If, however, with simple depressed fracture, there be decided symptoms of pressure upon the brain, and so marked as to be incapable of confusing with concussion, then an operation for their relief should not be delayed.

When, on the other hand, the fracture is compound, whether symptoms of pressure be not or be present, the depressed bone must be at once raised or removed, according to circumstances; "because," says ASTLEY COOPER, "a compound fracture is followed very generally by inflammation of the brain; and it will be of little use to trephine, when inflammation is once produced. It might be thought it would be time enough to perform this operation when inflammation had appeared; but this is not the case; for if the inflammation comes on, the patient will generally die, whether you trephine or not, and you will not arrest its fatal progress by trephining, but the operation will add to the danger of increasing the inflammation.” (p. 305.)

HENNEN, however, does not entirely agree with the necessity for trephining, even when there is depression with wound, and in those more severe cases where the injury has been consequent on gun-shot; and he mentions two very remarkable instances, in which neither was any operation for the removal of the depressed bone performed, nor did any symptoms of compression ensue. A soldier received a musket-ball on the 18th of June, on the right parietal bone close to the junction of the sagittal and lambdoidal sutures, which "fractured the bone to an extent corresponding with its own size. The ball was split into two portions, forming nearly right angles. It was easily removed, but from the narrowness of the passage, and from the depth to which the fractured portion of bone had been driven into the brain (being exactly an inch and one-fourth from the surface of the scalp) no operation was performed on the field; and as no one bad symptom occurred in the hospital, I did not allow the wound to be meddled with there. I trusted to venesection, a most rigid abstinence, open bowels, and mild easy dressings. On the 14th of July or 26th day, the wound was nearly closed without any one untoward symptom, and the functions were in every respect natural. In a few weeks after the man was discharged cured. In a similar case, where the man survived thirteen years, with no other inconvenience than occasional determination to the head on hard drinking, a funnel-like depression to the depth of an inch-and-a-half was formed in the vertex. I am in possession of several other instances of a similar kind. We have here sufficient proof that there is no absolute necessity for trepanning merely for depressed bones from gun-shot, although few would be so hardy as not to remove all fragments that came easily and readily away." (pp. 287, 288.)]

396. The sutures of the skull may by great violence be separated from each other. When this has been discovered by enlarging the wound or by proper incisions, and the separation of the sutures is not so great as to permit the ready escape of fluid from both sides, trepanning is indicated.

397. The severity of the violence which produces injury of the skull is an important point in determining on its danger, as in injuries caused by very great violence nearly always splintering of the bone, separation and injury of the dura mater, and so on, occur, which earlier or later produce dangerous symptoms; this is specially the case in gun-shot wounds. If in these wounds there be merely injury of the soft parts, laying bare the bone, or superficial injury without splintering, a simple but strict antiphlogistic treatment must be employed. But if they be connected with splitting of the bone, if they penetrate into the diploë, if the external table be torn off and the internal splintered, or if a piece of bone be impressed, then immediate trepanning is required.

["Fractures from gun-shot are almost universally of the compound kind," says HENNEN, "and are rarely unaccompanied with great depression of the skull. The difficulties of elevating or extracting the depressed portions of bone beat in upon the brain by gunshot, or the extraneous matter carried into its substance, are often very embarassing; the ball, from the projectile force communicated to it, not only fracturing the bone, but hurrying in with it the detached piece or pieces and jamming them under or among sound parts; frequently also it lodges among the fractured portions; frequently it imbeds itself between the more solid osseous plates, and forms a kind of nidus in the diploë; and sometimes it drives forward into the brain itself, eluding the search of the surgeon, and subverting the theories of the physiologist. In the majority of cases a leaden ball is either flattened against the bone, or, if it has struck obliquely, it is cut against the

