Traumatic injuries of the brain and its membranes, with a special study of pistol-shot wounds of the head in their medico-legal and surgical relations

Preface

This work is designed to be a concise and systematic exposition of the injuries which the brain suffers from external violence, a division of brain surgery which has th<5 greatest practical importance and has received the least careful attention. It is believed that it will not only be of interest to surgeons, but will meet the requirements of general practitioners in whose experience such injuries are infrequent, and who in exceptional instances have urgent need of the aid to be derived from a wider clinical observation than their own opportunities have permitted. It has been based essentially, if not exclusively, upon an observation of five hundred consecutive cases of recent occurrence. These cases are so large in number, and so varied in character, and in so many instances are complete in the record of essential historic and necroscopic detail, as in themselves to afford material for a comprehensive history of intracranial traumatism. The picture they represent is incomplete only in the illustration of secondary pyogenic infection involving the brain substance. In view of this clinical deficiency, the consideration given to cerebral abscess has been supplemented by some account of the conditions of septic invasion and of the degenerative processes which it occasions, abstracted, by permission of the distinguished author, from Macewen's " History of the Pyogenic Inflammations of the Brain and Spinal Cord."

The generalizations which have been made, and the conclusions which have been reached, from clinical observation, have been verified in each instance by necroscopic examination.

jy PREFACE.

In an appended series, all those cases in which necropsy was had, and a certain number of others which terminated in recovery or in which necropsy was otherwise impracticable, have been collated. This course has permitted the preservation of continuity in the text by the omission of interpolated illustrative cases, has afforded a means for the disproval of possible unwarranted or erroneous deductions, and has preserved much material for the use of independent observers hereafter. They have been classified simply from their relation to cranial fractures, and this, though an imperfect method of classification, is, by reason of the multiplicity of lesions in individual cases, the only one which has seemed practicable.

The lesions which attend pistol-shot wounds of the head have been considered apart from general injuries, as a method more clearly presenting their distinctive characteristics. Their complete history has necessitated an abstract of the results of a series of cadaveric experiments, instituted to determine for legal purposes the extent to which the conditions under which they have been inflicted can be predicated from the appearances they present. These observations have been sufficiently extensive to better define not only the positive value, but the limitations, of medical evidence in such cases than has been heretofore

possible.

This portion of the work which directly concerns medical jurisprudence is especially designed for the use of the legal profession in more precisely estimating the proper weight to be given to expert testimony in cases of this character.

The author has much pleasure in acknowledging his indebtedness to his colleagues of the Fourth Surgical Division of Bellevue Hospital, Dr. Jno. W. S. Gouley and Dr. Wm. F. Fluhrer, and of the Surgical Service of St. Vincent's Hospital, Drs. Stephen Smith, Frederick S. Dennis, and Jos. D. Bryant, through whose courtesy his opportunities for clinical observation have been greatly ex-

PREFACE. V

tended. He is also under very great obligation to successive house staffs of the same hospitals, and to the medical officers of the Coroner's Office during the past six years for the constant aid and co-operation which have made possible the collection of the great mass of facts which the nature of this work has involved. He has finally to make acknowledgment of the skilled marksmanship and otherwise valuable assistance rendered to him bv Drs. J. H. Titterington, Henry L. Whitener, and Harry L. Hibbard, late of Bellevue Hospital, and by Drs. John Freeland and Jno, D. Gorman, in the difficult and laborious task of cadaveric experimentation.

34 West Thirty-seventh Street, July, 1897.

PART I. General Traumatic Lesions

a preliminary consideration of cranial fracture.

PAGE

Classification of Injuries of the Head, ....... i

Cranial Fracture, 2

Classification, . . . ........ 2

Fracture of the Cranial Base, ........ 3

Direct and Indirect, ......... 4

Mechanism, . 6

Complications of Cranial Fracture, 11

Symptomatology and Diagnosis, 12

Fractures of the Vault, ......... 12

Fractures of the Base, ......... 13

External Hemorrhages of Cranial or Intracranial Origin ; . .13 their Comparative Frequency in Different Forms of Basic Fracture, 14

their Diagnostic Value, . . . . . . . . . iS

Escape of Brain Matter, ......... 21

Water}- Discharges, 21

CEdema of the Mastoid Region, ....... 23

Implication of the Cranial Nerves, ...;... 24

Localized Pain, .......... 26

Indirect Symptoms from Intracranial Complication, . ' . .27

Concomitant and Consecutive Complications, . . . .30

Treatment, 32

Fracture of the Base, ......... 33

Fracture of the Vault, ......... 34

Elevation of Depressed Bone, ....... 36

Trephination, . . 39

Vlll

TABLE OF CONTENTS.

CHAPTER I. Pathology

Shock, ty,

Exsanguination, and Diminu stic Degeneration

Fluid

Classification, .

Hemorrhages,

Epidural, .

Pial

Cortical, .

Dangers of Hemorrhages tion of Cranial Capac

Terminations in Absorption and Cy Thromboses of Dural Sinuses, Contusion, ....

