(45) In marching on Heilbron a man in the advance guard was

struck by a bullet at right angles just within the margin of

the hairy scalp. The regiment was at the time to all intents

and purposes outside the range of rifle fire, and the patient

was the only individual struck among its number. When brought

into the Highland Brigade Field Hospital, a single typical

entry wound was discovered; examination with the probe gave

evidence of a slight depression in the external table of the

frontal bone just above the temporal ridge. Although no

perforation was detectible by the probe, and this was

positively excluded on the raising of a flap (Major Murray,

R.A.M.C.), it was considered advisable to remove a 1/4-inch

trephine crown, the pin of the instrument being applied to the

margin of the depression. No depression or splintering of the

internal table was discovered, nor any injury to the dura, nor

blood upon the surface of that membrane. The man made an

uninterrupted recovery.

(46) A case of frontal injury was shown to me at Wynberg, in

which a distinct furrow could be traced across the upper part

of the frontal sinuses. There had been no symptoms beyond

temporary diplopia, and the wound was healed; no surgical

interference had been deemed necessary.

(47) In a man wounded at Poplar Grove, a single typical wound

of entry was found 3/4 of an inch above the right eyebrow and

the same distance from the median line. No primary symptoms

were observed, but on the evening of the second day the

temperature rose above 100° F., and the man seemed somewhat

heavy and dull. The patient was examined by Major Fiaschi and

Mr. Watson Cheyne, and it was decided to explore the wound. Mr.

Cheyne removed fragments both of external and internal tables,

one of the latter having made a punctiform opening, not

admitting the finest probe, in the dura-mater. The bullet was

traced into the nasal fossæ, where it was subsequently

localised with the aid of the Roentgen rays when the patient

came under my observation at Wynberg some days later (fig. 60).

_Gunshot fracture of the skull with concurrent brain injury._--This was

the commonest form of head injury, and possessed two main peculiarities;

firstly, the large amount of brain destruction compared with the extent

of the bone lesion; secondly, the fact that any region of the skull was

equally open to damage. In consequence of the second peculiarity, the

position and direction of secondary fissures are not so dependent on

anatomical structure as in the corresponding injuries of civil practice.

Thus, fractures of the base, for instance, were less constant in their

course and position. The cases as a whole are best divided into four

classes.

[Illustration: FIG. 60.--Mauser Bullet in Nasal Fossa. (Skiagram by H.

Catling.) Case No. 47]

1. Extensive sagittal tracks passing _deeply_ through the brain, and

vertical wounds passing from base to vertex or _vice versa_, in the

posterior two thirds of the skull. These will be referred to as general

injuries.

2. Vertical or coronal wounds in the frontal region.

3. Glancing or obliquely perforating wounds of varying depth in any part

of the head.

4. Fractures of the base.

Of these classes the first was nearly uniformly fatal; the second

relatively favourable, and with low degrees of velocity often

accompanied by surprisingly slight immediate effects; while the third

had perhaps the best prognosis of all, but this varied as to the defects

that might be left, and with the region of the head affected.

1. _General injuries._--Fractures of this class may be treated of almost

apart. For their production the retention of a considerable degree of

velocity on the part of the bullet was always necessary, and the results

were consequently both extensive and severe.

The aperture of entry was comparatively small, since to take so direct

and lengthy a course through the skull the impact of the bullet needed

to be at nearly an exact right angle to the surface of the bone. Any

disposition to assume the oval form, therefore, depended mainly upon the

degree of slope of the actual area of the skull implicated. In size the

aperture of entry did not greatly exceed the calibre of the bullet; in

outline it was seldom exactly circular, but rather roughly four-sided,

with rounded angles, slightly oval, or pear-shaped. The margin of the

opening consisted of outer table alone, the inner being always

considerably comminuted. Fragments of the latter, together with the

majority of those corresponding to the loss of substance of the outer

table, were driven through the dura mater and embedded in the brain.

These bony fragments were more or less widely distributed over an area

of a square inch or more, and not confined to a narrow track.

[Illustration: FIG. 61.--Diagram of Aperture of Entry in Occipital Bone,

showing radiating fissures exact length. The exit in the frontal region

was of typical explosive character. Range '100 yards'.]

The amount of fissuring at the aperture of entry was often not so

extensive as I had been led to expect. Fig. 61 is a diagram illustrating

a fairly typical instance; in some cases no fissuring existed. As a rule

the nearer to the base, the greater was the amount of fissuring

observed. The fissures were sometimes very extensive in this position,

probably as a result of the lesser degree of elasticity in this region

of the skull. Again, when the aperture of entry was near the parts of

the vertex where sudden bends take place, considerable fissuring of the

same nature as that seen in the superficial tracks (fig. 68) was

produced in the flat portion of the skull above the point of entrance.

Radial fissuring around the aperture of entry in the skull scarcely

corresponds in degree with that seen when the shafts of the long bones

are struck, and is far less marked and regular than when one of these

small bullets strikes a thick sheet of glass set in a frame. I saw

several apertures in the thick glass of the windows of the waterworks

building at Bloemfontein produced by Mauser bullets. They differed

little from the opening seen in an ordinary plate-glass window resulting

from a blow from a stone, except perhaps in the regularity and

multiplicity of the radial fissures. As in the skull, the opening was a

little larger than the calibre of the bullet, and the loss of substance

on the inner aspect considerably exceeded that on the outer.

The degree of fissuring is probably affected by the resistance offered

by the particular skull, or the special region struck, but as a rule the

elasticity and capacity for alteration in shape possessed by the bony

capsule, is opposed to the production of the extreme radial starring

observed in the long bones or a fixed sheet of glass. Corroborative

evidence of the influence of elasticity in the prevention of starring is

seen in the limited nature of the comminution of the ribs in cases of

perforating wounds of the thorax.

In the most severe cases we can only speak of the 'aperture' of exit in

a limited sense in so far as the opening in the scalp is concerned; this

was often comparatively small, not exceeding 3/4 of an inch in diameter.

Beneath this limited opening in the soft parts, the bone of the skull

was smashed in a most extensive manner. The portion exactly

corresponding to the point of exit of the bullet was carried altogether

away, but around this point a number of large irregularly shaped

fragments of bone, from 3/4 to 1 inch in diameter, were found loose, and

often so displaced as to expose a considerable area of the dura-mater.

Beyond the area of these loose fragments, fissures extended into the

base and vertex, in the latter case often being limited in their extent

by the nearest suture.

Over extensive fractures of this nature general oedema and

infiltration of the scalp, due to extravasation of blood, were present.

When the exit was situated in the frontal region ecchymosis often

extended to the eyelids and down the face, while in the occipital region

similar ecchymosis was often seen at the back of the neck.

The opening in the dura mater at the aperture of entry was either

slitlike, or more often irregular from laceration by the fragments of

bone driven in by the bullet. At the point of exit a similar limited

opening corresponded with the spot at which the bullet had passed, while

separate rents of larger size were often seen at some little distance.

The latter were the result of laceration of the outer surface of the

membrane by the margins of the large loose fragments of bone above

described.

Injury to the brain more than corresponded in extent to the fractures of

the bone. Pulping of its tissue existed over a wide area both at the

points of entrance and of exit. In the former position the amount of

damage was the less, the gross changes roughly corresponding with the

tissue directly implicated by the bullet itself, and the fragments of

bone carried forward by it. The degree of splintering of the skull

therefore in great part determined the severity of the lesion. At the

exit aperture much more widespread destruction existed, while masses of

brain tissue, small shreds of the membranes, fragments of bone, and

_débris_ from the scalp were found occasionally bound together by

coagulated blood and protruding from an exit opening of some size. The

largest masses of such _débris_ were most often seen in instances in

which the bullet had entered by the base to escape at the vertex of the

skull.

The brain in the line of injury suffered comparatively slightly, but

small parenchymatous hæmorrhages into its tissue indicated in lesser

degree the same type of injury undergone by the mass of brain pulp and

small blood-clots found at the external limits of the wound. Beyond this

extensive hæmorrhages at the base of the skull were common.

With regard to the extensive character of the brain destruction in the

region of the aperture of exit, it must be borne in mind that this

lesion corresponds in position with one which would exist even if the

injury were of a non-penetrating degree. A large proportion of the

contusion and destruction is therefore explained by violent impact of

the projected brain with the skull prior to the passage of the bullet,

and not to the direct action of the bullet on the tissues.

These cases of 'general injury' afford a marked example of the lesions

to which the term 'explosive' has been applied, and as such have an

important bearing on the theories held as to the mode of production of

explosive effect. The increased area of tissue damage at the aperture of

exit favours the theory of direct transmission of a part of the force

with which the bullet is endowed, to the molecules of tissue bounding

the track made by the projectile. Thus the area of destruction

corresponds with the cone-like figure which one would expect to be built

up by the vibrations spreading from the primary point of impact. The

exit region of the skull is subjected not alone to the force of the

travelling bullet, but also to that exerted over a much wider area by

the tissue to which secondary vibrations have been communicated. The

brain itself is, in fact, dashed with such violence against the bone as

to cause a great part of the injury.

No doubt the brain in its reaction to the bullet forms as near an

approach to a fluid as any solid tissue in the human body, and

experimental observation has shown how greatly its presence or absence

in the skull affects the degree of comminution on the exit side; hence

the fondness for the so-called hydraulic theory that has been always

exhibited in the case of these injuries. The localisation of the injury

in its highest degree to the neighbourhood of the exit aperture,

however, shows that in any case the main wave takes a definite direction

in a course corresponding to that of the bullet.

The real importance of the presence of the brain within the skull in

increasing the amount of damage at the exit end of the track, is as a

medium for the ready transmission of forcible vibrations. That the

latter are to some extent conveyed as by a fluid is evidenced by the

occasional presence of brain matter and fragments of bone in the

aperture of entry, which suggests recoil or splash such as would be

expected from a fluid wave.

Experience of the character of the lesions observed after severe

concussion by the ordinarily somewhat coarser forms of violence common

to civil life, fully explains the severity of the damage to the brain

tissue met with in injuries due to bullets of small calibre. Viewing the

elaborate arrangements which exist for the preservation of the central

nervous system from the moderate vibration incidental to ordinary

existence, it is easy to appreciate the harmfulness of such exquisite

vibratory force as that transmitted by a bullet of small calibre

travelling at a high rate of velocity.

_Effect of ricochet in the production of severe forms of injury._--In

connection with the lesions above described mention must be made of

cases in which the aperture of entry reaches a large size, or a portion

of the skull is actually blown away.

Examples of the former class were not uncommon; I will briefly relate

one.

(48) A Highlander while lying in the prone position at

Rooipoort, was struck by a bullet probably at a distance of

about 1,000 yards. A large entry wound in the scalp was

produced, while the defect in the skull was coarsely comminuted

and was capable of admitting three fingers into a mass of

pulped brain. Both brain matter and fragments of bone were

found in the external wound, which was situated just anterior

to the right parietal eminence. The bullet passed onwards

through the base of the skull, crossing the external auditory

meatus, fracturing the zygoma and probably the condyle of the

mandible, and eventually lodged beneath the masseter muscle.

Blood and brain matter escaped from the external auditory

meatus.

The patient was brought off the field in a semi-conscious

condition, the pupils moderately contracted but equal, the

pulse 66, very small and irregular in beat, the respiration

quiet and easy, and with paralysis of the left side of the

body. The fæces had been passed involuntarily.

