Bullet embedded in anterior fossa. (U. S. Army Med. Museum.)
GUNSHOT WOUNDS OF THE HEAD.
These have already been extensively considered in a previous chapter, so that but little more need be said of them here. Such wounds in the scalp are likely to be followed by sloughing. So far as gunshot fractures of the skull are concerned, there is frequently a marked discrepancy between the wounds of the inner and outer tables, that last perforated by the bullet being almost splintered. Penetrating wounds of the cranium by Mauser and similar bullets are not necessarily fatal. Many men were shot through the head during the Cuban and South African wars and yet did not die as a result of the wound. (See [Chapter XXII].)
Treatment.
—So far as treatment is concerned, gunshot injuries of the skull necessitate trephining or exploration, for checking of hemorrhage, disinfection of the bullet track when possible, often for a counterdrainage opening with through drainage either by tube or gauze. The bullet, if it can be found, should be removed. In searching for it the old porcelain-tipped probe of Nélaton has almost completely given way to Fluhrer’s aluminum probe, which is larger and longer and when rightly directed will by slight weight usually glide gently along a bullet track, thus leading often to the missile, and at the same time indicating by its direction where the counteropening should be made. Two other methods of detecting bullets are now in vogue. Girdner, some years ago, invented a telephone probe, by which, so soon as the instrument touches the missile, a telephone circuit is completed and the operator with a telephone receiver applied over his own ear hears the tell-tale “click” indicating the fact. This has been further improved by the substitution of a bell or “buzzer,” which tells its own tale when the probe touches the bullet.
A still more ingenious application of electricity for the purpose is that afforded by Röntgen’s discovery, and during the American and English campaigns of the past few years skiagrams of skulls showing bullets in various locations have become quite common. (See [Plate XIII.], p. 229.)
PROLAPSUS AND HERNIA CEREBRI.
Escape of brain matter beyond its normal level is not uncommon in connection with compound fractures or their sequels. It may be primary, escaping with the blood at the time of the accident, or secondary, occurring during the ensuing days. Any lesion of this kind in which the brain appears or can be handled is entitled to the term prolapsus, in contradistinction to hernia, which implies that, though escaping from the proper cavity, it is nevertheless covered by other textures—e. g., the dura or scalp.
The protrusion may vary in size from a small tumor to one the size of a fist. It is always the result of uncontrolled intracranial tension, and may be produced by hemorrhage, by serous imbibition, or as the result of brain abscess. When immediate it is of the first variety; when later, of the second or third. When abscess is present it usually delays protrusion, which is produced by degrees. Prolapse occurs through large openings, such as those made by gunshot wounds, the trephine, etc. Prolapse proper implies laceration of the dura. It pertains obviously to the convexity of the skull, occurring, however, in exceedingly rare cases into the orbit ([Fig. 379]).