Whatever method is used the greatest care should be taken to saw the
skull-cap without injuring the brain. The difference in thickness
of different portions of the cranium must be borne in mind. Sight,
sound and “the feel” are taken as guides. The outer and inner tables,
the diploë, and the dura have an entirely different resistance and
give a different sound. The saw-dust of the outer table is white,
that of the diploë red, that of the inner table white. As soon as
the saw strikes the dura a peculiar “rustling” or “scraping” sound
is heard, and this should be taken as the warning to stop sawing. On
curved surfaces it is best to begin sawing on the greatest convexity
and to continue until the saw is through and then to extend the cut
from this point. The sawing should be done lightly and quickly,
without too strong pressure. Set the saw carefully at first, to avoid
slipping. The small bone-saw is usually used for this operation; saws
attached to electric or dental engines are sometimes employed. Care
should be taken to bring the beginning and ending of the saw-cut into
the same plane; and the oblique cuts should be symmetrical.
As soon as the sawing is completed, no matter what method is used,
the T-chisel or skull-opener (Fig. 12) is used to spring off the
skull-cap. The chisel-blade is inserted into the saw-cut in the right
frontal region, and turned sideways with a quick, powerful movement
of the right hand. Any portions of the inner table not completely
sawed through (usually in the region of the petrous portion of the
temporal) are thus broken, and the dura is loosened sufficiently from
the inner table to allow the prosector to introduce the fingers of
the right hand beneath the skull-cap in the frontal region and to
hold down the dura while the fingers of the left hand inserted into
the frontal saw-cut pull the skull-cap backward with a powerful tug,
completely separating it from the dura, unless the dura is adherent
throughout, as is the case in very young children, old people, and in
certain pathologic conditions. In the latter case it may be necessary
to cut the dura along the line of the horizontal saw-cut and to
remove it with the skull-cap, cutting the falx as the skull-cap is
lifted. In young children the dura must always be removed with the
skull-cap. In the case of pathologic adhesions an attempt should be
made first to separate them from the lamina vitrea by cutting them
with a knife or chisel-blade inserted through the saw-cut. As the
adhesions are severed the skull-cap is lifted gradually backward.
Too much force should not be used in jerking off the skull-cap, else
the brain may be damaged. Whenever possible the dura should be left
intact, as a better judgment is thereby obtained of the intradural
pressure, and there is less danger of losing the contents of the
subdural space.
Public-domain text, read in full here on John Shaqi.
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