Injuries to the head formed one of the most fruitful sources of death, both upon the battlefield and in the Field hospitals. It has been suggested that the mere fact of wounds of the head being readily visible ensured all such being at once distinguished and correctly reported, while wounds hidden by the clothing often escaped detection. When the external insignificance of many of the fatal wounds of the trunk is taken into consideration this is possible; but, on the other hand, it must be borne in mind that the head is in any attitude the most advanced, and often the most exposed, part of the body, and even when the soldier had taken 'cover,' it was frequently raised for purposes of observation. For the latter reasons I believe injury to the head fully deserved the comparative importance as a fatal accident with which it was credited.
A number of somewhat sensational immediate recoveries from serious wounds of the head have been placed upon record. Observation, however, shows that these, with but few exceptions, belonged either to certain groups of cases the relatively favourable prognosis in which is familiar to us in civil practice, or that the wounds were received from a very long range of fire, and hence the injuries were strictly localised in character.
Wounds of the scalp.--Nothing very special is to be recorded with regard to these; they either formed the terminals of perforating wounds, or were the result of superficial glancing shots. The glancing wounds were of the nature of furrows, varying in depth from mere grazes to wounds laying bare the bone. Their peculiarity was centred in the fact that a definite loss of substance accompanied them, the skin being actually carried away by the bullet; hence gaping was the rule. Every gradation in depth was met with, but the only situations in which wounds of considerable length could occur were the frontal region in tranverse shots, or, when the bullet passed sagitally, the sides of the head, or the flat area of the vertex.
The danger of overlooking injuries to the bone was of special importance in the short subcutaneous tracks occasionally met with at the points at which the surface of the skull makes sharp bends. In all such wounds it was a safe rule to assume a fracture of the skull until this was excluded by direct examination. In some of the gutter wounds and subcutaneous tracks crossing the forehead and sides of the head, signs of intracranial disturbance were occasionally observed in the absence of external fracture, such as transient muscular weakness, unsteadiness in movements, giddiness, diplopia, or loss of memory and intellectual clearness. In connection with such symptoms the classical injury of splintering of the internal table of the skull, the external remaining intact, had to be borne in mind, but I observed no proven instance of this accident. I am of opinion, moreover, that its occurrence with small bullets travelling at a high degree of velocity must be very rare, since little deflection is probable unless the contact has been sufficiently decided to fracture the external table; while in the cases of spent bullets the injury is unlikely, as requiring a considerable degree of force.
Injuries to the cranial bones, without evidence of gross lesion to the brain.--It may be premised that these were of the rarest occurrence, and they may be most readily described by shortly recounting the conditions observed in a few cases I noted at the time. The injuries resulted from blows with spent bullets, from bullets barely striking the skull directly, or those striking over the region of the frontal sinuses. Wounds of the mastoid process will not be considered in this connection as being of a special nature (see p. 299).
I saw only one case of escape of the internal, with depressed fracture of the external, table of the skull.
(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.
In cases where inflammatory hernia cerebri developed, a secondary exploration was often indicated for the removal of fragments of bone or the evacuation of pus, otherwise the condition was best treated by dry dressings and gentle support.
Abscess of the brain was treated by simple evacuation and drainage by metal or rubber tubes: the operations were always of extreme simplicity, since the abscess in every case I saw was in the direct line of the wound track, and was readily opened by the insertion of a director or blunt knife. The only trouble in the after treatment was that already referred to, of preventing premature closure of the drainage opening.
I have made no special reference to the method of dressing, since it was of the ordinary routine kind. The most important factor in success was the efficient primary disinfection of the scalp; a piece of antiseptic gauze and some absorbent wool, efficiently secured, was all that was needed later.
