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A note on the management of gunshot wounds of the head in civil practice
A NOTE ON THE MANAGEMENT
GUNSHOT
WOUNDS
OF
OF THE HEAD IN CIVIL PRACTICE
E. S. GURDJIAN, M.D. AND HAROLD BUCHSTEIN, M.D. DETROIT,
G
UNSHOT wounds of the scaIp, skuII and intracrania1 contents are commonpIace in military experience but quite rare in civi1 practice. ExceIIent papers have been written on experiences of the Great War. First aid treatment of gunshot wounds by CriIe and the operative management of perforating wounds of the skuI1 by Cushing are among the exceIIent contributions on the subject. At the Receiving HospitaI a considerabIe number of gunshot wounds of the head are admitted every year and it may be worth whiIe to present a resume of our experiences. During a period of thirty-four months (January, 1930 to October, 1933) a tota of 45 cases of gunshot wound of the skuI1 were admitted to the SurgicaI Service. Thirty-two patients were men. Eight were coIored. On studying the age incidence it was found that the majority beIonged in the group between twenty-one and fifty; there were no cases under ten. About haIf were of suicida1 intent, the remaining were either accidenta1, received in fighting or administered by the Iaw. Of the suicida1 patients a11 but one were men and a11 were white. The entire group may be divided into two cIasses. First, those with no physica or x-ray evidence of skuI1 injury (I I cases) and second, those in which there was demonstrabIe injury to the skuI1 or its contents, or both (34 cases). Among those with no skuI1 injury the possibiIity of associated brain damage shouId not be overIooked. CASES
The types.
WITH
NO
FRACTURED
SKULL
head wounds were of three genera1 First, through-and-through wounds
MICH.
in which the buIIet penetrated the scaIp, traveIed for a distance beneath it, making its exit at a different point. There were 5 such cases. Second, grazing wounds in which the buIIet struck tangentiaIIy and cut a furrow in the scaIp (3 cases). Third, puncture wounds in which only a rounded and punched-out wound was present (3 cases). The Iatter were x-rayed in order to Iocate the buIIet in other parts of the body if present. In no case couId the buIIet be Iocated. Assuming that the buIIet was not anywhere in the body two possibiIities became apparent, that (a) the buIIet Ieft the wound in which it entered, and (6) that a bIank cartridge was used at cIose range. The Iatter can cause puncture wounds. AI1 I I patients were conscious on admission and neuroIogica1 examination reveaIed no abnormaIities referable to the wound with the exception of one case. This patient waIked into the hospita1 for first aid with a Ieft mid-parieta1 wound and was reIeased against advice. He returned the foIIowing day with right hemiplegia and aphasia. A Ieft tempora1 expIoration discIosed subdura1 hemorrhage and hemorrhagic brain surface. Two months Iater he regained speech practicaIIy in its entirety, motion returned to the Iower extremity but there was IittIe improvement to the upper extremity on the right. Th is case demonstrates the intracrania1 possibihties in cases with no apparent injury to the skuI1. CASES
WITH
FRACTURED
OR
PERFORATED
SKULL
There were 34 cases in this group. Ten entered the hospita1 conscious, 3 were semiconscious and 21 patients were unconscious. In 19 there was a wound of entrance 414
but none of exit. In 15 there was both a wound of entrance and exit. The most usual course was through and through right to left temple. In one case the outer table of the fronta sinus was penetrated but not the inner table. In 15, brain tissue was protruding from the wound. In 12 cases there was bIeeding from the ear, nose or mouth. As concerns the genera1 course in the hospital this group may be divided into three types. First, those who showed rapid collapse (16 cases). AI1 were unconscious. The temperature was rareIy normaI, often markedly subnormal, puIse was rapid, often uncountabIe, respirations were irregular, at times stertorous and occasionaIIS of the Cheyne-Stokes type. The blood pressure when recorded was Iow. These patients exhibited a rapid and progressive failure of their circuIatory and respiratory functions. Respiration became more and more irreguIar. Death was never in doubt and I I of 16 died within two hours after admission. The maximum time before death was nine and one-half hours. In the second group there was a somewhat different picture. AI1 were unconscious; pulse, respiration and temperature were within norma Iimits. These patients rapidIy became worse and their temperature rose unti1 marked hyperpyrexia was present before death. There was an associated increase in respiration and p&e. Five of 7 in this group died within sixteen to twenty-six hours after admission; one Iingered on for five days. These peopIe died a truIy increased intracrania1 pressure death. In a third group of I I cases the patients presented a marked contrast to the first two mentioned. AI1 couId answer questions; the temperature, puIse and respiration readings were approximately normaI. The neuroIogica1 findings varied in direct reIation to the site of trauma. Of these, 2 died (one refused operation). It is apparent from these groupings that those entering the hospita1 conscious, foIIowing a buIIet wound of the head have a very good outIook for recovery and a11
