The Use of Gold Foil in Fractures of the Cranium 
and Resulting Hernia Cerebri. 
Read at the Second Annual Meeting of the American Academy of 
Railway Surgeons, held at Chicago, Ill., Sept. 25-27,1895. 
BY W. L. ESTES, M.D. 
CHIEF SURGEON, L. V. RY., SO. BETHLEHEM, PA. 
REPRINTED FROM 
THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION, 
APRIL I,, 1896. 
CHICAGO: 
American Medical Association Press. 
1896. THE USE OF GOLD FOIL IN FRACTURES 
OF THE CRANIUM AND RESULT- 
ING HERNIA CEREBRI. 
W. L. ESTES, M.D. 
The three cases related in this paper are offered as 
illustrations of a slight advance in hetero-plastic at- 
tempts, and are unique in that they were done on the 
contents of the cranium, and not on the cranial walls 
themselves. The nearest approach I have found to 
the attempts I have made were by Weir, of New 
York, who did pioneer work in using gold foil to 
prevent adhesion of the dura to the cranial bones 
after serious fractures and removal of pieces of bone 
from the cranium, I have extended the use of the foil 
in one case to plug up the cavity in the cerebrum 
itself, and in two other cases to replace destroyed 
dura-not with the idea or indication of preventing 
adhesion, but of replacing the obturator function of 
the lost membrane, and so prevent a further escape of 
cerebral tissue and subsequent development of a 
hernia cerebri. 
The number of cases is too small to serve as an 
authoritative guide for future routine practice; these 
cases indicate, however, beyond the shadow of doubt 
the extreme tolerance of the brain and cranial con- 
tents to foreign bodies, and may encourage further 
attempts in even more radical directions. For in- 
stance, it happened once to me in operating on the 
cerebrum to open the lateral ventricle, and I found 
no ordinary plug nor suturing nor compression would 
prevent the constant escape of cerebro-spinal fluid, 
which finally caused the death of the patient. Hav- 2 
ing the experience of these cases in mind I should 
not now hesitate to form a new roof for the lateral 
ventricle with gold, or if need be plug its cavity with a 
cup of gold. The gold foil might also be useful in 
controlling the escape of cerebral tissue or help fill the 
cavity left after removal of tumors from the brain, and 
so on. It must be understood that this kind of 
hetero-plasty demands the strictest aseptic technique 
and most careful attention to details. 
A most valuable adjunct to the specific use of the 
gold foil inside the cranium, is the inhibitory action 
it exerts against the growth and development of 
microorganisms. This most beneficent quality was 
discovered at Johns Hopkins Hospital by Drs. Welsh 
and Halsted. It is true also of silver foil and metal 
plates and sutures generally which will resist the 
corroding action of the animal tissue, and fluids. 
This inhibitory action against microorganisms may ex- 
plain the remarkable aseptic course of the second and 
third cases, after the use of gold foil when the condi- 
tions previous to the operation were particularly fav- 
orable for subsequent suppuration. 
The gold foil I have used has been next to the 
thickest foil ordinarily used in dentistry, I sterilized 
it by a prolonged immersion in a 5 per cent, solution 
of carbolic acid and just before using it washed it 
thoroughly in a sterilized normal saline solution. 
During the operation a warm sterilized saline solution 
was used for all purposes of douching or washing 
about the wound or within the cranium. I invariably 
prefer to retnove by gentle douching any detached 
cerebral matter, clots, or debris from the cranial cavity, 
rather than by swabbing with any sort of gauze or 
sponge. I have found capillary drainage quite suffi- 
cient in these cases. I have used stout catgut, or 
a narrow piece of sterilized iodoformized gauze as 
drains. 
The arguments specially in favor of these hetero- 
plastic attempts, rather than autoplasty, are two-fold. 
1. After a stock of gold foil has been obtained it is 3 
always ready and is easily employed, whereas auto- 
plasty, after complete destruction of an area of dura 
or cerebrum, is extremely difficult and usually indeed 
impracticable. 2. Hetero-plasty introduces a sub- 
stance which if it prove an irritant does so simply by 
its presence, as a mechanical result, so to speak, and it 
acts as an efficient inhibitor of microgenesis, whereas 
autoplasty may, and commonly does, result in necro- 
biosis and infection of the already badly injured tis- 
sues. The former may be removed in toto without 
much disturbance and with relief to the symptoms, 
whereas in the latter case the result of the death 
of the organic graft is usually irreparable and far 
reaching. 