As usual the consideration of the treatment of cases in which the bullet was retained may be considered last. Such accidents were distinctly rare. I operated in only one (No. 54, p. 260) in whom the indications both for localisation and interference were obvious, since the bullet had palpably fractured the bone, although it had not retained sufficient force to enable it to leave the skull. In two other cases that I saw, in one the bullet was lodged in the zygomatic fossa, in the second just below the mastoid process. The former patient died; the latter exhibited symptoms indicative of injury to the occipital lobe (No. 68), and was successfully treated by Mr. J. E. Ker. I never happened to see a case in which a retained bullet in the skull was localised by the X rays, but such might have been possible in case No. 64, p. 275. In no case is primary interference indicated, unless a fracture exists where the bullet has tried to escape, or secondary symptoms develop pointing to irritation.
Under ordinary circumstances, moreover, the indications for removal of a bullet are not likely to be sufficiently imperative to necessitate the operation being undertaken until the patient can be placed under the best conditions that can be secured. This is the more advisable since such operations need the infliction of an additional wound, require great delicacy, and may be very prolonged in performance. The experience of civil practice has already sufficiently proved the small amount of inconvenience likely to follow the retention of a bullet in the skull.
I may again mention the fact that in explorations for the removal of bone fragments, fragments of lead, from breaking or setting up of the bullet, are sometimes found.
Taken as a whole, the operations on the head were extremely satisfactory from a technical point of view; the large depressed pulsating cicatrix so often left was the chief defect observed. The circumstances under which many of the operations had to be performed militated strongly, however, against the successful replacement of separated bone fragments, which might have rendered the defects less serious.
Secondary operations for traumatic epilepsy scarcely come within the scope of these experiences. In case 73, p. 292, it is of interest to note the manner in which the cavity due to loss of brain substance was filled up. No doubt a similar vicarious arachnoid space develops in all cases in which a soft pulsating swelling fills an aperture in the bones of the skull.
WOUNDS OF THE HEAD NOT INVOLVING THE BRAIN
Mastoid process.--The most important wound of the cranium not already mentioned was that involving the mastoid process and the bony capsule of the ear. Wounds of the mastoid process obtained their chief interest in connection with paralysis of the seventh nerve. This nerve rarely or never escaped, and, as far as my experience went, the facial paralysis was permanent (see cases 111-114, p. 355). I think the same prognosis holds good with regard to the deafness resulting from these injuries, and it is difficult to believe, with our experience of the effect of vibration on other nerve centres and organs, that the internal ear could ever escape permanent damage.
In a number of cases the tympanum itself, or the external auditory meatus, was directly implicated in tracks; in these, also, loss of hearing was the rule.
Wounds of the pinna when produced by undeformed bullets were usually of the same slitlike nature remarked in perforations of the cartilages of the nose, and healed with equal rapidity.
Wounds of the orbit.--Injuries to the orbit were very numerous and serious in their results, both to the globe of the eye and the surrounding structures.
Anatomical lesions.--The wound tracks, with regard to the injuries produced, may be well classified according to the direction they took; thus--vertical, transverse, and oblique.
Vertical wound tracks were on the whole the least serious, but this mainly from the fact of limitation of the injury to one orbital cavity. They were usually produced by bullets passing from above downwards through the frontal region of the cranium, and were received by the patients while in the prone position.
Transverse and oblique wounds owed their greater importance to the fact that both eyes were more likely to be implicated.
Besides these tracks, which actually crossed the cavities, a number involved the bony boundaries, producing almost as severe lesions in the globe of the eye, many of the patients being rendered permanently blind. The only difference in nature of such cases was the escape of orbital structures, and this was of minor importance in the presence of the graver lesion to vision. The following is an illustrative case:--
(74) Wounded at Colenso. Entry (Mauser), 1 inch below the centre of the margin of the right orbit; exit, behind the right angle of the mandible. Fracture of lower jaw, and development of a diffuse traumatic aneurism of the external carotid artery. The common carotid artery was tied for secondary hæmorrhage (Mr. Jameson) some three weeks later.
Vision was affected at the time of the accident; the fingers could be seen, but not counted. After ligation of the carotid the condition was possibly worse, and this needs mention as transitory loss of power in the left upper extremity also followed the operation.
