By Dr. Michael Echols
The following are case report examples of trephining, using a trephine, or trepanning discussed in the Medical and Surgical History of the War of Rebellion during the Civil War.
CHAPMAN, S. D., Private, Co. H, 92d Ohio Volunteers, received, at the battle of Chickamauga, September 23d, 1863, a gunshot, wound of the scalp, near the upper posterior angle of the right parietal, with a contusion of the bone. He was sent to Nashville, and admitted to Cumberland Hospital on the 25th. The wound produced little inconvenience until October 4th when grave head symptoms, such as delirium and convulsions, supervened. There was hemiplegia also. On October 5th, the patient was in a comatose condition, and trephining was resorted to. When the skull was perforated, exit was given to a quantity of pus, which had formed between the dura mater and cranium. Consciousness was restored almost immediately, and apparent steady improvement for the next twenty-four hours; but symptoms of compression then recurred, and the patient died on October 9th, 1863. At the autopsy, the right hemisphere was found partially disorganized, and covered with a layer of pus, which extended to the longitudinal fissure. The operator, Surgeon C. McDermont, U. S. V., reported the case.
FOSTER, JAMES B., Private, Co. F, 5th Missouri Militia, was, on August 25th, 1863, admitted to the hospital at Kansas City, Missouri, with concussion of the brain. The skull was not fractured, but there were symptoms of compression. The trephine was applied to the seat of injury, and a button of bone removed. The operation revealed a rupture of the middle meningeal artery, with copious haemorrhage. A clot of blood was removed from raider the pia mater, when clear blood escaped for a few minutes. Death occurred on August 27th, 1863, thirty hours after the operation. The autopsy revealed extravasation of blood over the entire surface of the brain. The report is signed by Dr. Joshua Thorne.
TREPHINING.--The following abstracts of cases of fracture of the skull from various causes other than gunshot injury, refer to instances in which the trephine was formerly applied:
CASE.--Private Joseph Burns, Co. C, 4th Kentucky Cavalry, aged 23 years, was struck on the head at 8 o'clock P. M., February 22d, 1864, by a shrug shot, which produced a fracture of the skull, extending from the vertex to the left orbit, through the parietal, frontal, and the great wing of the sphenoid. The patient was taken to Clay Hospital, at Louisville, Kentucky, on the evening of the accident, with symptoms of grave compression of the brain. During the night he had frequent convulsions. Early the following morning. Acting Assistant Surgeon John E. Crowe applied the trephine, and elevated the depressed bone. The patient had previously been comatose or convulsed every five or ten minutes; but in ten minutes after the operation he became conscious, and spoke rationally, stating the circumstances attending his injury and his military history. In a few hours, however, the convulsive paroxysms returned, and continued during the night. The patient died on the succeeding day, February 24th, 1864. Surgeon Alexander T. Watson, U. S. V., records the case.
CASE.--Private Patrick H. Green, Co. H, 125th New York Volunteers, while on furlough, received a blow on the left side of the head from a shrug shot, on the night of May 23d, 1863. He was treated by a private physician until June 3d, when he was admitted into the Ladies' Home Hospital, New York City. Twenty-four hours after his admission he had a spasm of the right side of the body, and, upon examination, there was found to be a depressed fracture of the skull. The scalp was laid open by an incision, and trephining was performed, and the depressed portions of bone were removed. The scalp wound was united by sutures, and a compress of cloths wet with tepid water were applied. Rest and quiet were enjoined. The convulsions ceased after the operation, and the wound discharged freely. The patient progressed favorably, and was discharged from service on September 21st, 1863, for hemiplegia. Acting Assistant Surgeon John W. Robie reports the case.
