The Surgery of the Skull and Brain

by Louis Bathe Rawling

Whether the skull be penetrated or perforated, the wounds are investigated after similar general principles. After careful shaving and cleansing of the whole scalp, and after application of the scalp-tourniquet, a scalp-flap is turned down, the centre corresponding as far as possible to the site of entrance or emergence of the bullet. The under aspect of the flap is examined for loose fragments of bone, hair, portions of headgear, &c. These are removed and the flap cleansed. The bone is next examined. All loose fragments are removed, both large and small. The smaller are discarded, the larger are boiled (for ten minutes) and preserved in hot saline solution for replacement at the termination of the operation, if such a course should be deemed advisable (see [p. 132]). Those fragments of bone which retain their pericranial attachments are merely elevated and turned aside, to be again placed in position at the proper time.

Trephining is seldom necessary, the hole in the bone usually allowing of the application of craniectomy forceps, if any enlargement should be requisite.

A good view of the dura mater can now be obtained. If that membrane be merely punctured or incised, the tear must be enlarged with blunt-pointed scissors so as to allow of complete examination of the underlying brain. Hæmorrhage from meningeal vessels is controlled by the application of ligatures to all vessels that cross the line of dural section.

The lacerated brain is gently irrigated with saline solution (at a temperature between 110° and 115° Fahrenheit), and all blood and pulped brain matter washed away. The cortex is then lightly examined with the finger and probe for any fragments of bone that may be embedded in the brain substance. The removal of such fragments should be conducted with all possible gentleness. The surgeon should be satisfied that no foreign body remains. The bullet, when encountered, is removed. Needless to say, the presence of a bullet and the existence of in-driven fragments of bone should be investigated previous to the adoption of operative measures by means of X-ray photography.

If the brain be penetrated or perforated a drainage tube is introduced through scalp-flap and dura mater in such a manner that its distal end lies in relation to the track through the brain or flush with its lacerated surface. Elsewhere the dura is sewn up (fine catgut sutures) and the scalp-flap replaced, the drainage tube being anchored to the scalp with a single suture. The tube should be allowed to remain in situ for at least forty-eight hours and longer if necessary, the surgeon being guided by the amount of discharge and by the general progress of the case. In all cases of doubt the surgeon should err on the side of leaving the tube in position for a longer period of time, merely shortening it daily. Premature removal may lead to disastrous results. There can be no question that ultimate success hinges to a large extent on primary or early healing of the wound.

The search for and removal of the bullet.

In the event of a wound of entry only, it may be presumed that the bullet is within the skull. Bullets, however, pursue such unexpected and devious courses within the skull, and possess such a tendency to gravitate towards the base of the brain, that no attempt should be made at removal except after full X-ray investigation, stereoscopic if possible.

To this rule there are two exceptions:—(1) where the bullet lies superficial in the brain substance, and (2) where there exists, at the opposite side of the skull, what may be termed an area of attempted exit, that is to say, an area of bone elevation and blood extravasation, suggesting that the bullet has penetrated through the brain and impinged against the opposite side of the skull. In both these instances operative measures are not only justifiable but often definitely indicated. On the other hand, it cannot be urged too forcibly that hasty and ill-determined explorations usually terminate in failure. Even under the most promising circumstances it by no means follows that the bullet will be found at the site of counter-trephining, as it may have rebounded to some more distant region of the brain, necessitating an operation conducted over a totally different region. Thus, in a case recently under my care, the bullet entered at the right temporal region, penetrated the brain and produced on the left side of the head a well-defined wound of attempted exit. The bullet, however, on striking the opposing side of the skull rebounded, and was subsequently found in the apex of the descending cornu of the right lateral ventricle. This case affords a good example of the uncertain course pursued by bullets entering the cranial cavity.

However, in certain cases of emergency and in others of expediency an immediate search should be made for the bullet. The operation should be carried out with a light hand and not unduly prolonged.

In order to find and remove the bullet various probes and extractors have been invented. Perhaps the best of these is Sheen’s bullet-forceps, probe, and telephone-detector.