The cases are as follows (The first case was pub- 
lished a few months ago in the Medical News. The 
other two cases are given here for the first time): 
Case 1. Cornelius B., a negro, 28 years of age, was brought 
to the hospital in an unconscious condition on the night of 
April 4, 1893. The ambulance surgeon was told that while the 
patient with a companion was out driving, Cornelius, by what 
means or agency could not be discovered, was thrown to the 
ground and kicked by the horse, becoming immediately uncon- 
scious. He was forthwith taken in charge by his companion 
and sent by railroad a distance of some twenty-odd miles, and 
finally was received at the hospital, still unconscious, three or 
four hours after the injury. No dressing or covering of any 
sort had been placed over the wound. Examination showed no 
injury anywhere, not even an apparent bruise, except on the 
right side of his head, where there was a punched-out sort of 
wound through the scalp and bone and deep into the cranial 
cavity. The location of this wound was 6.5 centimeters above 
the external auditory meatus and 2 centimeters in front of a 
line perpendicular to the external auditory meatus; it was 5.5 
centimeters behind and 3.5 centimeters above the external 
angle of the frontal bone. The wound in the scalp was round, 
but a laceration extended backward about 3 centimeters. The 
surrounding scalp was not lacerated or contused. Hemorrhage 
had entirely ceased and had not been profuse. The man's gen- 
eral condition was good. Although he was unconscious, 
enough reflex remained to cause him to move about when the 
wound was manipulated. After shaving and carefully cleans- 
ing and disinfecting his head he was chloroformed, the exter- 
nal or scalp wound was enlarged and the bone freely exposed. 
It was found that the depressed fracture of the bone involved 4 
an area of a little less than 2 centimeters and that all of this 
bone was driven down at almost a right angle to the cranium 
into the cerebrum, so that there was a sharply-defined rim of 
bone, with some radiating linear fractures, and about 3 centi- 
meters beneath, from the inner table of the cranium, the com- 
minuted fragments lay imbedded in the cerebrum. Outside of 
this bone the scalp had also been punched out and the frag- 
ment was lost. The opening in the bone was enlarged and by 
careful manipulation the fragments were lifted out of the cere- 
brum with a pair of narrow forceps. A few spiculae were so 
small and sharp and deeply imbedded that much care was 
required to locate and remove them. When the fragments 
were finally removed free hemorrhage took place from the cere- 
brum, but was checked by plugging the cavity with iodoform- 
ized gauze. Something like 15 cubic centimeters of lacerated 
cerebral tissue were washed away with a gentle stream of warm 
sterilized saline solution. The dura was lacerated to shreds 
and it was quite impossible to close the gap in the membrane. 
I concluded to pack the whole cavity with iodoformized gauze, 
and, by careful asepsis, endeavor to obtain healing by granula- 
tion. Accordingly, a careful dressing with an outside pressure 
bandage was applied and the patient put to bed. He stood 
the operation very well, reacted quickly, and under morphin 
passed a quiet night. The next day he was quite conscious, 
answered questions readily and had no paralysis. There had 
been considerable oozing and the dressings were saturated with 
blood. I changed the dressing. In spite of the greatest care 
there was an escape of more cerebral tissue, and as there was 
no membrane or scalp to help retain it I saw I should have 
trouble to prevent the escape of brain tissue whenever I dressed 
the wound, and every prospect of a final hernia cerebri. I 
replugged and redressed the wound as before and concluded to 
wait a day or two. I recollected, in thinking over the matter, 
that Weir had recently used gold foil to prevent adhesions 
between the dura and cranium and scalp, and had found it 
non-irritating, and that rapid and permanent healing occurred 
in his cases. I had to control the oozing of the cerebral tissue 
into a cavity and prevent its detachment and escape on account 
of a complete loss of all its envelopes. I concluded to try a ster- 
ilized cup made of heavy gold foil fitted down into the cavity 
of the cerebrum. 
On April 7, two days after the injury, I again had the 
patient chloroformed, and getting the dimensions of the hole 
in the cranium I fashioned a cup from the gold foil (which had 
been sterilized by immersion in a 5. per cent, solution of carbolic 
acid and then washed off in a warm sterilized saline solution, 
0.5 per cent, solution of sodium chlorid) into the shape of a 
hollow cone, with the base just big enough to fit closely to the 
inner rim of the inner table of the cranial wound and with a 
depth of about 2 centimeters. The plugs were removed from 5 
the cerebral* cavity, with again considerable escape of brain 
matter, which was washed out by a gentle stream of the warm 
sterilized saline solution, and the cup immediately introduced, 
apex downward. 1 fastened it in place by pressing the foil 
into the indentations and irregularities of the rim of the inner 
table and packed loosely into the cup some iodoformized gauze. 
I incised and loosened the scalp on either side of the wound so 
that I could slide it over and cover in the opening, sutured it, 
except a small space in the center through which an end of the 
bit of iodoformized gauze was allowed to project, and dressed 
it as before. 