CASE.--Private Charles H----,Co. G, 61st Ohio Volunteers, aged 37 years, was found lying in the street, at Alexandria, Virginia, on September 27th, 1863, in a comatose condition, with a wound on the right side of his head. He was conveyed to the New Hallowell branch of the 3d Division General Hospital, by the provost guard. On admission his breathing was stertorous, laborious, slow; his pulse was at 48, full and regular. There was a punctured wound over the lower portion of the right parietal, and an examination by the probe showed that the bone was fractured and depressed. A crucial incision was made through the scalp, and the cranium being freely exposed, it was found that the fracture was much more extensive than had been supposed. A disk of bone was removed by the trephine, and several detached pieces were removed by the elevator, no that, altogether, a portion four inches in length by two inches in width of the skull-cap was taken away. The flaps of the integument were then brought together and were united by sutures. Cold water dressings were applied. The immediate effects of the operation were very remarkable. In less than three minutes after the removal of the depressed fragments, the patient opened his eyes, and appeared to awake to consciousness, and in less than a minute more he spoke, articulating distinctly. For the first week after the operation His diet was restricted to barley water. On October 4th, seven days after the operation, he was reported to have had no bad symptom and he complained of nothing but hunger. The sutures had been removed, and the greater portion of the incision had united by first intention, He was now allowed the "extra diet" of the hospital, consisting of oyster broth, rice pudding, and the like. On October 20th, the patient was up and .about the ward. No untoward symptoms had intervened meanwhile, and the treatment had been unchanged. At this date the patient was put on "half diet," and the nearly cicatrized wound was dressed with simple cerate. He continued to do well until November 26th, when he was visited by his brother, who brought him some bad news from home which disturbed him very much, and he immediately went to bed and became stupid and sullen, taking no notice of anything. Is it not possible that his brother brought <ms_p1v2_58>him some stimulant as well! On October 27th, the patient had become comatose, with every sign of compression of the brain, and on October 28th, 1863, he died. At the autopsy, twenty hours after death, there was found to be an abscess in the right hemisphere and the neighboring brain substance was softened. The thoracic and abdominal viscera were healthy. The edges of the aperture were found to be rounded off and in process of repair. The notes from which the abstract is compiled were made by Acting Assistant Surgeon S. B. Ward, and the specimen was forwarded to the Army Medical Museum by Surgeon E. Bentley, U. S.V. It is represented in the wood-cut (FIG 22) on the preceding page.
CASE.--Private John T. Jenkins, 5th Alabama Regiment, was received into a regimental hospital at Union Mills, Fluvanna county, Virginia, in October, 1861, suffering from compression of the brain, produced by a blow. The skull was extensively fractured. Trephining was unsuccessfully performed. The patient died on October 26th, 1861. The case is noted on a monthly report of sick and wounded signed by Surgeon A. Venable, C. S. A., and no further particulars can be obtained.
CASE.--Private William H. Lowery, Co. C, 6th Tennessee Cavalry, aged 22 years, was wounded in an affray at Memphis, Tennessee, October 3d, 1864, receiving a punctured fracture of the right parietal bone, near its superior posterior angle, produced by a blow of a musket, the hammer passing through both tables of the cranium. He remained in the regimental hospital until October 13th, when he entered Gayoso Hospital. He was somewhat drowsy and stupid, but no other symptoms of compression existed. On the following day he was put under the influence of chloroform, and Acting Assistant Surgeon Julius Brey trephined the skull and removed a circular portion of the outer table and three depressed fragments of the inner table. The tip of the little finger could be introduced through the opening made in the skull, and it appeared that there was no injury to the dura mater. Cold water dressings were applied to the wound. The patient was restless for several days, and slightly delirious at night. Symptoms of cerebral disturbance were thought to be favorably modified by the use of the extract of Cannabis Indica. On October 18th, an intercurrent attack of pneumonia supervened. On November 3d, there were signs of cerebral hernia. Protrusion of the cerebral substance progressed so rapidly, that on November 6th, it was deemed expedient to compress the fungous mass by a bladder of ice. On November 7th paralysis of the left arm was observed. On the 16th, the cerebral hernia was still further compressed by a metallic disk. Coma supervened, and the patient died, November 17th, 1864. Surgeon T. N. Burke, U. S. V., furnished the notes of the case.
