Treatment of Penetrating Gun- 
shot Wounds of the 
Cranium. 
d" 
BY y 
JOSEPH D. BRYANT, M. I). 
REPRINTED FROM 
3Ti)e Neto Yor’t jßflclifcal journal 
for May 5, 1888. Reprinted from the New York Medical Journal 
for May 5, 1888. 
TREATMENT OF PENETRATING 
GUNSPIOT WOUNDS OF THE CRANIUM* 
JOSEPH D. BRYANT, M. I). 
It is not my Intention to fatigue yon with either a long- 
er a critical consideration of the generally accepted steps 
of treatment of penetrating gunshot wounds of the cra- 
nium. I do not desire to disturb in the least the well- 
established measures that are found along the paths of sur- 
gical inquiry, which have served as satisfactory guides both 
to the inexperienced and the experienced alike, on all occa- 
sions. It should be the purpose of each one who acts on 
principle, rather than on impulse or from policy, to do his 
share in so directing the lines of thoughtful consideration 
and conclusion in respect to professional methods that the 
profession of which he is a member may not be exposed to 
satirical expressions not unlike the one used by Young, who 
said in his epistle to Pope: “ And oftener changed their 
principles than shirt.” It is the purpose of this paper to 
add somewhat to the accepted method of the treatment of 
these forms of injury, or, at least, it is hoped that its pres- 
* Read before the Medical Society of the State of New York at its 
eighty-second annual meeting. 2 
TREATMENT OF PENETRATING 
entation and discussion may inspire a fuller confidence in 
the modern deviations of treatment—deviations that are 
recognized as the legitimate issue of antiseptic cleanliness 
and inventive genius. This paper will be devoted almost 
entirely to the consideration of the indications for treat- 
ment of the injuries which give to the paper its title. This 
course is thought to be an eminently proper one, since the 
indications for the treatment of a condition bear the same 
important relations to the treatment itself as exist between 
the compass point and the trusted pilot at the wheel. The 
indications for treatment are divided properly into constitu- 
tional and local. The local indications only will engage 
our attention at this time, together with the consideration 
of the deviations in the fulfillment of them that appeal' to 
be warranted by the recent advance in surgical technic. 
The commonly accepted local indications for treatment of 
tli ese injuries may be enumerated as follows: 
1. The arrest of haemorrhage. 
2. The elevation of depressed fragments of bone. 
3. The removal of foreign bodies from the wound. 
5. The combating of inflammation. 
4. The establishment of good drainage. 
The means to'be adopted tor the arrest of haemorrhage 
will depend on the source from which it comes. If it comes 
from the scalp, the common means employed for the arrest 
of haemorrhage in other situations will be found to be 
ample in this instance. If the flow of blood comes from 
the bone itself, 1 am accustomed to plug the bleeding-point 
with catgut. The shape and size of the catgut plug are 
made to correspond to the requirements of the case. The 
employment of this agent in the manner indicated possesses 
this virtue : the plug can be permitted to remain in position 
without the least concern, since it will become absorbed 
after having performed its obstructive function, and in no GUNSHOT WOUNDS OF THE CRANIUM. 
3 
instance need fear be had of any septic influence by reason 
of its presence. 
Hemorrhage from Meningeal Vessels.—Haemorrhage 
fiom the vessels of the pia mater can be controlled usually 
by simple pressure alone. The vessels associated with the 
dura mater, however, bleed with a much greater degree of 
persistence. The middle meningeal artery, for instance, and 
also its branches, not infrequently cause much haemorrhage, 
and not a little difficulty is experienced in arresting the 
bleeding. If the bleeding-point can be caught as it makes 
its appearance near the border of the fractured bone, the 
haemorrhage is easily controlled by ligature. In my obser- 
vation of this class of cases, the open end of the bleeding 
vessel is drawn so far beneath the border of the fractured 
bone that it can not be seized with a forceps directly. In 
this emergency I have employed the following plans for the 
arrest of haemorrhage: 
1. Plugging the bleeding-point with catgut. This is 
insecure and should not be employed if the haemorrhage is 
persistent. 
2. Clamping the bleeding vessel against the inner sur- 
face of the bone beneath which it runs. This plan can be 
canied into effect easily by aid of the Langenbeck clamp, 
oi of any other that will meet the indication. The blade 
of the clamp may be applied directly to the lower surface 
of the vessel, or an antiseptic compress may be interposed 
between the blade and the vessel. 