shouId be done to heIp them and to prevent and minimize post-traumatic infection, sequelae. MANAGEMENT
The rationa of operative treatment of gunshot wounds of the head depends upon two factors: (I) The prevention of intracerebral infection; (2) the remova of bony particIes, dead brain tissue and the buIIet (if possibIe) to minimize post-traumatic sequeIae. In gunshot wounds of the forehead region there is an added responsibility of hoIding at a minimum operative deformities of the skull. In this group 7 cases were operated on in addition to first aid treatment. In one with no injury to the skuI1 the operation consistedYin remova of a subdural hematoma through a subtempora1 approach. In 5 cases the operation consisted in remova of depressed fragments of bone and necrosed brain tissue. In this group the incision most usuaIIy used was horseshoe shaped in outIine with the gunshot wound opening usuaIIy in the center. Of course, the type of incision used depends entireIy on the extent of Iacerations. In civi1 practice gunshot wounds are more usually circumscribed and smaIIer. The initia1 wounds were carefull_ debrided in every instance. With a flap incision the entire area of depression is exposed and there is a better opportunity to remove this area en masse. If the bone is then repraced the deformity wouId necessariIy be less marked. Suction was used to remove particIes of bone embedded in brain tissue and softened brain substance. If the buIIet was in the close vicinity of the area operated on it was removed. If it was beyond our reach no attempt was made at remova1. AI1 but one were cIosed without drainage. In one case of old gunshot wound with buIIet on the waI1 of the body of the right IateraI ventricIe there were e\-idences of increased intracrania1 pressure, nameIy, choked discs and headaches. There was aIso motor cortex irritation evidenced by Ieft pateIIar and ankIe cIonus and notice-
FIG. IB. FIG. IA. Frc. I. Bullet wound of the head seen two years after trauma for headaches. Examination aIso showed biIatera1 choked discs and evidences of motor irritation in Ieft lower limb. Suspected cyst about buIIet. First operation did not discIose cyst formation. Decompression was thought sufficient but this only cured complaints. Area of decompression grew to massive size. Second operation, encephaIogram and removal of buIIet. No evidences of pressure since. Apparently, buIIet behaved like a brain tumor and cure could not be effected without its removal.
FIG. 213. FIG. 2A. FIG. 2. Gunshot wound of right frontoparieta1. Extensive comminution of fragments. Marked cerebra1 destruction and softening. Patient operated on twenty-six hours after admission. Repaired without drainage. HeaIed by first intention. Initial left hemipIegia cleared up compIeteIy. Patient has had no sequeIae up to present (thirty-two months). Pieces of bone were carefully preserved and replaced to minimize forehead deformities.
able spasticity of the Ieft lower limb. Because of its position and because of no evidences of cyst formation about the bullet we were satisfied with a decompression at the first operation. Although this cured the headaches and the choked discs the area of decompression grew to massive size and onIy after the remova of the buhet did this subside. It was justifiabIy concIuded that the buIIet acted Iike a brain tumor and cure couId not be effected without its removal. The accompanying encephalogram (Fig. I) shows norma ventricuIar contour in this case. This patient now has a slight residua1 paresis in the Ieft upper limb. In general the management of gunshot wounds of the head in this hospital consisted in (I) combatting shock when present; (2) first aid care of wounds, namely, shaving off scaIp hair, cIeansing and dressing of wounds; (3) administration of nntitetanic serum; (4) carefuI x-ray examination if patient’s condition permits; (5) operation of debridement, cIeansing of wound, removal of bony particIes and dead brain tissue. This is done as soon as the patient’s condition permits. LocaI anesthesia is preferred.