General Contusion of the Brain,

Anatomical Conditions, .

Duret's Theory of Displacement of the Cerebro-Spinal

Concussion and Compression, ....

Prescott Hewitt — Observations of Contusion,

Von Bergmann's Theory of Concussion and Compression

Structural Alteration Attends All Brain Injuries, Limited Contusion of the Brain,

Anatomical Conditions, Contusion of the Meninges.

Hemorrhage, ....

Subarachnoid Serous Effusion, Laceration of the Brain,

Anatomical Conditions, .

Terminations, .

Indirect Lesions — Secondary Inflammations,

Due to Accidental Infection of Primary Lesions.

External or Distant Origin of Pathogenic Germs

Infrequency of Occurrence, ....

Macewen's History of Intracranial Infection,

Acute Leptomeningitis. .

Acute Serous Leptomeningitis,

Purulent Leptomeningitis.

Red Softening.

White Softening,

Cerebral Abscess,

Secondary Abscess. .

Pyogenic Abscess.

Necrosis of Cerebral Tissue,

Localization of Primary Lesion Determines the Alternati Meningitis or Abscess, ......

Possibility of Intracranial Inflammation without Infection,

PAGE of

85 86

TABLE OF CONTEXTS. ix

Arachnitis a More Exact Term than Leptomeningitis. Encephalitis Always Pyogenic, ....

Cirrhotic Inflammation — Atrophy, ....

CHAPTER IL

Symptomatology.

Direct Lesions, •••........ qi

Unconsciousness, Delirium,

93 95

Condition of the Pupils, ......... 95

Temperature, ........... gy

Pulse, gS

Respiration — Marked Infrequency from Compression of the

Medulla, gg

Tabulation of Cases, . 100

Cyanosis and Pulmonarj' CEdema, ....... 103

Psychical Disturbances, ......... 104

Influence of Complications, ........ 104

General Contusion of the Brain, ........ 107

Variability of Symptoms, ........ 108

Cases Complicated by Hemorrhages, 113

Limited Contusion of the Brain, . . . . . . , . 114

Laceration of the Brain, ......... 115

Pulse and Respiration, .......... 121

Asymmetrical Radial Pulsation 122

Condition of the Pupils, . 124

Loss of Consciousness, ......... 125

Psychical Disturbances, 126

CHAPTER IIL Symptomatology — Contimced.

Symptoms Indicative of the Localization of Lesions, .... 129

Mental Disorders in Cases of Laceration of the Frontal Lobes, . . 129 Differences in Symptomatology as the Right or the Left Frontal Lobe, or as the Superficial or Deeper Portion of the Left Lobe, is

Involved — Tabulation of Cases, ...... 130

Illustrated by Histories of Pistol-Shot Wounds, .... 136

TABLE OF CONTENTS.

"AGE

Derangements of Muscular Action 138

Paralysis.

Incoordination,

Clonic and Tetanic Spasm

S3-mptoms from Lesion of Corpus Striatum, .

Optic Thalamus

Gyrus Fornicatus, ......

Pons

Temporal Lobe,

Conjugate Deviation

Loss of Urinary and Faecal Control.

Arachnitis,

I4S

General Symptoms

Superficial, .....

Deep.

Analysis of General Symptoms,

Localizing Symptoms

CHAPTER IV.

Diagnosis.

Unconsciousness as a General Indication of Traumatic and Idiopathic

Characteristics of Opium Narcosis,

" Ursemic Coma. .

" " Apoplectic Coma,

. 166

" Alcoholic Coma,

. 166

" " Traumatic Coma,

. 167

Diagnosis of Traumatic from Alcoholic Coma,

. 168

Coexistence of the Two Conditions,

. 169

Temperature, ......

. 170

Delirium, .......

• 171

• 172

Coexistence of the Two Conditions,

. 172

• 173

DiflEerentiation of Traumatic Lesions from Each Other,

• 174

• 174

Unconsciousness, .....

• 175

Temperature, ......

. 176

Respiration .

• 177

Pulse

• 177

TABLE OF CONTENTS. xi

PAGE

Condition of Pupils, -179

Mental Disturbances, ......... 180

Muscular Disorders, . . . . . . . . .i3i

Loss of Urinary and Fsecal Control, ...... 182

Aphasia — Not from Hemorrhage . .182

Unconsciousness, Temperature, Pulse, and Respiration, as the

Essential Factors in Diagnosis of Intracranial Lesions, . . 185 Secondary Inflam.mations, . . . . . . . . .185

Arachnitis, . 185

Diagnosis, when of Early Formation, from Primary Contusion, . . 188 Diagnosis, when of Later Development, from Results of Vascular Lesions and from Tumor 189

Symptoms Common to All Organic Diseases of the Brain, . . . igo

Symptoms Common to Abscess and Tumor igo

Diagnosis of Abscess from Tumor, igi

CHAPTER V.

Prognosis.

Direct Lesions, ........

Statistical Results in Five Hundred Original Cases,

Relative Danger of Fractures of Cranial Base and Vertex Dependent

upon Complications. ......