3. Cutting away the portion of bone that obscures the 
bleeding-point with a rongeur and catching and tying the 
point directly. The latter is the surer, consequently the 
better plan. 
Hemorrhage from a Sinus.—This form of haemorrhage 
is often tioublesome, but need not excite much apprehen- 
sion if the blood does not collect in the cranium in an TREATMENT OF PENETRATING 
/ 
amount sufficient to cause cerebral compression. The blood 
should be permitted to escape or be removed, and further 
accumulation of it be obviated by directly closing theHbleed- 
ing-point of the sinus. The closure can be accomplished 
easily by the direct application of an antiseptic compress 
to the wound of the vessel, if the wound is accessible. If 
the bleeding-point is inaccessible through the brain-wound 
and the haemorrhage is persistent or dangerous and not 
controllable by other means, then the seat of the*vound of 
the sinus should be located with the probe, case 
of a ball,’ and it should then be approached from without 
by aid of the trephine when practicable. rent is 
present in the sinus, its border can be united cat- 
gut. The application of a simple compress to ttfe wound 
of a sinus, however, is usually sufficient to meetHhe indica- 
tions. If the haemorrhage arises from injury of a sinus of 
the base of the brain, especially the petrosal, thb applica- 
tion of direct pressure on the bleeding-point cannot be so 
well accomplished. In thisffinstance a fatal flow of blood 
may be prevented by closing the external at 
the risk of causing compression of the brain by accumula- 
tion of blood in the woundc Problems of this character 
are not presented ofterj for solution, since the ndssile that 
wounds a sinus in this situation causes almost immediately 
fatal injuries of the brain-substance at the 
is not impossible in sinus wounds to pass by meffns of a 
probe a small tampon of an antiseptic astringent substance 
connected with a long thread through a straight channel to 
the point of haemorrhage. This tampon should be of proper 
size to admit of its easy passage along the track made by 
the ball. When it has been properly applied against the 
bleeding-point the probe can be withdrawn and the tam- 
pon permitted to remain in position. The thread connect- 
ed with it is allowed to hang from the wound, and is for GUNSHOT WOUNDS OE THE CRANIUM. 
5 
tli6 purpose of withdrawing the tampon when necessary. 
This plan has been employed successfully by Br. Gardner 
on several occasions for the purpose of checking haemor- 
rhage from the brain-substance. In many of these cases, 
however, death from compression by blood, or from injury 
of important nervous centers, ensues too quickly to permit 
the services of a surgeon to be of avail, even though they 
are exercised without delay. 
Haemorrhage from the Brain.-~\i considerable blood 
escapes from a wound of the brain, it is probable that the 
vascular structures in or about the ventricles are lacerated; 
to use a practical expression, “ The ball has gone through 
the ventricles.” Severe haemorrhage from a wound of the 
brain may be caused by the wounding of a sinus, or of 
an intracerebral vessel of considerable size. Fortunately, 
haemorrhage from a wound of the brain-substance only need 
cause no apprehension. Moderate, gentle pressure over the 
external opening, or tamponing the track of the ball, and 
elevation of the head when permissible, are sufficient to 
control it. Ihe dusky color of the blood, the direction of 
the wound of the brain-substance, and the persistency of 
the flow will indicate whether or not a sinus has been in- 
jured. As to the direction of the wound : It should not 
be forgotten that the impingement of a ball on a prolonga- 
tion of the dura mater, while passing, may cause such a 
deflection of the ball as to render its course after this time 
entirely a matter of conjecture. The manipulations to be 
made along the track of a missile for the purpose of locat- 
ing or removing it, or for the purpose of making a counter- 
opening through the skull, should not be attempted until the 
danger from haemorrhage has disappeared. The passage of a 
ball into or through normal brain-structure at other situations 
than those already mentioned is not attended with haemor- 
rhage of a dangerous nature, consequently any steps thought 6 
TREATMENT OF PENETRATING 
to be necessary as a means of treatment for the removal of 
a ball in the latter instance need not be delayed for this 
reason alone. 
Elevation of Depressed Fragments.—The importance of 
this indication and the means of meeting it are so well un- 
derstood already that it is superfluous to take the time for 
its consideration. 
