Chapter VII: Injuries to the Head and Neck (3)

The scalp should be first shaved and cleansed; if for any reason an operation is impossible, this procedure at least should be carried out, with a view to ensuring, as far as possible, future asepsis, infection in head injuries being almost the only danger to be feared. The shaving may need to be complete, but local clearance of the hair suffices in many cases. The hair having been removed, the scalp is cleansed with all care, a flap is raised of which the bullet opening forms the central point, and the wound explored. In slight cases the entry opening is the one of chief importance, and the exit may be simply cleansed and dressed. In some instances, as in direct fracture of the roof of the orbit from above, the exit should not be touched.

The flap having been raised, if the wound be a small perforation, a 1/2-inch trephine crown may be taken from one side; but it is rare for the opening to be so small that the tip of a pair of Hoffman's forceps cannot be inserted. The trephine is more often useful in cases of non-penetrating gutter fractures where space is needed for exploration, and the elevation or removal of fragments of the inner-table. Loose fragments may need to be removed from beneath the scalp, but the important ones are those within the cranium. These may either be of some size, or fine comminuted splinters of either table, often at as great a distance as 2 inches or more from the surface. The cavity must be thoroughly explored and all splinters removed. I have seen more than fifty extracted in one case of open gutter fracture. The brain pulp and clot should then be gently removed or washed away, and the wound closed without drainage. Fragments of bone, as a rule, are better not replaced, but complete suture of the skin flap is always advisable in view of the great importance of primary union, and the fact that a drainage opening exists at the original wound of entry, and that the wound is readily re-opened to its whole extent, should such a step be advisable.

The detection of fragments is easiest and most satisfactorily done with the finger, and in all but simple punctures the opening should be large enough to allow thoroughly effective digital exploration; the remarks already made as to the factors determining the size of fragments are of interest in this connection. The determination of the amount of brain pulp which should be removed is somewhat more difficult; one can only say that all that washes readily away should be removed, and its place is usually taken up by blood.

Few fractures of the base are suitable for treatment; the only ones I saw were those of direct fracture of the roof of the orbit or nose, produced by bullets passing across the orbits; here the advisability of interference with the injured eye led to opening of the orbit, and sometimes exposed the fracture. Some patients recovered, even when the damage had been sufficient to cause escape of pulped brain into the orbit.

The after treatment simply consisted in keeping the patients as quiet as circumstances would permit, and the administration of a fluid diet. In some cases recurring symptoms pointed to the continued presence of bone fragments; these were usually indicated by signs of irritation, or often of local inflammation, in the latter case infection taking the greater share in the causation. Such cases needed secondary exploration, and the wonderful success of this operation, even when the wound was evidently infected, was perhaps one of the most striking experiences of the surgery in general.

I should add a word here as to the most satisfactory time for the performance of these operations; as in all cases the earlier they could be undertaken the better, but in the head injuries the advantages of early interference were more evident than in any other region. This depended on the fact that, as in civil practice, the scalp is one of the most dangerous regions as far as auto-infection of the wound is concerned, and one of the most difficult to cleanse, except by thorough shaving. Beyond this the extreme simplicity of the operative procedure needed, called for few precautions beyond those for asepsis, and very little armament in the way of instruments, &c.

When on the march from Winberg to Heilbron with the Highland Brigade we had some five days' continuous fighting, and on this occasion several perforating fractures of the skull were brought in. The coldness of the nights at that time made evening operations an impossibility; hence the operations on these men were performed at the first dressing station, in the open air, at the side of the ambulance wagons, often during the progress of fighting around. Of several cases so operated on, all healed by primary union without a bad symptom of any kind, except one (see p. 249), in whom a very large entrance opening over the right cortical motor area led down to an extensive destruction of the brain, complicated by a fracture of the base in the middle fossa. This wound, from the first considered hopeless, became septic during the four days' travelling in an ambulance wagon that was necessary, and the man died at the end of fourteen days. As the whole cortical motor area was destroyed, death was, perhaps, the end most to be desired; but the fight that this man made for recovery, and the fact that his death, after all, was due to general infection and not to any local extension of the injury, very strongly impressed me with the possibility of recovery, even in such extensive cases, if only an aseptic condition can be maintained. I saw many other cases of the same nature, particularly in men who, as a result of unfortunate circumstances, were necessarily left out on the field for more than twenty-four hours. In some of these maggots were found in the wounds only thirty-six hours after the infliction of the injury.

