Brain Surgery, with Report of 
Mne Cases. 
Read in the Section on Surgery and Anatomy, at the Forty-fourth 
Annual Meeting of" the American Medical Association. 
BY F. C. SCHAEFER, M.D. 
Prof, of Clinical Surgery, Northwestern University Medical School; 
Prof, of Surgery. Woman’s Medical College; Surgeon 
to Wesley Hospital, Chicago. 
My subject might perhaps have been named more 
appropriately cranial surgery, as I wish to report 
nine cases of injury to the head ; all of them, however, 
interfered with the functions of the brain, and in 
three of them there was actual destruction of brain 
tissue. Of these nine cases, four recovered complete- 
ly, one improved so much, that we have reason to 
believe that he will in the course of time, recover 
sufficiently to be of some use to his family. Four 
died. As we have yet much to learn concerning the 
diagnosis and management of injuries to the head, 
and as all of them have their own peculiarities 
to a certain extent, it seems to me an accurate 
report of such cases will be of advantage to us; and 
undoubtedly we will have to depend largely upon 
clinical experience for the advancement of this 
work in the future. This, then, is my apology for 
occupying your valuable time : 
Reprinted from the Journal of the American Medical Association, 
July 29, 1893. 2 
Case 1.—Boy aged 10 years, fell during February, 1880, 
from a depot platform, striking his head against the corner 
of a fire-box of the wheel of a freight car. I saw him an 
hour later; he was in a comatose condition, motionless with 
a large, full, slow pulse, and sterterous breathing. There 
was an extensive contused and lacerated wound of the 
scalp, over the middle portion of the right parietal bone 
exposing the skull. After thoroughly cleansing the wound, 
having shaved the hair from the scalp, I enlarged the open- 
ing and found a depressed, stellate fracture. The skull was 
unusually thick for a boy of his age, 8-16 inch. The fracture 
presented five points at its center, all coming together, 
converging like the spokes of a wheel, at the center of an 
irregular circle two and a half inches in diameter. There 
were therefore five irregular triangular pieces of bone. 
Each triangular segment was attached at its base, but all 
of them had their outer table cracked where they joined 
the body of the bone. Their apices were depressed fully a 
third of an inch. In order to elevate the pieces I trephined 
through the base of one of them, then succeeded readily in 
replacing all. The dura mater was contused, cerebral 
pulsation absent before the operation. Restoration of the 
bone to position was followed by immediate return of func- 
tional action. The little fellow talked freely and told how 
he fell. The scalp was stitched with silk, dressed anti- 
septically ; the patient was left in bed, in a quiet room for 
about ten days. The wound healed by first intention. The 
button of the bone was not replaced. The boy is well. 
Case 2.—Boy 7 years old, October, 1889, fell from a 
loft in a livery stable, striking upon a heavy plank floor 
with the back of his head. Was carried home in an uncon- 
scious condition ; saw him an hour and a half later. His 
pulse was full and large, 68. Breathing sterterous ; pupils 
dilated. There was a large swelling over the occipital 
bone, above the superior curved line, extending two inches 
to the right and one inch to the left of the occipital 
protuberance. The scalp was severely bruised and raised 
by a hematoma. Anaesthesia was unnecessary. I cut 
through the scalp and periosteum making a curved 
incision two inches long with its convexity downwards. 3 
The blood immediately rushed out; the patient moved his 
limbs at once, gave a cry and waked up as from a dream. 
I quickly examined the skull and found a transverse 
crack two inches long, about half an inch above and 
running parallel with the superior curved line of the occipi- 
tal bone, extending more to the right than left side of the 
median line. The thin bone had been depressed by the 
blood between it and the periosteum, and had sprung back 
into position when that pressure was removed. 
Ten minutes after the operation the boy related how the 
accident occurred. Within a week he was again playing 
upon the street. 
Case 3.—Wm. aged 11 years, while visiting in the 
country a hundred miles from Chicago, July, 1887, fell from 
an apple tree a distance of twelve to fourteen feet. His 
father having been telegraphed for, came to have me ac- 
company him to see his boy. Not finding me at home, he 
took another surgeon with him. The city surgeon arrived 
at the patient’s bedside ten hours after the accident occurred. 
In the meantime, the mother who was with the boy, called 
a local doctor who found a large oval swelling in the left 
temporal region, together with contusion of the scalp here. 
The boy was unconscious. The physician said he was 
suffering from concussion of the brain ; did not think there 
was a fracture. The Chicago surgeon agreed with the at- 
tendant, concluded that there was nothing to do except to 
let him rest and applying a liniment to the wound, returned 
home. The patient remained unconscious for forty-eight 
hours, then became semi-conscious; at the end of a week 
he “woke up” as his mother said. During this week his 
bowels were constipated, and urine had to be drawn. After 
six weeks the child was brought home and I was called to 
treat him for a headache. At this time a ridge could be 
plainly felt in the middle of the fossa of the squamous 
division of the temporal bone, running parallel with the 
zygomatic process. What a chance the surgeon missed 
here of making a brilliant cure with one stroke of the knife ! 