On April 14 the wound was redressed, the sutures removed, 
and also the packing of gauze from the cavity of the gold cup. 
The wound was perfectly aseptic, the cup firmly fixed and in 
place, and there was no bulging and absolutely no escape of 
brain matter. A small bit of gauze was again introduced into 
the cup to give it solidity, and the dressings were reapplied. 
On April 27 the wound was again inspected. There had been 
no suppuration, and the wound was entirely closed except 
where the bit of gauze projected from the cup. This was 
removed and the external wound was allowed to come together. 
In a few days this was entirely and solidly united. The patient 
was allowed to be up and about. His faculties were all good, 
locomotion was good, and in short he showed no indication in 
any way of having lost any function ; nor were there any signs 
of irritation from the cup. I kept him about two weeks 
employed most of the time about the wards, doing the work of 
an orderly, that I might observe him and examine the seat of 
wound. There was absolutely no indication of any trouble or 
disturbance. He was discharged quite well May 20. The 
wound was firmly united and there was no pulsation percepti- 
ble through the opening in the cranium. 
Case 2. George S., a Hungarian, age 27 years, was brought 
to the hospital by the ambulance on June 21, 1894. He had 
been engaged in an altercation with some of his fellow work- 
men the day before and was struck by a stone thrown by one 
of them. He was felled to the ground, bled profusely, presum- 
ably was unconscious, though this point we could not find out, 
as we had no interpreter. A local physician was called in who 
found a comminuted depressed fracture and trephined ; possi- 
bly he raised some depressed fragments of bone. The scalp 
wound was sutured and dressed and the patient as soon as 
practicable sent to the hospital. When admitted the man was 
not only conscious, but could and did insist upon walking into 
the receiving room. He was a short, healthy looking fellow. 
Upon investigation there was found an irregular lacerated 
wound and a more regular oval wound situated in the right 
temporo parietal region. The oval wound was sutured. The 
sutures were removed and after careful cleansing and disinfec- 
tion a further exploration showed an extensive comminuted 6 
depressed fracture involving the anterior portion of the tem- 
poro-parietal region in the right side and the fracture extend 
ing downward and forward involving nearly the whole of the 
temporal fossa. A trephine wound about a centimeter in diam- 
eter through the anterior inferior portion of the parietal bone 
marked the upper limit of the fracture; below, the bone was 
in a number of irregular fragments and depressed. The patient 
was chloroformed, the external wound extended down into the 
temporal region and after careful retraction of soft tissues, 
during which hemorrhage was rather free, it was found that 
two large fragments of the temporal bone were depressed and 
that under the upper edges of these were a number of sharp 
small fragments which had been driven through the membranes 
and imbedded in the cerebrum. After raising the temporal 
fragments the small fragments were carefully taken out. Con- 
siderable hemorrhage followed this and escape of not a little 
cerebral tissue. It was now seen, after the hemorrhage had 
been controlled by pressure of iodoformized gauze, that the 
dura and other membranes had been entirely destroyed at the 
lower part of the wound near the inferior temporo parietal 
junction and that there was a persisting oozing of brain matter. 
It was quite impossible to bring the dura together throughout 
the whole area, the fragments of bones were irreparably com- 
minuted and soiled. It was determined, therefore, to supply 
the place of the dura with gold foil. Accordingly a rectangu- 
lar piece having been sterilized in carbolic solution (5 percent.) 
and washed off in warm sterilized saline solution, the brain 
matter was washed off with a gentle stream of hot saline solu- 
tion, together with blood and detritus, and an area of 2 c. by 
1 c. which was entirely destitute of any membranous covering 
was covered in by the gold foil, placed under the border of the 
surrounding dura, and held down by the pressure of the dura 
and the large fragments of the bones below. The scalp was 
immediately sutured, stout catgut drain was introduced at the 
more depressed part of the wound, and the ordinary iodoform- 
ized dressing applied. The wound healed with one change of 
dressings and the man was discharged quite well and appar- 
ently in first rate condition in every respect, July 7, sixteen 
days after the operation. 