Fractures of the bony wall were of every degree. The most severe that I saw were two in which lateral impact by a bullet crossing the cranial cavity caused general comminution of the whole orbital roof. Fissures of the roof were common in connection with 'explosive' exit apertures in the frontal region of the skull. Pure perforations usually accompanied the vertical or transverse wounds of the cavity, fragments at the aperture of entry then being projected into the orbit, sometimes penetrating the muscles.
Occasionally the margin of the cavity was merely notched.
The ocular muscles were often divided more or less completely, and occasionally some difficulty arose in determining whether loss of movement of the globe in any definite direction depended on injury to the muscle itself, or to the nerve supplying the muscle. The following case illustrates this point:--
(75) Entry (Mauser), 2 inches behind the right external canthus; the bullet pierced the external wall and traversed the floor of the right orbit beneath the globe, crossed the nasal cavity, and a part of the left orbit; exit, at the lower margin of the left orbit, beneath the centre of the globe of the eye.
Complete loss of sight followed the injury, and persisted for one week. Modified vision then returned.
Three weeks later there was diplopia; loss of function of the right external and inferior recti, although the ball could be turned downward to some extent by the superior oblique when the internal rectus was in action. Movements of the left globe were not seriously affected.
The pupils were immobile and moderately dilated, but atropine had been employed two days previously.
A year later the condition was as follows: There is some weakness of the right seventh nerve, as evidenced by want of symmetry in all the folds of the face, and in narrowing of the palpebral fissure.
When at rest the right eye is somewhat raised and turned outwards. Active movements outwards or downwards are restricted. There is diplopia, and the vision of the right eye is much impaired; the man can see persons, but cannot count fingers with certainty, although he sees the hand. Putting on one side the loss of free movement, there is no obvious external appearance of injury to the eye.
Mr. J. H. Fisher reported as follows:
Ophthalmoscopic examination shows the left eye and fundus to be normal. The right disc is not atrophied, but the whole of the lower half of the fundus is coated with masses of black retinal pigment. There is atrophy in spots of the capillary layer of the choroid, and the larger vessels of the deeper layer are exposed between the interstices of the pigment masses. There is no definite choroidal rupture. The lesion encroaches upon and implicates the macular region.
The injury is a concussion one, not necessarily resulting from contact, and certainly not due to a perforation. The loss of movement and faulty position are the result of injury to the muscles, and not to nerve implication.
The man complained that when he blew his nose the left eye filled with water and air came out. The left nasal duct was however shown to be intact, as water injected by the canaliculus passed freely into the nose.
Intra-orbital bleeding, subconjunctival hæmorrhage with proptosis and ecchymosis of the lids were usually well marked. The latter was sometimes extreme.
Injury to the nerves was naturally of a very mixed character. In many instances the branches of the first two divisions of the fifth nerve were obviously implicated and regional anæsthesia was common. This was often transitory when the result of vibratory concussion, contusion, or pressure from hæmorrhage. In other cases it was more prolonged as a result of actual division of the nerve. As is usually the case, when a small area of distribution only was affected, sensation was rapidly regained from vicarious sources, even when section had been complete.
As individual injuries, those to the optic nerve were the most frequently diagnosed. I am sorry to be unable to attempt a discrimination of injuries to the nerve alone from those in which both nerve and globe suffered, but the globe can rarely have escaped injury, either direct or indirect, when the bullet actually traversed the orbital cavity. (A few further remarks concerning injuries to the optic nerve will be found in Chapter IX.)
Injuries to the globe of the eye, either direct or indirect, accompanied most of the orbital wounds.
In some the lesion was of the nature of concussion. In such the bone injury was usually at the periphery of the orbit, or to the bones of the face in the neighbourhood. The loss of vision might then be temporary, persisting from two to ten days, then returning, often with some deficiencies.
In other similar external injuries, the lesion of the globe was more severe, and permanent blindness followed.