Removal of Foreign Bodies.—This indication is'a most 
important one, and it is in its fulfillment that the principal 
deviations from the previously accepted course of treatment 
will be noticed. The foreign bodies requiring removal from 
the brain are (1) fragments of bone, hair, textile fabrics,' 
etc.; (2) the missile itself. Such of these agents as may 
be located around the open mouth of the wound, or have 
entered an inch or two within the brain, have been removed 
frequently and with complete success. However, the ma- 
nipulation employed to remove a ball from the brain, even 
if it has entered that structure but a short distance, has 
been deemed a sufficient deviation from the proper course 
of treatment, at a recent date, to be presented in a court of 
justice as contributive to the death of the patient. It is 
not now worth the while to enter into the consideration of 
the exact distance the surgeon may explore the brain for 
the purpose of locating and removing a ball, since the ob- 
ject of this paper will be to commend the removal from the 
brain of such bodies at once, in nearly all instances, when 
their exact location can be determined. Let us pass now 
to the consideration of the questions: 
1. Should a ball be removed from the brain ? 2. If so, 
how should it be done? To determine a general rule of 
action regarding the first question, it is only necessary to 
inquire whether or not a greater number of patients have 
recovered after removal of balls from the brain, or after the 
missiles had been permitted to remain within it. It must GUNSHOT WOUNDS OF THE CRANIUM. 
7 
be presumed, of course, that all other things were equal in 
the two classes of cases. 
Dr. R. H. Wharton, of Philadelphia, published in the 
“Philadelphia Medical Times’’ of July 19, 1879, a concise 
tabulated satcment of the results of “an analysis of 316 
cases in which foreign bodies were lodged in the brain.” 
It is thought by the writer of the present paper that this 
number is entirely sufficient for the purpose of establishing 
the conclusions that will be drawn from them—conclusions 
which must be recognized as having little or no practical 
reference to antiseptic methods. An analysis of these 
cases shows that 236 of the entire number of missiles were 
“balls,” “portions of balls,” and “buck-shot.” Of this 
number the missiles were removed from the brain in 66 in- 
stances, and in 170 instances they were permitted to remain. 
Of the 66 cases in which removal was resorted to, 27 of the 
patients (40 percent.) died and 39 (59 per cent.) recovered. 
Of the 170 cases in which the missiles were not removed, 
97 of the patients (57 per cent.) died and 73 (43 per cent.) 
recovered. It is now easy to be seen that the death-rate is 
17 per cent, greater when the missiles are allowed to remain 
unremoved. 
In order to determine the relative rates of death and 
recovery after gunshot wounds of the different lobes of 
the brain, with and without removal of the missile, a series 
of 140 cases were collated at my request by Dr. Glover C. 
Arnold upon which to base the calculations. The great 
majority of these cases were taken from the histor}’ of the 
late civil war. It is proper to state that all possible caution 
was enjoined on Dr. Arnold in the selection and study of 
the cases. With but few exceptions, they were taken con- 
secutively as placed on record by the different authors. 
The point of entrance and the track of each missile, to- 
gether with the situation and final lodgment or exit of it, 8 
TREATMENT OF PENETRATING 
were carefully determined by comparing the statements of 
the records of each case with the topography of the normal 
brain as set forth in the works of accepted authorities of 
the topography of this organ. Of the 140 cases, 60 im- 
plicated the frontal lobes alone, and one half of the patients 
died. Of the 60 cases, in 3 only did the missile pass di- 
rectly through and out of the cranium, and 1 of the patients 
died and 2 recover’d. Of the remaining 57 cases, in 30 the 
missiles were removed; 16 patients died and 14 recovered. 
The missiles of the remaining 27 were not removed; of 
these, 13 died and 4 recovered. The parietal lobes were 
involved alone in 11 of the 140 cases, and 5 patients died. 
In 6 of the 11 cases the missiles were removed ; 1 died and 
5 recovered. Of the 5 remaining patients, 4 died and 1 
recovered. Of the 140 cases, the temporo-sphenoidal lobes 
were penetrated in 24 instances, and 9 patients died and 15 
recovered. The missiles were removed in 7of the 24 cases; 
2of the patients died and 5 recovered. In Bof the 24 cases 
the missiles passed through both lobes, and escaped from 
the cranium at the opposite side of the head ; 1 of the pa- 
tients died and 7 recovered. In 9of the 24 cases the mis- 
siles were not removed; 6of the patients died and 3 recov- 
ered. In 14 instances the occipital lobes were penetrated; 
of the patients, 6 died. Of the entire number, in 3 the 
missile passed completely through and out of the skull: 1 
patient died and 2 recovered. In sof the entire number 
the missiles were removed ; 2 patients died and 3 recovered. 
