With the Aumor's Compliments. 
SURGICAL ANATOMY of the BRAIN. 
F. W. LANGDON, M.D., 
[Reprint from Cincinnati Medical Journal, April, 1891.] 
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Cincinnati Medical Journal. 
Vol. VI.] Cincinnati, April, 1891. [No. 4. 
Original Articles. 
THE SURGICAL ANATOMY OF THE BRAIN 
A Lecture Delivered in the Regular Course at the Miami Medical College, Dec. 12,1890. 
By F. W. Langdon, M.D. 
Professor of Surgical Anatomy. 
Gentlemen:-There was a time when to open any one of the 
three great cavities of the body was considered to bring censure to 
the surgeon and death to the patient. That time has passed, within 
the memory of men still comparatively young in the profession, and 
to-day we open the peritonseal, the pleural and the cranial cavities 
in suitable cases with the practical result of saving many lives that 
would have been sacrificed to inactivity under the older order of 
things. 
The conditions which may render advisable the surgical open- 
ing of the cranium are,* 
1. Fracture with depression of bone. 
2. Fracture with intra cranial hemorrhage causing com- 
pression. 
3. Abscess. ; ? 
4. Tumor. I I 
5. Epilepsy due to traumatism. / 
6. Insanity due to traumatism. x ck * 
In general terms it may be stated that in order to justify sur- 
gical interference two conditions should be present. 
■■John B. Roberts, Operative Surgery of Brain, Phil. 1885. Also Trans. Am. 
Surg. Asso. 1885. 
121 122 
The Cincinnati Medical Journal. 
1. The lesion should be a gross one, circumscribed and cap- 
able of localization by functional signs or ocular inspection. 
2. Its situation should be above a line drawn from the supra- 
orbital arch to the external occipital protuberance. There may 
be occasional exceptions to this rule. 
In locating and planning operations in this area, use has been 
made of various methods of measuring and mapping out upon the 
scalp and skull the various functional areas affected.f 
The vault of the cranium has been divided into rectangular 
areas by ingenious systems of measurement, {Fere, Seguin, Nan- 
crede, Roberts, Amidon, Ranney), and by more or less complicated 
cranio meters, {Thane, Broca, Lucas-Championnierei) Yet it is evi- 
dent that, no matter how exact our mathematical rules may be, 
the results must only approximately locate the diseased areas; 
since rarely are two brains exactly alike in their proportions, nor 
are the two sides of the same brain precisely similar. 
It is obvious also that there are men with "long" heads 
{dolichocephali}, and "short" heads {brachycephalic, as well as those 
with "medium" heads {mcsoccphali or orthocephali). Moreover, it 
is pertinent to note that even Broca, who made the first and, for 
a time, the most exhaustive and authoritive study of this subject, 
speaks of a distance of " 18 or 20 M M: " and " The situation of the 
fissure of Sylvius may be approximately ascertained;" and "a few 
millimeters anterior to, " etc. 
Such inexactness from so high a source is sufficient to suggest 
the futility of attempting to locate, with mathematical exactitude, 
functions and lesions of the brain ; and emphasizes the fact that 
the anatomical personal equation, so to speak, of the operator, 
must determine the exact place of application of the trephine. 
Hence, the practical importance of personal familiarity with the 
anatomy of various brains ; and the practical rule to use a large 
trephine in exploratory openings generally. 
For reasons already stated, it would seem that no .system of 
mathematical measurements or of localization by craniometers 
can possibly apply to all heads, or possess the practical value of a 
method based on anatomical landmarks and relations. 
I propose therefore to indicate such a method of locating the 
principal areas which warrant operative procedures, a method 
which is more simple than, and at least as reliable as, any known 
to me. 
tSec this Journal, Feb. 15,1891, for reference to these areas. Original Articles. 
123 
The landmarks which are of especial value in these cases are : 
(See Fig. 1.) 
Fig. 1. (J natural size.) Direct profile view of skull, showing surgical 
landmarks and lines as designed by the author. Also dotted outlines of principal 
dural vessels. From a photograph of actual skull, with lines in situ. (Owing to 
perspective, the Rolandic line F-G, shows as a curve instead of a straight line as 
drawn ; the posterior portion of A-B also conveys a similar impression). 
A. Base of external angular process of frontal-level with highest part of 
supra-orbital arch. 
B. External occipital protuberance. 
C. Greatest zygomatic convexity, above middle of arch, C. This arch, C 
might be designated as the zygomatic " sub-arch," being the excavation in lower 
border of zygoma just in front of the "tubercle" of its anterior root. The little 
arch may be readily located on the living subject, and its centre corresponds with 
the greatest zygomatic convexity. 
