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 Wounds of the Brain 
 
 DR. JOHN B. CRAWFORD 
 
 COLUMBIA UNIVERSITY 
 
 DEPARTIViENT OF PHYSIOLOGY 
 
 College of Physicians and Surgeons.' 
 487 west fifty ninth street 
 
 NEW YORK 
 
lO 
 
WOUiNDS OF THE BRAIN 
 
 AN ESSAY 
 
 READ BY APPOINTMENT BEFORE THE 
 
 LUZERNE COUNTY MEDICAL SOCIETY 
 
 AT WILKES-BARRE, JAN'Y 14, 1885 
 BY 
 
 Dr. J. B. CRAWFORD 
 
 PUBLISHED BY REQUEST OF THE SOCIETY 
 
 wilkes-barre, pa. : 
 
 Prkss ok The Wilkes-Barre Record 
 
 m. dccc. lxxxv. 
 
%^^-OlAA^ 
 
 
WOUNDS OF THE BRAIN. 
 
 There are two classes of diseases, and likewise of 
 injuries, the treatment of which has not yet been very gen- 
 erally agreed upon, and which seems likely to long remain 
 unsettled. I refer to those widely differing conditions in 
 which the disease or the injury is so slight that the unaided 
 efforts of nature usually suffice to effect a restoration to 
 health, or a complete repair of the injury; and to those 
 malignant diseases and grave injuries irt which the best 
 directed therapeutic or surgical skill appears to exert but 
 little power in averting a fatal termination. Whatever is 
 done for the one class of cases seems to succeed; and con- 
 sequently an endless variety of supposed remedies and of 
 surgical procedures, each asserting superiority over its 
 rivals, claims our adoption; while, on the other hand, what- 
 ever means we apply or whatever measures we adopt, are 
 usually doomed to failure, and acquire only disrepute. 
 
 The subject of our discussion to-day — wounds of the 
 brain — is mainly included in the latter class. They are 
 always of grave import; yet while none are so trivial as to 
 be destitute of danger, or to be disregarded in treatment, 
 few, which are not immediately fatal, are so severe as to 
 preclude the possibility of recovery. It becomes impor- 
 tant, therefore, for the surgeon to determine how to direct 
 his efforts, in treating this class of injuries, so as to secure 
 the largest measure of that limited success that is attainable. 
 
 That great central mass of nervous matter called the 
 brain or encephalon, is confined within the bony cavity of 
 
the cranium, which it closely fills. It is surrounded by a 
 strong fibrous envelope which closely invests its exterior 
 and applies itself to all the intricacies of its conformation. 
 It consists, in the main, of a central mass of white medul- 
 lary matter surrounded by an envelope of gray or cortical 
 substance. Originating in the peripheral or gray matter, 
 innumerable nerve- fibres connect the corresponding por- 
 tions of the hemispheres, associate the different organs, 
 and converge from every portion of the periphery of the 
 cerebrum to penetrate the ganglia at its base, and pass into 
 its closely associated organ, the spinal cord. The blood 
 supply of this organ is derived from the internal carotid 
 and vertebral arteries. These several vessels, uniting, form 
 an important vascular plexus at the cerebral base, and send 
 their diminishing branches towards its periphery. It will 
 thus be seen that the more highly vitalized parts of this 
 organ are located in its central basilar portions ; that the 
 nerve-fibres, upon the integrity of which the continued 
 vitality and functional activity of all other portions of the 
 system depends, are concentrated in this portion of the 
 brain; and that the vascular supply of the entire organ is 
 concentrated in the same locality. If we trace either the 
 nerve fibres or the arteries from this central portion, we 
 find them diminishing in size and in relative proportion to 
 their surrounding tissues, as they approach the external 
 portions of the hemispheres. These anatomical characters 
 of the brain may help us to understand why it is that so 
 widely different results follow apparently similar injuries of 
 the brain; and why it is that recovery will at one time 
 follow extensive destruction of the cerebral mass, while the 
 slightest injury of another portion is instantaneously fatal. 
 It may be well, too, for purposes of diagnosis, to note 
 some physiological facts in relation to this organ. The 
 hemispheres are so slightly associated with the functions 
 of physical life, that extensive destruction or removal of a 
 