lodged in the brain close to the wound of entrance remova is good technique. If, however, it is at a great distance from its
FIG. 3. Traumatic porencephaly, right frontal. Gunshot wound of right forehead in rc,ltc. Pntirnt employed as a type-setter from 1919 to 1930. Apparently, no complaints during this period and a good wage earner. Since 1930 spells of cpilcpsy ten to fifteen times yearly. It is interesting that with such a porcncephlic cavity patient was able to carry on satisfactorily and earn a good living for rleven years before pathology made itself evident.
COMMENT
The management of gunshot wounds of the head is essentiaIIy simiIar to that of head injuries with different etioIogy. There are some differences, nameIy, that the buIIet may remain in the cranial cavity and that there is a greater possibility of shattered pieces of bone being dispursed through the brain in the direct vicinity of the wound of entrance. Otherwise, the treatment is one of compound fracture and it aims at prevention of intracerebra1 infection and minimizing post-traumatic sequelae. The wound is debrided in the usua1 manner, a11 foreign particIes and pieces of bone are removed, the softened a n d necrosed brain tissue is carefuhy sucked away, and the wound is closed without drainage except in the region of the fronta sinus. When the buIIet is
point of entrance, such as diagonally across in the opposite hemisphere, no attempt is made to remove it, as Iong as the patient carries on satisfactorily. There are many in this group carrying a bullet in the head which apparentIy causes no dysfunction. However, we reaIize that in some, post-traumatic sequeIae may not be evident for years (see Fig. 3). To be dogmatic about this matter would cause much disabiIity which should not be borne by the patient. In some there are eventua1 evidences which speI1 surgical intervention. A cyst may form about- the buIIet which may necessitate expIorat_ion. Actual fibrous tissue tumor may envelop the bullet (Dandy). In the case just discussed the buIIet had Iodged on the waII of the body of the right lateral ventricIe. The patient
4 18
American ~ournat of Surgery
Gurdjian
& Buchstein-Wounds
came in two years Iater with choked discs, headaches, and she was expIored for a possibIe cyst about the buIIet. No cyst being found a decompression was performed but this onIy reIieved the complaints. The area of decompression protruded to massive size. At a Iater date the buIIet was removed and since, there have been no evidences of pressure. It was justifiabIy concIuded that the buIIet behaved very much the same as a brain tumor and cure couId not be effected without its remova1. However, this is an exceptiona case and it is not a true argument for attempts at remova of buIIets embedded deep in brain substance, for a majority undoubtedIy do as we11 as couId be expected. CertainIy there is no guarantee that the remova of buIIet wiI1 eIiminate a11 undesirabIe sequelae. Where there are cIinica1 evidences Iater, the case can be deaIt with surgicaIIy.
of dead brain tissue, foreign particIes, shattered pieces of bone and the buIIet (if possibIe) wiI1 heIp toward this end. Shock shouId aIways be treated first even if this takes twenty-four to thirty-six hours. 2. The state of consciousness is of prognostic importance. Patients conscious on entrance or soon after represent the most favorabIe cIass for recovery, irrespective of extent of apparent trauma. In this group recovery obtained in about 80 per cent. Among those in deep coma death occurred either soon after entrance (rapid coIIapse) or after the first tweIve to fifteen hours from extreme hyperpyrexia and increased intracrania1 pressure (hyperpyrexic death). 3. In the absence of skuI1 injury, damage to the intracrania1 contents shouId not be dismissed as a possibiIity. An exampIe of subdura1 hemorrhage with no fracture or perforation of the skuI1 is given. REFERENCES
SUMMARY
Notes on miIitary Feather, 1924. CUSHING, H. Notes on penetrating &it. M. J., I : 221, 1918. DANDY, W. E. In Lewis’ Practice town, Prior, 1932, 12: 291.
CRILE,
In gunshot wounds of the head the aim is to prevent intracerebra1 infection and to minimize undesirabIe post-traumatic sequeIae. Debridement and remova I.
SEPTEMBER, ,934
G. W.
surgery.