The wound was cleansed and bone fragments removed. The patient

had to travel in a wagon for the next three days until the

column halted. The progress of the case was unsatisfactory, as

the wound became infected, and the man eventually died on the

14th day of general septicæmia, but with little evidence of

local extension of septic inflammation.

In this instance the head was no doubt struck by a bullet which

had previously made ricochet contact with the ground. I saw

several such cases.

Closely connected with such injuries are those in which large portions

of the skull and scalp were actually blown away. I never witnessed one

of these myself, but I recall two instances described to me by officers

who lay near the wounded men on the field. In one the frontal region was

carried away so extensively that, to repeat the familiar description

given by the officer, 'he could see down into the man's stomach through

his head.' In a second case the greater part of the occipital region was

blown away in a similar manner, and this was of especial interest as the

wounded man was seen to sit up on the buttocks and turn rapidly round

three or four times before falling apparently dead. The observation

offers interesting evidence of the result of an extensive gross lesion

of the cerebellum.

In the absence of exact information, it may well be that such injuries

as the two latter were produced by some special form of bullet, but as

both were produced while the patients were lying on the ground, and

therefore especially liable to blows from ricochet bullets, I am

inclined to attribute both to this cause.

In considering injuries of the above nature, one cannot help speculating

on the possible influence of a head-over-heels ricochet turn on the part

of the bullet while traversing the long sagittal axis of the skull. It

is not uncommon for apical target ricochets to present evidence of

damage to the apex and base of the mantle alone. This must depend on a

rapid turn on impact, which might well be imitated in the case of the

skull, and would then go far to explain the production of some of the

most severe forms of explosive exit wounds met with. See cases 48, 54,

68.

Short of ricochet, the influence of simple wobbling must also be

considered in shots from a long range. The entry wound may be large as a

result of this condition, but as the velocity possessed by the bullet is

low, the injuries would probably not be of a very severe nature.

In connection with the subject of wobbling, reference should be made to

the form suggested by Nimier and Laval, in which the wobble, as the

result of resistance to the apex of the revolving bullet, assumes the

form of movement seen when the spin of a top is failing. This would

explain a peculiarity in some wounds of entry over the skull first

pointed out to me by Mr. J. J. Day. When such wounds were explored, as

well as the presence of brain in the entry aperture, a number of

fragments of the external table of the skull were found everted and

fixed in the tissues of the scalp. As already suggested, this may be

mere evidence of splash, but it may be equally well explained by a

process of wobble around the axis of revolution of the bullet. This

might, no doubt, also be invoked to explain the displacement of some of

the fragments in fractures of the long bones, where considerable

resistance to the passage of the bullet is offered.

II. _Vertical or coronal wounds in the frontal region._--These injuries

were common, and offered some of the most interesting illustrations of

the variations in symptoms and effects following apparently exactly

identical lesions, judging from the condition of the external soft parts

alone; since the latter sometimes gave little indication of the force

(dependent on the rate of velocity) which had been applied.

With the lower degrees of velocity simple punctured fractures of the

skull resulted, without extensive lesion of the frontal lobes as

evidenced by immediate symptoms. The nature of the fractures differed in

no way from the punctured fractures we are familiar with in civil

practice. The openings of entry in the bone were irregularly rounded,

corresponding in size to the particular calibre of the bullet concerned.

The margin consisted of outer table alone, while the inner table was

either considerably comminuted, or a large piece was depressed, wounding

the dura-mater and projecting into the brain substance (see fig. 63).

The aperture of exit presented exactly the opposite characters, the

splintering comminution or separation of a large fragment affecting the

outer table, while the inner presented a simple perforation. The latter

condition is represented in figs. 71 and 72, and I will here give short

notes of four illustrative cases, as being the shortest and most

satisfactory method of conveying a correct idea of the nature of such

injuries.

[Illustration: FIG. 62--Aperture of Entry in Frontal Bone. Case No. 50.

1/2]

(49) _Vertical perforation of frontal bone._--Wounded at

Belmont, while in the prone position. Aperture of _entry_

(Mauser), at the anterior margin of the hairy scalp on the left

side; course, through the anterior part of the left frontal

lobe, roof of the left orbit, cutting the optic nerve and

injuring the back of the eyeball, floor of the orbit, the

antrum, the hard palate, and tongue. _Exit_, in mid line of the

submaxillary region. No cerebral symptoms were noted, and on

the fifth day the man was sent to the Base hospital without

operation; the pulse was then 70 and the temperature normal.

The movements of the eyeball were perfect, but blindness was

absolute. At the Base hospital the eye suppurated and was

removed. The patient was then sent home apparently well. He has

since been discharged from the service, and is now employed as

a painter in Portsmouth Dockyard.

(50) _Vertical perforation of frontal bone._--Wounded at

Paardeberg while in the prone position. Range, 600-700 yards.

Aperture of _entry_ (Mauser), at the fore margin of the hairy

scalp above the centre of the right eyebrow; course, through

the anterior third of the right frontal lobe, roof of orbit,

front of eyeball, margin of floor of orbit making a distinct

palpable notch, and cheek; _exit_ through the red margin of the

upper lip, 1/2 an inch from the right angle of mouth. The

bullet slightly grooved the lower lip.

The patient rose almost immediately after being struck, and

walked about a mile, although feeling dizzy and tired. The

wounds, which both bled considerably, were then dressed. After

three days' stay in a Field hospital, the patient was sent in a

bullock wagon three days and nights' journey to Modder River

and thence to the Base.

There was anæsthesia over the area supplied by the outer branch

of the supra-orbital nerve, extending from the supra-orbital

notch backwards into the parietal region, but none over the

area supplied by the second division of the fifth nerve.

On the tenth day there were no signs of cerebral disturbance

except a pulse of 48. The eyeball was suppurating, and the

temperature rose to 99° at night. The lids were still swollen

and closed.

A few days later the eyeball was removed and at the same time a

flap was raised and the fracture explored (Major Burton,

R.A.M.C.). An opening somewhat angular, 1/3 of an inch in

diameter, was found with a thin margin in the outer table of

the skull (fig. 62); when this was enlarged with a Hoffman's

forceps, an opening in the dura was discovered, and

cerebro-spinal fluid escaped. A piece of the inner table of the

skull (fig. 63), 3/4 by 1/3 an inch in size, was discovered

projecting downwards vertically into the brain. This latter was

removed and the wound closed. Healing by primary union

followed, and no further symptoms were observed.

[Illustration: FIG. 63.--Fragment of Inner Table depending

vertically from lower margin of puncture shown in fig. 62. The

centre was perforated. Exact size]

(51) _Transverse frontal wound._--Wounded at Paardeberg. The

man was sitting down at the time he was struck, in the belief

that he was out of the range of fire. The _entry_ and _exit_

wounds were almost symmetrical, placed on the two sides of the

forehead at the margin of the hairy scalp, 2-1/4 inches above

the level of the external angular processes of the frontal

bone. The patient lost consciousness for about half an hour,

then rose and walked half a mile to the Field hospital. The

wounds were dressed, and after a stay of three days in

hospital, the man was sent the three days' journey to Modder

River; during the journey he got in and out of the wagon when

he wished. After two days' stay at Modder, a journey was again

made by rail to De Aar (122-1/2 miles). The wounds were healed.

The man stayed at De Aar nearly a month, and then, rejoining

his regiment, made a two days' march of some 22 miles on hot

days. He had to fall out twice on the way by reason of

headache, feeling dizzy, and 'things looking black.' He did not

own to any loss of memory or intellectual trouble, but was

invalided to England. This patient returned to South Africa

later, and is now on active service.

(52) _Transverse frontal wound._--Within a few days an almost

identical symmetrical wound in the frontal region occurred in

the same district, from a near range. The patient became

immediately unconscious, and remained so until his death some

four days later, his symptoms being in no way alleviated by

operation and the removal of a quantity of bone fragments and

cerebral _débris_. At the _post-mortem_ examination, extensive

destruction of both hemispheres of the brain was revealed, and

large fissures extended into the base of the skull.

III. _Glancing or oblique perforating wounds of varying depth in any

portion of the cranium._--These injuries were the most common, the most

highly characteristic of small-calibre bullet wounds, the most

interesting from the point of view of diagnosis, prognosis, and

treatment, and beyond this they formed the variety most unlike any that

we meet with in civil practice.

They were met with in every region of the cranium, and in every degree

of depth and severity. The lesser are best designated as gutter

fractures, the deeper are perforating and gradually approximate

themselves to the type of injury described as class 1.

When the bullet struck a prominent or angular spot on the skull a

considerable oval-shaped fragment was occasionally carried away, leaving

an exposed surface of the diploë (case 60, p. 274). Under these

circumstances the apparent lesion on raising a flap was slight, but

exploration often showed extensive intra-cranial mischief. Thus in the

case referred to both dura and brain were wounded, and continuing

hæmorrhage led to the development of progressive paralysis, relieved

only by operation.

From the more deeply passing bullets a more or less oval opening

resulted, in which both tables were freely comminuted and displaced.

These cases differed from the typical gutter fracture only in length and

outline, and the nature of the accompanying intra-cranial lesion was

identical, while in the latter particular they differed much from

fractures in which the impact of the bullet was direct, in spite of a

near resemblance in the appearances in the osseous defect.

I saw one instance in which a circular fissure about 1-1/2 inch from

the actual opening of entry surrounded the latter, the area of bone

within the circle being somewhat depressed, though radial fissures were

absent.

In several of these cases fragments of lead were either found on the

fractured surface of the bone or within the cranial cavity, showing that

the bullets had undergone fissuring of the mantle, or had actually

broken up on impact.

_Gutter fractures._--The nature of the injury to the bones in these is

best illustrated by a series of diagrams of sections such as are shown

below.

[Illustration: FIG. 64.--Gutter Fracture of first degree. The drawing

does not show well the small fragments of bone usually carried from the

margins of the depression by the bullet.]

In the most superficial injuries the outer table was grooved and

depressed, usually with loss of substance from small fragments directly

shot away: these latter had either been driven through the wound in the

soft parts, or remained embedded on the deep aspect of the enveloping

scalp (fig. 64). In the less common variety the scalp was slit to a

length corresponding with the injury to the bone, but more often oval

openings in the skin existed at either end of the track. The inner table

was practically never intact, but the amount of comminution naturally

varied with the depth to which the outer table was implicated (fig. 65

_A_, and _B_).

The following is an illustrative example of this degree, and also

emphasises the consequences which may follow primary non-interference.

[Illustration: FIG. 65.--Diagrammatic transverse sections of varying

condition of bones in Gutter Fractures of the first degree. _A._ With no

loss of substance. _B._ With comminution.]

(53) _Superficial gutter fracture in parietal region.

Convulsive twitchings. Secondary paralysis._--Wounded at Modder

River. Range, 400 yards. A scalp wound 3 inches in length ran

vertically downwards, commencing 1 inch from the median line,

and situated immediately over the upper third of the right

fissure of Rolando. The patient was unconscious for several

hours after the injury, and later suffered with severe

headache, and twitchings in the left shoulder and arm.

The wound healed, but a well-marked groove was palpable in the

bone beneath, and the twitchings persisted. The latter came on

about every twenty minutes, and loss of power in the left upper

extremity, and to a less degree in the lower, developed. The

memory was defective, and the patient suffered at times with

headache. The pupils were equal but sluggish in action. No

changes were discovered in the fundus beyond a well-developed

myopic crescent at the lower and outer part of the left disc

(Mr. Hanwell).