D. Upper extremity of zygomatic vertical line. 
E. Greatest convexity of parietal eminence, in line with posterior margin of 
base of mastoid process. 
F. Upper extremity (concealed in this view, see Fig. 2,) of Parietal vertical 
line and of Rolandic line. 124 
The Cincinnati Medical Journal. 
G. Lower extremity of Rolandic line and intersection of Fronto-parietal 
(A-E) and zygomatic vertical (C-D) lines. An inch trephine opening at G will 
expose (i) the trifurcation of the anterior division of the middle meningeal artery ; 
(2) the bifurcation of the Sylvian fissure; (3) the third frontal convolution (speech 
area), and part of tongue and face areas. (See Fig. 2.) 
H. Intersection of A-B and C-D. A similar trephine hole here will expose 
(1) the bifurcation of the middle meningeal trunk; (2) the smell and taste areas 
in the tip of temporal lobe. 
I. Situation of trephine opening to tap abscess of temporal lobe and avoid 
petrous process, tentorium cerebelli and lateral sinus. 
J. Level of first temporo-sphenoidal convolution (hearing area) two inches 
vertically above centre of external auditory meatus. 
K. Lateral sinus in shaded outline. 
L. Posterior border of base of mastoid process crossed by continuation of 
parietal vertical line. 
The Lines. 
A-B. Fronto-occipital line, defining the lower boundary of cerebrum, 
excepting a portion of temporal lobe, which lies below. (See Fig. 2.) 
A-E. Fronto-parietal line, its posterior two-thirds nearly parallel with hori- 
zontal limb of Sylvian fissure, which lies less than half an inch below. (Sfee Fig. 2.) 
C-D. Zygomatic vertical line, from greatest convexity of zygoma, vertically 
upwards to median line. 
E-F. Parietal vertical line, from greatest convexity of parietal eminence to 
vertex, partly hidden by perspective in this figure; for its full length see figure 2. 
E-L, same line carried to posterior border of mastoid base and intersecting the 
" base-line " of Ranney at a right angle. 
F-G. Rolandic line, guide to situation-of fissure of Rolando; (also partly 
hidden and curved by perspective, see figure 2 for its full length). 
M-N. ''Base-line" of Ranney, useful as a check to secure accuracy of 
vertical lines. This line should correspond with the cusps of the upper incisors 
and the tip of the mastoid process. 
A. The base of the external angular process of the frontal 
bone, which is practically level with the highest part of the supra- 
orbital arch. 
B. The external occipital protuberance. A line, (which we 
may call the "fronto-occipital line") drawn between these points 
(A-B) will give us the lower limit of the base of the cerebrum, 
excepting the "tip" of the temporal lobe, which lies below. The 
posterior third (about) of this line (I-B) indicates the upper 
limit of the tentorium attachment and consequently the upper 
boundary of the horizontal portion of the lateral sinus. Observe 
that the point I is vertically above the posterior border of the 
mastoid process and would be crossed by a line continued down- 
ward from E-F to the base-line of Ranney. 
C. The greatest convexity of the zygoma. The location of 
this greatest zygomatic convexity may be verified on the living Original Articles. 
125 
subject, by first locating the "tubercle" of the anterior root of the 
zygoma; just in front of this tubercle is an arched excavation in the 
lower border of the zygoma, the concavity of the arch looking 
downward; this arch may be easily felt on the living subject and its 
centre indicates the greatest convexity of the zygoma above re- 
ferred to. 
D. Is the mid-point of a line carried over to the greatest 
convexity of opposite zygoma. To insure vertical accuracy of 
this line use an ordinary steel tape, and also keep it parallel with 
a line over vertex from one auditory meatus to the other; or 
keep it vertical to the "base-line" of Ranney, and note that its 
continuation downward terminates just behind the " angle " of jaw. 
E. The greatest convexity of the parietal eminence. Its 
location may be verified by carrying a line (E-F) to opposite 
parietal eminence and downward on either side to the posterior 
border of the base of the mastoid process ; with these points in line 
we get practically a vertical measurement. 
F. Is the mid-point of the line last mentioned and indicates 
the position of the upper extremity of the fissure of Rolando. 
G. The intersection of lines A-E and C-D. A medium 
sized trephine opening with its center at this intersection, will 
remove the anterior inferior angle of the parietal bone, the tip of the 
great wing of the sphenoid and expose three very important parts, 
namely: (i.) The trifurcation of the anterior division of the middle 
meningeal artery. (2.) the bifurcation of the fissure of Sylvius. 
(3.) The posterior extremity of the third frontal convolution (speech 
centre), arching over the vertical limb of the Sylvian fissure. 
H. The intersection of lines A-B and C-D, locates the "tip" 
of the temporo-sphenoidal lobe (smell and taste centres), and a 
trephine opening here would expose the bifurcation of the trunk 
of the middle meningeal artery. 