Undoubtedly the large swelling in the region was caused by 
a rupture of one of the deep temporal arteries or from the 
bone. The blood was boxed in by the unyielding temporal 4 
fascia and pressed the cracked bone against the dura 
mater and brain. The pressure symptoms disappeared 
with the absorption of the clot, the bone retaining sufficient 
elasticity to spring out. At the time of my visit, the child 
was afflicted with a slight frontal headache and enteritis; 
the parents imagined that the injury might have had some 
relation to this condition, which fortunately proved not to 
be the case, as he made a prompt recovery. 
Case 4.—A gentleman aged 45 years, engineer, was 
found lying on his back on the floor, in close apposition 
to the cube-shaped stone supporting a portion of a stationary 
engine, with a step ladder standing near. He was uncon- 
scious when a homeopathic physician came to see him. He 
was placed upon a stretcher, and examined by the doctor 
who found a scalp wound one and a half inches in length 
over the right half of the occipital bone, which he washed, 
stitcbed and dressed. The patient was taken home and 
looked after by this physician. It happened that this man 
carried an accident insurance policy, and in the natural 
course of events the insurance company sent their surgeon 
to look after the interests of the patient, or more properly 
stated, their interests. The company’s surgeon called twenty- 
four hours after the man was sent home. Not knowing who 
or where the attending physician was at that time, he 
asked permission of the man’s wife in behalf of the com- 
pany to see the patient. The permission was granted. 
The doctor quickly examined the case. Found pulse 48 
large, full, laborious. Pupils dilated widely. Sterterous 
breathing. The bladder filled to distention. He did not 
stop to open the bandages, but at once drew off a quart of 
urine from the bladder, and went in search of the doctor. 
Did not find him until the next day. On the fourth day the 
company’s surgeon suggested a consultation be neld with a 
regular surgeon, promising that the company would bear 
the expense. The attendant was willing to have a homeo- 
pathic surgeon. In order to pacify him the company’s 
physician said, you may have your homeopath, but let me 
bring a “regular surgeon” and the company will pay both. 
He finally consented to let the company’s doctor bring a 
surgeon to see the case with him. The doctor called me on 5 
the sixth day; I found a pin head opening in one end of the 
scalp wound, through which my probe entered readily, and 
I felt the rough outlines of a fracture. Gave it as my opin- 
ion that there was either a clot or depressed bone causing the 
symptoms. The homeopath’s attention was called to it, but 
he claimed that there was no fracture and held a consulta- 
tion with one of his guild, who agreed with him. The man’s 
wife said she wanted her husband let alone with her homeo- 
pathic doctor and wanted no more physicians to trouble him 
Of course I advised operation, but at the same time was 
guarded as to the prognosis, saying the clot might be 
absorbed, or possibly the bone might spring back into posi- 
tion and the patient make a recovery. If it was a clot 
there would be more hope, but it would take considerable 
time. In the meantime, however, I felt he was being per- 
mitted to take too great a chance. Be that as it may, two 
weeks later Dr. J. R. Corbus (who represented the company) 
said that the patient seemed to be gradually improving, al- 
though his urine still had to be drawn. Six weeks later was 
able to sit up. His right eye was much weaker than the other. 
In fact he could not see clearly with it. Motion in one leg 
was somewhat impaired. After six months he began to 
■walk about, toes of one foot dropped, causing a stumbling 
motion. The case came to court within a year, as the 
■company refused to pay the homeopathic attendant, claim- 
ing that an operation would have resulted in a more rapid 
cure and that they had been compelled to assume a greater 
risk than was necessary by the refusal to have proper 
■surgical aid. The attendant made his speech claiming to 
have cured the patient medically, while Surgeon Schaefer 
wanted to use the knife. Dr. J. R. Corbus being called to the 
witness stand, was asked what he thought about the case. 
His reply was : “By the grace of God the patient got well, 
homeopathy notwithstanding.” 
Case 5.—A Mr. T. aged 50 years, manager of railroad car 
-shops at the city limits of Chicago, rode home in the bag- 
gage car of an express train, as was his wont, at six o’clock 
-one July evening of 1890. The rails spread while the train 
was in motion. The gentleman had been sitting in an arm 
chair, facing the corner of a safe, perhaps a yard distant. 6 
As the car left the track he was thrown forward from the 
chair and struck the corner of the safe with his forehead. 
The accident occurred about seven blocks from the man’s 
home. He was momentarily stunned, but soon picked 
himself up and walked home unattended. I saw him an 
Fig. I. 
1.—Complete transverse fracture extending from behind one external 
angular process of the frontal bone to the other. The seam can be traced 
through the back part of the right orbital plate, the back part of the 
ethmoid bone, and left orbital roof. 
2-3.—Antero-posterior fractures extending from the supra-orbital arch 
to the transverse fracture. 
hour later in emergency. His left eyelid was black and 
swollen. It was seen that the frontal bone was fractured 
vertically in its left half, from near the inner end of the 
orbital arch upwards. The left side of the forehead was 
flattened. He had an unusually large frontal sinus, which 7 
made the wound look as if the anterior wall of the left sinus 
was pressed in. As the man was perfectly rational, show- 
ing no symptoms whatever of brain disturbance, it seemed 
altogether probable that the outer table only was broken.. 
Still I was in favor of cutting down immediately to examine 
the bone and do what might be necessary. The family were 
opposed to such action. It was therefore deferred. The 
next morning a consultation of surgeons was held. The 
1.—Vertical fracture extending from inner angle of the left orbit to 
join 
2—Fracture running across the forehead, extending from behind the 
left external angular process to a corresponding point on the right side. 