The twitchings became more frequent and latterly were

accompanied by somewhat severe muscular contractions in the

upper extremity, while the loss of power in the lower extremity

became more marked. Headache was also more troublesome.

The patient throughout refused any operation, saying he would

rather go home first, and at the end of a month he left for

England.

In the deeper injuries more and more of the outer table was cut away,

and the inner became gradually more depressed, fractured, or comminuted

(fig 66).

[Illustration: FIG. 66.--Gutter Fracture of the second degree.

Perforating the skull in the centre of its course. External table alone

carried away at either end.]

Bevelling at the expense of the outer table at both entry and exit ends

of the course existed, but in either case a portion of the inner table

was also detached and depressed. Sometimes the depressed portion of the

inner table was mainly composed of one elongated fragment; this was

either when the bullet had not implicated a great thickness of the outer

table, or had passed with great obliquity through especially dense bone

(see fig. 70). When the bullet had passed more deeply the inner table

was comminuted into numberless fragments. I have frequently seen 50 or

60 removed. Where such tracks crossed convex surfaces of the skull, the

two conditions were often combined; thus at one portion of the track,

usually the centre, the comminution was extreme, while at either end a

considerable elongated fragment of inner table was often found, the

latter perhaps more commonly at the distal or exit extremity (fig. 67).

[Illustration: FIG. 67.--Diagrammatic transverse sections of complete

Gutter Fracture. _A._ External table destroyed, large fragment of

internal table depressed. (Low velocity or dense bone.) _B._ Comminution

and pulverisation of both tables centre of track. _C._ Depression of

inner table (low velocity)]

The nature of the injury to the bone when the flight of the bullet

actually involved the whole thickness of the calvarium was comparable to

that seen in the case of the long bones when struck by a bullet

travelling at a moderate rate (see plate XIX. of the tibia, or what is

illustrated in the case of the pelvis in fig. 55). In point of fact, a

clean longitudinal track appeared to have been cut out. The length of

these tracks naturally depended upon the region of the skull struck.

When a point corresponding to a sharp convexity, or a sudden bend in

the surface, was implicated, an oval opening of varying length in its

long axis was the result; when a flat area, as exists in the frontal or

lateral portions of the skull, was the seat of injury, a long track was

cut.

_Superficial perforating fractures._--These formed the next degree; the

chief peculiarity in them was the lifting of nearly the whole thickness

of the skull at the distal margin of the entry, and the proximal edge of

the exit, openings; the flatter the area of skull under which the bullet

travelled the more extensive was the comminution. In some cases nearly

the whole length of the bone superficial to the track would be raised;

in fact, the bullet having once entered, the force is applied from

within in exactly the same way that it operates on the inner table in

the gutter fractures. A corresponding injury is met with in the case of

the bones of the extremities (see fig. 57 of the tibia), and again the

resemblance between these injuries of the skull and such perforations of

the long bones as are illustrated by skiagrams Nos. III. and XXIII. of

the clavicle and fibula is a close one.

[Illustration: FIG. 68.--Superficial Perforating Fracture. Illustrating

lifting of roof at both entry and exit openings]

I will add here a case of coexistent gutter fracture and perforating

wound of the skull, the conditions of the bone in which will illustrate

the behaviour of the outer and inner tables respectively, when struck

with moderate force.

[Illustration: FIG. 69.--Diagrammatic longitudinal section of Fracture

shown in fig. 68]

[Illustration: FIG. 70.--Fragment forming the main part of the floor of

Gutter Fracture in the squamous portion of the temporal bone. (Low

velocity, hard bone)]

(54) Wounded at Thaba-nchu. Guedes bullet. _Entry_ behind left

ear, just above posterior root of zygoma; gutter fracture;

bullet retained within skull. Above and corresponding to right

frontal eminence there was a hæmatoma, beneath which a loose

fragment of bone was readily palpable. When brought into the

Field hospital, twenty-four hours after the injury, the man

appeared to understand when spoken to, but made no answers to

questions. The urine was passed unconsciously, the bowels were

confined.

He was drowsy, the pupils widely dilated, the pulse 68, of good

strength, and the temperature 104°. He slept well the following

night and midday there was little change, except that the

pupils acted to light, and the pulse had risen to 88, becoming

dicrotic and small. The temperature was 103°, the tongue furred

and dry, but he was lying with the mouth wide open.

At 2 P.M. the wound was explored. The entry led down to a

typical gutter fracture in the squamous portion of the temporal

bone, at the point of junction of the vertical with the

horizontal part; the floor of the gutter had been displaced

inwards as a single fragment (fig. 70). A flap was raised in

the frontal region, where a scale of outer table (fig. 71),

clothed with diploic tissue, was found loose. Beneath this a

puncture on the frontal bone, about corresponding in size to

the bullet, was discovered. This opening was enlarged, and a

bullet detected and removed. The bullet was a Guedes, with no

marks of rifling, and was in no way deformed. At least a square

inch of the right frontal lobe was pulped, so that the bullet

lay in a cavity.

The patient improved somewhat during the next two days, and on

the third took a 16 hours' journey to Bloemfontein, where Mr.

Bowlby (who was present at the operation) kindly took him into

the Portland Hospital. The pulse gradually rose to 112, the

temperature remained on an average from 102° to 103°, the

respiration rose to 36, the face became somewhat livid, and on

the sixth day death occurred rather suddenly, apparently from

respiratory failure. For two days before his death the patient

sometimes asked for food, &c.; there was occasional twitching

of the left angle of the mouth, and, when the posterior wound

was manipulated, some twitching of the fingers of the left

hand. When the wound was dressed on the fourth day, there were

breaking-down blood-clot and signs of incipient suppuration.

Mr. Bowlby made a _post-mortem_ examination, and found

considerable pulping of the tip of the right frontal and left

temporo-sphenoidal lobes, and a thick layer of hæmorrhage

extending over the whole base of the brain.

[Illustration: FIG. 71.--Scale of outer table of Frontal Bone and

Diploë. Exact size, from fracture shown in fig. 72]

[Illustration: FIG. 72.--Perforating Fracture of Frontal Bone from

within Separation of plate outer table. (Low velocity.) 1/2]

The injury to the _cranial contents_ varied with the degree of bone

injury. Hæmorrhage on the surface of the dura may in rare instances have

been the sole gross lesion; I never met with such a condition, however.

In all the cases in which comminution had occurred, some laceration of

the dura, even if not more than surface damage or a punctiform opening,

had resulted. In the more serious gutter fractures an elongated rent of

some extent usually existed. In the perforating fractures two more or

less irregular openings were the rule. The amount of hæmorrhage, even if

the venous sinuses were implicated, was on the whole surprisingly small,

when the cases were such as to survive the injury long enough to be

brought to the Field hospital. I never saw a typical case of middle

meningeal hæmorrhage, although many fractures crossing the line of

distribution of the large branches came under observation. Case 60, p.

274, illustrated the fact that the osseous lesions of lesser apparent

degree are sometimes the more to be feared in the matter of hæmorrhage,

as compression is more readily developed.

The degree of injury to the brain depended on the depth of the track,

the resistance offered by the bones of any individual skull, the weight

of the patient, but chiefly on the degree of velocity retained by the

bullet. It was sometimes slight and local as far as symptoms would guide

us; but in the majority of cases out of all proportion to the apparent

bone lesion, if the range was at all a short one. Cases illustrative of

these injuries are included under the heading of symptoms.

It will be, of course, appreciated that the coarse brain lesions under

the third heading differed in localisation and in extent alone, and in

no wise in nature, from those observed in the two preceding classes. The

damage consisted in direct superficial laceration and contusion, and

beyond the limits of the area of actual destruction, abundant

parenchymatous hæmorrhages more or less broke up the structure of the

brain, such hæmorrhages decreasing both in size and number as

macroscopically uninjured tissue was reached. No opportunity was ever

afforded of examining a simple wound track in a case in which no obvious

cerebral symptoms had been present.

IV. _Fractures of the base._--In addition to the above classes, a few

words ought to be added regarding the gunshot fractures of the base of

the skull. These possessed some striking peculiarities; first in the

fact that they might occur in any position, and hence differed from the

typically coursing 'bursting' fractures we are accustomed to in civil

life as the consequence of blows and falls, and consequently were often

present without any of the classical symptoms by which we are accustomed

to locate such fissures. Secondly, the peculiar form was not uncommon in

which extensive mischief was produced from within by direct contact of a

passing bullet.

As far as could be judged from clinical symptoms, indirect fractures of

the base such as we are accustomed to meet in civil practice in

connection with fractures of the vault were decidedly rare, and, as has

already been mentioned, ocular evidence of extensive fissures extending

from perforating wounds of the vertex was wanting, except in the extreme

cases classed under heading I. For these reasons I am inclined to regard

them as uncommon.

Direct fractures of the base, on the other hand, were of common

occurrence, especially in the anterior fossa of the skull. These might

be produced either from within, the most characteristic form of gunshot

injury, or from without. The fractures from within were often simple

punctures of the roof of the orbit or nose.

Punctured fractures of the roof of the orbit caused little trouble as

far as the cranium was concerned, but the orbital structures often

suffered severely. I saw one or two very severe comminutions of the roof

of the orbit caused by bullets which had crossed the interior of the

skull; in one case the whole roof was in small fragments, while the

damage in others was not greater than chipping off some portion of the

lesser wing of the sphenoid. The roof of the orbit again was sometimes

very severely damaged by bullets which first traversed that cavity

itself; thus in one case which recovered, the bullet passed

transversely, smashing both globes, and fracturing the roof of both

orbits and the cribriform plate so severely as to lacerate both

dura-mater and brain, portions of the latter being found in the orbit on

removal of the damaged eyes.

Fractures of the middle and posterior fossæ were met with far less

frequently, partly I think because vertical wounds passing from the

vertex to the base in these regions were with few exceptions rapidly

fatal, and partly from the fact that the occipital region, being

ordinarily sheltered from the line of fire, was rarely exposed to the

danger of direct fracture from without. As an odd coincidence I may

mention that in my whole experience during the war I only once saw

bleeding from the ear as a sign of fracture of the base, apart from

direct injuries to the tympanum or external auditory meatus.

_Symptoms of fracture of the skull, with concurrent injury to the

brain._--These consisted in various combinations of the groups of signs

indicative of the conditions of concussion, compression, cerebral

irritation, or destruction. Although the symptoms possessed no inherent

peculiarities, yet certain characteristics exhibited served to

illustrate the fact that, as a result of the special mechanism of

causation of the injuries, the type deviated in many ways from that

accompanying the corresponding injuries of civil practice.

The characters of the external wounds will be first considered, followed

by some remarks concerning the symptoms attendant on the different

degrees and types of lesion, the symptoms special to injuries to

different regions of the head, and on the subsequent complications

observed.

In the simplest injuries the type forms of entry and exit wound were

found, and it has already been observed that in these, if symmetrical,

considerable difficulty existed in discriminating between the two

apertures. This is to be explained by the fact that the arrangement and

structure of the scalp are identical in corresponding regions; hence the

only difference in the conditions of production of the entry and exit

wounds exists in the absence of support to the skin in the latter. The

granular structure of the hairy scalp is opposed to the occurrence of

the slit forms of exit, hence the openings were usually irregularly

rounded. Any increase of size in the exit wound in the soft parts due to

the passage of bone fragments with the bullet, was equalised in that of

entry by the fact that the latter, as supported by a hard substratum,

was usually larger than those met with in situations where the skin

covers soft parts alone.

