Part 36
280. Gunshot wounds of the skull are attended by certain peculiarities. In ordinary circumstances there is usually an external wound and a fracture more or less comminuted, with depression; this wound will almost always require to be enlarged by a simple incision, so as to show the extent of the depression or the size of the broken and depressed portions of bone. When the bone is scarcely injured, and the periosteum is only bruised, or when the bone is even deprived of this covering, it does not follow that it should die or even exfoliate. In many instances the wound will gradually close in and heal, as if no such evil had occurred; and in those which do not terminate so favorably, the cure may only be delayed by the exfoliation of a layer or scale of bone from its outer surface, unless the mischief should have implicated the parts beneath.
A musket-ball striking directly against a bone sometimes makes a hole not larger than itself, with or without any radiating fracture; and one large trephine, if properly applied, will often embrace the whole of the mischief, and admit of the removal of the broken pieces. As a center-pin cannot be used, the trephine may be made to turn very well in most cases in a flat but thick bar of iron, having a hole in the middle, of such a size only as will allow the polished outside of the trephine to turn in it. Sufficient support for the instrument will be obtained by this means until it has made a groove in the bone for itself, when the operation may be continued as it would be in an ordinary case after the removal of the center-pin.
When a musket-ball ranges along the side or top of the head, it may break the outer, and depress and fracture the inner table to a considerable extent, for the space even of three or more inches. The broken portions of bone may in general be removed by means of good forceps and a straight saw; and no good reason can be given for delaying the operation unless the nature of the injury be doubtful, when it may be as well to wait for symptoms. It sometimes happens, although rarely, that a ball sticks so firmly in the bone that it cannot be extracted by working round it in any ordinary way with a pointed instrument. The difficulty usually arises from the ball having half buried itself in the diploe, so little of it being exposed as not to admit of a firm hold being taken of it. The large trephine, used in the way pointed out, has several times overcome this difficulty. The removal of the outer table has been sufficient where the inner one has not been driven into the dura mater; when any doubt is entertained on this point both should be removed.
281. A ball or other foreign substance may penetrate the brain directly or obliquely. When the ball penetrates the brain directly, it is not often that it can be removed, and the sufferer very rarely survives beyond a few days, even if the ball has been extracted; more particularly if the injury have occurred in the anterior part of the substance of the brain; several persons, however, have recovered, in whom the injury occurred toward the back part of the head, the ball being allowed to remain. It will be better in all such cases to allow the ball to remain, which it will often do for many days, until circumstances render it necessary to endeavor to find it. When it can be felt immediately under the surface of the brain, it ought to be removed like any other foreign substance.
Dr. Rogers relates the history of an excellent case, in which a young man aged nineteen received a wound on the frontal bone, just above the center of the left superciliary ridge, from the bursting of a gun on the 10th of July. It was not until the 4th of August that he discovered a piece of iron lodged within the head, in the bottom of the wound, (from which a considerable quantity of brain had come away,) which he extracted the next day. It proved to be the breech-pin of the gun, three inches in length, and three ounces in weight. By the tenth of December his patient was perfectly cured.
When a ball strikes the head obliquely, it may enter and pass out or lodge. Nearly all these cases die, but one occasionally escapes, and none should be allowed to die without assistance. When the entrance and exit of the ball are obvious, and not far distant from each other, the splinters of bone should be removed; and if the little bridge between the openings should be injured, the whole should be taken away by the straight saw; an operation which cannot, however, be necessary in the first instance, if the portion of bone be apparently sound.
At the battle of Talavera, a soldier of the 48th Regiment was brought to me in a state of insensibility; he had received a musket-ball on the upper part of the right side of the frontal bone, where it had entered, and had evidently passed backward; it could be followed by the probe rubbing against the bone for nearly four inches. The scalp over this point was soft, as if blood were effused below; and on dividing it, a fracture was seen bulging rather outward. The trephine was applied forthwith, and the bone removed, together with the ball, which only wanted a little more impetus to have come through. The brain was injured, and the man died two days afterward.
A French grenadier was wounded at the battle of Salamanca by a musket-ball, which struck him on the right side of the head, penetrated the temporal muscle, and lodged in the bone beneath, giving rise to symptoms of compression. On dividing the parts, I found that the ball had fractured and driven in a part of the temporal bone, one portion of the ball being above, and the other below the broken bone. The upper half of the ball was readily removed, but several small portions of bone were raised by the elevator and forceps before the remaining portion of the ball could be drawn from under the bone, which was not depressed, the ball having been cut in two by its edge. The dura mater was bruised, but not torn through. The wound suppurated freely; several pieces of bone exfoliated, and the patient was ultimately discharged in progress toward a cure.