CASE.--Private E. Miller, Co. G, 6th Virginia Cavalry, aged 17 years, was wounded, in a railroad collision on the Ohio and Mississippi Railroad, near Carlisle, Illinois, June 21st, 1865. He was taken to Illinoistown, under the care of his regimental surgeon, Dr. A. H. Thayer, and was thence sent to the Marine Hospital, St. Louis, Missouri, where a depressed fracture of the cranium was diagnosticated. Assistant Surgeon S. M. Horton, U. S. Army, decided that the symptoms of compression of the brain demanded an operation, and applied the trephine, and removed several fragments of bone; but the symptoms were not relieved, and the case terminated fatally in the night of June 23d, 1865. Surgeon T. F. Azpell, U. S. V., reports the case.
CASE.--Private Sumner H. Needham, Co. I, 6th Massachusetts Militia, on April 19th, 1861, during the attack upon his regiment, by riotous insurgents in Baltimore, Maryland, was struck on the forehead by a brick, which fractured the frontal bone. He was conveyed to the Baltimore University, where his wound was examined by Dr. William A. Hammond, who found symptoms of compression of the brain demanding the application of the trephine. The operation was immediately performed by Dr. Hammond, but the symptoms were not relieved, and the patient died in a few hours, April 19th, 1861. Mr. Needham, a resident of Lawrence, Massachusetts, was one of the earliest victims of the rebellion."
CASE.--A. B. Parish, Quartermaster's Department, received a lacerated wound of the frontal region, with fracture and depression of the frontal bone, by a kick from a horse, near Natchez, Mississippi, September 13th, 1864. He was admitted to the hospital, at Natchez, on the same day, in a semi-comatose condition. Soon after his admission, Acting Assistant Surgeon James S. King administered chloroform, and trephined the skull, and raised the depressed portion of bone with the elevator. The patient soon reacted. Tonics, stimulants, and low diet, were ordered. The patient gradually improved, and was discharged from the hospital, entirely cured, on October 13, 1865.
CASE.--Private P----, 14th Tennessee Confederate Infantry, aged 25 years, small in stature, but muscular, received, in a quarrel, a wound on the anterior portion of the parietal bone, from a stone held in the clenched fist of his adversary. He was stunned by the blow. Fearing punishment, he did not report at sick call for several days, when he was compelled to do so because of the supervention of erysipelas. He was soon relieved of this complication; but in a few weeks, became subject to epileptic paroxysms, which recurred every four or five days. he was discharged for disability, and went to his home, at Springfield, Tennessee. Convulsions recurred with such frequency and violence that he went to Nashville in May, 1862, to be treated by Dr. W. T. Briggs, of the medical school in that city. his general health was poor, the countenance pale, the bowels torpid, the pulse quick and irritable. A depression of the skull corresponded with the cicatrix of the original wound. There was no pain about the cicatrix; hut a sense of pressure on the whole side of the head. After ten days of preparatory treatment, Dr. Briggs, assisted by Drs. Bowling and Buchanan, removed a disk of bone with the crown of a very large trephine. The inner surface of the disk presented a sharp angle at the union of the edges of the depressed inner table. Special instructions were given that the patient should rest quietly in bed, but he disregarded these instructions, yet the wound healed in ten days, and there was no recurrence of the convulsions. He reëntered the Confederate service, as a so-called "Partizan Ranger," and was captured and sentenced to he hung, but escaped before the sentence was executed; and under these exciting circumstances had no return of epilepsy. The abstract of the case is compiled from a report by the operator.(*)
CASE.--Private James Rogers, Battery L, 4th Ohio Artillery, was struck on the head by a stone on May 3d, 1865, receiving a depressed fracture of the skull. He was admitted to the hospital at New Creek, Virginia, on May 7th, in a comatose state. He remained in this condition until May 9th, when he was placed under the influence of ether, and Assistant Surgeon S. M. Finley, 22d Pennsylvania Cavalry, applied the trephine and elevated the depressed hone. The patient reacted well, and simple dressings were applied. Erysipelas supervened, but was successfully combated by chloride of iron. The patient improved rapidly, the wound was cicatrized, and he returned to duty, well, on June 29th, 1865.