In some cases of gutter fracture the wounds of entry were large and

irregular, as a result of upward splintering of the bone at the distal

margin of the aperture of entry in the skull, and consequent laceration

of the scalp. Again, on the forehead very pure types of slit exit wound

were often met with in the position of the vertical or horizontal

creases. With higher degrees of velocity on the part of the bullet and

consequent comminution at the aperture of exit in the bone, the scalp

was more extensively lacerated, and large irregular openings in the soft

parts, often occupied by fragments of bone and brain pulp, were met

with. It is well to repeat here, however, that the presence of brain

pulp in a wound by no means necessarily indicated the aperture of exit,

for it was sometimes found in the entry opening also.

In the most severe cases, such as are included in class I., the exit

wound often possessed in the highest degree the so-called 'explosive'

character. From an opening in the skin with everted margins two or more

inches in diameter a mass of brain débris, bone fragments and particles

of dura-mater, skin, and hair, bound together by coagulated blood,

protruded as a primary hernia cerebri if the patient survived the first

few hours after the injury. In other cases of the same class the actual

opening was smaller, but the whole scalp was swollen and oedematous,

sometimes crackling when touched from the presence of extravasated blood

in the cellular tissue, while firm palpation often gave the impression

that the head consisted of a bag of bones over a considerable area.

Gutter fractures of the scalp were sometimes situated beneath an open

furrow, gaping from loss of substance, or beneath a bridge of skin; in

the latter case they were usually palpable. Simple punctures were also

usually palpable, but the smallness of the openings sometimes rendered

their detection more difficult than might be assumed.

I never saw a case in which the skull escaped injury when the bullet

struck the scalp at right angles, but the frequency with which Mauser

bullets were found within the helmets of men would suggest that this

must have sometimes occurred. A case of injury to the external table

alone has been described (p. 243). An illustration of the next degree of

injury is afforded by the following:--A bullet lodged in the centre of

the forehead, the point lying within the cranial cavity, while the base

projected from the surface: this patient suffered but slight immediate

trouble, so little, indeed, that he merely asked his officer to remove

the bullet for him, as it was inconvenient. The bullet was subsequently

removed in the Field hospital.

In a few cases the bullet entered the skull and was retained, when only

a single wound was found. Such cases are described in Nos. 54 and 68,

where the position of the bullet was determined by palpable fractures

beneath the skin. With regard to the retention of bullets, however, in

small-calibre wounds, it was always necessary to examine the other parts

of the body with great care, and to ascertain, if possible, the

direction from which the wound was received, as an exit was often found

some distance down the neck or trunk. Again the possibility of the

opening having been produced by glancing contact had to be considered.

In cases which survived the injury on the field, free hæmorrhage, as in

wounds of other regions, was rare, and although general evidence of loss

of blood was often noted in patients brought in, progressive bleeding

was seldom observed. Again, when the wounds were explored, the amount of

blood, although considerable, was usually not more than sufficed to fill

up the space consequent on the loss of brain tissue. This was especially

striking when large venous sinuses, as the superior longitudinal, were

involved in the injury. None the less, hæmorrhage at the base of the

brain was, I believe, responsible for early death in many of the severe

cases, especially when the wounds were near the lower regions of the

skull.

Escape of cerebro-spinal fluid was not so prominent a feature as might

have been expected, considering how freely the arachnoid space was

opened up in many cases. I think this was usually checked by early

coagulation of the blood, and later by adhesions. It must be remembered

also that extensive wounds were most common on the vertex, or at any

rate over the convex surface of the brain, while fractures of the middle

fossa were usually rapidly fatal.

_Concussion._--Cases exhibiting symptoms of pure uncomplicated

concussion were distinctly rare, as would be expected from the

mechanism of the injuries. On the other hand, symptoms of concussion

formed the dominant feature of all severe cases.

The symptoms in many instances consisted in great part in transitory

signs of the so-called 'radiation' type, such as are seen in destructive

lesions where the signs of nervous damage rapidly tend to diminish and

localise themselves.

As to the causation of the 'radiation' symptoms, it is difficult to

discriminate the effects of neighbouring parenchymatous hæmorrhages from

those of local vibratory concussion of the nervous tissue. The local

character of the signs seems, however, to point to causation by

molecular disturbance, resulting from the conduction of forcible

mechanical vibration to the brain tissue rather than to upset in the

intra-cranial pressure. Again the limited nature of the paralysis

observed, sharply defines it from the general loss of power accompanying

ordinary cases of concussion of the brain. The similarity of the

phenomena to those described in other parts of the body under the

heading of 'local shock' is sufficiently obvious.

The following instance well exemplifies the condition in question:

(55) Wounded at Spion Kop. A scalp wound 3 inches in length

crossed the left parietal bone nearly transversely, starting

1-1/2 and ending 2 inches from the median line: the centre of

the wound corresponded with the position of the fissure of

Rolando. The patient was struck at a distance of fifty yards

while kneeling; he fell and remained unconscious an hour and a

half. Right hemiplegia without aphasia followed. The wound was

cleansed and sutured, and in three days both arm and leg could

be moved, after which time the man improved rapidly. Three weeks

later when I saw him at Wynberg there was still comparative

weakness of the right side, but beyond some neuralgia of the

scalp, the man considered himself well. No groove could be

detected on the bone on palpation. (This case offers a good

example of the ease with which bone injury may be overlooked.

The man came over to England 'well;' but while on furlough, two

pieces of bone came away spontaneously. He is now again on

active service.)

_Compression._--Equally rare was it for pure symptoms of compression to

be exhibited. This depended on two circumstances: first, the rarity of

injuries giving rise to meningeal hæmorrhage; secondly, the fact that in

nearly every case a more or less extensive destructive lesion was

present, at the margins of which less completely destroyed tissue

remained, capable of giving rise to symptoms of irritation. Again, as we

have seen, free hæmorrhage into, or from the walls of, the cavities

produced in the brain was not a marked feature, and beyond this the

large defect in the cranial parietes was calculated to render a high

degree of compression impossible.

As the most serious head injuries presented a remarkable similarity in

their symptoms, I will shortly summarise their common features.

Every degree of mental stupor up to complete unconsciousness was met

with, but in some instances where the pulse, respiration, and general

bodily condition pointed to speedy dissolution, the patients answered

rationally often between moans or cries indicative of pain.

Widespread paralysis often existed, but this was seldom completely

general; more commonly it was combined with extreme restlessness of the

unparalysed parts, or sometimes, even when the whole of one hemisphere

was tunnelled, and in all probability widely destroyed, restlessness was

the only symptom. In some cases twitching of the features or the limbs

or severe convulsions were superadded.

The pupils were rarely unequal, and at the stage in which these patients

were first seen were usually moderately contracted. Wide dilatation was

uncommon throughout.

The pulse was with very few exceptions slow, sometimes irregular. In

some instances, when the wounds had been thought suitable for

exploration, the slow pulse was altered after operation to a rapid one,

and death usually quickly supervened.

Respiration was irregular, sometimes sighing; in the late stage often of

the Cheyne-Stokes type; actual stertor was exceptional, but the

respiration was often noisy.

The temperature was often raised from an early stage to 99° or 100°, and

if the patient survived a day or two, it often rose to 103° or 104°. How

far the secondary rise depended on sepsis it was not always easy to

determine. The urine was usually retained.

Cases presenting the above characters were usually those suffering from

lesions such as are described in class I., and mostly died in

twenty-four to forty-eight hours. The correspondence of the train of

symptoms with those due to combined brain destruction and severe

concussion is at once apparent.

To illustrate the nature of the symptoms in patients suffering from the

less extensive forms of injury, such as those included in classes II.

and III. under the heading of anatomical lesion, the relation of a short

series of histories will be advisable. I may first premise, however,

that the special characteristics of these were in some instances the

almost entire absence of primary symptoms of gravity; in others general

symptoms of a severity out of apparent proportion to the external

lesion; while in all destructive lesions, very widely distributed

radiation symptoms developed, often disappearing with great rapidity.

The symptoms consisted in those of concussion, irritation, local

pressure, and actual destruction.

The symptoms of concussion were either general, and then usually

transient, or local paralysis of the radiation variety, which also

rapidly improved.

Signs of irritation consisted in irritability of temper, drowsiness,

closure of the eyes and objection to light, contracted pupils sometimes

unequal, a tendency to the assumption of the flexed position at all the

joints, twitchings, and sometimes convulsions. Sometimes these appeared

early as a direct result of mechanical irritation from bone fragments or

blood-clot; sometimes only in the course of a few days, as a result of

irritation of parts recovering from the radiation effects which had

prevented earlier nervous reaction. Possibly in some cases the symptoms

of irritation depended upon an increase in the amount of hæmorrhage, and

in others upon the development of local inflammatory changes.

Local pressure, or actual destruction of brain tissue, was evidenced by

temporary paralysis in the former, permanent loss of function in the

latter, condition.

Fractures of the anterior fossa of the skull were attended by very

marked evidence of orbital hæmorrhage, as subconjunctival ecchymosis

(rarely pure), increased tension, and proptosis.

Injuries to the cranial nerves at the base, with the single exception of

lesion of the optic nerves, which was not rare, were in my experience

uncommon in the hospitals--a fact pointing to the very fatal nature of

direct basal injuries, except in the anterior fossa of the skull. Signs

indicative of injury to the olfactory lobe were occasionally observed.

I should, perhaps, again insist here on the rarity with which acute

diffuse septic infection occurred in cases of these degrees of severity,

also on the fact that interference with the wounds in the way of

secondary exploration, even when they were manifestly the seat of local

infection, was followed almost without exception by good immediate

results; and, lastly, that when suppuration did occur, it was usually

strictly local in character. The influence of the climate of South

Africa and our surroundings has already been discussed, but whether

climate, condition of the patients, or peculiarity in the nature of

causation of the wounds was responsible, in no series of cases was the

absence of acute inflammatory troubles more striking than in this one of

brain injuries.

Frontal injuries were those most frequently unaccompanied by primary

symptoms of severity; slowing of the pulse--this often fell to 40--and

occasional irregularity, were almost the only constant signs of cerebral

damage. Some patients temporarily lost consciousness, others rose at

once and walked to the dressing station, and in few cases was any

psychical disturbance noted in the early stages.

I think, however, it may be affirmed that frontal injuries, accompanied

by trivial signs, resulted without exception from the passage of bullets

travelling at a low rate of velocity. Thus in several of the instances

here related the patients at the time of reception of the wound were

under the impression that they were entirely beyond the range of fire,

and in one, in which well-marked signs of concussion followed, the

bullet, which had traversed the head, retained only sufficient force to

perforate the skin of the neck and bury itself in the posterior

triangle without even fracturing the clavicle, against which it

impinged. In men struck at a shorter range, signs of concussion, often

followed by transient radiation signs of injury to the parietal lobe,

were common. These signs were, I think, not as a rule due to surface

hæmorrhage, since they were of a purely paralytic nature and not

irritative. Several cases with partial or complete hemiplegia,

hemiplegia and aphasia, or facial paralysis are recorded below.

(56) _Frontal injury_.--Wounded at Magersfontein. In prone

position when struck, distance 700 to 800 yards. _Entry_

(Mauser), at the margin of the hairy scalp above and to the

left of the frontal eminence; course, through anterior third of

left frontal lobe, roof of orbit, obliquely across line of

optic nerve, inner wall of orbit, nose, right superior maxilla

piercing alveolar process, and passing superficial to inferior

maxilla: _exit_, one inch anterior to angle of jaw. The bullet

again entered the posterior triangle of the neck, struck the

right clavicle, and turned a somersault, so that its base lay

deepest in the wound.

