The Surgery of the Skull and Brain

by Louis Bathe Rawling

The tumour must be palpable immediately after the acute swelling has diminished.

At the site of the trauma constant or intermittent pain must be present.

A considerable number of cases of sarcoma of the skull will fulfil even these arbitrary conditions. Such sarcomata may definitely be labelled ‘traumatic’ sarcomata.

Whether dependent on injury or not, the symptoms associated with sarcoma of the skull vary according to whether the tumour is extrinsic or intrinsic—whether, for instance, the growth develops in the inward direction and presses on the brain, or grows from the pericranium and is directed externally. Intrinsic tumours, with the exception of some local pain, œdema of tissues, and dilatation of superficial veins, give rise to symptoms closely resembling those observed in intracranial tumour formation. When extrinsic, the tumour varies in size, but is necessarily attached to the bone, the base being the widest part of the tumour. In the earlier stages the overlying skin, with the exception of a few dilated vessels, is more or less normal. Later on, the integument becomes adherent to the tumour, then red and inflamed, and finally ulcerated, the growth now fungating to the surface. The tumour itself is of variable consistency, first hard, then softer, and lastly semi-fluctuating.

Pain, though not very severe, is more or less constant—of a dull, aching character. The extrinsic tumours may, however, give rise to acute neuralgic pain in the event of implication of cutaneous nerves; whilst the intrinsic, in the later stages of the disease, lead to the more severe types of headache observed in intracranial tumour formation.

Secondary nodules appear in other parts of the scalp—all appertaining, in their clinical characteristics, to the primary growth; the cervical glands become infected, and death results from repeated hæmorrhages, pulmonary complications, &c., usually within one to two years from the date of primary development.

Treatment.

The removal of an extrinsic tumour should only be carried out when the tumour is small and non-adherent to the tissues of the scalp. With respect to the intrinsic variety greater circumspection is required. The presence of cerebral symptoms and the inward extension of the growth—verified by symptoms and by X-ray investigation—may be regarded as implying that the conditions are beyond the reach of surgery. In both varieties of tumour, extensive glandular implication acts as a contra-indication to operation.

Under the more favourable conditions an attempt may be made at the extirpation of the growth. The operation should be rendered as bloodless as possible, for which purpose it is essential that the scalp-tourniquet should be applied as a preliminary measure. A scalp-flap is then framed, suited to requirements, and allowing of free exposure of the tumour and surrounding healthy tissues. The skull is then trephined to one side of the growth, and the disk removed. The dura is separated from the overlying bone, and by the circumferential application of de Vilbiss or other craniectomy forceps the central mass is isolated and removed. During these manipulations free hæmorrhage may be experienced from the numerous dilated diploic veins. For the arrest of this the surgeon should have ready to hand, ivory pegs, bone-wax, and other aids for the control of hæmorrhage (see [Chapter II]). The scalp-flap is then replaced.