Silver tubes and bone tubes have been utilized, but the results are sometimes disappointing. In one of my recent cases the two halves of a bone tube were utilized. The tube was cut across in an oblique manner at about its centre, the two parts set at right angles to one another and sewn together with silk. One arm is introduced into the ventricle, the other tucked underneath the dura mater. The child improved considerably, but the method is not altogether satisfactory and by no means easy of application. In another case I utilized strands of silver wire. The depth of brain-tissue necessary to reach the ventricular cavity was measured, and two or three strands of wire introduced so as to project well into that space, then steadied with forceps whilst the proximal ends were bent at right angles to the surface of the brain and tucked underneath the dura mater. The method was unsatisfactory.
Tubular drainage is not essential, for the fluid escapes from the ventricle as much alongside the tube as through its lumen. Still, I believe that tubular drainage is preferable to other methods, and, realizing the difficulty of introducing a right-angled tube--one arm to project into the ventricle, the other to lie beneath the dura mater--Messrs. Arnold & Son are now making for me small and light right-angled silver tubes so constructed that each limb can be inserted independently, after which they can be locked together. This method appears to overcome many of the difficulties previously encountered. The tube is inserted after the formation of the osteoplastic flap, as described above. The four dural flaps are then united, preferably by cross union of their apices, the bone-flap is replaced, and the scalp-flap sewn accurately into position. Collodion gauze, applied to the wound, aids in the prevention of cerebro-spinal escape.
The scalp and bone-flaps are framed, and the dural incision carried out low down, so as to make the opening to the brain as valvular as possible. All these precautions are taken to avoid leakage of cerebro-spinal fluid, a most troublesome complication--adding to the risk of infection and often resulting in an acute eczematous condition of the surrounding skin.