A small ball sometimes becomes so flattened by striking against the skull as to remain undiscovered when care is not taken in the examination. A soldier was wounded at the storming of San Sebastian by a ball on the side of the head, which was supposed not to have lodged. The wound did not heal, a small opening remaining, although no exfoliation took place, and the bone did not seem to be bare. On dividing the scalp to ascertain the cause of the delay in healing, a small ball, quite flat, was found; it had sunk down a little below the hole left for the discharge to which by its irritation it had given rise.
When a larger ball or a piece of a shell strikes the head, the fracture is usually extensive, and portions of bone, or a piece of the shell itself, are often lodged in the substance of the brain. There is nothing peculiar in the management of these cases, which are for the most part unfortunate.
282. A suture may be separated by a musket-ball, which impinges with a moderate degree of force directly upon it, but not without great danger. It can, however, only happen in young persons in whom the sutures are not obliterated as they are in elderly ones; in general it takes place when the ball happens to lodge as it were between the bones concerned in the formation of the suture. The first case of the kind which came under my observation occurred at the taking of Oporto. I met with a second at Albuhera, a third at Salamanca, and a fourth in a slighter degree at Orthez.
A heavy dragoon was wounded at the battle of Salamanca by a musket-ball in the body, which caused him to fall from his horse, injuring the top of his head. Little attention was paid to him until mischief was suspected from the lethargic state into which he fell, which could only be attributed to the blow on the head, where a tumor was observable. This, on being divided, showed a separation of the edges of the sagittal suture, from which some blood flowed. Two crowns of the trephine were applied on the twelfth day, in order to admit of the free discharge of some blood which had been extravasated from a wound in the longitudinal sinus, after which the symptoms subsided, and the patient gradually recovered.
A ball may pass apparently through the fore part of the head from side to side without doing much mischief beyond depriving the sufferer of sight. It does not in these cases injure the brain, but passes immediately below it and through the back part of both orbits. In four such cases the recovery was rapid, but the blindness was irremediable.
283. The danger of injury to the frontal sinuses has been greatly exaggerated, and vanishes in a great degree when attention is paid to their structure. The uncertainty of the depth of the cavity between the tables of the bone, and the irregularity of the exposed surface of the inner table, which may through carelessness be mistaken for depression, should be remembered.
A soldier of the 29th Regiment was wounded at the battle of Talavera by a ball, which struck him on the lower part of the right side of the forehead, fracturing the external wall of the frontal sinus. On examination, the ball could be felt lodged in the sinus, whence it was readily removed by enlarging the opening, and the man recovered without any bad symptoms.
At the storming of Badajos, a soldier of one of the regiments engaged at the little breach was struck by a small ball about the size of a swan-shot; it penetrated the frontal sinus of the right side, and stuck in the inner table, the outer being considerably injured and splintered by the blow. The splinters having been removed, the small ball could be seen sticking in the inner table of the bone, whence it was easily extracted, leaving the dura mater bare beneath. He was sent to Elvas, and recovered with a good and firm cicatrix.
After a wound of the frontal sinus has healed, the air has been known to raise up the integuments of the forehead into an elastic crepitating swelling whenever the patient blew his nose, so that a compress and bandage on the part were required for its relief; but these cases are very rare.
284. Wounds of the bony parts within the orbit are often attended by the most serious consequences. A boy, nine years of age, was struck by his playfellow with the end of a thick iron wire on the right eye, which blackened it. There was no external wound; but as there was some bloody chemosis at the upper part and the inside, there was a probability of the wire having penetrated deeply, although the opening could not be discovered by the probe. The accident had happened two days before, but he did not think himself ill. He was well purged, and cold water was applied externally. Two days after, he complained of sickness, headache, and some pain over the brow. He was bled freely from the temple of that side by leeches, and well purged by calomel and jalap. On the sixth day his mother reported him as having been delirious and restless all night. He was found stupefied, answering with difficulty and incoherently; pulse very quick, skin hot and dry, with some convulsive twitches of the face and arms; pupils slightly obeying the influence of a strong light, but not dilated. He was again bled freely from the temple, but his breathing became more difficult, he fell into a comatose state, and died in the night. On examining the head, the stiff iron wire was found to have passed under the upper eyelid, between it and the eye, through the posterior part of the orbitar plate of the frontal bone and into the anterior lobe of the brain, which was softened at that part, and bedewed with matter.