CleveIand,
wounds of the brain. of Surgery.
Hagers-
GUNSHOT
WOUNDS
OF
OF THE HEAD IN CIVIL PRACTICE
E. S. GURDJIAN, M.D. AND HAROLD BUCHSTEIN, M.D. DETROIT,
G
UNSHOT wounds of the scaIp, skuII and intracrania1 contents are commonpIace in military experience but quite rare in civi1 practice. ExceIIent papers have been written on experiences of the Great War. First aid treatment of gunshot wounds by CriIe and the operative management of perforating wounds of the skuI1 by Cushing are among the exceIIent contributions on the subject. At the Receiving HospitaI a considerabIe number of gunshot wounds of the head are admitted every year and it may be worth whiIe to present a resume of our experiences. During a period of thirty-four months (January, 1930 to October, 1933) a tota of 45 cases of gunshot wound of the skuI1 were admitted to the SurgicaI Service. Thirty-two patients were men. Eight were coIored. On studying the age incidence it was found that the majority beIonged in the group between twenty-one and fifty; there were no cases under ten. About haIf were of suicida1 intent, the remaining were either accidenta1, received in fighting or administered by the Iaw. Of the suicida1 patients a11 but one were men and a11 were white. The entire group may be divided into two cIasses. First, those with no physica or x-ray evidence of skuI1 injury (I I cases) and second, those in which there was demonstrabIe injury to the skuI1 or its contents, or both (34 cases). Among those with no skuI1 injury the possibiIity of associated brain damage shouId not be overIooked. CASES
The types.
WITH
NO
FRACTURED
SKULL
head wounds were of three genera1 First, through-and-through wounds
MICH.
in which the buIIet penetrated the scaIp, traveIed for a distance beneath it, making its exit at a different point. There were 5 such cases. Second, grazing wounds in which the buIIet struck tangentiaIIy and cut a furrow in the scaIp (3 cases). Third, puncture wounds in which only a rounded and punched-out wound was present (3 cases). The Iatter were x-rayed in order to Iocate the buIIet in other parts of the body if present. In no case couId the buIIet be Iocated. Assuming that the buIIet was not anywhere in the body two possibiIities became apparent, that (a) the buIIet Ieft the wound in which it entered, and (6) that a bIank cartridge was used at cIose range. The Iatter can cause puncture wounds. AI1 I I patients were conscious on admission and neuroIogica1 examination reveaIed no abnormaIities referable to the wound with the exception of one case. This patient waIked into the hospita1 for first aid with a Ieft mid-parieta1 wound and was reIeased against advice. He returned the foIIowing day with right hemiplegia and aphasia. A Ieft tempora1 expIoration discIosed subdura1 hemorrhage and hemorrhagic brain surface. Two months Iater he regained speech practicaIIy in its entirety, motion returned to the Iower extremity but there was IittIe improvement to the upper extremity on the right. Th is case demonstrates the intracrania1 possibihties in cases with no apparent injury to the skuI1. CASES
WITH
FRACTURED
OR
PERFORATED
SKULL
There were 34 cases in this group. Ten entered the hospita1 conscious, 3 were semiconscious and 21 patients were unconscious. In 19 there was a wound of entrance 414
but none of exit. In 15 there was both a wound of entrance and exit. The most usual course was through and through right to left temple. In one case the outer table of the fronta sinus was penetrated but not the inner table. In 15, brain tissue was protruding from the wound. In 12 cases there was bIeeding from the ear, nose or mouth. As concerns the genera1 course in the hospital this group may be divided into three types. First, those who showed rapid collapse (16 cases). AI1 were unconscious. The temperature was rareIy normaI, often markedly subnormal, puIse was rapid, often uncountabIe, respirations were irregular, at times stertorous and occasionaIIS of the Cheyne-Stokes type. The blood pressure when recorded was Iow. These patients exhibited a rapid and progressive failure of their circuIatory and respiratory functions. Respiration became more and more irreguIar. Death was never in doubt and I I of 16 died within two hours after admission. The maximum time before death was nine and one-half hours. In the second group there was a somewhat different picture. AI1 were unconscious; pulse, respiration and temperature were within norma Iimits. These patients rapidIy became worse and their temperature rose unti1 marked hyperpyrexia was present before death. There was an associated increase in respiration and p&e. Five of 7 in this group died within sixteen to twenty-six hours after admission; one Iingered on for five days. These peopIe died a truIy increased intracrania1 pressure death. In a third group of I I cases the patients presented a marked contrast to the first two mentioned. AI1 couId answer questions; the temperature, puIse and respiration readings were approximately normaI. The neuroIogica1 findings varied in direct reIation to the site of trauma. Of these, 2 died (one refused operation). It is apparent from these groupings that those entering the hospita1 conscious, foIIowing a buIIet wound of the head have a very good outIook for recovery and a11