In variability of degree of completeness, these lesions of the globe corresponded exactly with those produced in other parts of the nervous system by bullets striking the bones in their vicinity, and they were no doubt the result of a similar transmission of vibratory force.
In a third series of cases the globe suffered direct contusion, and in a fourth was perforated and destroyed.
In cases in which permanent blindness was produced without solution of continuity of the sclerotic coat, the nature of the lesion was probably in most cases vibratory concussion and the development of multiple hæmorrhages from choroidal ruptures of a similar nature to those seen in the brain and spinal cord. The actual hæmorrhagic areæ varied in size; but, as far as my experience went, gross hæmorrhages into the anterior chamber did not occur without severe direct contact of the bullet.
In the vast majority of the cases blindness, whether transitory or permanent, developed immediately on the reception of the injury, and was possibly in its initial stage the result of primary concussion.
Cases were, however, seen occasionally in which the symptoms were less sudden, of which the following is an example. I did not think that the mode of progress seen here could be referred to simple orbital hæmorrhage, although this existed, but rather to intravaginal hæmorrhage into the sheath of the optic nerve. On external inspection the globes appeared normal.
(76) Wounded at Paardeberg. Entry (Mauser), over the centre of the right zygoma; the bullet traversed the right orbit, nose, and left orbit. Exit, immediately above the outer extremity of the left eyebrow.
The patient stated that he could 'see' for thirty minutes with the right eye and for an hour with the left, immediately after the injury. He then became totally blind, and has since remained so. During the next three weeks there were occasional 'flashes of light' experienced, but these then ceased.
At the end of three weeks the condition was as follows: Ocular movements good in every direction except that of elevation of the globe. The levator palpebræ superioris acted very slightly; the right, however, better than the left.
There were marked right proptosis, less left proptosis, and slight patchy subconjunctival hæmorrhage of both eyes. The pupils were dilated, motionless, and not concentric.
The patient was invalided as totally blind (November, 1900).
Mr. Lang, who saw this patient on his return to England, kindly furnishes me with the following note as to the condition. There was extensive damage to both eyes, hæmorrhage, and probably retinal detachment as well as choroidal changes.
The quotation of a few illustrative examples typical of the ordinary orbital injuries may be of interest:--
(77) Vertical wound.--Entry, into left orbit in roof posterior to globe, and internal to optic nerve; exit, from orbit through junction of inner wall and floor into nose.
Complete blindness followed the injury, but upon the second day light was perceived on lifting the upper lid. There was marked proptosis, subconjunctival ecchymosis, swelling and ecchymosis of the upper lid, and ptosis. Anæsthesia in the whole area of distribution of the frontal nerve.
At the end of three weeks, fingers could be recognised, but a large blind spot existed in the centre of the field of vision. The general movements of the globe were fair, but the upper lid could not be raised. The proptosis and subconjunctival hæmorrhage cleared up.
Little further improvement occurred; six months later the patient could only count the fingers excentrically. A very extensive scotoma was present. The optic disc was much atrophied, the calibre of the arteries diminished and the veins full (Mr. Critchett). The ptosis persisted. It was doubtful in this case whether the ptosis depended on injury to the nerve of supply, or on laceration and fixation of the levator palpebræ superioris. The latter seemed the more probable, as the superior rectus acted. The absence of any sign of gross bleeding into the anterior chamber is opposed to the existence of a perforating lesion of the globe in this case.
(78) Entry (Mauser), from cranial cavity, just within the centre of the roof of the right orbit; exit, from the orbit by a notch in the lower orbital margin internal to the infra-orbital foramen; track thence beneath the soft parts of the face to emerge from the margin of the upper lip near the left angle of the mouth. Collapse of globe, proptosis, subconjunctival hæmorrhage, oedema and ecchymosis of lids.
Shrunken ball removed on twenty-fourth day (Major Burton, R.A.M.C.).
(79) Entry (Mauser), at the posterior border of the left mastoid process, 3/4 inch above the tip; exit, in the inner third of the left upper eyelid. Globe excised at end of seven days. Facial paralysis and deafness.