The two ends of this fracture joint d the ends of the transverse fracture 
in Fig. I. 
Fig. II. 
patient was still rational, clear headed, having use of all 
of his functions, with no indication of compression. Six days 
later I was invited by the surgeon in charge, my friend Dr. 
L.McArthur (by whose consent I report this case), to assist 
in elevating the bone. A change had occurred on this day. 
His speech was faltering, deglutition difficult, pulse weaken- 
ing. He was somnolent. An incision revealed the following : 8 
There was a vertical fracture towards the inner end of 
the left orbital arch extending towards the coronal suture. 
The external angle of the frontal bone was broken loose 
from the malar articulation, while this angle had been 
driven inwards two-thirds of an inch or more. With great 
difficulty Dr. McArthur pried the angle back into position. 
Of course this depression implied a fracture of the orbital 
plate of that side. Two days later I made the autopsy and 
found what the illustrations show. A transverse fracture 
extending from the external process of one side to the 
other, across the base of the skull, passing through the orbital 
plates near the lesser wings of the sphenoid and through 
the back part of the cribriform plate of the ethmoid. Con- 
necting the ends of the fracture there was a complete 
fracture of the vertical portion of the frontal bone running 
parallel with the coronal suture. In addition to these, 
there were the vertical fracture alluded to connecting with 
the transverse fracture on the forehead ; and three fractures 
through the left orbital plate, two extending from orbital 
arch to the transverse fracture within the skull, the other 
half way back. The triangular shell thus produced at the 
outer angle of the frontal bone was driven almost an inch 
into the left frontal lobe. Here the autopsy revealed a 
large cavity in the brain which had been occupied by the 
bone. There was a clot in the channel of the cavernous 
sinus. With this extensive traumatism there were no 
symptoms of brain injury present until the sixth day. 
Case 6.—Boy, W. L., aged 17 months. While playing upon 
the porch at the back end of a flat, sixteen feet above the 
ground, suddenly fell down stairs, probably rolled two or 
three steps, fell seven feet striking the top of a fence with 
the crown of his head, and dropped from the fence to the 
ground, five feet below, which was covered with ice. There 
he was found a half minute later, lying flat upon his back 
and head. He was carried to his bed, and a messenger sent 
for me. A physician happened to be in the building at the 
time. He was at once called; after looking the child over 
concluded he was suffering from concussion of the brain. 
A half hour later I came to him. Examined the child criti- 
cally. Found he could move his limbs. His pupils responded 9 
to the light slowly. For one instant only his left eye was 
thrown off of parallelism with the other. It quickly moved 
into line, however. This at once made me suspicious of 
brain injury. I then ran my hand over the top and back of 
the head. The occiput was flattened, while in front of it 
there was a prominence. The child was drowsy, still could 
be easily awakened, and had control of its functions. I next 
walked out to the porch to see how far and where the boy 
fell. The extent of the fall was so great, that I felt con- 
vinced that the skull must be badly fractured. In the ab- 
sence of grave pressure symptoms, it seemed unnecessary 
to operate at once. I therefore advised warm fomentation 
and sedative treatment. Gave it as my opinion that the 
skull was extensively fractured and said that at the first in- 
stant when severe brain symptoms appeared, such as con- 
vulsions or paralysis, I would cut through the scalp and 
do what seemed best. Twenty-four hours later there oc- 
curred clonic spasms at the left angle of the mouth. I at 
once ordered a barber to shave off the hair preparatory to 
operation. Chloroformed patient; scrubbed head with soap 
and water ; washed with bichloride and ether. Cut through 
the scalp at a point corresponding to the upper portion 
of right fissure of Rolando; found an irregular fracture 
extending to the right and left; followed it up in both direc- 
tions. It extended to within one-half inch of the right ear, 
and to within one inch of the left ear running across the back 
part of both parietal bones. A peculiarity which interested 
me greatly was the fact that the borders of the broken bone 
were separated one-eighth of an inch which explained to my 
mind the absence of pressure symptoms from the beginning ; 
the open seam of necessity increased the intracranial area. 
At the back part and middle the bone was considerably 
depressed for distance of two inches; at the right side in 
front of the upper portion of the fissure of Rolando I tre- 
phined and found a tablespoonful of clotted blood beneath 
the dura mater, which membrane was lacerated here. The 
dura mater was torn in several places and at the middle of 
the wound brain tissue lay loose in the seam of fracture. 
After thoroughly cleaning the entire wound I lifted up the 
depressed bone, stitched the dura mater, brought the edges 10 
together through the entire length of the wound, placed 
small drainage tubes in two places which were carried 
through small trephined openings of the skull. Dressed an- 
tiseptically. Boy’s eyes brightened, responded quickly to 
light. Improved for twenty-four hours, when his pulse and 
temperature rapidly crept up and he died on the fourth day, 
of meningitis. 