In 6 of the entire number they were not removed ; 3 patients 
died and 3 recovered. The cerebellum was penetrated in 
6 instances, in 3 of which the ball passed completely 
through and escaped from the skull. All of these patients 
died. Of the remaining 3, in 1 the missile was removed 
and the patient died. Of the 2in which the missiles were 
not removed, 1 patient died and 1 recovered. The frontal GUNSHOT WOUNDS OF THE CRANIUM. 
9 
and parietal lobes suffered in 4 instances, and 2 of the pa- 
tients died. Of the entire number, the balls were removed 
in 3 instances; 1 patient died and 2 recovered. In one case 
the ball was not removed ; this patient died. In 6 instances 
the frontal, temporal, and sphenoidal lobes were penetrated 
conjointly. In each of these instances the missile escaped 
primarily. Three of the patients died and 3 recovered. 
The frontal, temporo-sphenoidal, and occipital lobes were 
involved simultaneously in 8 instances; 6 patients died and 
2 recovered. In 3of the 8 cases the missiles escaped prr 
rnarily ; 2 patients died and 1 recovered. In 2 instances 
the missiles were removed; 1 patient died and 1 recovered. 
The balls were permitted to remain in 6 instances, and all 
the patients died. Two examples of conjoined perforation 
of the parietal and occipital lobes were found, of which 
1 ended fatally and 1 in recovery. In the fatal case the 
ball had escaped primarily. The ball was removed in the 
successful case. The temporo-sphenoidal and occipital lobes 
were implicated in 4 instances, and 2 patients died. One 
of these results followed the primary escape of the missile. 
The other ball was removed, and the patient recovered. 
Of the 2 in whom it was not removed, 1 died and 1 recov- 
ered. In 1 case of the 140 the ball traversed the temporo- 
sphenoidal lobe, pons, and crura cerebelli; this patient died. 
The following table of the 140 cases will enable the reader 
to note the facts more readily than can be done from the 
text: 10 
TREATMENT OE PENETRATING 
LOBES OP BRAIN IMPLICATED. 
BALLS REMOVED 
AND ESCAPED PRI- 
MARILY. 
BALLS NOT RE- 
MOVED. 
No. 
Died. 
Recov- 
ered. 
No. 
Died. 
Recov- 
ered. 
Frontal 
33 
17 
16 
27 
13 
14 
Parietal 
6 
1 
5 
5 
4 
1 
Temporo-sphenoidal 
15 
3 
12 
9 
6 
3 
Occipital. 
8 
3 
5 
6 
3 
3 
Cerebellar 
4 
4 
0 
2 
1 
1 
Frontal and parietal 
3 
1 
2 
1 
1 
0 
Frontal and temporo-sphenoidal... 
6 
3 
3 
0 
0 
0 
Frontal, temporo-sphenoidal, and 
occipital 
5 
3 
2 
3 
3 
0 
Parietal and occipital 
2 
I 
' 1 
0 
0 
0 
Temporo-sphenoidal and occipital. 
2 
1 
1 
2 
1 
1 
Temporo-sphenoidal, pons, and 
crura cerebelli 
1 
1 
0 
0 
0 
0 
Total 
85 
38 
47 
55 
32 
23 
It is to be seen with a glance that the missiles were re- 
moved or escaped primarily in 85 of the 140 cases. Of the 
85 patients, 47, or 55-3 per cent., recovered. In 55 of the 140 
cases the missiles were allowed to remain unmolested ; of the 
patients, only 23, or 4DB per cent., recovered. This show- 
ing places the rate of recovery when the missiles escape pri- 
marily and are removed 13-5 per cent, higher than when 
they were allowed to remain unmolested. The rate of re- 
covery under similar, circumstances was 17 per cent, as 
shown hy the series of 236 cases selected from Dr. Whar- 
ton’s collection. The difference of percentage between 
these two series of cases is too small to be of special prac- 
tical utility. However, the great care that was exercised 
by Dr. Arnold in the collection of the 140 cases makes the 
deductions that can be derived from them especially valua- 
ble. Dr. Arnold read the history of each case carefully and 
established the facts on which the conclusions are based by GUNSHOT WOUNDS OF THE CRANIUM. 