Relative Danger of Different Intracranial Complications, Analysis of Recovering Cases, .....

Prognostic Indications from Individual Symptoms, Secondary Inflammations, ......

Arachnitis, ........

193 193

CHAPTER VI.

Principles of Treatment.

Operation for Intracranial Injuries, • . 208

Epidural Hemorrhage 208

Conditions of Operation. ........ 210

Subdural Lesions, .......... 212

Pial and Cortical Hemorrhages, ....... 212

General Contusion, .......... 214

Laceration of the Brain 215

Late Pathic Conditions, ......... 219

Dangers of Operation 220

XI 1

TABLE OF CONTENTS.

General Conduct of Operation General Treatment, Secondary Inflammations, Arachnitis, Abscess,

Superficial, Deep,

PAGE

. 222

■ 223

. 227

. 227

. 230

PART II. Pistol-Shot Wounds of the Head

CHAPTER VII.

Medico-Legal Relations.

Observations Made upon the Cadaver, Extracranial Lesions,

0.3S cal.. Head,

o. 3S cal.. Bod}-,

0.32 cal.. Head,

0.22 cal., "

Generalization of Results, Modifying Conditions, Characteristics of Cutaneous Wound of Exit, How far Wounds Inflicted during Life Differ from Those

Cadaveric Experimentation, .....

Comparative Importance of Different External Conditions

in Estimating Range and Calibre, ....

Medico-Legal Importance of the Study of These Lesions, cessity of Sufficiently Extended Experimentation,

Decisive in only a Limited Number of Cases, Cranial Lesions, ......

Peculiarities Common to all Calibres of Ball, Cranial Penetration, ....

0.44 cal.. Pistol of Most Efficient Type,

0.44 cal.. Pistol of Inferior Type,

Modifying Conditions, Dimensions of Cranial Wounds,

Produced in Enumeratec and the Ne

235 239 239 250

254 260 266

276 2 86

290 292

TABLE OF CONTENTS.

Xlll

PAGE

Summary, . 314

Cranial Wounds of Exit,

Cranial Comminution and Fissuring,

Intracranial Lesions,

CHAPTER VIIL

Surgical Relations.

Symptomatology, ....

Profundity of Unconsciousness,

Immediate Subjective Symptoms, Diagnosis, ....

Fluhrer's Probe,

Nelaton's Probe,

Girdner's Telephonic Probe,

Use of Rontgen Rays,

Acupuncture,

Diversion of the Bullet, .

Examdnation of the Eye and Orbit,

Examination of Cervical Region, Treatment, .....

Several Views as to Further Treatment,

Illustrations from Published Cases,

Results of Expectant Treatment,

Incision of Dura Mater, .

Operation with a View to Drainage only. Analysis of Published Cases with Reference to the Results of Reten tion of Bullets within the Cranial Cavity,

Conclusions, ......

Analysis of Published Cases with Reference to the Comparative Danger of Retention and Removal of Bullets Deeply Situated within the Cranial Cavity

Conclusions, Treatment of Superficial Wounds of Entrance and Exit Exaggerated Estimate of the Danger of Operation, Details of Operation, . . .

Counter-Operation, ......

Circumstances Adverse to Counter-Operation, Disinfection and Drainage, .....

Prognosis, ........

Statistics

Treatment, . • , • • • • •

360 366

XIV TABLE OF CONTENTS.

The Condensed Histories of Three Hundred Intracranial Traumatisms.

CASES verified BY NECROPSY.

Fractures of the Cranial Base,

Fractures of the Cranial Base from Pistol-Shot Wound, Fractures Confined to the Cranial Vertex, ..... Fractures Confined to the Cranial Vertex from Pistol-Shot Wound, Encephalic Injuries without Cranial Fracture

PAGE

395 477 493 503 513

CASES unverified BY NECROPSY.

L^nclassified 537

Intracranial Lesions from Pistol-Shot Wounds with Recovery, . . 577

INJURIES OF THE BRAIN AND OF ITS MEMBRANES.

PART I.

GENERAL TRAUMATIC LESIONS.

A PRELIMINARY CONSIDERATION OF CRANIAL

FRACTURE.

Injuries of the head may be topographically classified as superficial or extracranial, cranial, and intracranial.

These may occur independently or may variously complicate each other.

The external injuries may be excluded as of no importance in a consideration of intracranial lesions except as aids in diagnosis, and in the case of cutaneous wounds, as a possible means of infection in meningitis or in the course of cerebral abscess.

The cranial injuries are contusion and fracture, and of these contusion followed by consequences of moment is infrequent and has no closer relation to intracranial injury than have contusions of the more superficial parts. Fractures so usually complicate, or are complicated by, structural changes in the brain or its meninges ; and are often so directly connected with the pathic results of intracranial lesions, either by osteal hemorrhage or by affording a channel for the invasion of septogenic germs, as to justify some particularity of attention to their peculiarities.

Fracture.

The classification of fractures of the cranium is primarily the same as of fractures of other bones:

I. Simple

Compound.

Comminuted.

Complicated.

II. Complete

Incomplete.