. Medical and surgical therapy . ll pointed spiculesof bone must be cut off with the gouge-forceps. Theflap is firmly held by an assistant, and all projectionswhich are liable to press on the dura mater and thebrain arc geiitly chiselled away. Finally, the circumfer- 814 WOUNDS OF THE SKULL ence of the perforation is smoothed by removing alldamaged pieces of bone with very sharp gouge-forceps. Fig. 42.—The flap being held quite steady by the assistant, the operatorsmooths ofE the orifice of entry of the missile from the internal aspectof the bone. All these manoeuvres should be done while theb
. Medical and surgical therapy . ll pointed spiculesof bone must be cut off with the gouge-forceps. Theflap is firmly held by an assistant, and all projectionswhich are liable to press on the dura mater and thebrain arc geiitly chiselled away. Finally, the circumfer- 814 WOUNDS OF THE SKULL ence of the perforation is smoothed by removing alldamaged pieces of bone with very sharp gouge-forceps. Fig. 42.—The flap being held quite steady by the assistant, the operatorsmooths ofE the orifice of entry of the missile from the internal aspectof the bone. All these manoeuvres should be done while thebone-flap is held firmly in strong forceps by anassistant (fig. 42). It is obviously much less simplethan chipping away the skull with cutting pliers TRUE CRANIECTOMY 815 haphazard and without any guide, but it is muchmore satisfactory from a surgical point of the toilet of the inner surface of the bone-flaphas been finished, the surgeon turns to the lesions of thedura and the brain, taking the greatest care meanwhile. Fig. 43.—Prolonged irrigation with warm physiological serum is thebest method for freeing the brain from the numerous and oftenvery small and hardly visible foreign bodies. not to disturb any adhesions that already exist betweenthese two important structures. Detached splintersof the inner table are often adherent to the dura, andthey should be removed with the greatest the dura has been torn and a portion of the skullis missing, the presumption will be that this fragmenthas jicnctrated the brain through the breach in thedura mater. Gentle search must be made for it there 810 ]VOUXI)S OF Tlll^: SKULL with the tip of the iin<]fer and a forceps, and it willoften be found. The lips of the wound in the duramater must be trimmed, but as a rule this membraneshould not be incised. When the brain itself is injured, an effort mustbe made to cleanse the cerebral wound as much aspossible, but even in this all excessive handling mustbe avoided.
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Keywords: ., bookcentury1900, bookdecade1910, booksubjectsurgery, bookyear1918