11 
topographical measurements. In many instances the facts 
were verified by comparing them with the report of the 
autopsies of the cases. Only such of the 140 cases as pos- 
sessed a reasonably complete history in all important re- 
spects were reported. It is interesting also to note the 
frequency of primary escape of missiles from the skull, and 
the relation which the escape bore to the frequency of re- 
covery. 
Tabulated Statement of the Cases in which Missiles escaped primarily: 
FROM 
No. 
Died. 
Recovered. 
Frontal lobes 
3 
1 
2 
Parietal lobes 
0 
0 
0 
Temporo-sphenoidal lobes 
8 
1 
7 
Occipital lobes 
3 
1 
2 
Cerebellar lobes 
3 
3 
0 
Frontal and parietal lobes 
0 
0 
0 
Frontal and temporo-sphenoidal lobes. . . 
6 
3 
3 
Frontal, temporo-sphenoidal, and occipital. 
3 
2 
1 
Parietal and occipital lobes 
1 
1 
0 
Temporo-sphenoidal and occipital lobes .. . 
1 
1 
0 
Temporo-sphenoidal, pons, crura cerebelli . 
1 
1 
0 
Total 
29 
14 
15 
It is noticeable, from observation of the preceding state- 
ment, that a majority of the patients recover when the missiles 
escape primarily. The difference, however, is but a slight 
one, still this difference is an argument in favor of removal. 
It appears, by comparison of the two tables, that the results 
are much better when the missiles are removed by the sur 
geon than when they escape primarily. The greater force 
of the missile and the greater injury inflicted by it in the 
latter instance are substantial reasons for the dissimilarity 
of the results. 
It can be stated, in view of the preceding results, as a 
principle that a ball should be removed from the brain. It 
is now proper to inquire as to the causes of death in con- 12 
TREATMENT OF PENETRATING 
nection with these forms of injury. Abscess of the brain 
was the cause of death in 42 (18 per cent.) of the entire 
number of cases of the first series (236). In 13 of the 42 
cases (31 per cent.) abscess followed removal of the ball at 
various periods of time. In one instance it occurred seven 
years after removal. Usually, however, its occurrence was 
closely associated with the time of the removal itself. In 
the remaining 29 cases of abscess (69 per cent.) the missiles 
were not removed. In these cases the abscesses formed at 
various intervals of time—from a few days to thirteen years. 
In three of the latter instances abscess formed seven years 
after the receipt of the injury. 
We will inquire now as to the subsequent condition of 
patients in certain cases of so-called recovery. Fourteen 
were more or less afflicted with headache. Of these, in 
two only had the missiles been removed. Eight suffered 
from some form of paralysis of the trunk or limbs, and in 
but one of these had the missile been removed. Six suffered 
in a degree from mental impairment; in two of these the 
ball had been removed. In three instances partial or total 
blindness followed, in all of which the missiles remained in 
the brain. Epilepsy resulted in three cases, in one of which 
the ball had been removed. Sudden death while under ex- 
citement followed in three cases, in none of which the ball 
had been removed. In one case in which the ball had not 
been removed death followed a year after from pressure on 
important parts within the cranium. Of the 66 cases in 
which the missiles were removed from the brain, 27 (41 per 
cent.) ended in complete and permanent recovery. Of the 
170 cases in which the missiles were permitted to remain in 
the brain, but 20 per cent, of the patients are reported to 
have recovered without sequels. It does not matter whether 
or not a ball may become encysted so long as it appears from 
the majority of cases that a larger percentage recover when GUNSHOT WOUNDS OF THE CRANIUM. 
13 
this form of missile is removed than when it is allowed to re- 
main unmolested and amenable only to the efforts of Nature. 
It is doubtless true that in certain individual instances a pa- 
tient might survive longer if a ball were allowed to remain 
unmolested, yet sooner or later, in the majority of these cases, 
disaster will occur. An encysted ball may gravitate toward 
the base of the brain, and, if it does not cause disturbance 
or death en route, it will be quite certain to do so at a later 
period. The possibility of a ball becoming encysted, and 
the method of its occurrence, can have but little practical 
bearing in the light of past experience, and the possibility 
of its occurrence or non-occurrence should not be given 
serious weight at the present time, except the considera- 
tion be coupled with recommendations which will lead to 
a far more frequent encystment than has heretofore taken 
place. 