Case 3. George E., 20 years of age, Pennsylvanian by birth, 
was run down by a train of coal cars on the evening of Feb. 19, 
1895. He was picked up and brought to the hospital about one 
hour and a half after the accident. The young man was in a 
wretchedly low condition when he arrived. He was uncon 
scions, had scarcely any perceptible pulse, extremely pale and 
relaxed, and covered with dirt, soot and coal dust. Examina- 
tion showed a complete crush of the left leg to just below 
the knee joint; the right foot also comminuted and the tissues 
involved up to the lower third of the leg. There was also a 
wound on the left side of the head about 3 centimeters above 7 
the supra orbital ridge, back of the edge of the hair at the fore- 
head, and about 6 centimeters from the middle line ; this was 
a fairly clean cut wound, running in a slightly curved line back- 
ward in a general way parallel with the middle line. The left 
parietal bone was fractured so that the fracture was almost 
linear. Running backward, it corresponded almost with the 
area of the external wound. The fracture was about 6 centi- 
meters in length. There was considerable oozing of blood and 
cerebral tissue. The patient's condition seemed hopeless. 
The ambulance surgeon had already applied an Esmarch's 
tourniquet to either limb as near the crushed tissues as possible. 
The limbs and head were now carefully washed, shaved and 
disinfected and an aseptic dressing applied. He was hurried 
to bed and surrounded with hot water bags, and stimulated 
actively by strychnia and digitalis hypodermatically. He was 
very restless and required large doses of morphia to quiet 
him. The next morning (February 20) he was conscious, 
but dull; his general condition had so far improved that he 
was etherized and both his lower extremities were ampu- 
tated. The left one through the condyles of the femur and 
the right through the lower third of the leg. The depressed 
parietal bone was also elevated, the cerebral tissue and 
blood carefully washed away and the scalp sutured. The 
patient stood these three major operations remarkably 
well. He began at once to improve, the wounds all did 
well, the head wound especially. He was very drowsy for 
several days, but could be aroused and could answer questions. 
His mental state improved daily and aside from some drow- 
siness and occasional periods of irritability and restlessness 
there was no cerebral manifestation of evil, until March 3, 
twelve days after the operation. During the night of March 3 
he had a violent convulsion, epileptiform in character. The 
wound of his head was entirely healed at this time and there 
had been no suppuration. There seemed to be no depression 
at the seat of fracture and there was no abnormal tenderness. 
He had no further disturbance until the night of the 7th when 
he again had a convulsion. On the 8th he had frequent con- 
vulsions ; toward evening and during the night the convulsive 
attacks became almost continuous and the patient fell into a 
very weak comatose condition. Careful observation showed 
that the convulsion began by turning the face to the right, 
then twitching of the muscles of the face, followed by 
movements of the right hand and fingers, it then became 
general. His condition on March 9 was very low, but I 
determined that there was something remaining at the seat 
of the fracture which was still an irritant. Under chloroform 
the scalp was incised along the cicatrix, the flaps turned back 
and a 1% centimeter trephine applied at the posterior extremity 
of the fracture in the parietal bone. After the button 
was removed by a chisel and a strong steel elevator the 8 
fractured bones (which were seemingly not depressed) were 
elevated and held up by an assistant. There was pretty free 
hemorrhage which required hot saline solution and pressure 
with sterilized .gauze to control. The seat of operation was so 
near the longitudinal sinus I was constantly afraid I should 
wound it. Luckily this did not happen however. When hem- 
orrhage had been controlled it was seen at once that a detached 
fragment of the inner table had been driven down into the 
frontal lobe of the cerebrum and lay imbedded in the softened 
brain tissue. The dura was entirely destroyed for a space of 
about 2x3 centimeters, and there was a pretty large escape of 
brain matter. After all the softened tissue, shreds, etc., had 
been removed and the offending piece of bone taken out, a 
pretty large cavity was left in the anterior lobe of the cerebrum 
near the middle line. Indeed the process of the dura which 
separates the two hemispheres in the longitudinal fissure was 
laid bare from its cerebral side on the left. This cavity seemed 
about 2 c. deep, about 1.5 c. wide and about the same length ; 
The whole of this superficial area could not be covered by the 
dura. A piece of gold foil cut large enough to cover in this 
space, and prepared as in Case 2, was laid over this cavity and 
the dura mater sutured and drawn about the foil as much as 
possible to hold it in place. The large fragment of bone was 
replaced, but the trephine button was left out, scalp sutured, 
catgut drain introduced and wound dressed as usual. The 
patient was pretty low after the operation (the 9th). He had 
a slight convulsion during the evening. After this there was 
no further trouble. He had no other convulsion, the wound 
healed rapidly. There was no paralysis except perhaps a slight 
facial paralysis which soon disappeared. The mental state was 
very dull for about a week. He would answer questions intel- 
ligently, but slowly and was drowsy. His pupils were dilated 
for more than a week. After this he steadily improved, his usual 
mental state returned, and he was discharged March 28 quite 
well. 
This case, besides illustrating the usefulness of gold foil, 
shows to a marked degree the amazing vitality of a human 
being and the tolerance of multiple synchronous major opera- 
tions if great care be used to prevent loss of blood.