5 
 
 considerable portion of their substance may take .place 
 without necessitating a fatal result. They seem to be 
 especially connected with the manifestation of conscious 
 intelligence; and while their complete integrity is essential 
 to the highest manifestation of intellectual power, extensive 
 portions of their substance may suffer morbid alteration, 
 mechanical injury, or destruction of substance without 
 necessitating a fatal result, or an entire abolition of mental 
 power. They combine the mechanism of conscious sensa- 
 tions and voluntary movements. The recent improvements 
 in our knowledge of cerebral physiology relate chiefly to 
 the localization of these powers. They demonstrate that 
 certain portions of the cerebral cortex are connected with 
 the phenomena of motion, others with sensation, while 
 still others are associated with nervous phenomena of diffe- 
 rent kinds. "The cerebral hemispheres," says Dalton, "do 
 not act indiscriminately, as a whole; but the convolutions 
 of particular regions have a structure and properties differ- 
 ing from those elsewhere." The knowledge thus far gained 
 relates chiefly to three different points, to wit: centres of 
 sensation, centres of motion, and centres of language _ 
 But it is chiefly with the centres of motion that the diag- 
 nosis of cerebral injuries is mainly concerned. These 
 portions of the cerebral substances lie around the fissure 
 of Rolando, and embrace the anterior and posterior centra! 
 convolutions. This portion of the human brain, as well as 
 the corresponding portion of the brain of animals, in which 
 like phenomena have been observed, is characterized by 
 the presence of giant pyramidal cells, which are only found 
 in those portions of the cerebral substance, and constitute 
 a structure that is found only within the limits of the 
 motor area. It has been further ascertained that the power 
 of voluntary motion of the face and tongue originate in the 
 lower third of this region; that motions of the arm have 
 their origin in the middle third, while motions of the lower 
 
extremity originate in the upper third of this motor area. 
 Injuries of other portions of the brain may often be inferred 
 by certain nervous phenomena; but the localization of 
 most other functions of the cerebral hemispheres has not 
 yet been ascertained with such accuracy as to make it a 
 reliable and infallible basis of diagnostic opinion or of 
 surgical procedure. 
 
 The location of the human brain is such as to make it 
 especially liable to a great number and variety of traumatic 
 injuries. Forming the highest portion of an erect body, 
 exceedingly liable to be overturned, it usually receives from 
 such an accident the severest shock that is borne by any 
 portion of the system. It is the objective point of fists, 
 bludgeons and missiles in all personal encounters; and it 
 seems to be the recipient of an undue proportion of the in- 
 juries resulting from accidental causes. In war it en- 
 counters a larger proportion of destructive missiles than 
 come in contact with any other portion of the body of cor- 
 responding size. The delicacy of the structure of this 
 organ, and the want of firmness or tenacity of its tissues 
 renders it liable to destructive lesions from a degree of 
 violence that would do little harm to other portions of the 
 system. A blow from the fist upon any portion of the 
 cranium leaving, perhaps, no external mark of violence, may 
 cause a fatal lesion of some portion of the brain; or the re- 
 sulting concussion may, without appreciable lesion, so 
 shock and paralyze the nervous centres as to endanger, or . 
 perhaps to destroy life.* Or a haemorrhage within the 
 cranium may be produced by similar apparently slight 
 causes, and by its pressure involve an equally dangerous 
 result. 
 
 But it is the more violent forms of injury of the brain 
 and its associated organs that I propose at present to con- 
 
 *See note i. 
 
slder. These consist, for the greater part, of fractures of 
 the skull and consequent and associated injuries of the 
 cerebral mass and its enveloping membranes. Fractures of 
 the cranial bones, unless associated with lesion of the brain, 
 do not come within the purview of our present discussion. 
 While fractures of the skull may and often do, occur with- 
 out an involvement of the brain, the latter organ is often 
 injured by displaced fragments of the cranial bones, pressing 
 upon the surrounding membranes, or penetrating its sub- 
 stance. Sharp or pointed instruments sometimes penetrate 
 it more or less deeply. Missiles, like bullets, fragments of 
 shells, arrows, fragments of iron impelled by an exploding 
 boiler, etc., produce an endless variety of injuries of this 
 organ. These may penetrate its substance to any depth, 
 may pass entirely through, or lodge within its substance, 
 and may carry with them fragments of bone, portions of 
 clothing or other material, to be deposited along the line 
 which they traverse through this organ. 
 