If a ball should be removed, how should it be done ? 
Mr, Thomas Longmore says in Holmes’s “System of Sur- 
gery,” vol. ii, p. 188: “If the site of lodgment ... is 
obvious, it should he removed with as little disturbance as 
possible, hut trephining for its extraction when the place of 
lodgment is not known ... is an unwarrantable operation.” 
I think all judicious surgeons of the present time will con- 
cur in this assertion. The removal of a ball from the brain 
is divisible into certain steps : 
1. Ascertaining its location. 
2. The selection of the most feasible route by which to 
reach it when located. 
A hall may be located by probing the canal it has made 
in the brain-structure, if it has taken a straight line and 
is still lodged in the line of the course primarily taken. 
If, however, it has infringed in its course on a prolonga- 
tion of the dura mater, or if the course has deviated for 
any other reason than this one, the missile is manifestly TREATMENT OF PENETRATING 
inaccessible to the touch of a probe that is introduced at 
the entrance wound of the ball. To attempt to locate a 
ball in the brain by passing a probe of any pattern or ma- 
terial whatever along a devious track is not only unsur- 
gical, but dangerous and culpable. It therefore follows 
that the surgeon should be able to determine at what point 
the ball-track deviates from a straight course at all times. 
This requires a delicate and cautious hand, a large, light 
probe, and the aid of gravity when it can be consistently 
utilized. The aluminium probe recently suggested by Dr. 
Fluhrer combines both the necessary lightness and the 
proper size for the purposes of exploration. A probe which 
is to be introduced into the brain should be quite as large 
at or near its middle as at the advancing extremity, since 
the form of the body of the probe serves to guide the ad- 
vancing end correctly at all times, with reference to the 
center of the wound. The bulbous-end probe with a stem- 
like handle—Nekton’s, for instance—is not the proper in- 
strument to introduce into the brain, for it may be carried 
astray unless the stem is kept exactly at the middle of the 
opening in the brain made by the ball. The ordinary small 
probe employed for the purpose of exploring other portions 
of the body should not be introduced into the brain for the 
purpose of locating a ball. Flexible probes, too, should 
likewise be avoided, for no one can tell the number of the 
false tracks which they may make by reason of the inability 
of the surgeon to control the advancing end, or calculate as 
to its exact situation. 
Having selected the proper probe, then, when possible, 
place the head in such a position as to gain every ad- 
vantage in the insertion of the probe along the tract of 
the wound that the force of gravity can offer. The probe 
is passed along the track of the missile, as long as it 
passes easily, until finally the ball, the opposite side of GUNSHOT WOUNDS OF THE CRANIUM. 
15 
the cranium, a prolongation of dura mater, or a change 
in the course of the track is encountered. The character 
of the obstacle arresting the advance of the probe may be 
determined by the firmness of the opposition, the direction 
taken by the probe, and the distance it is inserted. If the 
ball is touched, the opposing force will be slighter than if 
the probe impinges on the opposite side of the cranium. If 
a prolongation of the dura mater or a sudden curve in the 
ball-track is met with, the absence of the metallic and bony 
nature of the obstacle will be manifest. In either instance 
only a slight degree of force should be employed. If the 
ball is touched, it may then be removed with a suitable for- 
ceps passed along the tract of the wound to its location. 
If the ball is near the opposite side of the cranium, say 
within an inch or so of it, and can be located from without, 
it should then be removed through a counter-opening, espe- 
cially when difficulty is experienced in grasping it with a for- 
ceps through the line of entrance. It is far better that a 
ball be removed by a short route through sound brain-tis- 
sue than that the already injured brain-tissue in the course 
of its track be further lacerated in almost vain endeavors to 
seize and remove it. The former method not-only limits 
the amount of brain injury, but affords at once an opportu- 
nity for the establishment of through-and-through drainage. 