(80) Entry (Mauser), from cranial cavity through centre of roof of orbit; exit, through maxillary antrum. Total blindness. Movements of ball good, no loss of tension. Proptosis, subconjunctival hæmorrhage, ecchymosis of eyelids. No improvement in sight followed. One month later the globe suppurated and was removed. The bullet had divided the optic nerve and contused the ball.
Prognosis and treatment of wounds of the orbit.--Except in those cases in which return of vision was rapid, the prognosis was consistently bad in the injuries to the globe. When the globe was ruptured it, as a rule, rapidly shrank. The case (80) quoted above is the only one in which I saw secondary suppuration.
With regard to active treatment, the majority of the cases were complicated by fracture of the roof of the orbit, and in many instances concurrent brain injury was present. In all of these, as a general rule, it was advisable to await the closure of the wound in the orbital roof prior to removal of the injured eye, if that was considered necessary. The only exception to this rule was offered by instances in which the bullet passed from the orbit into the cranium; in these primary removal of fragments projecting into the frontal lobe was preferable. As already indicated, such wounds were comparatively rare except in the case of bullets coursing transversely or obliquely.
The wounds were, as a rule, followed by considerable matting of the orbital structures.
Wounds of the nose.--I will pass by the external parts, with the remark that perforating wounds of the cartilages were remarkable for their sharp limitation and simple nature. I remember one case shown to me in the Irish Hospital in Bloemfontein by Sir W. Thomson, in which at the end of the third day small symmetrical vertical slits in each ala already healed were scarcely visible. This case very strongly impressed one with the doctrine of chances, since on the same morning I was asked to see a patient in whom a similar transverse shot had crossed both orbits, destroying both globes and injuring the brain.
A retained bullet in the upper portion of the nasal cavity has already been referred to (fig. 60). This accident was naturally a rare one; in that instance the bullet had only retained sufficient force to insert itself neatly between the bones.
Wounds crossing the nasal fossæ were comparatively common. The interference with the sense of smell often resulting is discussed in Chapter IX.
Wounds of the malar bone were not infrequent. The small amount of splintering was somewhat remarkable considering the density of structure of the bone. In this particular the behaviour of the malar corresponded with what was observed in the flat bones in general. A case quoted in Chapter III. p. 87, illustrates the capacity of the hard edge of the bone to check the course of a bullet, and cause considerable deformity and fissuring of the mantle.
Wounds of the jaws. Upper jaw.--A large number of tracks crossing the antrum transversely, obliquely, or vertically were observed. In the first case the nasal cavity, in the others the orbital or buccal cavity, were generally concurrently involved. It was somewhat striking that I never observed any trouble, immediate or remote, from these perforations of the antrum. If hæmorrhage into the cavity occurred, it gave rise to no ultimate trouble. I never saw an instance of secondary suppuration even in cases where the bullet entered or escaped through the alveolar process with considerable local comminution. The branches of the second division of the fifth nerve were sometimes implicated. In one instance a bullet traversed and cut away a longitudinal groove in the bones, extending from the posterior margin of the hard palate, and terminating by a wide notch in the alveolar process.
A good example of a troublesome transverse wound of the bones of the face is afforded by the following instance:--
(81) Entry (Mauser), through the left malar eminence, 1 inch below and external to the external canthus; exit, a slightly curved tranverse slit in the lobe of the right ear.
The injury was followed by no signs of orbital concussion, and no loss of consciousness. There was free bleeding from both external wounds and from the nose. The sense of smell was unaffected, but taste was impaired, and there was loss of tactile sensation in the teeth on the left side also on the hard palate. There was no evidence of fracture of the neck of the mandible, nor of the external auditory meatus, but there was considerable difficulty in opening the mouth widely or protruding the teeth. The latter difficulty persisted for some time, and was still present when I last saw the patient.