unshattered edge of the cranium, and is either simply jagged, or is divided into two or more distinct parts, forming with each other various angles, influenced in their acuteness by the projectile force, the distance, obliquity, &c., &c. It not unfrequently happens that a perfect division of the ball takes place, and the two distinct masses lodge, or one lodges and the other flies off, or else it takes its course through a different set of parts, or imbeds itself in a different spot from that where it originally struck. In all these cases, the removal of extraneous matters, the extraction of the fractured portions, if they lie loose, and the elevation of the depressions, where it can be done without the infliction of additional violence, are, of course, the first steps to be taken; but instances (particularly on the field) will occur, where this cannot be done. The grand and leading point to be kept in view, in all cases, is the great tendency of the brain and its membranes to inflammation, the uncertain period at which it may occur, and the very doubtful consequences which may succeed its occurrence. So irregular, however, and as it were so capricious is nature, that, whilst the slightest causes produce inflammation in its most violent and aggravated forms, extensive injuries, fracture, depression, and even permanent compression from lodgment of balls, have been followed by no such consequences." (pp. 285, 6.)]

Dr. CUNNINGHAM of Hailsham relates (a) the case of a lad of fourteen years, who, by the bursting of a pistol which he was firing, received its breech in his head. The wound was of a circular form, within three lines of the left superciliary ridge, and a corresponding piece of the frontal bone was driven, without fracturing beyond its edge, or injuring the surrounding integument. A table-spoonful of brain had escaped; he was bleeding profusely, and in a state of collapse. Careful probing could not reach any foreign body; he was therefore merely kept very quiet, and saturnine lotions applied to the forehead. On the following day slight bleeding continued; he had had a convulsion during the night. He lies perfectly quiet, says he is in no pain, but sleepy. An aperient was given, which freely moved his bowels. On the third day his pulse was not so compressible, but variable; the skin hot, and cheeks flushed, but otherwise much the same. Puts out his tongue when asked to do so, but answers no questions. The wound is filled with coagulum. Cold lead wash and bread poultice applied, and fever-mixture given. He was relieved of the feverish symptoms next day, and rather more sensible. In the course of a few days the clot was thrown off, and a free discharge of pus followed, which gradually lessened, and the wound appeared to heal as fast as possible. His strength seemed gradually returning; the pulse became more healthy; he answered questions, and could see around him very well. On being asked where he felt pain, he put his hand to the back of his head, but would not raise it up. This state continued to the twenty-second day, when he appeared rather suddenly to be sinking; on the following day he was perfectly comatose, and on the twenty-fourth after the accident he died. On removing the upper part of the cranium the wound of the brain was found to have perfectly healed. The dura mater adhered all round the aperture in the skull, which had diminished to half its original size, so that at first I began to think my diagnosis had been incorrect; but when I reached the ventricles, I perceived the trace of a foreign body; a little further there was a good deal of disorganization from the formation of pus, and resting against the occipital bone and over the tentorium lay the breech of the pistol, an iron screw weighing nine drachms.” (p. 559.) This is a very interesting case as shewing the facility with which a severe wound of the brain may be repaired, as well as the time which may be occupied by that process. Its result is that usually occurring at a more or less early period after the lodgment of foreign bodies in the skull.

I recollect ASTLEY COOPER used to mention, in his lectures on gun-shot wounds, an instance of the lodgment of a ball in the frontal sinuses of a nobleman who was shot in a duel. The ball was left, for what reason I do not remember, and it continued quiet for some months, after which it irritated the bone, which became carious, and gradually made its way through the nostrils, and through the bony palate into the mouth, and in making its escape wounded the palatine artery from which there was a free bleeding. I think the patient recovered.-J. F. S.