A woman, who had been struck by her husband on the left eye with a tobacco-pipe, while preparing her frying-pan for cooking, knocked him down with the pan, and ruptured his right eye, which was lost. She then pulled out a piece of the pipe which was sticking in the orbit, between the lid and upper and inside of her own eye, which was uninjured. She complained of little but the bruise, and rather brought her husband than herself for advice. Bled and purged, she did not complain of anything for several days, when she said she had been very ill all night, with nausea, headache, and shivering; with hot and dry skin, pulse very quick, the upper eyelid paralytic; she looked very ill, became delirious at night, and died two days after the first complaint of serious illness. On examination, half an inch of the red waxed end of the tobacco-pipe was found to have gone through the sphenoid bone, by the side of the sella turcica, and to have lodged in the brain, whence it was removed bedewed with pus, the brain being yellow and softened around it.
A wound of the longitudinal or lateral sinuses, allowing a free discharge of the blood poured out, is of comparatively little consequence. It is, on the contrary, a very fatal injury when the blood is permitted to accumulate.
285. A protrusion of the brain, often improperly called a fungus cerebri, is of two kinds, and occurs at different periods of time. The first kind is principally composed of coagulated blood, usually appears immediately after, or within two days after, the injury, and is generally fatal. The second takes place at a later period, although it has occurred on the third or fourth day, and is formed for the most part of brain. These protrusions rarely take place when a considerable portion of the skull has been lost or removed, the brain then being able to expand to such an extent as the inflammatory impulse from within may render necessary. When the opening is small, and the dura mater has not been injured, it has seldom been observed. It is then principally when the opening in the skull has been of greater extent than the size of one piece of bone removed by the trephine, the dura mater having yielded either in consequence of the injury or by ulceration, that this evil takes place; it is not, under proper treatment, a fatal, although it is always an extremely dangerous occurrence.
In the first kind of protrusion, the dura mater must necessarily be torn to some extent, and the tumor which comes through it is of a dark-brown color, glazed and covered in general by the pia mater. These protrusions were accompanied, in every case I have seen, by delirium and other symptoms of inflammation of the brain and of its membranes, and not by coma, until near the fatal termination of the disease. I have seen them torn off by the patients themselves during life, or before death; and satisfied myself that they all arose from hemorrhage into the substance of the brain, probably immediately below its surface, which became more elevated as the inflammation proceeded, and was gradually protruded at the part where there was the least opposition. When the tumor was torn off, little hemorrhage ensued, but a dark-brown blood cavity was seen in the substance of the brain; and when cut off and examined, the protruded part seemed to be covered by the pia mater, with or without a layer of cerebral matter, and was made up generally of coagulated blood. No case of this kind recovered.
In the second kind of protrusion, or that which usually although not necessarily takes place when the first or active inflammatory symptoms are on the decline, the tumor is formed of the substance of the brain. It has been supposed that in whatever manner a case of hernia cerebri may arrive at a favorable termination, there must inevitably be a loss of brain proportionate to the extent of the protrusion--a conclusion which the experience of the Peninsular war did not confirm, while it may lead to the establishment of an erroneous practice for the too early removal of the protrusion. The loss of a portion of one of the hemispheres of the brain is now known to occasion little or no inconvenience in many instances, either to the intellectual or corporeal faculties; nevertheless, as the precise quantity of brain which a person may lose with impunity has not been ascertained, it may be as well not to deprive a patient of any, provided its removal can be dispensed with; and that it may be so dispensed with, the practice of that war gave positive proof in several instances, by the protruded part being gradually withdrawn within the skull, the wound having afterward healed by the ordinary processes of nature.
There were three cases of recovery from a protrusion of the brain after the battle of Toulouse.
Bernard Duffy, 40th Regiment, aged twenty-four, was wounded on the 10th of April, and admitted into the Caserne de Calvete Hospital, on the 13th, with fracture and depression of the upper part of the os frontis. Some portions of detached bone were removed; he was largely bled and purged.
On the 14th, he complained of severe pain in the head, giddiness, dimness of sight, and drowsiness. The pupils were much dilated; pulse 60, and full. An incision was made down to the bone, and the divided arteries were allowed to bleed freely. One perforation was made by the trephine, and the whole of the detached and depressed pieces of bone, which were of considerable size, were removed, one of them having penetrated the dura mater.--15th. Has less pain in the head; pulse full and slow; pupils dilated, with a tendency to coma, but he is sensible when spoken to. V. S. ad ℥xxiv. Continue the purgatives.--18th. Is less drowsy; pupils more contracted. The surface of the dura mater is sloughy, and a small, dark-colored excrescence is rising up through the opening in the cranium.--22d. The fungus cerebri has considerably increased in size during the last few days; in other respects he is doing well.--24th. The wound looks clean; the discharge is healthy. The fungus increases in size, and is rather above the edges of the wound; some sloughs have separated from it, and it has now a red and tolerably clean appearance.--26th. The wound granulates regularly; the excrescence seems to enlarge rather at the base than at the upper part; it was touched slightly with lunar caustic without any pain or unpleasant symptom being produced.--30th. Continues doing well. The pupils are still somewhat dilated, but contract readily on the admission of light; appetite good; bowels regular; and the patient says he has no complaint. Discharge from the wound healthy; the fungus is prevented from increasing by a slight application of the argenti nitras every second day. He has not required any medicine for some time past.--May 6th. The wound has closed around the fungus, which is a little above its edges; it is touched slightly every day with lunar caustic or the sulphate of copper. The pulsation of the brain elevating and depressing the fungus is perfectly distinct; no constitutional derangement. Was discharged cured to Bordeaux.