 When the recipient of one of these injuries survives 
 long enough to allow a surgeon to be called to his assis- 
 tance, the doctor usually feels a greater degree of embar- 
 rassment and uncertainty in regard to the measures to be 
 adopted for the promotion of his patient's recovery, as well 
 as to the probable result of either the injury or its treatment, 
 than he is accustomed to experience in the management of 
 any other class of injuries. His patient is probably uncon- 
 scious, and no interrogation of him can elicit any informa- 
 tion that can serve to guide his treatment. A slight exter- 
 nal wound is, perhaps, the only visible injury; yet it is 
 evident that beneath the cranium, hidden from view, inac- 
 cessible to the touch, and secluded from all his powers of 
 observation, there exists a serious lesion of the brain. In 
 regard to its precise nature, its exact location or extent he 
 feels altogether uncertain; and he is likely to feel a corres- 
 ponding uncertainty as to the most appropriate and efficient 
 
measures to be adopted. If he turns to the standard 
 authors in surgical hterature for guidance, he finds but 
 scanty aid — for the precepts there laid down for his guid- 
 ance in such cases, are diverse and contradictory. If he 
 relies upon his own experience and judgment, he is likely 
 to find that what he has seen in other apparently similar 
 cases is by no means repeated in the present one. His 
 greatest embarrassment comes from the impossibility of 
 knowing, with precision the exact nature or extent of the 
 injury. If he attempts to explore the wounded organ and 
 to ascertain the location and extent of the injury, he is not 
 only liable but likely to complicate the existing injury. If 
 he pursues a "' Mastcjdy inactivity" h\^ patient may die for 
 the want of some simple procedure, like the removal of a 
 spiculum of bone or other material that has been carried into 
 the substance of the brain, and which is easily accessible. 
 What then can he do? — Or what should he do? How 
 shall he decide the uncertain problem and execute the 
 serious duty that confronts him? It would seem that the 
 course of duty must lay somewhere between officious inter- 
 ference on the one hand and a blind and passive trust in 
 the recuperative powers of nature on the other. There are 
 undoubtedly cases in which the most radical and heroic 
 procedures are not only justifiable but imperative. There 
 are others in which any active interference can only do 
 positive harm, and greatly diminish any existing chances of 
 recovery. A wise discretion, therefore, will incline him to 
 set aside all rigid rules of procedure; to discard so called 
 "authorities," and to judge for himself what are the indica- 
 tions for treatment in the particular case that he has in hand. 
 He should consider that there are widely differing degrees 
 of susceptibihty in different portions of the brain — that the 
 anterior and middle lobes of the brain are more tolerant of 
 traumatic lesion than other portions of the organ,* and 
 
 *See note ii. 
 
that while they are more liable to suffer from the effects of 
 severe concussion, and in their basilar parts are especially 
 liable to laceration from the latter cause — they more fre- 
 quently recover from destructive injuries, like penetration, 
 laceration, and loss of substance, than do any other portions 
 of the cerebral mass. He should remember too that all les- 
 ions of the brain become more serious as they approach the 
 central and basilar portions, and that the difficulties and dan- 
 gers of surgical interference in these localities are corres- 
 pondingly enhanced. He should in noca.se act with undue 
 haste. The case may at first seem much worse than it real- 
 ly is. The brain may be so shocked, aside from any actual 
 lesions, that its functions are, for the time, almost suspend- 
 ed — just as a bar of magnetic iron loses its magnetic power 
 by receiving a violent blow. He should, therefore, unless 
 some urgent necessity for immediate interference exists — 
 such as a dangerous compression or irritation from a depres- 
 sed or detached fragment of skull or other substance, or an 
 exhausting haemorrhage— give sufficient time for the system 
 to rally, so far as it may, from the more transient effects of 
 the injury, before proceeding to any operative measures. 
 
 In whatever he undertakes to do, he should be guided 
 by the conditions and symptoms presented. There may 
 be slight external marks of injury; and yet there may be 
 an extensive fracture of the inner table of the skull, pro- 
 ducing compression, laceration, or haemorrhage of the 
 brain. If the signs of these conditions, or any of them, 
 are present and persistent, an exploration of the injured 
 part, and elevation of the depressed bone, — and if need be, 
 — the removal of a superficial clot, and measures for the 
 arrest of haemorrhage should be undertaken. This may 
 involve the use of the trephine,* and it should be boldly 
 resorted to when the indications for its use are apparent. 
 This class of cases is usually very perplexing to the sur- 
 
 *See note iii. 
 