shouId be done to heIp them and to prevent and minimize post-traumatic infection, sequelae. MANAGEMENT
The rationa of operative treatment of gunshot wounds of the head depends upon two factors: (I) The prevention of intracerebral infection; (2) the remova of bony particIes, dead brain tissue and the buIIet (if possibIe) to minimize post-traumatic sequeIae. In gunshot wounds of the forehead region there is an added responsibility of hoIding at a minimum operative deformities of the skull. In this group 7 cases were operated on in addition to first aid treatment. In one with no injury to the skuI1 the operation consistedYin remova of a subdural hematoma through a subtempora1 approach. In 5 cases the operation consisted in remova of depressed fragments of bone and necrosed brain tissue. In this group the incision most usuaIIy used was horseshoe shaped in outIine with the gunshot wound opening usuaIIy in the center. Of course, the type of incision used depends entireIy on the extent of Iacerations. In civi1 practice gunshot wounds are more usually circumscribed and smaIIer. The initia1 wounds were carefull_ debrided in every instance. With a flap incision the entire area of depression is exposed and there is a better opportunity to remove this area en masse. If the bone is then repraced the deformity wouId necessariIy be less marked. Suction was used to remove particIes of bone embedded in brain tissue and softened brain substance. If the buIIet was in the close vicinity of the area operated on it was removed. If it was beyond our reach no attempt was made at remova1. AI1 but one were cIosed without drainage. In one case of old gunshot wound with buIIet on the waI1 of the body of the right IateraI ventricIe there were e\-idences of increased intracrania1 pressure, nameIy, choked discs and headaches. There was aIso motor cortex irritation evidenced by Ieft pateIIar and ankIe cIonus and notice-
FIG. IB. FIG. IA. Frc. I. Bullet wound of the head seen two years after trauma for headaches. Examination aIso showed biIatera1 choked discs and evidences of motor irritation in Ieft lower limb. Suspected cyst about buIIet. First operation did not discIose cyst formation. Decompression was thought sufficient but this only cured complaints. Area of decompression grew to massive size. Second operation, encephaIogram and removal of buIIet. No evidences of pressure since. Apparently, buIIet behaved like a brain tumor and cure could not be effected without its removal.
FIG. 213. FIG. 2A. FIG. 2. Gunshot wound of right frontoparieta1. Extensive comminution of fragments. Marked cerebra1 destruction and softening. Patient operated on twenty-six hours after admission. Repaired without drainage. HeaIed by first intention. Initial left hemipIegia cleared up compIeteIy. Patient has had no sequeIae up to present (thirty-two months). Pieces of bone were carefully preserved and replaced to minimize forehead deformities.
able spasticity of the Ieft lower limb. Because of its position and because of no evidences of cyst formation about the bullet we were satisfied with a decompression at the first operation. Although this cured the headaches and the choked discs the area of decompression grew to massive size and onIy after the remova of the buhet did this subside. It was justifiabIy concIuded that the buIIet acted Iike a brain tumor and cure couId not be effected without its removal. The accompanying encephalogram (Fig. I) shows norma ventricuIar contour in this case. This patient now has a slight residua1 paresis in the Ieft upper limb. In general the management of gunshot wounds of the head in this hospital consisted in (I) combatting shock when present; (2) first aid care of wounds, namely, shaving off scaIp hair, cIeansing and dressing of wounds; (3) administration of nntitetanic serum; (4) carefuI x-ray examination if patient’s condition permits; (5) operation of debridement, cIeansing of wound, removal of bony particIes and dead brain tissue. This is done as soon as the patient’s condition permits. LocaI anesthesia is preferred.
lodged in the brain close to the wound of entrance remova is good technique. If, however, it is at a great distance from its
FIG. 3. Traumatic porencephaly, right frontal. Gunshot wound of right forehead in rc,ltc. Pntirnt employed as a type-setter from 1919 to 1930. Apparently, no complaints during this period and a good wage earner. Since 1930 spells of cpilcpsy ten to fifteen times yearly. It is interesting that with such a porcncephlic cavity patient was able to carry on satisfactorily and earn a good living for rleven years before pathology made itself evident.
