatic division, direct injury, 
which nearly always means fracture, is the only etio- 
logical factor. 90 
7. Palliative measures for retarding or arresting 
the progress of the growth, and certain forms of com- 
pression intended to act as a curative agent, are use- 
less applications—the latter, in addition, being capable 
of producing alarming head symptoms, and hence 
may be harmful. 
8. General surgical interference is not called for, 
because the history, nature, and progress of the lesion 
is opposed to indiscriminate operation; being of that 
character to render such treatment unnecessary. 
When, however, operation is deemed expedient or is 
demanded, the following methods seem to be open 
for adoption: 
First, if the growth be either of the diffused type, 
or that form consisting of a varix-sinus, exposure and 
ligation of the pedicle (if such exist), or, if neces- 
sary, deligation of the sinus in its course, the trephine 
being boldly employed to furnish requisite space for 
the necessary attending manipulation. The lateral 
ligature and suture, when applicable, are preferred to 
complete ligation. 
Second, if the tumor be composed of varicose 
emissary vessels, or, perhaps, of diploic dilatations, 
either electro-puncture or strangulation of the base 
are justifiable procedures, but preference is given to 
electro-puncture. 91 
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