10 
 
 geon; for the slight external injury serves as but a doubt- 
 ful guide in locating the serious injury which he is seeking 
 to relieve. The localization of cerebral functions, as ascer- 
 tained by recent physiological investigations, will, in some 
 instances, enable him to determine the seat of the injury.* 
 In other cases there may be a more or less extensive ex- 
 ternal wound, with manifest depression; and yet the case 
 may present no symptoms that would justify the measures 
 necessary for an elevation of the bone. These cases should 
 be sedulously watched. Symptoms may be developed that 
 demand an application of the trephine. Whatever symp- 
 toms appear, or whatever complications arise, should be 
 met and combatted, as they become apparent, by an appli- 
 cation of the general principles of surgery — otherwise 
 they should be skillfully let alone. In still other cases, an 
 extensively shattered skull, and a like extensively wounded 
 brain, may be presented. The patient may be conscious or 
 comatose, sensitive, anaesthetic or paralytic, according to 
 the location and extent of the injury. A prompt removal 
 of depressed and displaced fragments of bone and other 
 foreign or vulnerating materials, when they can be readily 
 found will, in such cases, be the most judicious course. If 
 the patient survives the direct effects of one of these in- 
 juries, there are various complications that may arise in its 
 subsequent history. Inflammation of the brain, and of its 
 membranes, with their resulting sequences, are to be, if 
 possible, averted; or met and combatted by prompt and 
 vigorous measures if they appear. The patient should in 
 all cases be kept quiet, and if possible in a darkened room. 
 The head should be elevated and kept cool. The cerebral 
 circulation should be moderated by bromides, and general 
 antiphlogistic measures adopted. If symptoms of cerebral 
 or meningeal inflammation arise, no time should be lost, 
 and no reasonable effort spared, in combatting them. The 
 
 * See note iv. 
 
II 
 
 head should be shaved, and ice applied to the scalp. Active 
 purgation, counter-irritants to the extremities, and the local 
 abstraction of blood, should be resorted to; even the "lost 
 art" of bleeding might here well be revived, and again put 
 into requisition. Should bromides prove inefficient in 
 controlling nervous excitement, opium should be substi- 
 tuted for or combined with it. Every measure that can 
 tend to diminish cephalic irritation should be promptly and 
 energetically employed. As the inflammatory process, 
 unless limited or controlled, must certainly be fatal, its 
 appearance should always be met by early, prompt and 
 energetic treatment. Should the patient survive the acute 
 inflammatory stage, there still remain the dangers of 
 diffused suppuration; of abscess; of paralysis; of fungus 
 cerebri; with the more remote contingencies of cerebral 
 softening and epilepsy. If paralysis appears early in the 
 case, it usually indicates destruction of some cerebral 
 nerves, or of that portion of the brain in which they origi- 
 nate. Unless it is due to pressure from a depressed portion 
 of bone, it is in that case, usually permanent. If it comes 
 on later, it is probably due to arrest of function, — as from 
 clot or abcess, and the prospect of ultimate improvement 
 is somewhat better. If an abcess forms, and can be located 
 with sufficient precision, its contents should be evacuated. 
 If the condition known as "fungus cerebri" appear, gentle 
 compression, astringents locally applied, and excision of 
 the protruding mass are to be resorted to. 
 
 As the formation of ascess is one of the frequent 
 sequences of cerebral or meningeal inflammation, especially 
 that resulting from traumatic causes, it is often as difficult 
 as it is important, to decide upon its location when the fact 
 of its existence has been determined. If it is known to be 
 superficial; — if it lies immediately beneath the cranial bones 
 or immediately beneath the dura mater — i e, if it has 
 resulted from inflammation of the cranial bones, or of the 
 