CASE.--Private John R----, Co. H, 2d Michigan Volunteers, aged 41 years, was wounded on July 17th, 1865, in a street affray, receiving flour wounds of the head from stoney thrown at him. He was admitted to Armory Square Hospital, Washington, D. C., on the following day. He was perfectly conscious, yet had marked contraction of the pupils, with accelerated pulse, and a tremulous voice. There was considerable ecchymosis about the orbits. The first wound examined was over the frontal eminence, and penetrated no further than the aponeurosis of the occipito-frontalis muscle. The second was in the centre of the coronal suture, and slightly denuded the pericranium. The third was in the right temporal region, and likewise was a scalp wound. The fourth was on the right parietal eminence; and, upon a close examination, it was discovered that a minute depression of the bone, half an inch in diameter, existed, evidently produced by a blow from the sharp edge of the stone. The patient was a stout, muscular man, in good health; he suffered no nausea, and little pain. He was immediately placed under the influence of ether, and Surgeon D. W. Bliss, U. S. V., after shaving the scalp, made a crucial incision three inches in length, having the wound at the intersection of the incisions, and then, reflecting the flaps, applied the crown of a trephine and removed a disk of bone, which was found to include, with remarkable exactness, a depressed fragment of the vitreous photo. Between the diploe and depressed lamina there was a coagulum. The dura mater was uninjured. The wound was partly closed by four sutures, an opening being left over the perforation, into which a pledget of charpie was inserted. The patient recovered favorably from the anaesthetic, and was put to bed and ordered to observe perfect quiet and strict diet. The case proceeded without an unfavorable symptom. On July 23d, the sutures were removed. On July 24th, the compress of charpie was taken away, and a healthy granulating surface appeared beneath. These facts in regard to the case were reported by Assistant Surgeon Charles A. Leale, U. S.V. The pathological specimen was presented to the Army Medical Museum by the operator, and is represented in Photograph No. 87 of the Surgical Section of the Army Medical Museum, and in the accompanying wood-cut, (FIG. 24.) The disk is seven-eighths of an inch in diameter, and is slightly reduced in the illustration. On August 24th, 1865, the patient was transferred to Harper Hospital at Detroit, Michigan. The case continued to progress favorably, and the man recovered without a bad symptom. He was discharged from service on September 8th, 1865.
CASE.--A. B. Parish, Quartermaster's Department, received a lacerated wound of the frontal region, with fracture and depression of the frontal bone, by a kick from a horse, near Natchez, Mississippi, September 13th, 1864. He was admitted to the hospital, at Natchez, on the same day, in a semi-comatose condition. Soon after his admission, Acting Assistant Surgeon James S. King administered chloroform, and trephined the skull, and raised the depressed portion of bone with the elevator. The patient soon reacted. Tonics, stimulants, and low diet, were ordered. The patient gradually improved, and was discharged from the hospital, entirely cured, on October 13, 1865.
CASE.--Private Charles E. Towns, Co. I, 9th New Hampshire Volunteers, was thrown from his horse, and falling upon his head, received a fracture of the cranium. He was treated in the regimental hospital until February 1st, 1865, when he was admitted to the hospital of the Second Division of the Ninth Army Corps. The accident is not recorded on the regimental reports, and it is impracticable to ascertain its date. Such facts as are known are derived from the report of the Corps Hospital. On the patient's admission it was decided that compression of the brain with depressed bone existed; and the operation of trephining was performed by Surgeon L. W. Bliss, 51st New York Volunteers. The date and other particulars are wanting. The patient died, February 20th, 1865. The case was reported by Surgeon F. N. Gibson, 9th New Hampshire Volunteers.
CASE.--Private Charles Williams, Co. B, 161st New York Volunteers, was admitted into St. Louis Hospital, New Orleans, Louisiana, January 12TH, 1865, with an extensive fracture of the cranium and compression of the brain, caused by a blow received in a steamboat collision, January 9th, 1865, between the U. S. Transport J. H. Dickey and the Transport John Rain, on the Mississippi River, fifteen miles below Vicksburg. The trephine was applied and a portion of depressed bone was elevated, and another portion was removed. The patient died on January 18th, 1865. Surgeon A. McMahon, U. S. V., records the case on his monthly report without particulars of the operation or after treatment.
Image: Cased Trepanning Set
From: medicalantiques.com
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