PROGNOSIS.—The danger of wounds of the brain is greatest and most im mediate in injuries of the base, of the polls, and of the crura cerebri; it is least and most remote when the scat of the lesion is in the upper and anterior part of the hemispheres, in some cases there being no positive indication of any injury when so located. Unless the pops or medulla have been wounded, the patient seldom dies at once. Children often bear extensive injuries to the brain, and even considerable loss of brain-substance without immediate or remote effects of serious nature. As a general rule, the younger the patient, the greater the chance of recovery. The prognosis is usually more favorable in men of the laboring classes.
TREATMENT.—In these injuries to the brain the head should be clean shaved, and the parts should be washed, scrubbed, and cleansed with an antisep tic solution. All foreign bodies on the outside should be washed away or re moved with forceps. Foreign bodies. fragments of bone, etc., which have en tered the brain should be removed and the depressed bone elevated. Disinfec tion of the brain-cavity and arrest of lumnorrhage by pressure, hot water, or ligature should follow. The dura should be sutured, if not too much lacerated, missing portions being covered in by a portion of the pericranium. The wound should be drained, rubber tubing being preferable, the flaps of scalp replaced and sutured, and a generous antiseptic dressing applied. If secondary abscess appears, and it should be carefully watched for, the pus should be evacuated as soon as detected.
Gunshot Wounds of the Head.—These injuries may involve the integrity of the scalp, the skull, or the brain. The seri ous nature of these lesions is not always appreciable at first sight. A glancing shot may have injured apparently the scalp alone, while in reality the skull may have suffered such injury that ne crosis of the bone will follow, fracture of the internal table, perhaps with splinter ing or depression; or even the brain and its membranes may be at once or later involved. In these injuries the scalp
often sloughs extensively, the tissues being devitalized by the "energy" of the ball; perforation or deep penetration is not the only means by which the energy of a projectile is measured, for its dis ruptive, tissue-destroying powers are of equal importance. In other more serious cases extensive injuries of the brain and skull may result.
Experiments on animals have shown that a bullet in its passage through the brain does not leave a smooth track, but that it leaves, behind it, tears which radiate out from it. The gray substance is usually more torn than the white; this suggests that the latter is firmer.
(T'hila. lied. Jour., May 7, 'OS).
When gunshot wounds involve the brain they may be either perforating or penetrating; perforating, when the mis sile passes entirely through the head, and penetrating when the missile enters the brain, but does not emerge. The se verity of the injury to brain or skull varies within very wide limits. The wound of exit is always larger than that of entrance; this difference is more marked in the skull than in the soft parts. In a perforating wound of the skull the wound of entrance in the ex ternal table may be very small, while the inner table may be severely fractured; at the wound of exit the outer table usually suffers most, and the entire opening will be much larger than the wound of entrance. Besides the pres ence of the missile, there may be frag ments of hair, bone, etc., present along the tract of the wound, and more or less hemorrhage and infection as explained In WouNDs OF THE BRAIN.
The symptoms are similar to those given under WOUNDS OF THE BRAIN and FRACTURES. Localizing symptoms, however, may be absent more or less completely, owing to the far-reaching effects of this class of injuries.