If the ball has gone straight through to the opposite side 
of the skull and has ricocheted from the point of impinge- 
ment, the establishment of a counter-opening at this point 
not only permits of thorough drainage, hut affords the only 
rational route by which to seek for the ball at its final loca- 
tion. It is proper to say at this time that the direction a 
ball may take after striking the inner table of the opposite 
side, and the distance it may go afterward, are purely mat- 
ters of conjecture. No practical rule for the guidance of 
the surgeon can be laid down in these cases. The ball 16 
TREATMENT OF PENETRATING 
should be sought for, however, in the direction of the incli- 
nation of the skull at the point of impingement. The dis- 
tance the ball will go from this point will depend, of course, 
largely on the momentum and the amount of the resistance 
encountered. It is often somewhat difficult to determine 
the location at which to trephine so as to make the counter- 
opening at the point of actual or perspective impingement 
of the missile. In a case of my own in which the point of 
impingement was so low on the opposite side of the head 
Fig. I.—a, the extra-cerebral portion of a probe ; b, the line taken by the 
probe through the brail); ccc c, lines placed parallel with the probe with 
the aid of a string. 
that the situation of the arrested end of the probe could 
not be well judged by the eye, I resorted to the following 
plan, which pointed out the location at once, and can not GUNSHOT WOUNDS OF THE CRANIUM. 
17 
fail to do so at all future times : A perfectly straight, long 
probe of large size was carried carefully along the track of 
the ball till the extremity was arrested by the opposite side 
of the skull. About four inches of the probe then remained 
outside of the skull. A string was then attached to the 
extreme end of the outer portion, and was caused to pass 
across the convexity of the cranium in several directions 
(Fig. 1) to the side opposite the point of entrance. The 
portion of the string corresponding to the extra-cranial por- 
tion of the probe was caused to be parallel with this por- 
tion of the probe in eacb instance while being carried across 
to the opposite side of the cranium. The point of crossing 
of the lines on the opposite side corresponded of necessity 
Fig. 2.—c c c c, lines converging on opposite side of head ; d, point to trephine 
to the actual or perspective location of the distal end of the 
probe, as the parallelism of the lines with the probe was 
preserved in each instance (Fig. 2). Thus the proper situa- 18 
TREATMENT OF PENETRATING 
tion for making a counter-opening through the skull was indi- 
cated unerringly at once. In my own case the inner surface 
of the button of bone that was removed bore the imprint of 
the ball impingement. 
The modifications of the functions of the special areas 
and nerves of the brain that may result from a gunshot 
wound of it are entitled to respectful consideration as 
means of determining the course taken by the missile. 
They are not to be relied on, however, in locating the 
resting-place of the missile. Their condition ought al- 
ways to be interrogated at the onset, and, in fact, should 
be carefully scrutinized during the entire observation of the 
case. The later manifestations of these areas will be more 
distinct and trustworthy than the manifestations following- 
soon after the receipt of the injury, because the shock and 
the inflammatory state will obscure or obliterate them in 
the latter instance. At the present time the induction bal- 
ance and the telephonic probe are the agents which, above 
all others, have reduced the localization of a missile within 
the cranium to a scientific certainty in the majority of 
cases. I will leave the description and the explanation of 
the practical use ot these implements to the gentleman 
who is to follow, Dr. Girdner, whose name is indissolubly 
associated with each of them. In concluding this portion 
of the subject, let it be said at once that a ball that can 
not be located should be permitted to remain unsouo-ht. 
Finally, force should never be used in probing a ball-track 
in the brain for the purpose of locating the missile. Frag- 
ments of bone that may be scattered a’ong the tract of the 
wound should be removed with forceps when discovered. 
The fragments of skull found in and about the wound 
should be preserved and carefully fitted together and com- 
pared with the area of the opening in the skull to deter- 
mine if other fragments have escaped notice. Finer frag- GUNSHOT WOUNDS OF THE CRANIUM. 
19 
ments in the course of the wound will escape with the 
discharges, and the head should he so placed as to fa- 
cilitate their escape at the most dependent point of the 
wound. 