The patient was unconscious for a short time, suffered with

general headache and giddiness, and was somewhat irritable. On

the third day the pulse was 70, temperature normal, and he was

sent to the Base. There was considerable proptosis, oedema

and discoloration of the eyelid, and subconjunctival

ecchymosis, but the movements of the eyeball could be made and

light could be distinguished. The sense of smell was apparently

absent. A week later the headache was gone, the pulse numbered

80 to 90, the temperature was normal, he slept well, sat up in

bed and smoked, took his food well, and exhibited no cerebral

symptoms. He could detect the smell of tobacco, but not as a

definite odour.

No further symptoms were noted, the sense of smell returned,

the swelling of the eyelid and proptosis decreased, but the

upper lid could not be raised. When the lid was drawn up, there

appeared to be vision at the margins of the field with a large

central blind spot. The patient left for England at the end of

a month apparently well.

(57) _Gutter fracture of frontal bone._--Wounded at Paardeberg.

_Entry_ (Mauser), 3/4 of an inch within the margin of hairy

scalp above outer extremity of right eyebrow; gutter fracture;

_exit_, 2 inches nearer middle line, at the same distance from

the margin of the hairy scalp. The patient was knocked head

over heels, his main feeling being a sense of dulness in the

right great toe. He sat up and got a first field dressing

applied, then lay down, but as he was still under fire, he

retired 1,000 yards to the collecting station; here he dressed

some patients, and later mounted an ambulance wagon and was

driven to the Field hospital. The next day he helped with the

work of the hospital, amongst other things controlling the

artery during an amputation of the arm. He then took a three

days' and nights' journey to Modder River in a bullock wagon,

during which journey he had a fit, which was general, the

thumbs being turned in and a wedge being necessary between the

teeth to prevent him biting his tongue.

On the sixth day the wound was examined, and between this and

the tenth day he had several fits of the same nature as the

first, accompanied by stertorous breathing and profuse

sweating. On the tenth day Mr. Cheatle opened up the wound and

removed numerous fragments of bone, leaving a clean gutter 2

inches by 3/4 of an inch. After the operation no further fits

occurred, and eight days later he was conscious, but was

excitable and talked at random. On the twentieth day he arrived

at the Base after 30 hours' railway journey (623 miles). He was

then quite rational, but unable to make any demands on his

memory and very sensitive to noise; at times he wandered in the

evenings and his temperature rose as high as 100°. The wound

was open and granulating, the floor pulsating freely.

Three weeks later the wound was still open, and the skin dipped

in at the lower margin. The mental condition was much improved,

although attempts at giving a history of his case were

obviously tiresome.

The wounds in the leather headband of this patient's helmet

were interesting, the round aperture of entry in the exterior

of the helmet being followed by a starred exit aperture in the

leather band, the second entry opening in the leather band

being again circular, and the external opening in the puggaree

a transverse slit.

(58) _Transverse superficial perforating frontal

injury._--Wounded at Graspan. Aperture of _entry_

(Lee-Metford), at upper and outer part of left frontal

eminence; _exit_, at margin of hairy scalp over outer third of

right eyebrow. On the second day the patient complained of

giddiness and headache; the pulse was 60. He was then walking

about. The wounds were explored and typical entry and exit

apertures discovered in the frontal bone from which cerebral

matter was protruding. Both openings were enlarged (Mr. S. W.

F. Richardson) with Hoffman's forceps, and a considerable

number of splinters of the inner table were removed from the

aperture of entry.

The headache gradually passed off, but there was throbbing

about the scar, and pulsation was visible for some three weeks,

after which no further symptoms were observed.

(59) _Oblique frontal gutter fracture._--Wounded at

Magersfontein. _Entry_ (Mauser), 1/2 an inch to right of median

line of forehead, 3/4 of an inch from the margin of the hairy

scalp; _exit_, about 3/4 of an inch anterior to the lower

extremity of the right fissure of Rolando. Weakness of left

facial muscles, especially of angle of mouth. No further motor

symptoms. Wounds explored (Mr. Stewart); numerous fragments of

bone and some pulped cerebral matter were removed. Patient

developed no further signs; the paralysis, although improved,

did not completely disappear. The man a year later was still on

active duty, the paralysis almost well, and no further ill

effects of the injury remained.

In the fronto-parietal or parietal regions, signs of damage to the

cortical motor area were seldom absent, sometimes evanescent, at others

prolonged. In some cases the signs were permanent and followed by

evidence of local sclerosis.

The motor area on both sides of the brain was sometimes implicated; thus

in a child shot at Kimberley the bullet entered in the right frontal

region, and emerged to the left of the line connecting bregma and inion

a little behind its centre. Paralysis of both lower extremities

resulted, power rapidly returning in the right, while incomplete

paralysis persisted in the left.

In only one instance (see case 73, p. 292) was any permanent sensory

defect observed, and the mental condition of this patient would have

certainly suggested a functional explanation for its presence, had it

not been for the accompanying inequality in the axillary surface

temperatures.

In a second case (No. 67) blunting of sensation followed a definite

lesion of the inferior parietal lobule. In this instance an occipital

lesion was associated with the parietal.

(60) _Parietal gutter fracture._--Wounded at Magersfontein. A

scalp wound 3 inches in length ran transversely across the

right parietal bone at the level of the lower third of the

fissure of Rolando. A second wound of entry was found crossing

the third dorsal spine; the bullet was retained and was

palpable over the right scapula. There was left facial

paralysis, weakness and numbness of both upper extremities,

especially of the left, and some difficulty in swallowing. The

man was sent to the Base, where he arrived on the fourth day.

The symptoms had then become much more marked, consciousness

was incomplete, and articulation slow and imperfect. There was

complete left hemiplegia, and deviation of the tongue to the

right. The pulse was 40. An exploration (Mr. J. J. Day) showed

that an oval plate of the outer table of the parietal bone had

been struck off. A trephine was applied to the exposed diploë

and a crown of bone removed; considerable comminution of the

inner table had occurred, several large fragments having

perforated the dura-mater. The latter did not pulsate; it was

therefore freely incised, and many more fragments of bone and a

large quantity of blood-clot removed.

The first effect of the operation was slight, but ten days

later rapid improvement commenced, the first sign being

acceleration of the pulse, which rose to 70. On the eighteenth

day the original symptoms still remained to a diminished

extent, but a fortnight later there remained traces of the

facial weakness only, and there was little difference in the

grip of the two hands. The patient was shortly afterwards sent

home. Ten months later he returned to South Africa on active

service.

(61) _Fronto-parietal gutter fracture._--Wounded at Graspan.

_Entry_ (Mauser), 1 inch within the margin of the hairy scalp,

1/2 an inch to the left of the median line; _exit_, 3-1/2

inches posterior in same line. Complete right-sided hemiplegia.

The wounds were explored on the fourth day (Major Moffatt,

R.A.M.C.) and a gutter fracture involving the frontal and

parietal bones exposed. The dura-mater was lacerated and brain

matter from the frontal lobe escaped freely. A large number of

bone fragments were removed. On the fourth day after the

operation, the patient became unconscious with right-sided

twitchings, but rapidly improved, and at the end of three

weeks, except for slight headache, he was well, the power of

the right side being good. Ten months later he rejoined his

regiment in South Africa, no apparent ill effects remaining.

(62) _Fronto-parietal perforating fracture._--Wounded at

Magersfontein. _Entry_, within the margin of the hairy scalp;

_exit_, behind and below the left parietal eminence, the track

crossing about the centre of the fissure of Rolando. Right

hemiplegia, the lower half of the face only being involved. The

wounds were explored and a large number of fragments of bone

and a quantity of pulped cerebral matter removed. Six days

later the hemiplegia persisted, speech was slow, headache was

troublesome and the pulse not above 45. After this, gradual

improvement took place, and a month later the lower extremity

and face had regained good power. The upper extremity remained

flaccid and paralysed, except for some slight power of movement

of the shoulder.

(63) _Fronto-parietal perforating fracture._--Wounded at

Magersfontein. _Entry_ (Mauser), 2-1/2 inches from the median

line, 3-1/2 inches from the occipital protuberance; _exit_, 3/4

of an inch from the median line, 4-1/2 inches from the

glabella; sanious fluid escaped from both ears. There was left

facial paralysis, complete paralysis of the left upper

extremity, and partial paralysis of the left lower extremity.

The patient was deaf, drowsy, and the pulse 45.

Exploration showed the entry wound to be in the parietal, the

exit to involve both parietal and frontal bones. The openings

were enlarged, and a number of fragments of bone, together with

pulped cerebral matter and blood-clot, were removed. The wound

healed, except at the front part, where a small prominence

suggested a hernia cerebri.

The patient improved slowly; fourteen days after the operation

he could hear well, and the flow from the ears had ceased. The

facial weakness was slight, the upper extremity was still

powerless, but he could move the lower and draw it up in bed.

At the end of six weeks the wound had healed, and he was got up

and dressed.

At the end of two months he was well enough to be sent home;

there was only a trace of facial weakness; the right upper

extremity, however, was powerless and slightly rigid,

occasional twitchings occurring in it. Considerable power had

been regained in the lower extremity, so that the patient could

walk with help, but foot-drop persisted; the gait was spastic

in character, the reflexes were much exaggerated, and there was

marked clonus. The patient was sensible, but his manner

suggested some mental weakness. Both the openings in the skull

were closed by very firm material, apparently bony.

This patient became a Commissionaire some ten months later. His

mental condition is normal, and loss of memory seems confined

to the events immediately following the injury. The lower

extremity has improved, but the upper is useless.

(64) _Parietal injury: retained bullet._--Wounded at

Paardeberg. Aperture of _entry_ (Mauser), 1 inch diagonally

below and anterior to left parietal eminence. No exit. The

patient was trephined by the surgeons of the German ambulance

at Jacobsdal.

Sixteen days later he arrived at the Base. A circular pulsating

trephine opening was then to be felt beneath the flap, but no

information was forthcoming as to the bullet. The patient

could speak, but lost words and the gist of sentences; he

could remember nothing as to himself since the day of the

injury. There was right facial weakness; he could not close the

right eye or whistle, but there was little apparent want of

symmetry; there was weakness in the grip of both hands, more

marked on the right side; both lower extremities could be

moved. The reflexes were normal, although the left limb was

slightly rigid. The pupils were equal, reflex normal; slight

nystagmus. Pulse 72, small and regular. Temperature normal.

Rapid improvement followed.

During the fourth week the temperature rose to 103°, and

remained elevated for six days, but no local or general signs

appeared; at the end of five weeks there was little evidence of

the paralysis remaining. The patient was discharged from the

service on his return home.

In the upper part of the occipital region glancing or superficial

injuries were comparatively favourable; those near the base, especially

if perforating, were very dangerous. Two such cases are referred to

elsewhere. Case 69 is included as the only example of cerebellar injury

I happened to see who lived any appreciable time after the accident.

The main interest in these cases centres in the defects produced in the

area of the visual field. I am extremely indebted to my colleague, Mr.

J. H. Fisher, who has kindly determined this for me in three of the

following cases. It will be noted that in two instances the injury was

to the left occipital lobe. In these the resulting hemianopsia was of

the pure lateral homonymous character, and in both the visual symptoms

were accompanied by a certain degree of amnesic aphasia (65 and 68).

