Chapter VII: Injuries to the Head and Neck (1)

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.

ANATOMICAL LESIONS

_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.

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.

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.

(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.

(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.

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.

(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).

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).

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.

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.

(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.

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.