Case 7.—Wm. N., aged 22 months. Was called to treat 
this child for a headache in the evening of the fifteenth 
day. His parents said that he had been sick for about 
two weeks; the headache came every afternoon at 
about 2 o’clock, and left him towards midnight. The 
pulse was small and rapid, 120; temperature 100°F. Eyes 
responded to the light. The head ached all over the 
frontal region. Tongue heavily coated. Nothing was 
said about traumatism. Bowels were constipated. Pre- 
scribed bromides, cathartics and quinine. Called the 
next day at 7 o’clock p. m., found the patient feeling bet- 
ter, pulse a little stronger. Temperature 99° F. Continued 
bromide of potassium. Third visit, fourth day, 9 a. m. 
He was slumbering; every now and then he cried out in his 
sleep. The cry was shrill, as if caused by sharp pain. This 
set me to thinking. I at once asked the parents if their son 
had met with an accident recently. They thought not.. I 
asked the question again, saying little ones frequently 
stumble and fall. The mother then spoke up saying that 
she remembered that he fell about two weeks ago, but there 
was no bruise upon him. My next question was who saw him 
fall? “ Freddie, his 12-year old brother.” The brother was 
called. In reply to my question he said that he played with 
the patient two weeks before, his brother clinging to his 
neck and back while he sat on the edge of a lounge; he 
ducked his head pretending to throw him over his head; 
did this once too often when the latter slid to the floor head 
first, striking heavily upon the cranium. This was sufficient. 
I examined the skull carefully, found a very slight uneven- 
ness over the coronal suture of the left side of the head, 
scarcely perceptible ; pressure upon the point caused him to 
cry the same shrill cry as heard before. Pressed upon a corre- 
sponding point of the opposite side but elicited no response. 11 
There was no longer any doubt in my mind as to the cause 
of the origin of the headache. 
I immediately informed the father that an incision through 
the scalp was indicated, to explore the skull and possibly to 
lift a depressed bone. The father at once repelled the idea, 
claiming that the child had the headache nearly a week 
before the accident occurred. Having no time to waste, I 
advised him to call in another surgeon, and if the latter 
should agree with me I would go on with the operation ; if 
there was a disagreement he could let the other surgeon 
take the case. Two surgeons were called, Dr. I. N. Danforth 
and Dr.McDonell. After hearing the full history of the case 
and having examined the head, they concurred with me. 
By this time the boy was very weak; pulse 130, small, tem- 
perature 101° F. In the meantime the head had been shaved 
by a barber. I cleaned the scalp and cut down to the bone, 
making an oval flap. Found a slight fossa at coronal suture, 
an inch to the right of the median line ; the teeth of the suture 
could be seen obliquely placed. Removed a %-inch button. 
The cerebral pulse was absent. The dura mater looked black. 
Aspiration drew off a teaspoonful of serum. Opened the 
dura mater; a tablespoonful of cerebral fluid escaped, with 
considerable lymph and clotted blood; pulsation was now 
normal. There was a circumscribed leptomeningitis pres- 
ent. It was thought advisable by all of us to leave a small 
gauze drain in the wound. I stitched the dura mater and 
scalp with fine silk ; applied usual antiseptic dressings. The 
headache was relieved ; patient’s eyes grew clearer, responded 
promptly to the light. After thirty-six hours his temperature 
ran up to 102° F.; two days later he died. There was no pus 
in the wound. He died of leptomeningitis. 
Case 8.—Wesley Hospital Record.—Mr. K., aged 47 years. 
Father died of apoplexy. Mother lived to old age. Lost a 
sister aged 30 years from consumption. He enjoyed good 
health up to two years ago. During the fall of 1887 he was 
sand-bagged and robbed on the street while going home in 
the evening. Was struck on the head with some metallic 
instrument. The scalp was torn open to the extent of about 
an inch, over the upper and middle part of the right pari- 
etal bone, extending outwards from near the median line. 12 
He was stunned for a few minutes only. The wound was 
dressed by his wife ; it healed in a few days. The patient 
went to work the morning after the accident and felt as 
well as usual, barring a little tenderness about the wound. 
He had forgotten all about this important incident until 
reminded of the presence of a scar upon the scalp. Two 
years ago his limbs swelled and a physician said he had 
Bright’s disease. At the same time his head troubled him. 
Was afflicted with vertigo. There was a constant headache 
and tenderness on the right side of the skull. After a few 
weeks of suffering he was suddenly seized with “ spasms ” 
of the left side of his face and of the left arm and leg. 
These spasms began in the left fingers, extended up the arm 
to his shoulder, next over the entire left leg. His head 
turned to the left side, and there was a constant twitching 
at the left angle of the mouth. Lost the use of His limbs 
for several days after the attack. Could not talk well after- 
wards ; his memory became impaired and sensations were 
dull on the entire left side from that time on. The convul- 
sions came five times—several months apart—within two 
years. Each successive paroxysm was longer and more 
severe than the preceding one. Had the last attack of the 
five before entering the hospital a few days before Thanks- 
giving, 1892, at which time he was almost comatose for 
thirty-six hours. Since coming here, December 21, 1892, the 
convulsive seizures have occurred on an average about 
once in twelve days. 
