CHAPTER 12
WOUNDS OF THE SKULL AND BRAIN
INJURIES of the skull and brain occur very frequently. Their proportion is commonly said to be from 12 to 15 per cent. of the total number of injuries. More than half of the wounded succumb on the battlefield.
With the firing-line in sheltered trenches, these injuries increase in number; but the total of cases seen at the ambulances remains about the same. Soldiers who receive these kinds of wounds
rapidly succumb.
Injuries of the Scalp.
The soft tissues (the scalp) covering the skull are bruised by bullets, furrowed, perforated as if by a seton, on the lateral parts. Shell fragments divide, perforate, or lacerate them often to a great extent; sometimes it seems as if the wounded men had been scalped. Cold steel weapons may cut through the scalp in many places. Slightly compressive aseptic or antiseptic dressings will generally suffice to secure their healing. Their evolution is simple.
When the skull is struck by a bullet, contusions, cracks, and fissures, depressions, slight grazings, grooves, single Perforations, double or through-and-through perforations are observed.
CONTUSIONS, FISSURES, FRACTURES OF THE INNER TABLE, ETC.
Contusions are the results of tangential shock or of direct shock (low velocity). Sometimes they may he recognized by denudation of the bone; at other times they may only be suspected.
Cracks and fissures involve both tables of the skull or one table only. Those of the outer table are exceptionally met with (Delorme). Fissures of the inner table are linear, curved, circular-, oval-, radiant-, X- or T-shaped, and are accompanied by slight loosening of the dura mater. In general, in fissures of both tables, the fragments of the inner table are depressed. The diagnosis is effected by de visu verification of the fissures on the outer table. When we find these last, we may conclude that the inner table presents the same kind of lesion, but in a more serious form.
Depressions due to bullets are only exceptional.
GROOVES AND FURROWS.-Grooves and furrows occur frequently. In the least serious form they consist of superficial, canalicular abrasions, with very regular borders of the outer table or of the outer table and the diploë. These grooves specially extend over the comparatively flat surfaces of the skull.
Even when the lesion on the outer table appears of the most simple nature, it is in most cases complicated with splintered fragments of the inner table ; these are free and pressed down on to the dura mater or on to the brain.
It is not impossible for, the inner table to remain absolutely intact, as we have just seen in two cases in which it appeared very distinctly, uniformly smooth in appearance, at the bottom of the groove. When the groove includes the whole thickness of the bony wall, the resulting small splintered fragments are as a rule propelled rather towards the aperture of exit than towards the meninges and the brain.
SINGLE PERFORATIONS.-Single perforations, or perfora tions of one wall only, are comparatively rare; -they especially occur when the projectile is fired point-blank from a long distance, or when the bullet has ricochetted. The aperture of entry is like a punched-out opening, circular or oval, its diameter being a little less than that of the projectile, with somewhat greater loss of substance towards the inner table. The bevelled surface of the inner table has supplied the few free or still adherent splinters, which have scarcely left the periphery of the gap in the bone.
Contusion of the nervous substance is less pronounced in the intracerebral track than in
through-and-through perforations. The tunnelled cerebral wound hardly ever contains splinters; but if it does, they are small. The organic fragments, or the shreds of clothing that may be swept along, are small or absent; the bullet itself has lodged in some part of the cerebral substance.
In some instances the bullet becomes fixed against the internal part of the skull, at a point symmetrically opposite to the wound of entrance, bruising the bone, fissuring it on its outer table, or on both of its tables, or even limiting the focus of large splinters that prepared its exit.
DOUBLE PERFORATIONS.-Double or through-and-through perforations are the most common cranial lesions resulting from modern bullets, but they are seldom observed in the rear. They present circular- or oval-shaped apertures of entry like those of perforations of one wall-i.e., bevelled at the expense of the inner table. As for the aperture of exit, on the table the bullet first passes through -i.e., on the inner table - it is circular, regular in shape, cut as with a punch, and, on the outer table, the last one perforated, it is enlarged, bevelled, splintered, the splinters being adherent or loose. There is contusion of the intracerebral track for a short distance, or for a distance of several centimetres from it, according to the velocity of the bullet. The track contains loose splinters, disseminated in the cerebral substance, if the wound had been received at long range with low velocity; in the opposite case the free splinters are driven forward. At the aperture of entry the dura mater is torn and loosened; at the exit it is perforated, but not loosened.