In 65 the injury was definitely unilateral, and at the time of the

operation I decided that at least an inch and a half of the posterior

extremity of the left occipital lobe was totally destroyed.

In 68 the lesion was probably confined to the left lobe, but it is

impossible to exclude slight injury to the right lobe also. In this

instance amnesic aphasia was a far more marked symptom than in 65, and

the position of the lesion suggested damage both to the visual and

auditory word centres.

Cases 66 and 67 are instances of damage to both occipital lobes. In 66,

although the wound was a glancing one, and did not perforate, it was so

near the median line, and accompanied by such severe damage to the bone,

that a symmetrical lesion of the cuneate and precuneate lobules of both

right and left sides is to be inferred. In 67 the great longitudinal

fissure was traversed by the bullet obliquely. It is of great interest

to observe that in each of these cases the lesion of the visual field

was a horizontal one and affected the lower half in place of assuming a

lateral distribution.

In all four cases the primary effect of the occipital injury was the

same--viz. absolute blindness--while the return of vision in each was of

the nature of the dawning of light. I regret that I am unable to furnish

any detail as to increase of the field of vision in the progress of the

cases, but circumstances rendered continuous observation of the patients

impossible.

In each case deafness was apparently the direct result of concussion of

the ear on the side corresponding to the wound. Deafness of the opposite

ear was never noted.

In case 67 some general blunting of sensation was noted in the paralysed

upper extremity, and in this patient, no doubt, injury to the inferior

parietal lobule accompanied the occipital lesion.

(65) _Injury to left occipital lobe._--Wounded at Belmont. A

single transverse wound, 2 inches in length, extended across

the occipital bone, 2 inches above the level of the external

protuberance. When seen on the third day the wound was gaping

and pulped cerebral matter was found in it. The patient was

very drowsy, lying with closed eyes, and complaining of great

coronal and frontal headache. He could distinguish light and

darkness, but not persons. Total blindness immediately followed

the injury, persisting some three days, and the patient spoke

of return of sight as of the appearance of dawn. The pupils

were equal, moderately dilated and acted to light, which was

unpleasant to him. He was somewhat irritable and silent, but

apparently rational. Temperature 99°. Pulse 56 full. Tongue

clean. No sickness, no difficulty in micturition.

Fifty-six hours after the injury the wound was opened up and

cleaned, and an oval fractured opening about 3/4 by 1/2 inch

was exposed 3/4 inch to the left, and 2 inches above the

occipital protuberance. The margins of the opening showed

several small fragments of lead attached to the bone. A

3/4-inch trephine was applied at the left extremity of the

opening, and it was found that about a square inch of the

internal table was comminuted and driven into the brain,

together with several small fragments of lead. On introducing

the finger, about 1-1/2 square inches of the occipital lobe

were found to be pulped, and the finger could be swept across

the tentorium. There was no sinus hæmorrhage (nor did the

history suggest that hæmorrhage had ever been severe). The

cavity was carefully sponged out, and the wound closed with a

drainage aperture. Little change followed in the patient's

condition, and on the sixth day he was sent to the Base

hospital.

Three weeks later the wound was firmly healed. The patient

still complained of frontal headache, and wore a shade, as the

light hurt his eyes and made them water freely. The pupils

acted, but were wide; objects could be distinguished, and also

persons. Otherwise, the man's condition was good: he began to

get up, and at the end of six weeks returned to England.

A year later the man was earning his living as a Commissionaire

porter. He complains of giddiness when he stoops, or when he

looks upwards, and at times he suffers much with headache both

in the region of the injury and across the temples.

There is a bony defect and slight pulsation at the site of the

injury, but no prominence. When attempts are made to read the

lines run together, and a dark shadow comes before his eyes. He

speaks of the latter as still terribly weak. Speech is slow and

somewhat simple, but he makes no mistakes as to words. Memory

is bad for recent events.

Mr. Fisher makes the following report as to the eyes: Pupils

and movement of eyes normal in every respect. No changes in

fundi.

Vision, R. 5/12 with--0.5 5/6

L. 5/9 with--0.5 5/5

[Illustration: FIG. 73.--Right Visual Field, in case 65. Injury to left

occipital lobe. Field for white. Test spot 10 mm. Good daylight. Right

homonymous hemianopsia]

[Illustration: FIG. 74.--Left Visual Field, case 65]

There is therefore practically full direct vision. Though the

man chooses a concave glass he is not really myopic. There is

typical right homonymous hemianopsia; the answers, when tested

with the perimeter, are quite certain, and the fields

absolutely reliable.

The man's statements confirm the condition; he is aware of his

inability to see objects to his right-hand side, and is apt to

collide with persons or objects on that side.

The lesion is one of the left occipital cortex in the cuneate

lobe and the neighbourhood of the calcarine fissure. The speech

suggests a slight degree of aphasia.

(66) _Injury to occipital lobes._--Wounded at Magersfontein

while in prone position. Distance, 500 yards. He says he was

never unconscious, but for two days was absolutely blind. His

eyesight gradually improved, but headache was very severe, and

sleeplessness nearly absolute. On the eighth day the wound,

which was situated over the right posterior superior angle of

the parietal bone, was opened up, and a number of fragments of

bone and a quantity of pulped brain removed from a depressed

punctured fracture, surrounded by an annular fissure,

completely encircling it, 1-1/2 inch from the opening. The

portion of brain destroyed was probably a considerable portion

of the cuneate and precuneate lobules of both sides, as well as

a portion of the first occipital convolution, and the superior

parietal lobule of the right side. There was no evidence of

injury to the superior longitudinal sinus in the way of

hæmorrhage.

After the operation the patient slept better, but still

complained of headache, and when he arrived at the Base, the

flap became oedematous, and the stitch holes and also the

central part of the wound suppurated. The temperature rose to

101°. The wound was therefore re-opened, and a number of

additional fragments of bone, some as deeply situated as 2

inches from the surface, were removed. Steady improvement

followed, and at the end of a further three weeks the wound was

healed, the headache had ceased, and there were no abnormal

symptoms, except that light was unpleasant to the right eye,

and the field of vision was manifestly contracted (Mr. Pooley).

A year later the man was employed as a letter-carrier. He

complains of headache at times, and on six occasions has had

'fainting fits.' He says that the latter commence with tremor,

that his legs then give way and he falls. In a quarter of an

hour he gets up, and feels no further inconvenience. Speech is

perfect, there is no deafness. The bone defect is very nearly

completely closed.

Mr. Fisher reports as follows as to the vision. There is a high

degree of hypermetropia in each eye, the R. has nearly 6.0 D

and the L. about 5.0 D. With correction he gets practically

full direct vision with each.

[Illustration: FIG. 75.--Right Visual Field, in case 66. Injury to both

occipital lobes. Field for white. Test spot 10 mm. Good artificial

light. Defect in field complicated by functional symptoms]

[Illustration: FIG. 76.--Left Visual Field, in case 66. Defect in lower

half of field]

The patient has been examined before, and has been informed

that his vision quite incapacitates him from further service.

He began by stating that he could not see on either side of

him, but only straight in front; that he is apt to collide with

people in walking, was nearly knocked down by a horse, and that

his acquaintances accuse him of passing them unnoticed. The

fields of vision are very small, but the loss is not typically

in the temporal half of either. That of the right eye which we

know as the spiral field, becoming more and more contracted as

the perimeter test is continued, is what is found in functional

cases; that of the left, however, shows a characteristic loss

of the lower part of the field of vision, and agrees with the

statement of the man that he can see the upper part of my face

but not the lower when he looks at me. Such a loss agrees with

a lesion involving the upper part of the cuneate lobe above the

calcarine fissure.

I feel satisfied that there is considerable loss in the right

field also, but the functional element obscures its exact

nature.

The fundi, pupils, and ocular movements are all normal.

(67) _Injury to occipital lobes and left motor and sensory

areas._--Wounded outside Lindley (Spitzkop). Range within 1,000

yards. _Entry_, one inch within the right lateral angle of the

occipital bone, external wound more than 1/2 an inch in

diameter; _exit_, 2 inches from the median line, over the upper

half of the left fissure of Rolando. Behind the wound of exit

comminution of the parietal bone, extending back to the

lambdoid suture, existed. I attributed this to oblique lateral

impact by the bullet on the inner surface of the skull.

The patient could afterwards remember being struck, but became

rapidly unconscious. When brought into the Field hospital some

five hours later the condition was as follows: Semi-conscious,

can speak, apparently blind, pupils equal, of moderate size, do

not react to light. Right hemiplegia. No sickness. Moans with

pain in head. Passes water normally.

Considerable hæmorrhage had occurred from each wound, the scalp

was puffy, and the bones yielded on pressure over the left

parietal bone, indicating considerable comminution.

The night was so cold that no operation could be considered, so

the head was partly shaved, the wounds cleansed, and a dressing

applied. The next morning the Division marched at 5 A.M., and

it was considered wise to leave the man at Lindley in the local

hospital.

[Illustration: FIG. 77.--Right Visual Field, in case 67. Injury to both

occipital lobes. Field for white. Test spot 10 mm. Good artificial

light. Defect in lower half of field]

[Illustration: FIG. 78.--Left Visual Field, in case 67]

No operation was performed there, but I heard later that the

man recovered full consciousness at the end of five days, and

at the end of a fortnight he commenced to see again.

Six weeks later he travelled to Kroonstadt, thence to

Bloemfontein, and thence to Cape Town and home to Netley. The

paralytic symptoms meanwhile steadily improved.

Seven months later his condition is as follows: Scarcely a

trace of facial paralysis. Slight power of movement of arm,

forearm, and fingers, but grip is very weak. Little power of

abduction of the shoulder or of straightening the elbow. The

latter movement is made with effort and in jerks. Sensation

over the back of the arm is somewhat lowered, and is 'furry' at

the finger tips. There is very little wasting of the muscles

noticeable.

Walks well, but with some foot-drop. Slight increase of

patellar reflex. He says that he does not walk in the street

with confidence, as he often feels as if omnibuses &c. were

coming too near him.

He is absolutely deaf in the right ear.

The openings in the skull are closed, the occipital lies about

halfway between the external auditory meatus and the external

occipital protuberance, while the parietal still affords

evidence of the earlier comminution, one fissure passing

backwards as far as the lambda, and the whole surface is lumpy

and uneven.

The track through the brain no doubt involved a considerable

extent of the outer aspect of the right occipital lobe and the

cuneate lobule. It must also have crossed the great

longitudinal fissure, and penetrated the left Rolandic region,

just above its centre, probably involving the precuneate

lobule, and a portion of the internal capsular fibres as well

as the cortex on the left side. The deafness was probably due

to concussion of the internal ear.

Mr. Fisher has kindly furnished the following note regarding

the vision. The pupils, movements, and fundi are quite healthy.

There is good direct vision R. or L. 5/5 fairly, and together

5/5. The man complains he has lost his side sight, also the

lower; he demonstrates the latter quite obviously with his

hand, and says he has to repeatedly look down when walking. He

thinks no improvement has taken place during the last month.

The accompanying fields of vision show the loss quite

characteristically.

(68) _Injury to left occipital lobe._--Wounded at Paardeberg.

_Entry_ (Mauser), through the lambdoid suture on the right side

of the mid line. Bullet retained, but a palpable prominence

behind the left ear suggested its localisation.

The patient became at once unconscious and remained so for

several days. He was completely blind; vision returned later,

but only to a limited degree. There was complete loss of

memory as to the events of the day.