Mandible.--Fractures of the lower jaw were frequent and offered some peculiarities, the chief of which were the liability of any part of the bone to be damaged, and the absence of the obliquity between the cleft in the outer and inner tables so common in the fractures seen in civil practice.
The neck of the condyle I three times saw fractured; in each instance permanent stiffness and inability to open the mouth resulted. This stiffness was of a degree sufficient to raise the question whether the best course in such cases would not be to cut down primarily and remove a considerable number of loose fragments, and thus diminish the amount of callus likely to be thrown out.
Fractures of the ascending ramus and body were more frequent. They were accompanied by considerable comminution, but all that I observed healed remarkably well, and in good position, in spite of the fact that many of the patients objected to wear any form of splint.
The most special feature was the occurrence of notched fractures, corresponding to the type wedges described in Chapter V. When these fractures were at the lower margin of the bone, the buccal cavity occasionally escaped in spite of considerable comminution, the latter confining itself to the basal portion of the bone.
When the base of the teeth, or the alveolus, was struck, a wedge was often broken away, and from the apex of the resulting gap a fracture extended to the lower margin of the bone.
When fractures of the latter nature resulted from vertically coursing bullets, much trouble often ensued. I will quote two cases in illustration:--
(82) Wounded at Rooipoort. Entry (Mauser), through the lower lip; the bullet struck the base of the right lateral incisor and canine teeth, knocked out a wedge, and becoming slightly deflected, cut a vertical groove to the base of the mandible; exit, in left submaxillary triangle. The bullet subsequently re-entered the chest wall just below the clavicle, and escaped at the anterior axillary fold. The appearance of these second wounds suggested only slight setting up of the bullet; the original impact was no doubt of an oblique or lateral character.
The injury was followed by free hæmorrhage and remarkably abundant salivation (I was inclined to think that the latter symptom was particularly well marked in gunshot fractures of the body of the mandible), and very great swelling of the floor of the mouth.
The patient could not bear any form of apparatus, but was assiduous in washing out his mouth, and made a good recovery, the fragments being in good apposition.
(83) Entry (Mauser), over the right malar eminence; the bullet carried away all the right upper and lower molars, fractured the mandible, and was retained in the neck.
A fortnight later an abscess formed in the lower part of the neck, which was opened (Mr. Pooley), and portions of the mantle and leaden core, together with numerous fragments of the teeth, were removed. The bullet had undergone fragmentation on impact, probably on the last one (teeth of mandible), and still retained sufficient force to enter the neck.
This case affords an interesting example of transmission of force from the bullet to the teeth, and bears on the theory of explosive action.
In the treatment of fractures of the upper jaw, interference was rarely needed. In the case of the mandible, a remark has already been made as to the advisability of removing fragments when the neck of the condyle has suffered comminution. The removal of loose fragments is necessary in all cases in which the buccal cavity is involved. Experience in fracture of the limbs has shown a tendency to quiet necrosis when comminution was severe, in spite of primary union. This is no doubt dependent on the very free separation of fragments on the entry and exit aspects from their enveloping periosteum. In the case of the mandible, considerable necrosis is inevitable, and much time is saved by the primary removal of all actually loose fragments.
A splint of the ordinary chin-cap type with a four-tailed bandage meets all further requirements, but the patients often object to them. Cases in which the fragments could be fixed by wiring the teeth were not common, as the latter had so frequently been carried away. The usual precautions as to maintaining oral asepsis were especially necessary.
The results of fractures of the mandible were, in so far as my experience went, remarkably good, as deformity was seldom considerable. The absence of obliquity and the effect of primary local shock were no doubt favourable elements, little primary displacement from muscular action occurring.
Wounds of the cheek healed readily, and the same was noticeable of the lips. Wounds of the tongue healed with remarkable rapidity when of the simple perforating type, often with little or no swelling or evidence of contusion. At the end of a few days it was often difficult to localise them.
In connection with this subject a remarkable case which occurred at the fighting at Koodoosberg Drift is worthy of mention, although the projectile was a shell fragment and not a bullet of small calibre.