Another, and still more remarkable, instance of the lodgment of a foreign body in the frontal sinuses, which subsequently began to make its way out, is mentioned by Dr. O'CALLAGHAN (b). An officer in our Indian army received, by the bursting of his fowling-piece, on 22nd Jan. 1828, a circular wound, about an inch in diameter, above the nasal process of the frontal bone, the outer table of which was destroyed. He was knocked down by the blow, but rose immediately without assistance, and walked to a neighbouring cottage, where the wound continued bleeding for several hours, and produced faintness approaching to delirium. On the following day, the surrounding parts (a) Lancet, 1827-28, vol. ii. (b) Dublin Medical Press, 1845, p. 82.

over the right eye were much swollen and tender; he had constant pain shooting through the forehead, and restlessness, so as to prevent his sleep; pulse 80; mental faculties unimpaired. On the 28th he was moved in a palanquin to Badulla. He recovered under the most simple treatment; but during the course of his cure there was a constant discharge of bloody serum mixed with pus from the wound; and pus with bits of bone passed from the nostrils. On 29th March he was conveyed to Colombo. Soon after he returned to his duty; but in the latter end of the year he was troubled with the protrusion of a metallic body through the palate, and a very offensive discharge, of which, however, he was not aware, having lost the sense of smell at the time of the accident. In May 1835, the metal had projected so far as to render attempts at its removal, by filing it off, feasible; but the endeavour to do so was productive of such excessive agony that it was not persisted in. He continued in much the same state, and died on 25th March of the following year, from imprudence in drinking. On examining the head after death, the whole of the iron breech of the gun, with the screw attached, weighing nearly three ounces, and its length two inches and three-quarters, were found lodged in the forehead. The anterior portion of the right hemisphere of the brain rested on the flat part of the breech, and separated from it only by a false membrane.]

398. What has been already said, in many respects applies to Injuries of the Brain and its membranes. The dura mater may be wounded or torn, either by the injuring instrument or by depression of the piece of bone, irritated, pressed, or inflamed by the blood poured out; or its connexion with the skull may be disturbed, in which case the vessels connected with it are torn; or it may be so injured by bruising that it inflames, suppurates, and so on. The brain may be variously damaged by the wounding instrument or by depressed bone; balls, or other foreign bodies, may remain lodged in it; and even entire parts of the brain may be bruised or lost. The consequences of concussion are also sometimes observed deep in the brain, as well as directly opposite where it has been struck, as proved by outpouring of blood and other signs at parts other than those which were struck. The mass of the brain may be thereby torn, or be pressed apart by the fluid poured out in the brain. These injuries are always extremely dangerous. The symptoms which either occur at once, or come on at a shorter or longer period, are those of commotion, of inflammation, or pressure of the brain.

["Perforations of the bone, from bayonet thrusts, are rare and generally fatal," says HENNEN," but whenever the patient survives, their mechanical treatment will consist merely in extracting spicula of bone, and elevating any depression that may occur. Where bayonet or pike thrusts take place in the orbits, temples, or through the roof of the mouth, or the occipital foramen into the base of the brain, they are most generally fatal; indeed those through the orbit and base of the cranium are almost invariably so." (p. 280.)

We have in the museum at St. Thomas's Hospital an example of fatal perforation of the orbital plate of the frontal bone, of which ASTLEY COOPER gives an account, by a girl, aged twelve years, falling on a pair of scissors, the point of which entered between the eyelid and the fore part of the globe of the eye; on the scissors being drawn out some blood followed; the eyelid fell, and she was unable to raise it; she did not however complain much of pain in the orbit, and had no pain in her head. Up to the third day" she walked about without fatigue, but then soon tired. On the fourth day she was still free from pain, except a little in the eye, but could not see with the other eye. She still walked about the room with assistance." On the fifth day she was out in a coach, enjoyed the ride though she could not see, and was in good spirits, but on returning home," complained of fatigue, and went immediately to bed. At seven in the evening she was seized with convulsions in her limbs, and now and then her features were distorted. At twelve o'clock that night the convulsions left her, and her senses returned, which had been lost during the fit. She now for the first time complained of pain in her head, which she said was very violent and attended with a sensation of great weight. At nine o'clock on the morning of the sixth day the convulsions returned, and continued till her death on the following morning. On opening the cranium, a fracture was found in the orbitar process of the os frontis, in which there was a hole