When admitted at Rondebosch into No. 3 General Hospital the

condition was as follows: The field of vision is limited, and

examination shows right homonymous hemianopsia. When any one

comes into the tent the patient sees a shadow only until his

bed is reached.

When spoken to the patient 'thinks and thinks,' and then

apologises for not answering, saying he will remember at some

future time. He is absolutely unable to remember times, names,

or localities, but places his hand to his head and appears to

think deeply in the effort to recall them. Occasionally when

you go into his tent he suddenly remembers something he has

been trying to think of for some days, and will tell you.

A fortnight later after an attack of influenza the patient was

not so well, and vision was apparently becoming more impaired.

An incision was made (Mr. J. E. Ker) so as to raise a flap the

centre of the convexity of which was 2-1/2 inches behind the

left external auditory meatus. A slight prominence and a

fissure was discovered in the temporal bone, and over this a

trephine was applied. On removal of the crown of bone the

bullet was discovered with the point turned backwards (having

evidently undergone a partial ricochet turn) on the upper

surface of the petrous bone, just above the lateral sinus. The

dura-mater was healed but thickened, and some clot upon its

surface was removed.

The wound healed per primam, and a rapid recovery was made. Ten

days later a running water-tap was able to be detected 120

yards from the tent door. The hemianopsia however persisted.

The following letter, dictated by the patient to his wife, and sent to

me, gives a clear account of his condition ten months later:--

I am pleased to say my memory is better than it was some time

ago, though at times I am entirely lost and really forget all

that I was speaking about. I also find that I often call things

and places by their wrong names. I sometimes try to read a

paper or book which I have to read letter by letter, sometimes

calling out the wrong letter, such as B for D &c., and by the

time I have read almost halfway through, I have forgotten the

commencement.

My sight is about the same. There is no improvement in the

right eye, and the doctor at Stoke said that the left eye was

not as it ought to be and might get worse.

I ofttimes go to take up a thing, but find I am not near to it,

though it appears to me so.

I have no pain to speak of in the head, though at times a

shooting pain.

I have a continual noise in the left ear as if of a locomotive

blowing off steam, and a deafness in the left ear which I had

not before being wounded.

I am extremely indebted to my friend Mr. J. Errington Ker for the notes

of the above case, so successfully treated by him.

(69) _Injury to occipital lobe._--Wounded at Modder River.

Scalp wound in occipital region. Two days later on arrival at

the Base the patient was extremely restless and in a condition

of noisy delirium. The wound was explored (Mr. J. J. Day) and a

vertical gutter fracture discovered 1/2 an inch above and to

the left of the occipital protuberance. The gutter was 1-1/2

inch in length and finely comminuted, the dura wounded, and the

left occipital lobe pulped. A number of fragments of bone (one

lodged in the wall of, but not penetrating, the lateral sinus)

and pulped brain were removed. No improvement took place in the

general condition, but the patient lived twenty-two days,

during which time he coughed up a large quantity of gangrenous

lung tissue and foul pus.

At the _post-mortem_ examination a wound track was found

extending to the crest of the left ilium, where the bullet was

lodged. The patient was no doubt lying with his head dipped

into a hole scooped out in the sand (a common custom) when

struck; the bullet then traversed the muscles of the neck,

entered the upper opening of the thorax, where it struck the

bodies of the second and third dorsal vertebræ, one third of

the bodies of each of which were driven into an extensive

laceration of the lung; it then grooved the inner surfaces of

the eighth and ninth ribs, fractured the tenth and eleventh,

and passing the twelfth traversed the deep muscles of the back

to the pelvis. Beyond the injury to the occipital lobe, the

cerebellum was found to be lacerated and extensively bruised

and ecchymosed.

_Complications._--_Hernia cerebri_ as a primary feature has already been

mentioned as one of the peculiarities of some explosive wounds. In the

later stages of the cases in which primary union did not take place the

development of granulation tumours was often seen, sometimes in

connection with slight local suppuration, sometimes over a cerebral

abscess. In some cases a wound which had once closed reopened and a

hernia developed. This sequence was chiefly of prognostic significance

as an indication of intra-cranial inflammation, usually of a chronic

character, and affecting rather the lowly organised granulation tissue

formed in the cavity than the brain itself. When primary union of the

skin flap and wound failed, the process of definitive closure of the

subjacent cavity was always a very prolonged one, and it was in such

cases that a great proportion of the so-called herniæ developed.

_Abscess of the brain._--Local abscesses formed in a considerable

proportion of the cases where serious damage to the brain had occurred,

in whatever region this happened to be. I never saw one develop in cases

where primary union had taken place, even when bone fragments had not

been removed; neither did I ever see an abscess situated at a distance

from the original injury. I take it that the latter is to be explained

by the early date of the suppuration, and the fact that in the great

majority of small-calibre wounds the exit opening exists in the

situation of the contre-coup damages of civil practice.

The main feature in the symptoms when abscesses developed was the

insidious mode of their appearance, usually at the end of fourteen to

twenty-one days, and their comparative mildness.

Very slight evidences of compression were observed; thus, varying

degrees of headache, drowsiness, irritability of temper or depression,

twitchings, or in some cases Jacksonian seizures, combined with slow

pulse and slight rises of temperature. I never happened to see complete

unconsciousness. The slight evidence of compression was perhaps

explained in most cases by the large bony defect in the skull, which

acted as a kind of safety-valve. Again the firm nature of the

cicatricial tissue which formed at the periphery of the injury and

extended up to the skull and there formed a more or less firm

attachment, also preserved the actual brain tissue to some degree from

either pressure or direct irritation. After evacuation of the pus, the

usual difficulty was experienced in ensuring free drainage, and

definitive healing and closure of the cavities was very slow. The

following two cases will illustrate the character of the cases of

cerebral abscess we met with:--

(70) _Fronto-parietal abscess._--Wounded at Magersfontein

(Mauser). _Entry_, 1-3/4 inch above the line from the lower

margin of the orbit to the external auditory meatus, and 1-3/4

inch behind the external angular process; _exit_, a little

posterior to the left parietal eminence. There was right

hemiplegia. The wounds were explored, and a large number of

fragments of bone and pulped brain were removed, especially

from the anterior wound. No great improvement followed, and the

patient was sent to the Base. At this time there was a large

hernia cerebri at the anterior wound which was suppurating.

A further operation was here performed (Mr. J. J. Day). The

hernia cerebri was removed, also several fragments of bone

which were found deeply imbedded in the brain. The patient then

improved, but a month later his temperature rose, and on

exploration an abscess was discovered in the frontal lobe and

drained.

Subsequently the patient suffered with Jacksonian seizures,

sometimes starting spontaneously, sometimes following

interference with the wound. The convulsions commenced in the

muscles of the face, and the twitchings then became general.

Meanwhile the right upper extremity remained weak, although the

fist could be clenched, and all movements of the limb made in

some degree.

Some difficulty was experienced in maintaining a free exit for

the pus, which was however overcome by the use of a silver

tube. All twitchings ceased about a month after the opening of

the abscess, the man improved steadily, and he left for England

fifteen weeks after the reception of the injury, walking well,

with a firm hand-grip, and the wounds soundly healed.

(71) _Frontal injury. Secondary abscess._--Wounded at Modder

River. Aperture of _entry_ (Mauser), just external to the

centre of the right eyebrow; _exit_, above the centre of the

right zygoma. The wound did not render the man immediately

unconscious, but he lost all recollection of what had happened

to him for the next three or four days. The wounds were

explored on the second day, at which time the patient was in a

semi-conscious drowsy state, the pupils contracted and the

pulse slow. A number of fragments of bone and pulped brain

matter were removed.

Subsequently to the operation the patient showed more signs of

cerebral irritation than usual, lying in a semi-conscious state

and more or less curled up. He answered questions on being

bothered. He improved somewhat, and was sent to the Base,

where the improvement continued, but he suffered much from

headache.

Later the headache became much more severe, and eleven weeks

after the injury the man complained of great pain both locally

and over the whole right hemisphere; he lay moaning, with the

temperature subnormal, and the pulse very slow. At times there

was nocturnal delirium.

The wound had remained closed and apparently normal, but now a

small fluctuating pulsating nipple-like swelling developed in

the situation of the aperture of entry. This was incised, and

two ounces of sweet pus evacuated (Professor Dunlop). A tube

was introduced, and removed later on the cessation of

discharge.

Removal of the tube was followed by a recurrence of the same

symptoms, and this occurred on no fewer than six occasions

whenever the wound closed.

At the end of twenty weeks the patient appeared quite well, the

wound had been closed six weeks, the previously irritable

mental state was replaced by placidity, and he was sent home.

_Diagnosis._--The importance of proper exploration of scalp wounds to

determine the condition of the bone has already been insisted upon. The

localisation of the position and extent of the injury to the cranial

contents depended simply on attention to the symptoms, and needs no

further mention here.

_Prognosis._--This subject can only be very imperfectly considered at

the present time, since only the more or less immediate results of the

injuries are known to us, while the more important after consequences

remain to be followed up.

As to life the immediate prognosis has been already foreshadowed in the

section on the anatomical lesions. It is there shown that the first

point of general importance is the range of fire at which the injury has

been received. At short ranges, as evidenced by the history, the

characters of the wounds, and the severity of the symptoms, the

immediate prognosis was uniformly bad, a very great majority of the

patients dying, and that at the end of a few hours or days.

The rapidity with which death followed depended in part on the actual

severity of the wound, and still more on the region it affected; the

nearer the base and the longer the track the more rapidly the patients

died, and this always with signs of failure of the functions of the

heart and lungs due to general concussion, pressure from basal

hæmorrhage, or rapid intracranial oedema. In my experience no patients

survived direct fracture of the base in any region but the frontal,

although many, no doubt, got well in whom fissures merely spread into

the middle or posterior fossa. Patients with very extensive injuries at

a higher level, on the other hand, often survived days, or even a week,

then usually dying of sepsis.

The actual relative mortality of these injuries I can give little idea

of, but it was a high one both on the field and in the Field hospitals;

thus of 10 cases treated in one Field hospital, after the battle at

Paardeberg Drift, no less than 8 died; while of 61 cases from various

battles who survived to be sent down to the Base during a period of some

months, only 4 or 6.55 per cent. died. Many of the latter, as is seen

from the cases here recorded which were among the number, were none the

less of a very serious nature. The early causes of death in patients

dying during the first forty-eight hours have been already mentioned;

the later one was almost always sepsis.

As in civil practice the best immediate results were seen in injuries to

the frontal lobes, and after these in injuries to the occipital region.

In the latter permanent lesions of vision were, however, common. The

above injuries apart, the prognosis depended on the severity and depth

of the lesion. The frequency and extent of radiation symptoms often made

it possible to give a more hopeful prognosis than the immediate

conditions seemed to warrant, if the exact situation of the lesion, and

the probable velocity at which the bullet was travelling, were taken

into account; since the actual destructive lesion, when the velocity had

been insufficient to cause damage of a general nature, was often very

strictly localised.

Another very important point in the immediate prognosis was the primary

union of the scalp wound; if this could only be ensured, few cases went

wrong afterwards. Such remote effects as I witnessed were mainly the

results of the actual destructive lesion, such as paralyses and

contraction. I know of only one case in which early maniacal symptoms

closely followed on a frontal injury, and here the symptoms accompanied

the development of an abscess. Some patients were depressed and

irritable, and some were blind or deaf, probably from gross lesion; in

one patient the mental faculties generally were lowered.