(84) A Highlander was the unfortunate possessor of an entire set of upper teeth set in a gold plate. A small fragment of a shell perforated the upper lip by an irregular aperture, and struck the teeth in such a manner as to turn the posterior edge of the plate towards the tongue, which latter was cut into two halves transversely through to the base.
The patient asserted that the plate had been driven down his throat, but nothing was palpable either in the fauces or on external examination of the neck. He spoke distinctly, but there was dysphagia as far as solids were concerned.
On the second day swelling of the neck due to early cellulitis developed, especially on the left side, and signs of laryngeal obstruction became prominent. Chloroform was administered, but on the introduction of the finger into the fauces, respiration failed and a hasty tracheotomy had to be performed. No foreign body was palpable with the finger in the pharynx.
Tracheitis and septic pneumonia developed, and the man died of acute septicæmia thirty-six hours later. Death occurred just as the Division received marching orders, and no post-mortem examination was made. As a result of palpation at the time of the tracheotomy, the probabilities seemed against the presence of the tooth plate in the pharynx, but the absence of positive evidence scarcely allows the case to be certainly classed as one of cellulitis and septicæmia secondary to wound of the tongue.
WOUNDS OF THE NECK
Wounds of the neck were not unfrequent and were of the gravest importance; there can be little doubt that they accounted for a considerable proportion of the deaths on the field. On the other hand, the neck as a region offered some of the most striking examples of hairbreadth escape of important structures. Consideration of a number of the vascular lesions (see cervical aneurisms, p. 135) also shows conclusively that in no region did the small size of the bullet more materially influence the result, since no doubt can exist that all these wounds would have proved immediately fatal if produced by projectiles of larger calibre.
In this place only a few general considerations will be entered into, as most of the important cases are dealt with under the general headings of vessels, nerves, and spine; but it is convenient to include here the few remarks that have to be made concerning the cervical viscera.
The wounds of the soft parts might course in any direction, but vertical tracks from above downwards were rare. In point of fact, these occurred only in connection with perforations of the head, and as vertical wounds of the latter were received in the prone position, usually when the head was raised, the necessary conditions for longitudinal tracks were seldom offered. One case of a complete vertical track in the muscles of the back of the neck has been already quoted (No. 69, p. 286).
Tracks coursing upwards from the trunk were somewhat more frequent in occurrence; thus a considerable number traversing the thorax were seen. In such instances the aperture of exit was generally situated in the posterior triangle, and some of the brachial nerves often suffered.
The commonest forms of wound were the transverse or the oblique. A large number of cases with such tracks will be found among the cases of injury to the cervical vessels and nerves. In some instances the course was restricted to the neck alone, in others the trunk or upper extremity was also implicated.
The favourable influence of the arrangement of the structures of the neck, which allows of the ordinary displacement excursions necessary for deglutition, respiration, and their cognate movements, was very strongly marked. Thus in several cases the bullet traversed the neck behind the pharynx and oesophagus without injuring either viscus, and the escape of the main vessels and nerves was equally striking. In such wounds the wedge-like bullet without doubt separated and displaced all these structures, causing mere superficial contusion.
In connection with the latter statement, the rarity of direct sagittal wounds in the hospitals should be mentioned. This is probably to be explained by the facts that wounds in the mid-line of the neck implicated the cervical spinal cord, and that sagittal wounds implicating the vessels were apt to lead more directly to the surface, and thus external hæmorrhage was favoured. A few examples of cervical tracks will suffice to illustrate these remarks:--
(85) Entry (Lee-Metford), below angle of scapula; exit, centre of posterior triangle. Injury to the lung, and hæmothorax. No damage to neck structures.
(86) Entry (Mauser), over Pomum Adami; exit, below right scapular spine. Median and musculo-spiral paralysis.
(87) Entry, a large oval aperture through ninth right rib, 1/2 an inch external to scapular angle; exit, anterior border of sterno-mastoid opposite Pomum Adami. Second entry, opposite angle of mandible; exit, in centre of cheek.