When the velocity of the bullet is excessive, the whole cerebral substance may be dilacerated, and the radiated fissures, which were very limited when caused by long-range firing, are here very much increased in number and in extent. The aperture of exit is large, and from it flows a diffluent cerebral mass. This may be called the explosive lesion of firearms. With double perforations, survival is only possible when the firing has been from a long range, and the velocity of the bullet has been low.
TANGENTIAL PERFORATIONS.-This is a variety of cranial traumatism of which recent wars have shown the relative frequency. They are perforations the orifices of which are oblique and near together, preceded by a groove and joined together by numerous fissures, which form the limits of short and generally adherent splinters. The bullet has thrown off in its course a few free splinters, shreds of hair, and sometimes particles of headgear. The cerebral dilaceration is more superficial, less severe than in other perforation's. Consequently these wounded are quite likely to recover. They, together with those suffering from grooves, present the most favourable cases, and also the ones that more particularly require surgical intervention.
Fissures complicating tangential perforations are more or less extensive and numerous; they are circular, linear, or radiant, often uniting both apertures.
INJURIES FROM LARGE PROJECTILES.-Shrapnel bullets inflict injuries similar to those produced by rifle bullets. Contacts and single perforations are with them more frequent than double perforations. Grooves are very rare. The orifices of the perforations are a little larger than those of rifle bullets.
Large Fragments of shells produce contusions, fissures, depressions, and especially dilacerations.
If the general features of cranial orifices are, so to speak, always the same, there is reason, from the point of view of symptomatology, as from that of prognosis, to distinguish the through-and-through perforations according to their location. We have sketched several groups of them that ought to be kept in view and better studied: the antero- posterior or postero-anterior perforations, fronto-occipital, fronto-temporal, fronto-parietal, parieto-occipital; bilateral, bitem poral, biparietal, bioccipital; the perforations that follow along a vertical or oblique plane, a line from the vault to the base, or vice versa.
Diagnosis.-The diagnosis of open cranio-encephalic wounds inflicted by projectiles is generally easy. Discharge of cerebro-spinal fluid, loss of cranial tissue - perceptible to the finger, sometimes visible - issue of cerebral material fyom the aperture of exit, or from the aperture of entry, the direction followed by the missile, cerebral disturbances of deficit or of
meningo-encephalic excitement, are the general characteristics of through and through perforations, of single perforations, of grooves involving the whole thickness of the bones of the skull, accompanied by laceration of the dura mater.
Shallow grooves are recognized by an extensive cranial depression with sharp edges.
Pain, at first evoked by pressure of the finger along the fissures, and pericranial swelling denote the pressure and direction of fissures.
Contusions, cracks, and fissures, with or without depression of the inner table, are of delicate, uncertain diagnosis. The last will be suspected when the finger causes pain at a distance from the wound, and meningeal irritation points to a depression of the inner table (pains and contraction on the side corresponding to the lesion). As a rule, in these injuries direct exploration must be avoided. In case of doubt one is to act as it the suspected lesion existed. Under conditions of absolute asepsis exploration of the wound, with the help of an incision or a freeing of the integuments from all constriction, may be warranted.
On the other hand, in the other varieties of injuries, particularly in furrows, grooves, perforation of a single wall, tangential perforations, double perforations, in which exploration helps to confirm a diagnosis which may require operative interference, aseptic exploration is allowable and often necessary.
Many of the wounded with cranio-cerebral traumatisms, who get beyond the first-aid lines, surprise the surgeon by the absence or the attenuation of the symptoms they present. Under a small wound, whose edges are already adherent, that presents but slight suppuration, and that might be taken for a simple wound of the soft parts, the skull is found to be gouged out or perforated, and broken down cerebral substance is seen. If the wound is slightly raised, it is due to a small cerebral hernia. These soldiers have often walked for a long distance. Nothing in their general appearance would lead one to believe they were suffering from a serious lesion; they talk, eat, they take their place by themselves, and cheerfully too, on the table for surgical dressing. However, if one is warned, in some we discover a certain amount of indifference, in others some want of intelligence. The absence of symptoms, the readiness with which their cranio-cerebral traumatisms are mistaken for simple wounds, account in a great measure for their having been transported over long distances. We have already seen many of such unfortunate patients. The prognosis, so favourable at the beginning, deceived us in the same way that their diagnosis had already done.