Symptoms during the Seizure.—Clonic convulsions begin- 
ning in the second finger of the left hand. Immediately 
after the “initial” symptom appeared in the finger the 
convulsions extended to the other fingers, wrist, arm and 
shoulder in rapid succession, also to the muscles of the face 
and leg. Teeth came firmly together, causing a “ gritting ” 
movement; several times the tongue was bitten. These 
symptoms of irritation were followed by a period of uncon- 
sciousness and hemiplegia, the unconscious state lasting from 
a few hours to a day. The paralysis only partially disap- 
peared. The limbs could be moved, although he had little 
use of them. The left hand was closed most of the time; 
with a little effort he could open it. Hand pressure was 13 
very weak compared with the right one. Upon waking he 
looked dazed. There was almost complete hemiansesthesia, 
and a constant twitching at the left angle of the mouth; 
also ataxic and amnesic aphasia. Memory greatly impaired. 
Status Presens.—Before operation made the following notes : 
Is in fair flesh. Presents a “ nervous look.” Has partial 
hemiplegia of the left side. Drags the left leg while walk- 
ing. Carries his left hand closed. Muscular power greatly 
diminished. Pressure with left hand very feeble. There is 
limited motion of the left arm. Can lift it to the horizontal 
with shoulder, slowly; left hand opens halfway slowly. 
There is almost complete loss of general and tactile sensa- 
tion. Hemiansesthesia may be said to be almost complete. 
Is unable to tell which linger or toe is being pricked with a 
pin. Does not feel it about the face. Our interne, Dr. 
Boomer, stuck a pin almost through the lobe of the left ear 
and the patient gave no evidence of having felt it. Touch 
any portion of the left half of the body and extremities 
with bottles of hot water, he takes no notice of the heat. A 
snowball was placed against his left arm, leg and face with- 
out his knowledge; he remained ignorant of its presence. 
Can not add a column of six simple numerals. Does not 
know the value of the figures. Does not know when he had 
the last convulsion. Can not remember when his wife called 
to see him last, although she was here yesterday. His 
vocabulary is limited. Is afflicted with both amnesic and 
ataxic aphasia. Speaks a wrord hesitatingly; seems too 
tired to speak another; shakes his head; evidently can not 
think the word. Can not write a connected sentence of five 
words. Drops one or two words in the effort. L. E.— 
fundus very much congested ; V. 20-60. R.E.—V. 20-20. 
On presenting this patient before the class I said the 
localization symptoms of irritation and of partial destruc- 
tion are well-marked. There are the local headache, 
tenderness and pain ; the “signal” symptoms as first noticed 
by his wife, in the left middle finger, followed by clonic 
convulsions of successive groups of muscles ; the hemianses- 
thesia; tremors at the left angle of the mouth; tetanic 
contracture of the left levator orbicularis and of the pla- 
tysma muscles; also the hemiplegia of the left side pointing 14 
directly to the right side of the brain as the location of the 
fons et origo of the man’s condition. Reading these symp- 
toms in the light of modern pathological knowledge we may 
feel absolutely sure that there is a lesion about the cortex 
of the brain corresponding to the right motor area, as map- 
ped out by Ferrier and Horsley. 
1. Base line. I. Inion. 
2. Parallel tangent line. B. Bregna. 
3. Bi-auricular. S. Stephanion Superior. 
4. Fissure of Rolando. S. “ Inferior. 
The circle represents trephine ring, P. Pteryon, 
button within. O.P. Occipito Parietal fissure. 
N. Nasion. L. Lambdoid suture. 
G. Glabella. 
Fig.III. 
The history of the case points to traumatism as the ori- 
gin—causing inflammation, infection, or both, with their 
sequelae. There may have resulted thickening of the bone ; 
possibly a splinter was driven into the brain from the inner 
table and has led to the formation of a local abscess. There 
is the possibility of a blood clot alone, or as a complication 
of the conditions already mentioned. 15 
The patient’s head had been shaved and thoroughly 
scrubbed with soap and water and washed with a bichloride 
of mercury solution, 1 to 2000. I now took the measure- 
ments for locating the fissure of Rolando. My method is 
to project a base line from the crown of the teeth of the 
upper jaw backwards, which will cross below the mastoid 
process on a line with the condyles of the occipital bone. 
Next a vertical line carried at right angles with the 
Fig. IV. 
1. Base line. Broken line of the oval indicates the 
2. Parallel tangent line. area of adhesions, and bounds the 
3. Bi-auricular line. space occupied hy the blood clot, 
Circle indicates opening into skull, beneath the dura mater. 
base line (see Illustration 3,) upwards through the middle 
of the auditory meatus to the top of the head and parallel 
with the base line. At a point 6 cm. above the middle of 
the auditory meatus make a dot with tincture of iodine; 
from this dot carry a line obliquely backwards and up- 
wards at an angle of 33 degrees with the bi-auricular line. 