12 
 
 dura mater, or arachnoid, its evacuation can readily be 
 accomplished by an application of the trephine. In such 
 cases the seat of the original injury will often be an efificient 
 guide in determining the location of the abcess. If it be 
 located in the superficial substance of the brain, its situa- 
 tion may often be determined, and its evacuation effected 
 in a similar manner. Of course the trocar or the aspirat- 
 ing needle will be required in addition.* It may be im- 
 portant to determine in advance of an operation whether 
 an e.Kisting abscess is d±ep or superficial, — in other words, 
 whether it is the result of cerebral or meningeal inflamma- 
 tion. There are no means presented by the syniptojiis 
 resulting from these conditions, which have enabled us to 
 distinguish inflammation of the brain from that of its en- 
 veloping membranes. It has been suggested by Dr. Agnew 
 — and the correctness of his suggestion has been frequently 
 confirmed by observation — that this matter might be deter- 
 mined by observing the comparative force in the temporal 
 and carotid arteries. The temporal, occipital, frontal, and 
 meningeal branches of the internal maxillary arteries have 
 a free inosculation in the diploe of the cranial bones, 
 making a free vascular communication between the arach- 
 noid and dura mater and the cranial bones and scalp; 
 while the brain and pia mater receive their blood supply 
 from the internal carotid and vertebral arteries. It follows, 
 therefore, that in meningeal inflammation, when the arach- 
 noid, the dura mater and their exterior structures are alone 
 inflamed, the temporal arteries will be observed to beat 
 with peculiar force ; when the pia mater and the brain are 
 alone involved in the inflammatory process, the carotid 
 arteries display a similar energy. When the brain and all 
 its membranes are alike implicated, both sets of vessels are 
 similarly affected. 
 
 The rupture of a vessel within the cranial walls often 
 
 *See note v. 
 
13 
 
 gives rise to a dangerous compression, of the brain, with 
 resulting paralysis and coma. Its extent is frequently such 
 that its location cannot be decided by the symptoms which 
 it produces. Like other injuries of the brain, the resultin^^ 
 effects are observed on the opposite side of the body. This, 
 with the marks of injury which may have been left by the 
 blow which produced it, often give the only clew to its 
 location. As the only relief for such an accident consists 
 in the removal of the compressing clot, if it is superficial, 
 and if its site can be determined with reasonable probabili- 
 ty, the trephine should be applied and the clot removed. 
 If symptoms of compression have been developed imme- 
 diately after the reception of the injury, it is to be supposed 
 that the point of haemorrhage is where the middle menin- 
 geal artery enters the cranial cavity, or at the anterior 
 inferior angle of the temporal bone. If the trephine be 
 applied to this point, the compressing clot m ly sometimes 
 be found and removed — if not, the meningeal artery may 
 be tied and further haemorrhage arrested. When failing to 
 find the offending clot at this point, if the symptoms are 
 sufficiently urgent, a similar exploration may be made 
 along the course of the inferior meningeal artery. Extra- 
 vasation in the cavity of the arachnoid has occasionally 
 been relieved by a similar procedure. When it lies beneath 
 the pia mater or in the deeper tissues of the brain, I am 
 unacquainted with any efficient measures for its relief 
 
 Penetrating and perforating wounds of the brain are 
 usually made by missiles projected by firearms. These fre- 
 quently carry into and lodge within the cerebral substance 
 some foreign materials, like felt, hair, fragments of the 
 cranial bones, etc. The missiles themselves may either 
 lodge within the cranial cavity or make their exit by a 
 second perforation of the skull. A very large proportion of 
 these injuries are speedily fatal. A less number survive 
 for a limited period; and a still smaller proportion either 
 partially or completely recover. 
 
H 
 
 If the wound be a perforating one it will usually be 
 found that the missile has traversed a direct course through 
 the brain between the points of its entrance and its exit in 
 the cranial walls. It will ordinarily be easy and safe to ex- 
 plore its course through the encephalon, to discover and to 
 remove any foreign or injurious materials that may have 
 lodged along its course. The inner table of the skull will 
 always be found more extensively fractured, at the point of 
 entrance than the outer one; and more or less completely 
 detached pieces of the inner table will usually be found im- 
 pinging upon the membranes, perforating their walls or 
 penetrating more or less deeply the cerebral tissues. These 
 should, if practicable, be removed; and if the small size of 
 the external opening interferes with the necessary proced- 
 ures it should be enlarged by the trephine.* It seems 
 needless to say that these measures should be conducted 
 with the utmost delicacy and care and that the greatest 
 caution should be observed in guarding against the possi- 
 bility of inflicting any addit onal wound or injury of the 
 brain or its membranes. 
 