The injuries of neutral cerebral zones (frontal region) may not be revealed by any symptoms. In general, how-ever, in transverse frontal perforations we observe blindness, anosmia, strabismus.
In Parietal and temporal perforations, disturbance in the mobility of the limbs and face, aphasia, cecity, visual disorder, are seen. But these symptoms may be absent or but little marked.
Occipital perforations may give rise to disturbance of sight and of equilibrium, to vertigo, to priapism.
Antero-posterior Perforations often have very indistinct symptoms. Vertical Perforations are nearly always rapidly fatal.
If in a patient with a great number of wounds we notice signs of cerebral shock, the disturbances in hearing, sight, sensation and motion, which may be also observed, are but transitory. Moderate or severe cerebral shock is mainly connected with the concussion between the skull and shell fragments.
Symptoms of compression : Disturbance in feeling, in motion, in the organs of sense, loss of corneal sensibility, mydriasis, stertorous respiration, coma, are only seen in depressed fractures due to large fragments of projectiles. In military cranial lesions, most of which are open, these symptoms are hardly ever connected with hemorrhage; this is contrary to what occurs in ordinary practice. The signs of contusion are deficit signs. They may be very obvious or almost absent. The present campaign opens up to neurologists, as well as to physiologists and to French surgeons, a wide field of study which should not be lost, and to which, in the author's opinion, sufficient attention is not paid. Certain bullets make in the brain paths as clean and as simple as those produced in experiments on animals. We are too apt to forget that when these last were undertaken the object was to study a symptomatology and certain disturbances that are, interpreted and sometimes shown by our wounded in quite a different manner.
Evolution.-With the present small perforations produced by rifle-bullets, aseptic evolution is far less rarely seen than in former times.
Professor Ferraton regards as closely connected with an attenuated infection, the early psychic accidents (maniacal excitement, which can be mistaken for alcoholic delirium) and other cerebral disturbances, which will be considered in another chapter (epilepsy, dementia, etc.).
It is infection (through hair, shreds of headgear, soiled bullets, irregular dressings, etc.) extending from light suppuration and circumscribed meningo-encephalitis to generalized meningo-encephalitis, that makes these lesions so dangerous, and causes a mortality oscillating between 15 and 57 per cent.
Prognosis.-As a rule the prognosis of encephalic lesions is of the gravest. Most of the wounded die on the battle- field (from 40 to 55 per cent.), 6 to 28 per cent. succumb in the ambulances or in the hospitals.
The prognosis of through-and-through cranio-cerebral perforations is the most severe of all. Only those made by bullets of low velocity (small apertures) can be studied. The wounded who offer resistance to the first symptoms surprise the surgeon by the length of the track and the benignity of the sequelae, but this cannot make us forget the large number of soldiers who perished shortly after their traumatism.
Recoveries from single perforations by bullets are less exceptional.
Of all the open lesions, grooves are the less serious when they are properly treated.
Non-penetrating wounds heal in most cases. In lesions produced by bullets the prognosis is in general in close relationship to the velocity of the projectile and to the importance of the parts involved. Frontal wounds are the less severe. Extensive injuries from shell fragments
Among those that recover, one-fourth succumb to sequelae, and at least one-half of the remainder are left permanently infirm,
Treatment.-Lesions of the skull and brain are, of all those involving the parenchymatous organs, the ones which are in the greatest need, according to some authorities, of surgical interference.
In their treatment it would be wise to keep within a margin of systematic abstention and systematic intervention,
Indications relating thereto may be summed up as follows:
1. Contusions, cracks, and fissures require no primary intervention. It is only in fissures complicated by depression of the inner table with meningeal or cerebral irritation (pains and contractions on the same side as the lesion in cases of meningeal irritation; pains and contractions on the opposite side in cases of cerebral irritation) that trephining of the skull over the point of impact would be warranted.