Thus marked out, approximately, the course of the fissure 16 
of Rolando. Having mapped out the fissure we again 
washed the scalp thoroughly. Before cutting through the 
scalp I pierced it with a drill and marked the line for the cen- 
tral pivot of the trephine. To prevent hemorrhage the lock 
stitch devised by my friend, Dr. Frank, was used. With 
the stitch I cut off from the circulation an elliptical area 
measuring 12% by 10 cm. (5 by 4 inches). Within the area 
I cut down through the scalp and periosteum, making an 
oval flap 6 cm. wide, and lifted it up from behind forward 
to the extent of 7 cm., (2 4-5 inches), leaving the base of the 
flap in front; thus the opening in the scalp was placed at 
the most dependent portion. The flap was held back with 
warm sterilized gauze by Dr. Cullen, our interne. I now 
placed the trephine upon the skull so as to cover the fissure 
of Rolando, but had it extend further back of the fissure 
than forward, so as to get nearest the point in the skull 
covered by the scar in the scalp. The trephine was one and 
one-half inches in diameter. The bone was quite dense, five- 
sixteenths of an inch thick. The sclerosed condition of the 
bone was evidently due to osteitis. The dura mater was 
crossed by several large veins, and bled readily on being 
touched. After passing the needle through the dura mater, 
a half teaspoonful of blood entered the syringe. Finding 
nothing between the dura mater and calvarium to account 
for the man’s condition I tied the veins and cut the dura 
mater one-fourth of an inch from the margin of the open- 
ing, and carried the incision around three-fifths of the cir- 
cumference of the ring. The membrane was very thick 
and cut like leather, presented a yellowish appearance. 
A blood clot now came into view—it was semi-liquid. 
By inclining the head to the right side, we caused the clot 
to glide out; the quantity was about two tablespoonsful. 
There was considerable lymph in the arachnoid membrane 
all over the exposed surface. My index finger passed read- 
ily under the cranial vault and was swept about its circum- 
ference two inches forward and downward, an inch back- 
ward and half an inch inward to the longitudinal sinus. 
Around the entire area there were adhesions present show- 
ing that there had been at least a localized meningitis here 
and probably a leptomeningitis. The arachnoid could not 17 
be separated from the pia mater. Looking closely at the 
exposed surface the membranes were as one, thickened by 
lymph deposits. I tore the adhesions asunder between the 
arachnoid and dura mater by very gently pressing against 
them, the force of the pressure being directed towards the 
outer membrane. No hemorrhage worth mentioning fol- 
lowed this procedure in the present instance. My fingers 
were a little blood-stained. I explored the brain farther 
with the needle. It descended into the ascending frontal 
convolution towards Broca’s speech center. Only a little 
brain substance entered it. Pierced the posterior portion 
of the ascending parietal convolution, behind the fissure 
of Rolando and above it. Noticed the patient’s left 
leg jerk as the needle entered the cortex. The needle 
next entered directly behind (or as nearly as one could 
compute) the Rolandic fissure near the hand and 
finger centers. There was no evidence of abscess in 
any of these points; hardly felt justified in exploring 
farther in the presence of the pathological, conditions 
already found. Washed the exposed parts with sterilized 
water, using very little pressure with the syringe, having 
first surrounded the tissues involved with sterilized gauze 
sponges to prevent the water from pouring into the sub- 
dural space beyond the limit of disease. There was a dark 
appearance of the deep membranes in spots, probably due 
to deep congestion of the pia mater, and the brain seemed 
to yield more readily to pressure here as if it was a little 
softer than in other parts. 
As the vessels of the pia mater dip into the brain, the 
presence of softening of the brain would not be surprising. 
Leptomeningitis is said to be a cause of such a pathological 
condition. Had I been confident that the brain tissue had 
undergone degeneration it would not have seemed justifia- 
ble, in the face of what had already been done, to extirpate 
it. Removal of it would have produced permanent mono- 
plegia. Not knowing what nature might accomplish by the 
regenerative process it seemed wise not to disturb it. I pro- 
ceeded to close the wound, by first stitching the dura mater 
with catgut, in continuous suture, leaving a small opening 
at the lowest part for drain and insert a small drainage 18 
tube, having chiseled a groove in the margin of the button 
and taken out a few chips of the parietal bone directly oppo- 
site to prevent pressure on the tube. The button of bone 
was replaced. The scalp was stitched with silkworm gut, 
an opening being left at the lowest portion for the drainage 
tube. I now removed the lock stitch. Next dusted iodo- 
form over the scalp wound, covered the head with two layers 
of iodoform gauze, four layers of sublimate gauze, placed a 
thick layer of cotton around the entire head and a Moorish 
bandage or cap over all. 
Note:—Feb. 21. The patient lifts his left leg and bends 
the knee while walking. Before the operation he dragged 
the leg. The twitching at the left angle of the mouth ceased 
three weeks ago. General and tactile sense partially re- 
stored. Says he feels his left arm and leg, as if there was 
life in them; they seemed dead before. Can recognize 
which finger is touched with a point of a pin, without see- 
ing it. The ear is sensitive to the touch. Headache has 
left him. Talks better, frequently speaks a sentence of a 
dozen words. Sometimes the words come smoothly and 
rapidly, at other times somewhat hesitatingly. Brain tires 
easily. An hour and a half after the operation was completed 
he said, ‘‘Doctor, can’t you shut off that man’s whistle?” 
referring to a patient in an adjoining room whose whistling 
annoyed him. The words were spoken distinctly and with 
little hesitation. Two weeks ago he could not open the left 
hand or lift the fingers. Now he opens the hand widely and 
extends the fingers. Has had no convulsions. Is improving 
daily. I omitted mentioning that our patient took iodid 
of potassium up to two weeks preceding the operation to 
make sure that no error should occur in operating. There 
was no indication of syphilis and the history of trauma- 
tism had not been ascertained. As already mentioned, 
the gentleman said nothing about the injury to the scalp 
until it was discovered by ocular and digital examination, 
and his attention was called to it. 