William Donaldson was admitted, on the 13th of April, 1814, into the Dépôt de Mendicité Hospital, having received a gunshot wound in the head on the 10th of April, which fractured the right parietal bone to a considerable extent. The brain protrudes; pulse quick and small; bowels open. V. S. ad ℥xvi.--14th. The pulsation of the brain is evident, and the protrusion increases; he complains of no particular pain; the discharge is profuse, and of a thin, black, watery quality; pulse 90; bowels freely open. V. S. ad ℥xvi. Continue the purgatives.--15th. The pulse and bowels natural, the protrusion has scarcely increased; discharge profuse, and still gleety; a small compress was laid over the dressings, and a bandage was lightly applied.--16th. Pulse and secretions natural; the wound looks more healthy; the discharge something better in appearance; the fungus does not increase.--19th. Is doing well, and does not complain of pain; functions natural; the protrusion somewhat less; discharge good. A small quantity of cloth has come away.--21st. Discharge improved. Continue the purgatives.--26th. The protrusion evidently diminishes, and begins to heal at the edges.--30th. The hernia cerebri has considerably diminished; secretions natural; a small quantity of bone has come away; discharge diminished.--May 4th. The wound is healing rapidly; the patient is now permitted to get out of bed, and has half diet. Another very small piece of bone has come away.--10th. The wound is now nearly healed.--Between the 15th and the 25th several small pieces of bone came away.--On the 26th, on introducing the probe, a small piece of bone followed it; and on further examination a large piece was felt quite loose, and was removed by incision. Discharged cured to Bordeaux.
Gentle pressure was made on the protrusions, according to the feelings of the individuals, in both these cases; when made too firmly, it gave rise to swimmings and pain in the head, retardation of the pulse, a sense of sickness and fainting, and on one occasion to syncope. Pressure could only be borne when very lightly applied while the protrusion was increasing, but could be gradually augmented when it became stationary, and during its diminution and secession. The pressure was continued until after the wound had healed.
I had occasion, at Santander, to remove a portion of bone, including the upper part of the lambdoidal suture of the right side, from the head of a soldier of the Light Division, in consequence of symptoms of irritation having come on after an irregularity in drinking. He had been wounded by a musket-ball on the heights of Vera, which had fractured and depressed the skull at that part some weeks before. A piece of bone was depressed, and had irritated the dura mater at the part; the membrane had some matter upon its surface, and was evidently abraded. The operation gave relief, but a tumor soon sprang up, evidently composed of brain. The patient was again bled, purged, and starved; calomel and opium were given in moderate doses, and the protrusion ceased to increase; about the same time it changed color, became yellow, fetid, softer, and soon wasted away, pieces of dead matter separating at each dressing, until it sunk within the level of the skull; after which healthy granulations sprung up, and the wound healed.
In the fatal cases, paralysis, accompanied by stupor and other symptoms of compression of the brain, invariably supervened before death.
The preceding cases prove that persons may recover after having had a protrusion of the brain, without as well as with the loss of a portion of its substance, the difference in all probability between the cases being dependent on the degree of mischief which gave rise to them. In the fatal cases I have seen, the protrusion was manifestly a part of the substance of the brain, and firmer than the hemisphere beneath, which was soft, pulpy, and of a yellow and sometimes of a reddish color, the lateral ventricle being filled with a sero-purulent matter, pus being also spread over the surface and intermingled with the pulpy structure, into which the brain had been changed. The protrusion was the consequence of low inflammation of the brain; and greater caution had been necessary during the progress of the mischief than had been enforced. It was the observation of this, and of other circumstances not less important, which led me to enjoin that rigid system of management insisted upon in all cases of injury of the head. There can be no doubt that the formation of many of these protrusions was aided by the opening made in the dura mater, which would have restrained their growth if it had been sound. The dura mater therefore should never be opened if it can be avoided.