 In penetrating wounds of the brain, when the mis- 
 sile has lodged within the cranial mass, the position of 
 the attending surgeon is often a difficult and embarrass- 
 ing one. The patient has survived the immediate effects 
 of the injury, but a bullet or other projeciile has pene- 
 trated the brain and lodged he knows not where. He is 
 uncertain of the course it has taken — of how deeply it 
 has penetrated, or what damage it has inflicted along the 
 track which it has traversed; or what irritating or vulnerat- 
 ing materials it may have lodged along its course. He can 
 do little towards rescuing his patient from his perilous con- 
 dition until he has gained accurate information upon these 
 doubtful points. But the procedures necessary to elicit 
 this information may, unless carefully executed, be fraught 
 
 *See note vi. 
 
15 
 
 with peril, both to his patient and to himself If he makes 
 no attempt to discover and to remove the missile, and death 
 ensues, he is likely to be charged with negligence and want 
 of skill, and made to suffer in reputation and in purse. If 
 he explores the wounded brain, and seeks to discover and 
 to remove the ofifendinp" materials, his best conceived efforts 
 in this direction may totally fail, and ensuing death be at- 
 tributed to his most laudable efforts to avert it The old 
 travesty upon the doctrine of predestination — 
 
 " You'll be damned if you do, 
 You'll be damned if you don't," 
 
 seems especially applicable to him; and if still more unfor- 
 tunately the case which he has in hand should be one of 
 attempted or accomplished homicide, he is liable to be 
 assailed, and traduced as the party upon whom the guilt 
 and penalty involved in the case should mainly rest, and he 
 should make it certain that nothing in his procedures can 
 verify such an accusation. 
 
 What course then, should a surgeon take when as- 
 suming the duties and the responsibilities pertaining to a 
 case of penetrating wound of the brain? 
 
 In assuming charge of such a case, or of any other, 
 the surgeon should ignore all considerations relating to 
 himself, to his pecuniary interests or his reputation. His 
 duty to his patient should be the sole consideration that 
 determines his course. He has no right to adopt any 
 measure, or to perform any operation, inspired by a desire 
 for the eclat that its success may bring him ; still less has 
 he a right to abstain from any measure that in his judgment 
 is necessary for the promotion of his patient's recovery, or 
 that is best calculated to promote it, from any apprehension 
 of censure that would attend its possible failure. 
 
 He should carefully observe the general condition of 
 his patient, the location and appearance of the external 
 
i6 
 
 wound; obtain any information he can in regard ta the 
 nature, size and propelling force of the missile, and of the 
 direction from which it came. This information may aid 
 him greatly in determining his subsequent steps. If the 
 missile has passed beyond the surface; if it is of large size 
 and of such a nature that it must necessarily be a source of 
 irritation and danger, a careful exploration of its track 
 should be made. Far this purpose the finger is the best 
 instrument. If the missile or other foreign materials be 
 found, their prompt removal should be effected.* If it has 
 penetrated too deeply to be discovered in this manner, a 
 blunt or bulbous probe, like that of Nelaton, may be passed 
 carefully along the track made by the missile for the pur- 
 pose of discovering its location. This should be done in 
 the most careful manner possible ; — for it is to be remem- 
 bered that the texture of the brain is so destitute of con- 
 nective tissue that an exceedingly slight degree of force 
 may penetrate it in any direction. An ordinary probe 
 should not be used for this purpose, or if used at all, abso- 
 lutely no force should be applied to it after entering the 
 brain. If its own weight will carry it along the course of 
 the wound, it may, perhaps, be used in that manner with 
 reasonable safety. It is likely to do no harm, and to give 
 as little information. But a slight degree of force applied 
 to its propulsion constitutes a new element of danger; for 
 as Dr. Agnew says, no one can tell, when applying any 
 force to an ordinary probe, under such circumstances, 
 whether he is following the track of a missile, or whether 
 he is burrowing a new channel through the brain. All 
 recognized authorities condemn such a method of probing 
 the brain, and an additional wound made by such a proce- 
 dure may be more dangerous than the original injury, and 
 constitutes not only a surgical blunder, but a surgical 
 crime. t Unless the missile, — especially if it be a leaden 
 
 *See note vii. fSee note xi. 
 