Feb. 29. Had bone ache; bone was tender. There was 
evidence of necrosis. I opened the wound, removed the 
button, and chiseled away small bits of bone. March 
31. Had a convulsion. Reopened the wound and re- 
moved a semicircle of dead bone about the cranial open- 
ing. There were adhesions between the dura mater and 
arachnoid. For a time he seemed to improve again. April 
6, while telling some of his friends that he felt better than 
he had for years, he was taken suddenly with epileptic 19 
seizures. They recurred daily. On the 11th of April I 
opened the wound once more, hoping to find a removable 
cause for the convulsions. Found adhesions to the dura 
mater and softened brain tissue, with two small abscesses 
of the size of pea. Died April 16. 
Autopsy revealed extensive area of softened brain tissue, 
with two small abscess centers the size of a pea, and the 
dura mater re-attached. For at least one inch below and 
back of the trephine opening the bone was one-sixteenth of 
an inch thicker than that of the opposite side. 
Case 9.—729. Wesley Hospital Record. Admitted March 
20,1893. Mr. W.. aged 52 years. Has always been well and 
hearty. A locomotive engineer by profession. Eighteen 
months ago was badly hurt in collision of electric cars. 
Struck the side of his head against a door frame. Six hours 
later, in the night, while drinking a little water fell to the 
floor unconscious and paralyzed. Next morning conscious- 
ness returned, but he remained hemiplegic. Was aphasic 
four months. Remained in bed nine months. Has imper- 
fect motion and loss of muscular sense in the entire left 
side. General sensation greatly impaired. Is troubled with 
insomnia. The right parietal bone feels somewhat flattened, 
as if it was stove in. 
Notes taken before operation : 
Left hand assumes silver fork position, with excessive 
extension of all the fingers. Can be about one-third way 
closed. Can not bring the ends of fingers within five inches 
of the palm of the hand. Raises the left arm to an angle of 
about 30° with the side of the chest. Forearm in extension 
forms an angle of 15° with the humerus. Rises from the 
chair slowly, with difficulty and trembling, using his right 
arm as a prop on the arm of the chair. Can not stand erect; 
body leans forward at the pelvis so as to form an angle of 
15° with the thighs. Left shoulder droops three and one- 
half inches. While sitting he can with the aid of the right 
arm carry the left leg over the right knee by making repeated 
efforts. Patellar reflex is exaggerated. On closing his eyes 
while standing his body oscillates and lie fears falling. Can 
not walk a step without strong support, and never has done 
so since receiving the stroke. He moves his leg with great 20 
difficulty, leaning upon the shoulder of an attendant. Does 
not bend the knee, but drags the leg. Walks on the outer 
side of the foot. His knees jerk occasionally when he tries 
to walk. Left ankle is weak and turns easily. General 
muscular tremors noticed after standing five minutes ; more 
noticeable on the left side. Has imperfect control of the 
urine ; urinates three or four times at night. Micturition vari- 
able during the day time. Experiences difficulty in passing 
urine; may take two minutes to start it, and can not con- 
trol the flow at will. Bowels move with difficulty. Tactile 
sense dull; can not distinguish between two points unless 
they are two inches apart, and then- is not certain. Distin- 
guishes heat and cold with difficulty on the entire left side 
of his body, face and limbs. Pin points applied to the left 
foot and leg cause reflex jerking, although he hardly knows 
what troubles him. No cremasteric or elbow reflex elicited. 
Left arm and leg are stiff ; they bend with difficulty, espe- 
cially the arm. Nearly all of the muscles are contractured, 
the extensors most severely. He cries easily and is very 
irritable. 
On the 13th of April, after having the patient most thor- 
oughly prepared, I cut through the scalp, making an oval 
flap as usual, so as to raise it from behind and below; lifted 
the periosteum with it. Foundlffie parietal bone depressed 
near its center. With Roberts’ trephine modified, one and 
one-half inch diameter, I sawed out a button. The dura 
mater was quickly exposed. The skull was only a trifle over 
one-eighth thick and quite elastic. It was not broken, but 
simply bent in like the side of a battered stove pipe. There 
was no cerebral pulse apparent. All around the border of 
the opening just made the bone could be seen curving in 
and pressing upon the dura mater. The latter at once 
raised up to the level of the external surface of the sur- 
rounding bone. The elevator could not bring the edges of 
the bone away from the dura mater sufficiently, so I delib- 
erately enlarged the hole in all directions, perhaps one- 
eighth of an inch, and again pried the bone with elevator. 
Was now rewarded with restoration of pulsation, which the 
members of the class noticed distinctly at the distance of 
eight feet. There was no bleeding during the operation. 
My plan* of constricting the head with a double circle of 
one-third inch solid rubber cord tied with stitches to the 
scalp at two places worked admirably. There was, however, 
free hemorrhage after the constrictor was removed, largely 21 
from the bone. The wound was stitched with silkworm gut. 
It healed promptly. The day after operation he closed his 
left hand firmly, and pressed mine with force. A few days 
ago the gentleman left the hospital greatly improved. Our 
interne, Dr. Seymour, took the following notes May 27: 
*My method of controlling hemorrhage in operations about the head 
is here shown. A firm solid rubber cord, % to % of an inch in 
diameter (1). is wrapped tight about the head twice. The cordis not 
tied into a knot, but the ends are crossed in front and tied together with 
a heavy silk thread placed around them (3). The thread sinks into the 
cord sufficiently to keep the ends from slipping. The cord is held in 
position by means of two or more suture threads. These are placed in 
position by means of a curved needle, which is passed through the 
scalp under the cord. They are then tied around the cord as in illus- 
tration (2). Two or more of these loops may be used at different points. 