large enough to admit the point of the finger. In the dura mater, opposite this, there was a corresponding opening, with a portion of bone in it; between the membrane and bone some extravasated blood was collected. In the pia mater and brain there were also openings; upon the former there were some purulent appearances, in the latter there was an incipient suppuration, with inflammation extending into the ventricle." (pp. 295, 96). GUTHRIE mentions two cases of similar injury. A boy was struck by his play-fellow with the end of a thick iron wire, on the right eye, which blackened it. There was no external wound; but, as there was some bloody chemosis at the upper part and inside, there was a probability of the wire having penetrated deeply, although the opening could not be discovered with the probe. He vomited shortly after, and for two days ate little, but did not think himself ill. He was then well purged, and cold water applied. Two days after he was complaining of sickness, headache, and pain over the brow, and looked ill. It was now suspected that the instrument had penetrated the brain, although the ecchymosis was in a great measure gone, and the eye was unaffected. He was bled freely from that temple with leeches, and freely purged with calomel and jalap. On the evening of the fifth day he was very ill, and delirious and restless all night; on the next was stupified; answered with difficulty and incoherently; had a very quick pulse, hot and dry skin; some convulsive twitchings of the face and arms; pupils slightly obeying a strong light, but not dilated. He was again bled freely; but his breathing became difficult; he fell into a comatose state, and died during the sixth night. The iron wire was found to have passed under the upper eyelid, between it and the eye, through the posterior part of the orbitar plate of the frontal bone, and into the anterior lobe of the brain, which was softened at that part and bedewed with matter.

A woman was struck on the left eye with a tobacco-pipe. She pulled a piece of the pipe, which was sticking in the orbit, from a wound under the lid, between it and the upper inner part of the eye, which was uninjured. A probe could be passed some distance in the course of the wound. She complained of little but the redness of the eye and the bruise. She was bled and purged, and had no symptoms for a week, when she complained of having been very ill at night, with nausea, headache, and shivering, hot dry skin, very quick pulse, and the upper eyelid paralytic. She was then bled largely, and purged freely, but became delirious the same night, and died in two days after first complaining of serious illness. Half an inch of the red-waxed end of the pipe had gone through the sphenoid bone, by the side of the sella tursica, and lodged in the brain, from whence it was removed bedewed with pus, the brain being yellow and softened around it. GUTHRIE says he has also seen two similar cases in children, and terminating in the same way. (pp. 137, 38.)

The relation of these cases shows the importance of giving a very cautious opinion as to the probable result of thrust wounds into the orbit, when at first there seems little expectation of material mischief.-J. F. S.

A very remarkable instance of recovery from wound of the brain, by a cheese-knife, is given by Dr. CONGREVE SELWYN (a) of Cheltenham :-" W. B., aged four years, whilst eating his dinner, in September, 1821, with his plate on a kitchen chair, placed one foot on the bar of that, and the other on the bar of another chair close by, and the chairs receding from each other, in consequence of the motion given to them, whilst his limbs were extended, he fell. The knife, a common cheese-knife, about four and a quarter inches long in the blade, and averaging three quarters of an inch broad, entered the right orbit nearly horizontally, to the depth of three inches and a quarter, immediately beneath the superciliary ridge, and penetrating (through the posterior part of the orbital plate of the frontal bone) the substance of the brain, injuring in its course the optic nerve and the levator palpebræ muscle, or the motor filament supplying it. The father told me it required all his force to dislodge the knife from its situation. The hæmorrhage was very slight. After the removal of the knife some portion of the brain protruded; more was discharged on the eighth day after the injury. He did not sleep for a fortnight after the accident, and was delirious during the night. The treatment consisted of low diet, little or no medical treatment, and the application of strips of adhesive plaster to the wound, which was entirely healed in six weeks. There was never any exfoliation of bone." He was alive and well seventeen years after, and the following is the interesting account of his then condition. "The eye shows the globe to be sound and healthy in structure, (this is not quite correct, as presently shown,-J. F S.,) though less prominent than the other. Its muscular actions are all regularly performed, except that of the m. levator palpebræ superioris. The vision is entirely lost in that eye; the pupil dilated, and wholly insensible to the stimulus of light. All the senses are perfect

(a) Lancet, 1827-28, vol. ii.

excepting the vision of the injured eye. The memory is very defective. He is incapable of applying to any pursuit requiring mental activity. His disposition is irritable, especially after indulging in liquor, or after any unusual stimulus He has occasional pain on the injured side of the forehead, and has once since had typhus fever. His bodily health is now good, and he has the free use of his limbs." (p. 16.)]