Good Drainage of the Wound.—Good drainage can be 
secured best by making a counter-opening and by enlarg- 
ing somewhat the bony rim of the point of entrance. In 
the case of my own already mentioned, after the counter- 
opening had been made, numerous carbolized horse-hairs 
were passed along the track of the ball and allowed to pro- 
trude from both openings of the wound. With this ma- 
terial for drainage of the brain, individual hairs can be 
withdrawn as healing advances, as has been done for a long 
time in other parts of the body. This method will provide 
continuous drainage until the withdrawal of the last few 
hairs will permit the final healing of the wound. If a 
counter-opening is not made, then the external wound 
should be kept open, and the discharge from it facilitated by 
a dependent position of the lower end of the track. If the 
brain-substance protrudes, it can be retained in place by a 
thin sheet of aseptic metal, with a small opening in the 
center to correspond with the opening of the wound of the 
brain. If the dependent end of the wound tends to close, its 
patency can be maintained by inserting into it through the 
opening in the plate a small, short, fenestrated drainage- 
tube. The upper open end of the tube may be sufficient 
for the purposes of drainage without the fenestra. The in- 
troduction into the wound and through it of a gentle stream 
ot antiseptic fluid with the first dressing, and afterward 
when necessary, should be practiced. Salicylate-of-sodium 
solutions and Thiersch’s fluid are highly commended for the 
purpose. A counter-opening at the seat of impingement of 
the ball enables the surgeon to continue the search for the 
ball with the least possible injury to the brain-structure. If 20 
TREATMENT OF PENETRATING 
the ball is not found at the seat of impingement, it will have 
ricocheted from this point in a course that is best indicated 
by the direction of the inclination of the inner table of the 
skull at the point of impingement. However, this indica- 
tion is too problematical to permit free probing of the brain 
in the absence of other evidence of the course taken by the 
ball. A careful examination of the brain at this point will 
probably reveal the direction taken by the missile, which 
should be followed carefully as in the former instance. Tn 
the case of my own this plan was observed, and, although 
the signs indicative of the secondary course of the ball were 
plainly to be seen in the brain-substance, still it was not 
practicable to touch the ball with a probe. The autopsy 
revealed the fact that the probe had gone the entire dis- 
tance traveled by the ball from the point of impingement, 
yet the ball had not been touched by the probe because it 
had dropped or gravitated between the borders of a deep 
sulcus which ran nearly at right angles to the secondary 
track of the ball. The ball could not have been touched 
by a straight probe without damaging the, as yet, healthy 
brain-substance directly between it and the counter-open- 
ing. The counter-opening will drain not only the primary, 
but the secondary track of the ball as well, if the force of 
gravity will permit. It will likewise favor the discharge of 
pus that may be formed as a result of the presence of the 
ball or the injury of the brain. The ball itself may be aided 
to gravitate toward the counter-opening, especially if it 
has remained unmolested. Good drainage must be sought 
for at all times; in fact, if good drainage is not established, 
little benefit need be expected from other steps of treat- 
ment. 
Combating Inflammation.—This indication need not 
occupy our time now, for the means employed to meet it at 
the present offer but little of a novel nature when compared GUNSHOT WOUNDS OF THE CRANIUM. 
21 
with those of the past. Finally, the strictest antiseptic 
technics must be employed with every step, whatever plan 
of treatment is selected. I respectfully submit the fol- 
lowing conclusions for your consideration ; 
1. A bullet should be removed from the brain as soon 
after its reception as its situation can be determined and 
the patient’s condition will permit. 
2. A bullet should be removed from the brain at a later 
period if symptoms supervene and it can be located. 
3. A bullet that has been located in the brain and has 
not been removed should be removed before the super- 
vention of symptoms, when it assumes a migratory char- 
acter. 
4. No effort should be made to remove a ball from the 
brain if it can not be located. A MANUAL OF 
OPERATIVE SURGERY 
JOSEPH D. BRYANT, M. D., 
Professor of Anatomy and Clinical Surgery, and Associate Professor of Ortho- 
pedic Surgery in Bellevue Hospital Medical College; Visiting Bur- 
geon to Bellevue Hospital, and Consulting Surgeon to the 
New York Lunatic Asylum, etc. 
NEW EDITION, REVISED AND ENLARGED. 
Bvo, 530 pages and 793 Illustrations. Cloth, 5§5.00; sheep, 56.00. 
“ This is one of the best working text-books on surgery that 
we know of. . . .”—New England. Medical Monthly, 
, . A careful examination of the pages has convinced us 
that it is a thoroughly good book that should be in the hands of 
every general practitioner. . . .”—American Lancet. 
“ This is just the book that thousands of American physicians 
who are compelled to do some surgery, have long looked and 
wished for. ... It is practical in every respect. . . —Peoria 
Medical Monthly. 
. It is especially useful to physicians in the country, who 
have not the amount of surgical practice required to keep them 
familiar with the entire field of operations.”—American Practi- 
tioner and News. 
New York: D. APPLETON & CO., 1, 3, & 5 Bond Street.