Fig. V. 
Can close his left hand completely and gives a strong grip 
with it. Can touch both ears and top of his head with the 
left hand. Can straighten out the left foot and extend it. 
While lying in bed can flex the left leg at the thigh and 
knee. Walked to the front door and back (100 feet) without 
the assistance of even a cane, getting up and sitting down 22 
alone. Sways a little .when standing with eyes closed. Stands 
nearly erect. Can raise arm at the shoulder to right angle 
with the body. General and tactile sense greatly improved, 
but not perfect. Talks more fluently ; his words are uttered 
with more force. Is less emotional and has better control 
of his temper. Has control of sphincters. Discharged 
greatly improved May 27. Advised massage treatment and 
electricity for the muscles, which I believe will in time 
enable him to go to work. 
Discussion. 
Dr. McRae of Atlanta, Ga.—These injuries are so frequent 
that we all meet them, and it is our duty to operate in every 
case. I recently had two cases which exemplify this. One 
was an injury the result of a fall from a horse, which caused 
a triangular depression on the top of the head. I never saw 
such violent hemorrhage from a fracture of the skull as 
occurred in that case. I immediately ran my finger into 
the wound in the scalp, and shortly the hemorrhage ceased. 
I then prepared for operating, but as soon as I tried to 
make an opening in order to elevate the bone the hemor- 
rhage commenced again violently. I packed with iodoform 
gauze, stitched up the scalp, put on an antiseptic dressing 
and sent the patient home. The man made an excellent 
and uninterrupted recovery. 
Another case was that of a boy 14 years of age who was 
struck over the parietal eminence. I found the bone 
depressed, and quite a quantity of brain substance had 
escaped. I operated immediately and he made a good 
recovery. 
A third case was that of a boy who fell from a horse, but 
as no immediate serious symptoms developed, the family 
did not call in a physician. He got along all right for a 
while, and then a persistent headache began to manifest 
itself, later a progressive paralysis, and now he is only able 
to sit up in bed. This demonstrates what the outcome is 
liable to be without operation. 
Dr. Averill of Pennsylvania—About four years ago I was 
called to see a child 3 years old who had been kicked by a 
horse. The superior portion of the frontal bone was frac- 
tured, with depression of the upper edge to the extent of 
about one-half or three-fourths of an inch, lacerating the 
meninges extensively as well as the brain tissue. I removed 
probably two or three ounces of brain substance, excised 
the lacerated meninges, brought together the soft tissues of 
the scalp, dressed antiseptically and obtained a very satis- 
factory recovery. There was never any febrile condition, 
little pain, and the recovery was complete in about five 
weeks. 23 
Dr. Griffith of Kansas City—These reported cases are 
very interesting to me. My idea is that we can not be too 
careful about the prognosis in these cases, and also about 
insisting on going into the scalp to ascertain whether or 
not the skull is injured; there is nothing dangerous about 
this procedure, and we can promise the family that no harm 
will result from it. I think the method mentioned for stop- 
ping hemorrhage of the scalp unique. In our place we do 
it by the pressure method, opening the scalp, running a loop 
stitch clear around a given area going down on to the skull 
proper, and in this way we get a complete closure of all 
the vessels in this area. 
Dr. Reyburn, Washington, D. C.—I am more inclined to 
operative interference in these cases than I was in the early 
years of my practice. I think that where there is any sus- 
picion of a serious injury it is best to open the scalp and 
ascertain positively the condition existing. I will cite in 
support of this a couple of cases in my own experience: 
One case was that of a boy who had been struck over the 
head by an iron bar, and shortly afterward went into vio- 
lent convulsions. I immediately, upon my arrival, opened 
the scalp and removed the depressed bone. The improve- 
ment was immediate and the case went on to recovery. 
At about the same time another boy was similarly injured, 
but he did not come under my hands at once, nor did he 
receive the attention which he should have had. On the 
third day I removed a spicule of bone which extended into 
the brain; soon after symptoms of inflammation of the 
brain developed and death resulted. So I repeat that my 
advice is, where there is any doubt in the mind of the sur- 
geon, to invariably open the scalp and clear away any such 
doubts. There is no danger whatever in such a proceeding 
except in a child of from 2 to 5 years of age, but when the 
individual is older than that, in waiting there is danger of 
the development of inflammation of the brain. 
Dr. Schaefer—In reply to Dr. Griffith’s remarks about 
the loop stitch I will say that it was introduced by a Chicago 
surgeon, Dr. Frank, a few years ago. I followed this method 
in one of my cases and came to the conclusion that it was 
inferior to the plan described in this paper. It increases 
the danger of infection, as it is necessary to cover quite an 
area, and the needle will have to enter the tissues perhaps 
fifty times, while in the method illustrated only two or 
three, and occasionally four stitches, are required. I am 
pleased with the stand taken by Dr. Reyburn of Washing- 
ton. I believe that more of these cases could be saved by 
timely operation. In all probability those who die after the 
operation would have died anyway.