Wound of lung. Musculo-spiral paralysis still persisting at the end of nine months.
(88) Entry (Mauser), 2 inches above left clavicle at margin of trapezius; exit, 1 inch from sternum in left first intercostal space. Contusion of brachial plexus, with mixed signs, which disappeared in two months. No signs of vascular injury.
See also cases of cervical aneurism, &c.
Wounds of the pharynx.--I saw only three cases of wound of the pharynx; in each the injury was in the nasal or buccal segment of the cavity, and in each the soft palate was injured, in two instances the wound being a small perforation.
All three cases belong to the somewhat miraculous class. The first (89) was the only one in which the wound gave rise to subsequent trouble. The second was under the charge of Mr. Bowlby, and will no doubt be more fully recounted by him, as interesting signs of injury to the cervical cord were present. In the third the occipital neuralgia was the only troublesome symptom.
In both cases 90 and 91 the high position of the wound in the fixed portion of the pharynx no doubt accounted for the absence of any infective trouble.
(89) Wounds of the pharynx.--Entry (Lee-Metford), immediately below the tip of right mastoid process; the bullet traversed the neck, entering the pharynx close to the right tonsil, crossed the cavity of the pharynx and the mouth, emerging through the left cheek. Great swelling of the fauces and dysphagia persisted for some days after the injury, and there was considerable hæmorrhage.
Infection of the posterior portion of the track from the pharynx resulted, and suppuration continued for some weeks: a small sequestrum eventually needed to be removed from the tip of the transverse process of the atlas.
(90) Entry (Mauser), through mouth; the bullet pierced the soft palate and the posterior wall of the pharynx, and passed out between the transverse process of atlas and the occiput. No serious pharyngeal symptoms.
(91) Entry (Mauser), through the mouth, knocking out the left upper canine and bicuspid teeth. Perforation of the soft palate just to the right of the base of the uvula and the posterior wall of the pharynx; exit, 1-1/2 inch internal to and 1/2 an inch below the tip of the right mastoid process. Hæmorrhage persisted for half an hour, and the patient could not swallow solids for a week. Great occipital neuralgia followed the wound.
Wounds of the larynx.--I saw only one wound of the larynx (see No. 10, p. 135). In this instance the thyroid cartilage was wounded on either side at the level of the Pomum Adami. Transitory hæmorrhage and signs of oedema were the only signs referable to the wound, but in addition the bullet contused the left vagus and gave rise to temporary laryngeal paralysis. The same course was observed in a second case of perforation of the larynx of which I was told.
Wounds of the trachea.--The two cases recounted below are the only tracheal injuries I met with; in one the oesophagus was also implicated. This patient died from mediastinal emphysema. In the second case the wide development of emphysema was prevented by the early introduction of a tracheotomy tube.
(92) Entry (Mauser), on the outer side of the right arm, 3-1/2 inches below the acromion; exit, 3 inches below the tip of the left mastoid process, through the sterno-mastoid. Thirty six hours later there was very free hæmorrhage into the right posterior triangle, emphysema at the episternal notch, dysphagia, and complete obliteration of the cardiac area of dulness. Respiration was rapid (40) and extremely noisy. Pulse 130, small and weak.
A tracheotomy was performed (Mr. Stewart), but the patient died an hour later. When the operation was performed a considerable amount of mucus from the oesophagus was discovered in the wound. The bullet had passed obliquely between trachea and oesophagus, wounding both tubes.
(93) Entry, at the centre of the margin of the left trapezius; exit, in mid line of the neck over the trachea. Dyspnoea was noted the next morning, which increased during a journey in a wagon. On the third day the dyspnoea was more troublesome and emphysema began to develop in the neck. A tracheotomy was performed (Mr. Hunter), and the tube was kept in for four days. No further trouble was experienced, and the wound shortly closed, and the patient, a surgeon, returned to his duties. Temporary signs of median nerve concussion and contusion were noted.