'7 
 
 ball, — can be readily found and easily extracted, it is usually 
 safer to allow it to remain within the cranial cavity than to- 
 undertake its discovery and extraction by promiscuous 
 probing and violent measures for its removal*. Explora- 
 tion of the brain, if resorted to at all, should be done early. 
 In consequence of the almost entire absence of contractile 
 tissue in the brain, a bullet or other missile in penetrating 
 it, leaves an open track along its course. If a small probe 
 be introduced into such a wound, its own weight, if the 
 position be favorable, will be sufficient to carry it forward 
 as long as the wound remains unobstructed by clots. But 
 wlien these form and have acquired firmness, they will 
 offer about the same resistance as the normal brain struc- 
 ture, and then it must become difficult or impossible for 
 the surgeon to know whether he is pushing his instrument 
 along the course of a wound previously existing, or 
 whether he is inflicting another and an equally dangerous 
 one. 
 
 Does the probability of benefit to the patient, arising 
 from an exploration of the brain, and a search for a missile 
 which has lodged in its deeper structures, justify such a 
 proceeding? If dangerous symptoms arise, and if the 
 foreign body can be discovered in any portion of the brain, 
 and its extraction accomplished by such measures as do 
 not add to the original peril, their removal should usually 
 be undertaken. But if they cannot be found without a 
 promiscuous and guideless hunt through the brain, they 
 had better be let alone. This organ occasionally shows a 
 remarkable tolerance of foreign bodies, especially metallic 
 substances, like lead and iron, which readily become 
 encysted, and have remained for long periods of time com- 
 paratively harmless tenants of the brain, or giving but 
 slight evidence of disturbance from their presencef. I 
 would, therefore, in a doubtful case, prefer to give a patient 
 
 * See note viii. fSee note ix. 
 
the benefit of the chances which this fact affords, rather 
 than to subject him to the dangers which attend the inflic- 
 tion of an additional injury, with the remote and uncertain 
 prospect of resulting benefit. 
 
 If the missile inflicting the wound be of small size and 
 the external wound correspondingly small, and no danger- 
 ous symptoms are presented — unless the missile is located 
 quite superficially — no attempt should be made to explore 
 its course through the brain, or to attempt its removal. 
 Such measures would probably be attended with more 
 serious consequences than the original injury. I have seen 
 patients recover from such a wound in the anterior and 
 middle portions of the brain without ever exhibiting any 
 symptoms that w^ould indicate a serious injury. 
 
 Or if, on the other hand, the missile has evidently 
 penetrated the deep and central portions of the brain and 
 lodged among the ganglia at its base, there is little to be 
 hoped for from any attempt to discover its exact location 
 and to effect its removal. It is likely to be fatal sooner or 
 later if it remains; but the probability of prolonging life 
 by attempting its removal is so slight as scarcely to justify 
 an effort in that direction. 
 
 If it has penetrated the upper or frontal portion of the 
 brain, if the missile is of large size and is of a nature that 
 must necessarily render it a permanent source of irritation; 
 or if it has passed through, or nearly through the brain, 
 and lodged at or near the surface, its removal should be 
 attempted. In the latter case, a counter-opening through 
 the skull will facilitate its extraction. Here, as in every 
 wound of the brain, thorough drainage and the most scrup- 
 ulous aseptic dressings should be rigidly adhered to 
 through the entire course of treatment. 
 
 Experience has shown that there are few portions of 
 the brain into which missiles have not found their way* 
 
 *See note x. 
 
19 
 
 and lodged for considerable periods of time, without giving 
 rise to any serious disturbance of the system. These, it is 
 true, are exceptional cases — but we know that they may 
 occur; and they do occur with such frequency that in 
 doubtful cases it would seem more prudent to accept the 
 slender chances that their possibility bestows, rather than 
 to complicate, by surgical procedures, even a prospectively 
 fatal injury with a view to the doubtful benefits that may 
 arise from their performance. 
 
 Whether the wounding missile be removed from the 
 brain or left within it, the subsequent treatment should be 
 conducted upon the general principles already stated. 
 
NOTES. 
 
 Note i. — Otis. Med. and Surg. Hist. War of Rebellion, pt. i, 
 surg. b., pg. 65. Thirteen cases of deaths reported from concussion 
 of brain. 
 
 Note ii. — Ifi/d, pg 68. Fractures of /ron fa/ bones, resulted . . . 
 22 cases: 10 died, 6 discharged, 5 returned to duty. Parietal, 33 
 cases: 15 died, 12 discharged, 4 returned to duty, 2 unknown. 
 Temporal, 7 cases: 6 died, i discharged. Occipital. All died. 
 Base of skitll, 1 1 cases. All died. 
 