COMMENT
The management of gunshot wounds of the head is essentiaIIy simiIar to that of head injuries with different etioIogy. There are some differences, nameIy, that the buIIet may remain in the cranial cavity and that there is a greater possibility of shattered pieces of bone being dispursed through the brain in the direct vicinity of the wound of entrance. Otherwise, the treatment is one of compound fracture and it aims at prevention of intracerebra1 infection and minimizing post-traumatic sequelae. The wound is debrided in the usua1 manner, a11 foreign particIes and pieces of bone are removed, the softened a n d necrosed brain tissue is carefuhy sucked away, and the wound is closed without drainage except in the region of the fronta sinus. When the buIIet is
point of entrance, such as diagonally across in the opposite hemisphere, no attempt is made to remove it, as Iong as the patient carries on satisfactorily. There are many in this group carrying a bullet in the head which apparentIy causes no dysfunction. However, we reaIize that in some, post-traumatic sequeIae may not be evident for years (see Fig. 3). To be dogmatic about this matter would cause much disabiIity which should not be borne by the patient. In some there are eventua1 evidences which speI1 surgical intervention. A cyst may form about- the buIIet which may necessitate expIorat_ion. Actual fibrous tissue tumor may envelop the bullet (Dandy). In the case just discussed the buIIet had Iodged on the waII of the body of the right lateral ventricIe. The patient
4 18
American ~ournat of Surgery
Gurdjian
& Buchstein-Wounds
came in two years Iater with choked discs, headaches, and she was expIored for a possibIe cyst about the buIIet. No cyst being found a decompression was performed but this onIy reIieved the complaints. The area of decompression protruded to massive size. At a Iater date the buIIet was removed and since, there have been no evidences of pressure. It was justifiabIy concIuded that the buIIet behaved very much the same as a brain tumor and cure couId not be effected without its remova1. However, this is an exceptiona case and it is not a true argument for attempts at remova of buIIets embedded deep in brain substance, for a majority undoubtedIy do as we11 as couId be expected. CertainIy there is no guarantee that the remova of buIIet wiI1 eIiminate a11 undesirabIe sequelae. Where there are cIinica1 evidences Iater, the case can be deaIt with surgicaIIy.
of dead brain tissue, foreign particIes, shattered pieces of bone and the buIIet (if possibIe) wiI1 heIp toward this end. Shock shouId aIways be treated first even if this takes twenty-four to thirty-six hours. 2. The state of consciousness is of prognostic importance. Patients conscious on entrance or soon after represent the most favorabIe cIass for recovery, irrespective of extent of apparent trauma. In this group recovery obtained in about 80 per cent. Among those in deep coma death occurred either soon after entrance (rapid coIIapse) or after the first tweIve to fifteen hours from extreme hyperpyrexia and increased intracrania1 pressure (hyperpyrexic death). 3. In the absence of skuI1 injury, damage to the intracrania1 contents shouId not be dismissed as a possibiIity. An exampIe of subdura1 hemorrhage with no fracture or perforation of the skuI1 is given. REFERENCES
SUMMARY
Notes on miIitary Feather, 1924. CUSHING, H. Notes on penetrating &it. M. J., I : 221, 1918. DANDY, W. E. In Lewis’ Practice town, Prior, 1932, 12: 291.
CRILE,
In gunshot wounds of the head the aim is to prevent intracerebra1 infection and to minimize undesirabIe post-traumatic sequeIae. Debridement and remova I.
SEPTEMBER, ,934
G. W.
surgery.
CleveIand,
wounds of the brain. of Surgery.
Hagers-