2. Depressed fractures produced by large shell fragments, and giving rise to symptoms of compression, necessitate raising of the splinters, and not their removal. Trephining is here only a procedure to facilitate the task of the surgeon. The trephine must not be employed if the surgeon, without its use, can seize the splinter where it has passed between the fracture and the dura maier.
3. Single perforations must be treated primarily by conservatism. If by enlarging the cranial loss of substance with the gouge or the trephine free access is obtained to the loose splinters of the inner table, it must be remembered that these splin ters, not having been driven forward, are seldom irritating; that, on the other hand, the surgeon who wishes to operate can do nothing to rid the brain of splinters lodged in the track, and that, moreover, his intervention would be blamable if he wished primarily and as a general rule to search for the bullet and to remove it. To open widely these wounds, which are generally not infected, is to open a door for infection and to risk cerebral hernia.
4. Through-und-through perforation must be treated without operation. In these grave lesions, to increase the cranial opening at the level of the bony aperture of entry would only facilitate the removal of the sedentary splinters of the first inner table, and could not insure either the removal of organic foreign bodies formed of shreds of clothing or of splinters thrown forward into the track or into its extremities. For the removal of the superficial splinters located near the orifice of exit of the second table the trephine would be useless, these splinters being either adherent, when they should be kept in place, or free - that is to say, easily extracted without trephining.
5. Grooves, cranial furrows, remain to be considered. Their treatment forms the triumph of operative surgery. Intervention here becomes a necessity; it gives beneficial results when the irreparable loss of substance to which the skull is subjected is not excessive, and when it is limited to what is strictly necessary.
Here, as we have already seen, more or less numerous splinters derived from the inner table have been liberated; often they have been depressed, driven into the cerebral substance. The encephalic focus is superficial, and is easy to clean. Therefore there is good reason for intervention; but it must be remembered that the breach is long, and that one is liable to bring about very extensive and regrettable loss of cerebral substance if the opening be too freely enlarged. It is not the procedure of a true surgeon to willingly and cases are precisely those in which primary intervention is justifiable (Billet). Puncture should. be carried out from the appearance of the first symptoms. Symptoms which impel us to employ surgical intervention are fever, frequency of pulse, presence of microbes in the fluid obtained by lumbar puncture (meningitis). In abscess this fluid is not turbid, but clear (Auvray).
In cerebral abscess we must intervene when we see some signs of the necessity of doing so (hernia).
HFRNIA OF THE BRAIN.-This is a very frequent complication, which occurs in two forms: primarily, from twenty-four to thirty-six hours after traumatism, as a diffluent prolapse of the brain, with either an almost normal aspect, in which splinters of bone are found, or, consecutively, as a mass, the size of a nut, a hen's egg, an orange, dark reddish in colour, turgid, fleshy, partly reducible, but whose reduction may bring on comatous or convulsive symptoms.
Hernia is generally the sign of the evolution of meningo- encephalitis or of a cerebral abscess.
It is very frequently the regrettable consequence of the extensive cranial dilapidations caused by the surgeon. Therefore it is a good reason to raise against systematic trephining (H. Billet).
Hernia of the brain is a very serious complication. During the recent wars the mortality fluctuated between 54 and 58 per cent. (Billet).
To hinder infection, to avoid large surgical losses of substance, constitute in these cases the basis of preventive therapeutics.
Ligature, excision, strong compression, are condemned. We must content ourselves with exercising slight compression, dressing at rare intervals, and carrying out a puncture, if we suspect an abscess; finally, we must treat the meningitis. Subsequently the surface of a granulating and irreducible hernia should be covered with skin. FOREIGN BODIES.-The foreign bodies implicated in intra- cerebral tracks are projectiles (rifle bullets, entire or in fragments, changed in shape or deflected, shrapnel bullets, and especially shell fragments); in half of the cases they are shreds of headgear, pieces of hair, and projected splinters.
The presence of one single penetration is almost pathognomonic of the presence of a projectile, but radiography alone can establish both the general diagnosis and the localization.
Primarily, SYSTEMATIC ABSTENTION FROM SEARCHING FOR THE PROJECTILE IN INJURIES FROM RIFLE BULLETS SHOULD BE THE RULE.