I. Site of opening to tap abscess of temporo-sphenoidal 
lobe, avoiding petrous process, lateral sinus and tentorium. 
In abscess of the temporal lobe, the result of middle ear 
suppuration, an opening is required to evacuate the pus. The 
principal vessel to be avoided is the lateral sinus, and its route is 
well marked out by line LB, to opposite the base of mastoid 
process, at which point it descends at almost a right angle to the 
base of the skull; by keeping clear of and above this angle, we may 
escape not only the sinus, but the tentorium cerebelli which 
encloses it, and so avoid infiltration of the cerebellar fossae. 126 
The Cincinnati Medical Journal. 
J. Cortical area of hearing, two inches vertically above 
meatus. 
K. Course of lateral sinus; note its close correspondence 
with lines I-B and I-L. 
THE LINES. 
A-B. (Fronto-occipital line). This line has been already 
referred to (see B in text). 
CD. (Zygomatic vertical line.) In addition to indicating 
(at intersection G) important regions (see G in text) this line 
crosses just below the median line (D) the posterior extremeties of 
the first and second frontal convolutions, wherein are located the 
motor centres for the head and neck movements as well as the 
oculo motor area. (See Fig. 2.) 
A-E. We may call the fronto parietal line. The important 
structures at its intersection with C-D have been already referred 
to. (See G.) It may also be noted that its posterior two-thirds 
(G-E) parallels practically the horizontal limb of the Sylvian fissure 
which fissure lies below the line and at no point, perhaps, farther 
removed than half an inch. This may be a useful guide therefore 
to the second parietal (supra-sylvian) and first temporo-sphenoidal 
(hearing area) convolutions. 
E-F. The parietal vertical line, indicates at the vertex the 
upper extremity of the fissure of Rolando. 
E-L. A continuation of this line to the posterior border of 
the mastoid base, would be a useful guide to the point (I) for tre- 
phining the temporo-sphenoidal lobe (see I in text). 
F-G. Is the Rolandic line or guide to the fissure of Rolando; 
of which it may be said that its lower third traverses the facial 
motor area, its middle third the upper extremity motor area and 
its upper third the lower extremity motor area. Finer distinctions 
and localizations are shown on our diagram. (Fig. 2.) 
M-N. Is the base-line of Ranney drawn between the cusps of 
the incisor teeth and the tip of the mastoid process. The vertical 
lines should cross it at a right angle. 
In the absence of a complete head, you will find an antero- 
posterior median section of the skull a useful aid in comparing 
some of these external guides with their corresponding internal 
markings, as for instance, the bifurcation of the middle meningeal 
artery and the lateral sinus. 
In order to demonstrate the practical utility of these lines I 
draw them here upon the subject to locate the fissure of Rolando, Original Articles. 
127 
Fig. 2. (| natural size.) Oblique profile view of skull (with vertex 
tilted toward observer), so as to show surgical lines and areas to vertex. From a 
photograph of same skull and lines as Fig. i. (The tilting, by raising the incisor 
teeth apparently throws the " base-line " below them. 
1. Fissure of Sylvius-horizontal limb. 
2. Lower limit of temporo-sphenoidal lobe in dotted outline. 
I. Same as I in Fig. i. 
Half-inch circles mark situations of trephine openings to expose localized 
functional areas. As all proportions in both figures are accurately reduced to one 
half actual size, all that is necessary in comparing with the living head is to double 
all distances or measurements desired. 
the middle meningeal trifurcation and the Sylvian bifurcation. 
Laying aside the scalp, I remove with the saw, the bone for a 
quarter of an inch on either side of our Rolandic line as marked, 
carrying the section downward, to intersection (G) in the same 
direction. Raising the loosened section of bone, we perceive on its 
under surface the grooves for the anterior branch of the middle 128 
The Cincinnati Medical Journal. 
meningeal artery, at its point of trifurcation. The dura, (carrying 
the arteries) is now incised and the flap laid back, exposing the 
visceral arachnoid through which we may perceive the pia and the 
underlying convolutions and fissures. Here nearly in the centre of 
our opening and visible in its entire length, is the fissure of 
Rolando, with the psycho-motor convolutions bounding it on 
either side. 
Thus by means of six lines, based on anatomical landmarks 
only, without measurements in inches or millimetres, or apparatus 
of any kind, excepting an ordinary steel tape line, or a narrow strip 
of card board, we may locate upon the living head most of the 
important surgical regions of the brain and its membranes; and I 
venture to state that the rules here laid down will be found as 
reliable in practice as the most elaborate systems of mensuration, 
or craniometry by more or less complicated apparatus. 
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