In spite of the surprising immediate recoveries which occurred, and the

small amount of experience I am able to record as to remote ill effects

of these injuries, I feel certain that a long roll of secondary troubles

from the contraction of cicatricial tissue, irritation from distant

remaining bone fragments, as well as mental troubles from actual brain

destruction, await record in the near future.

Since my return to England I have heard of four cases of injury to the

head, which died on their return, as the result of the formation of

secondary residual abscesses; and of one who died suddenly, soon after

his return to active service in South Africa apparently well. These

occurrences are sufficiently suggestive.

It may be of interest to add here two cases of secondary traumatic

epilepsy of differing degree:--

(72) _Gutter fracture over left temporo-sphenoidal lobe.

Traumatic epilepsy._--A trooper in Brabant's Horse was wounded

at Aliwal North, in March, in several places. A Mauser bullet

entered the head 1-1/2 inch above the junction of the anterior

border of the left pinna with the side of the head. The exit

wound was situated just below and behind the left parietal

eminence. The patient stated that the shot was fired by a man

he recognised in a laager 150 yards distant from him.

The man remained unconscious eleven days, and when he came

round paralysis of the right upper extremity, and weakness of

both lower extremities, were noted. There was also ataxic

aphasia.

The wounds healed, but two months later the man began to suffer

from fits every few days. He spoke of them as fainting fits,

but they were accompanied by general twitchings.

The patient was shown to me in July by Major Woodhouse,

R.A.M.C. The strength of the right upper extremity was then

good, and he walked well. Speech was slow, but correct. The

pupils were equal, and acted normally.

The mental condition was weak, and the temper irritable. The

man had hallucinations, and was very obstinate: there was

complete deafness of the left ear. He refused surgical

treatment, but was really hardly a responsible individual.

(73) _Gutter fracture in right frontal region. Traumatic

epilepsy._--Wounded at Pieter's Hill. Gutter fracture crossing

the outer aspect of the frontal lobe, immediately above the

level of the right Sylvian fissure. The wound was perforating

at the central part, but only reached as far back as the lower

end of the ascending frontal convolution. The patient was

rendered unconscious and was removed to Mooi River. He was

there seen by Sir William MacCormac, who removed a number of

fragments of bone. The patient rapidly recovered consciousness

after the operation, but was completely hemiplegic. After a

month he suddenly found he was able to move his lower

extremity, and later the paralysis became steadily less.

On his return home the man obtained employment as a

Commissionaire, but nine months after the injury, while his

wife was helping him on with his coat one morning, he was

suddenly seized with a fit; the paralysed arm was jerked up,

and convulsions became general, a wedge needing to be inserted

to prevent the tongue suffering injury.

When admitted into the hospital, the cicatrix of the wound was

considerably depressed, and the central part was evidently

continuously attached to the surface of the brain. Pulsation

was both visible and palpable, there was little or no

tenderness on examination, and the patient did not complain of

pain.

Little trace of the left facial paralysis remained. The man

walked well, but with foot-drop. The left upper extremity was

rigid, but chiefly from the elbow downwards. The fingers were

flexed, but a slight increase of grip could be effected. No

other active movements of hand. The elbow was held flexed, but

could be straightened to about 3/4 range on effort. The

shoulder could be slightly abducted, but wide movements were

made by the scapular muscles.

Sensation was dull over the left side of the face, also over

the left side of the neck. There was complete loss of cutaneous

sensibility over the lower half of the forearm and hand, and a

similar patch in the left axilla. Over the rest of the

extremity the sensation was better on the flexor than on the

extensor aspects. There was little alteration in the common

sensation elsewhere, except that the contrast between that of

the dorsum and sole of the foot was somewhat more marked than

usual. The temperature of the insensitive axilla was one degree

higher than that of the right.

The left knee jerk was somewhat exaggerated.

On December 15 an incision was made through the old cicatrix

directly over the defect in the skull. On separating the skin

it was found directly adherent to the cicatrised dura, and when

this was incised a large vicarious arachnoid space was opened

up. The space was crossed by a number of strands of connective

tissue, and the cavity had no epithelial lining. The fluid ran

out freely, and the space was evidently in free communication

with the general arachnoid cavity. A trephine crown was taken

out at the posterior end of the gutter, and the surface of the

brain explored, but no fragments of bone were found. I

therefore replaced the crown, and closed the bony defect in the

floor of the gutter with a plate of platinum fitted into a

groove made in the bony margin. The wound was then sutured.

Primary union took place, and there was no constitutional

disturbance beyond one temperature of 100° on the evening of

the second day; otherwise the temperature remained normal, and

the pulse did not rise above 75.

On the second evening a fit occurred, coming on while the

patient was apparently asleep. It lasted about a quarter of an

hour and was general, the patient becoming for a short time

unconscious, and passing water involuntarily.

On the third morning two similar fits occurred, the first a

severe one, during which the patient passed a motion

involuntarily. The commencement of all three fits was observed

by the nurse only, but in each the convulsions apparently

commenced in the face and then became general.

Three months later no further fits had occurred, and the

patient, who throughout had said he felt remarkably well,

complained of nothing. The upper extremity was apparently

slightly less rigid than before the exploration, and the

patient said he walked somewhat better than before. The closure

of the skull was perfect.

_Treatment._--The treatment of fractures of the skull possesses a degree

of surgical interest that attaches to no other class of gunshot injury,

since operative interference is necessary in every case in which

recovery is judged possible. The injuries are, without exception, of the

nature of punctured wounds of the skull, and the ordinary rule of

surgery should under no circumstances be deviated from. An expectant

attitude, although it often appears immediately satisfactory, exposes

the patient to future risks which are incalculable, but none the less

serious. Happily the operations needed may be included amongst the most

simple as well as the most successful, and expose the patient with

ordinary precautions to no increase of risk beyond that dependent on the

original injury.

Cases of a general character, or in which the base has been directly

fractured other than in the frontal region, are seldom suitable for

operation, since surgical skill is in these of no avail; but in all

others an exploration is indicated. I use the word 'exploration'

advisedly, since what may be called the formal operation of trephining

is seldom necessary except in the case of the small openings due to

wounds received from a very long range of fire; in all others there is

no difficulty, but very great advantage, in making such enlargement of

the bone opening as is necessary with Hoffman's forceps.

The scalp should be first shaved and cleansed; if for any reason an

operation is impossible, this procedure at least should be carried out,

with a view to ensuring, as far as possible, future asepsis, infection

in head injuries being almost the only danger to be feared. The shaving

may need to be complete, but local clearance of the hair suffices in

many cases. The hair having been removed, the scalp is cleansed with all

care, a flap is raised of which the bullet opening forms the central

point, and the wound explored. In slight cases the entry opening is the

one of chief importance, and the exit may be simply cleansed and

dressed. In some instances, as in direct fracture of the roof of the

orbit from above, the exit should not be touched.

The flap having been raised, if the wound be a small perforation, a

1/2-inch trephine crown may be taken from one side; but it is rare for

the opening to be so small that the tip of a pair of Hoffman's forceps

cannot be inserted. The trephine is more often useful in cases of

non-penetrating gutter fractures where space is needed for exploration,

and the elevation or removal of fragments of the inner-table. Loose

fragments may need to be removed from beneath the scalp, but the

important ones are those within the cranium. These may either be of some

size, or fine comminuted splinters of either table, often at as great a

distance as 2 inches or more from the surface. The cavity must be

thoroughly explored and all splinters removed. I have seen more than

fifty extracted in one case of open gutter fracture. The brain pulp and

clot should then be gently removed or washed away, and the wound closed

without drainage. Fragments of bone, as a rule, are better not replaced,

but complete suture of the skin flap is always advisable in view of the

great importance of primary union, and the fact that a drainage opening

exists at the original wound of entry, and that the wound is readily

re-opened to its whole extent, should such a step be advisable.

The detection of fragments is easiest and most satisfactorily done with

the finger, and in all but simple punctures the opening should be large

enough to allow thoroughly effective digital exploration; the remarks

already made as to the factors determining the size of fragments are of

interest in this connection. The determination of the amount of brain

pulp which should be removed is somewhat more difficult; one can only

say that all that washes readily away should be removed, and its place

is usually taken up by blood.

Few fractures of the base are suitable for treatment; the only ones I

saw were those of direct fracture of the roof of the orbit or nose,

produced by bullets passing across the orbits; here the advisability of

interference with the injured eye led to opening of the orbit, and

sometimes exposed the fracture. Some patients recovered, even when the

damage had been sufficient to cause escape of pulped brain into the

orbit.

The after treatment simply consisted in keeping the patients as quiet as

circumstances would permit, and the administration of a fluid diet. In

some cases recurring symptoms pointed to the continued presence of bone

fragments; these were usually indicated by signs of irritation, or often

of local inflammation, in the latter case infection taking the greater

share in the causation. Such cases needed secondary exploration, and the

wonderful success of this operation, even when the wound was evidently

infected, was perhaps one of the most striking experiences of the

surgery in general.

I should add a word here as to the most satisfactory time for the

performance of these operations; as in all cases the earlier they could

be undertaken the better, but in the head injuries the advantages of

early interference were more evident than in any other region. This

depended on the fact that, as in civil practice, the scalp is one of the

most dangerous regions as far as auto-infection of the wound is

concerned, and one of the most difficult to cleanse, except by thorough

shaving. Beyond this the extreme simplicity of the operative procedure

needed, called for few precautions beyond those for asepsis, and very

little armament in the way of instruments, &c.

When on the march from Winberg to Heilbron with the Highland Brigade we

had some five days' continuous fighting, and on this occasion several

perforating fractures of the skull were brought in. The coldness of the

nights at that time made evening operations an impossibility; hence the

operations on these men were performed at the first dressing station, in

the open air, at the side of the ambulance wagons, often during the

progress of fighting around. Of several cases so operated on, all healed

by primary union without a bad symptom of any kind, except one (see p.

249), in whom a very large entrance opening over the right cortical

motor area led down to an extensive destruction of the brain,

complicated by a fracture of the base in the middle fossa. This wound,

from the first considered hopeless, became septic during the four days'

travelling in an ambulance wagon that was necessary, and the man died at

the end of fourteen days. As the whole cortical motor area was

destroyed, death was, perhaps, the end most to be desired; but the fight

that this man made for recovery, and the fact that his death, after all,

was due to general infection and not to any local extension of the

injury, very strongly impressed me with the possibility of recovery,

even in such extensive cases, if only an aseptic condition can be

maintained. I saw many other cases of the same nature, particularly in

men who, as a result of unfortunate circumstances, were necessarily left

out on the field for more than twenty-four hours. In some of these

maggots were found in the wounds only thirty-six hours after the

infliction of the injury.

I have said nothing as to the treatment of the large primary herniæ

cerebri in wounds of an explosive nature, since these were rarely

subjects suitable for operation; but in the instances of minor severity

they were treated as the other cases where the pulped brain lay mostly

within the skull.

In cases where the wounds were in the frontal or fronto-parietal

regions, and hemiplegia existed, the rapid improvement in the paralytic

symptoms, after operation, was very marked, showing that the signs were

mainly, or entirely, due to 'radiation' injury. I am inclined to think

that temporary injury of this kind from vibratory disturbance and small

parenchymatous hæmorrhages, were far more often the cause of the

paralysis than surface hæmorrhage, since the latter was rarely found in

large quantity. Large clots, however, no doubt growing in both size and

firmness, occasionally occupied the area of destroyed brain, and these

sometimes manifestly exercised pressure that was at once relieved by

their evacuation.