 Note hi.— J. A Liddell. Am. J. Med. Sciences, April, 1882. 
 Sixty-three cases of fracture of inner table of skull without external 
 fracture: .Seven cases recovered, six of -these were trephined — in 
 one necrosis of external table occurred — 56 ended fatally 
 
 Noi'E IV. — Stromcyer claims to be able to correctly diagnose 
 and to locate fractures of inner table of skull by percussing with a 
 silver probe over the suspected section. 
 
 Notk v. — Fenger. Am. J. Med. Sci., July, 1884. Aspirated 
 abscess in frontal lobe 2^ inches from surface — entered needle in 
 several directions before finding abscess — recovery. 
 
 NdTI', V!. — Med & S. II. W. R , p't. i, pg. 276. Operation by 
 Dr. Bliss -recovery. 
 
 Notk v;l — ibid — V'g. 196, et seq. 
 
 N;r!'|.. V!i:. — ,'^w/ ]?6 wounds of cranial cavitv loi fatal— 85 
 casc-T of removal of missile witli .13 iccoverics. 101 cases in which 
 projcctik" was not removed, 59 fatal and 42 more or less completely 
 rc'.ovcred. 
 
 Noil'. 1 ; - Dr. II, D. Noyes. (Am. J. Med. Sciences, July, 
 1884,) removed breecli pin of gun .\ "/-if^ Inches long, }4 inch wide, 
 fiorn nose ocIhl aii'i b ain, in wiiii h it had remained five months 
 without producing serious disturbance. //'iJ, pg. 59. Dr. Daniel 
 liurr reported case in which tube and nipple of gun were carried in 
 
21 
 
 brain four months without disturbance of health. Ibid, Jan. 1885, 
 pg. 128. Dr. G W. H. Kemper relates case of breech pin of gun 
 \%, inches long removed from brain— recovery. 
 
 Note X. — Gross System of Surgery, vol. ii, pg. 160 et. seq. 
 
 No'l'E XI. — "There can be no doubt that all extraneous sub- 
 stances within view or reach, in cases of penetrating wounds of the 
 cranium, should be removed by the surgeon; but before he com- 
 mences any unguided search for them in the fragile structure of the 
 brain, he ought seriously to consider the injury which he may inflict. 
 He should remember that patients have died under the surgeon's 
 hands while exploring the brain to find foreign bodies; and further- 
 more, that life has been preserved in many instances where they 
 have not been looked after, or their presence unsuspected. When 
 the track of a leaden ball, or any other body is to be traced through 
 the brain, an elastic bougie may well be employed for the purpose. 
 In its absence a female catheter, or the porcelain-tipped probe of 
 Nelaton may be employed. These instruments should be allowed to 
 sink into the wound by their own weight; they should not be pushed 
 forcibly ojiiuard. It is better to temporize than to probe, violently, 
 an injured brain. Great care should be taken that the exploring 
 instrument is not thrust out of the track of the foreign body. When 
 the site of the missile cannot be found by one, or at most two explo- 
 rations of the wound, further attempts to find it by probing should 
 not be allowed." — Holmes' System of Surs;ery, vol. i, p. 657. 
 
 "The finger is, of course, the best probe, but all officious inter- 
 ference is to be avoided, inasmuch as it is far better to let the missile 
 and even detached pieces of bone remain where they are, than to 
 search for them at the risk of severe additional injury." — Gross' 
 System of Surgery, vol. ii, p. 161. 
 
 "In cases of penetration, any exploration in search of the missile 
 should be conducted with the utmost caution. It is impossible, after 
 a probe has passed out of sight, to know whether it is following the 
 track made by the ball, or whether it is penetrating the brain sub- 
 stance; and therefore, when the opening in the skull is sufficient to 
 admit the finger, the latter should be used in preference to any other 
 means of exploration. If fragments of bone, or any other foreign 
 matter can be detached without needlessly pressing the examination, 
 they should, by all means, be extracted; but unless they are quite 
 accessible and easily located, all such attempts can only be produc- 
 tive of evil, and should be discouraged, " — Agnew's Surgery, vol. i, 
 p. 293. 
 
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