399. In these wounds the first indication always is the careful search for and withdrawing of foreign bodies; if they stick fast in the membranes of the brain or in the brain itself, an attempt must be made to loosen them by a cut, and to draw them out without violence. Balls in the substance of the brain are to be discovered by careful probing: if they be superficial they may be often withdrawn with a pair of forceps; care, however, must be taken that they be not pushed further into the brain (1). The head is to be put into such position that the fluids may readily escape, by which also the foreign body often moves, so that at a later period it can be drawn out. Trepanning is therefore always necessary when the given object cannot be attained by the existing wound (2). The dressing, should be mild; the wound covered lightly with dry charpie, a compress and fastened with the three-cornered head-cloth. The after-treatment must correspond to the degree of inflammation.

According to A. COOPER (a) pieces of bone penetrating the brain, if symptoms of pressure do not exist, should not be removed, because thereby, in all probability, extravasation would ensue. BRODIE (b) recommends that foreign bodies penetrating the brain should only be drawn out if it can be done without any fresh wound, and he endeavours to support this opinion by cases.

[(1) HENNEN's observations upon this point appear to me very important. He says:"We would also naturally remove all extraneous bodies within view or reach; but before we commence any unguided search after them, we ought seriously to balance the injury that we may inflict. I by no means wish to be understood to say, that we ought not to endeavour cautiously to follow the course of a ball, when unfortunately it has got within the cavity of the cranium. M. LARREY asserts that can be done with safety and effect. He informs us that he traced a ball which entered the frontal sinus of a soldier during the insurrection at Cairo, by means of an elastic bougie, from the orifice to the occipital suture, in the direct course of the longitudinal sinus; and, by a corresponding measurement externally, he was enabled successfully to apply a trepan over it and extract it; the patient recovered. M. PERCY, on the other hand, gives a fatal instance where a ball was absolutely within reach of the forceps, and yet, for want of a sufficient opening, and manual dexterity in the operator, it slipped into the brain; and although the opening was enlarged by the trepan, it could not be recovered. In the works of some of the older authors we meet with cases where epilepsy and various other bad symptoms have followed the attempts at extracting arrows and other missiles sticking in the brain; and in more modern practice there are many instances where patients have lain in a state of apoplectic stertor, with a ball lodged in the brain, for some time, but have expired on its removal. One instance of this kind has been reported to me, where a soldier died the very moment the ball was extracted. A modern surgeon would be severely and justly censured for not at least making a trial; but we are encouraged to look for the eventual safety of our patients, when the course or actual site of the ball or other body is unknown, by recorded and well-authenticated instances of life being preserved, when they either have not been looked after, or their existence has not been suspected. The records of Surgery furnish us with many proofs of metallic and other bodies lying for long periods between the cranium and dura mater; but experience shows that the extraneous bodies may lie even in the brain itself without producing death. I have seen no less than five cases where a ball has lodged in the substance of the cerebrum, without immediately producing a fatal event." (pp. 288, 289.)

LAWRENCE also mentions an example of a young man who discharged a brace of pistols into his mouth. One bullet "was found in the neighbourhood of the jaw, but the other was not to be met with at all. Inflammation of one eye took place after the accident, the cornea became turbid, and the sight of it was lost." He lived a fortnight, and on examination the other bullet was found to have gone through the orbit, behind the globe, on the side on which the sight was afterwards lost. It had entered the (a) Lectures on Surgery, by TYRRELL, vol. i. P. 315. (b) Above cited, p. 413.