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.
Click here to view
Instruments and cased sets used for trepanning
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.