Abstention from systematic search for intracerebral splinters should also be the general rule. It is impossible to discover their location; their removal would expose the patient to excessive damage, and might not be complete. Impossible also is the removal of shreds of headgear, the presence of which has been revealed by a loss of substance in the headdress.
The present bullets are often tolerated. They may be extracted SUBSEQUENTLY, but only when their presence is unbearable. We are inclined to advise an early removal of shrapnel bullets and of shell fragments that carry with them and so often hold infecting foreign bodies, provided, however, these bullets and shell fragments have previously been carefully located by radiography.
Removal by forceps may give rise to further damage. For removing metallic foreign bodies we would advise the use of a curette mounted on a handle. This curette is similar to a urethral extractor scoop, and can be bent.
SYMPTOMS CONSECUTIVE TO TRAUMATISMS OF THE SKULL AND BRAIN.-Let us pass by adherent cicatrices, cranial losses of substance that are somewhat extensive and so difficult to repair with raised cicatrices, badly protecting the brain from noises that cause pain when they strike on it.
Solutions of continuity one is obliged to cover with india- rubber plates.
Cerebral disturbance consecutive to injuries of the skull and brain constitutes one of the most mournful pages in the .history of these wounds. This disturbance is extremely frequent. Thus, among the considerable number of wounded in the Secession War, only two presented no cerebral disturbance. A VERY LARGE MAJORITY of the men violently struck onthe head in warfare are BRAIN PATIENTS constantly under the in fluence of extremely grave cerebral disease (Laségue), and who for this very reason have claims to the good-will and charity of the War Office authorities.
Another peculiarity in the history of these cases is that these troubles very often appear at a remote date from the traumatism,
The military surgeon should constantly bear in mind these data.
These troubles are of various kinds : (a) Psychic, (b) sensitive or (c) sensorial, (d) motor.
Billet, according, to, Holbeck, has established their proportion. It would be necessary, however, to complete on a larger basis the ratios observed up to the present time.
The most usual psychic disorders have to do with modifications of' character - the various kinds of memory are diminished or abolished (simple amnesia, -retrograde amnesia- that is to say, loss of remembrance of events that happened prior to the wound); they manifest themselves by all the varieties of insanity, mainly melancholia and dipsomania, acute mania, general paralysis. Medical men have wished to make predisposition play an important part in these manifestations. It would be more just and true to reduce this importance (Delorme) Besides, even if, with certain wounded, pre- disposition did exist, it should in no wise lessen their claims to a pension.
Violent and persistent pains, vertigo, either spontaneous or on the slightest inclination of the head, are usual.
Impairment of hearing, of sight, of taste, are very frequent. Contractions, especially epilepsy, are very frequently observed.
Traumatic epilepsy seems specially to depend on two causes: inclusion of a projectile or of bony spicules in the brain, cerebral irritation caused by a cicatrix which creates an epileptogenic zone (Billet). It therefore seems that in these two categories of facts operative cure ought to be attempted in spite of reservations that might be made as to the therapeutic value of these interventions (excision of the cicatrix, removal of the foreign bodies).
In cases of Jacksonian epilepsy, operation seems more prejudicial than serviceable.
The failure of surgical intervention seems to be due to the fact that it is impossible to remove all cerebral cicatricial lesions and to prevent their return.
Deficit, consecutive, and motor troubles manifest themselves by more or less persistent paralysis.
LEGAL POSITION OF SOLDIERS WOUNDED IN THE SKULL AND BRAIN.-To the fourth class of infirmities that give a right to a pension, belong the wounded who present:
1. Complete hemiplegia or complete paraplegia of trau- matic origin.
2. Grave deterioration of cerebral functions - loss of memory, of speech, imbecility, dementia, insanity, etc. - resulting from a wound of the head.
3. General paralysis, with incontinence.
The following wounded necessarily figure in the fifth class. Those presenting-
1. Incomplete hemiplegia or incomplete paraplegia.
2. General progressive paralysis at the critical stage.
3. Epilepsy, epileptiform fits, functional spasms resulting from a traumatism.
4. Paralysis of an important organ (muscles of the eye, etc.).
5. Extensive and deep cicatrix of the skull, with loss of substance of the pericranium and of the bones in their entire thickness.
In the sixth class we have the wounded who present:
A persistent fistula, the result of necrotic or carious periostitis.