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).
[Illustration: FIG. 379
Prolapsus cerebri. (Bryant.)]
=Prognosis.=--The prognosis is generally unfavorable. There is always risk of edema or infection, either of which may prove fatal.
Infiltration, gangrene, suppuration, or repair by granulation may so disfigure and disguise the real brain substance as to lead to _error of diagnosis_. It by no means follows that every tumor presenting through an opening in the skull is of this character. When gangrene and spontaneous separation occur, spontaneous recovery may follow, the stump being covered by granulations and finally roofed over by connective tissue.
=Treatment.=--Treatment in the primary cases should include the most rigid asepsis with removal of all foreign particles. Localized pressure does some good, especially in those cases where it can be tolerated. Signs of abscess should always be watched for, and deep exploration is often justified or indicated. While excision or cauterization are often heralded as successful, they are by no means without their dangers. Nevertheless in selected and suitable cases excision may be freely practised. Cases that admit of it should wear a protective shield properly molded to the part. Skin transplantation, or even osteoplastic repair of the defect, may give good results in favorable cases.
SEPTIC INFECTIONS WITHIN THE CRANIUM.
Under the general term _septic infection_ are included:
_A._ Abscess;
_B._ Thrombosis;
_C._ Sinus phlebitis;
_D._ Meningitis;
_E._ Encephalitis.
These are different manifestations of infection, the clinical picture differing according to the tissues and localities involved. For the production of these infectious conditions no special bacteria other than those already catalogued in