Chapter VII: Injuries to the Head and Neck (2)

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

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.

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.

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.