I have said nothing as to the treatment of the large primary herniæ cerebri in wounds of an explosive nature, since these were rarely subjects suitable for operation; but in the instances of minor severity they were treated as the other cases where the pulped brain lay mostly within the skull.

In cases where the wounds were in the frontal or fronto-parietal regions, and hemiplegia existed, the rapid improvement in the paralytic symptoms, after operation, was very marked, showing that the signs were mainly, or entirely, due to 'radiation' injury. I am inclined to think that temporary injury of this kind from vibratory disturbance and small parenchymatous hæmorrhages, were far more often the cause of the paralysis than surface hæmorrhage, since the latter was rarely found in large quantity. Large clots, however, no doubt growing in both size and firmness, occasionally occupied the area of destroyed brain, and these sometimes manifestly exercised pressure that was at once relieved by their evacuation.

In cases where inflammatory hernia cerebri developed, a secondary exploration was often indicated for the removal of fragments of bone or the evacuation of pus, otherwise the condition was best treated by dry dressings and gentle support.

Abscess of the brain was treated by simple evacuation and drainage by metal or rubber tubes: the operations were always of extreme simplicity, since the abscess in every case I saw was in the direct line of the wound track, and was readily opened by the insertion of a director or blunt knife. The only trouble in the after treatment was that already referred to, of preventing premature closure of the drainage opening.

I have made no special reference to the method of dressing, since it was of the ordinary routine kind. The most important factor in success was the efficient primary disinfection of the scalp; a piece of antiseptic gauze and some absorbent wool, efficiently secured, was all that was needed later.

As usual the consideration of the treatment of cases in which the bullet was retained may be considered last. Such accidents were distinctly rare. I operated in only one (No. 54, p. 260) in whom the indications both for localisation and interference were obvious, since the bullet had palpably fractured the bone, although it had not retained sufficient force to enable it to leave the skull. In two other cases that I saw, in one the bullet was lodged in the zygomatic fossa, in the second just below the mastoid process. The former patient died; the latter exhibited symptoms indicative of injury to the occipital lobe (No. 68), and was successfully treated by Mr. J. E. Ker. I never happened to see a case in which a retained bullet in the skull was localised by the X rays, but such might have been possible in case No. 64, p. 275. In no case is primary interference indicated, unless a fracture exists where the bullet has tried to escape, or secondary symptoms develop pointing to irritation.

Under ordinary circumstances, moreover, the indications for removal of a bullet are not likely to be sufficiently imperative to necessitate the operation being undertaken until the patient can be placed under the best conditions that can be secured. This is the more advisable since such operations need the infliction of an additional wound, require great delicacy, and may be very prolonged in performance. The experience of civil practice has already sufficiently proved the small amount of inconvenience likely to follow the retention of a bullet in the skull.

I may again mention the fact that in explorations for the removal of bone fragments, fragments of lead, from breaking or setting up of the bullet, are sometimes found.

Taken as a whole, the operations on the head were extremely satisfactory from a technical point of view; the large depressed pulsating cicatrix so often left was the chief defect observed. The circumstances under which many of the operations had to be performed militated strongly, however, against the successful replacement of separated bone fragments, which might have rendered the defects less serious.

Secondary operations for traumatic epilepsy scarcely come within the scope of these experiences. In case 73, p. 292, it is of interest to note the manner in which the cavity due to loss of brain substance was filled up. No doubt a similar vicarious arachnoid space develops in all cases in which a soft pulsating swelling fills an aperture in the bones of the skull.

WOUNDS OF THE HEAD NOT INVOLVING THE BRAIN

_Mastoid process._--The most important wound of the cranium not already mentioned was that involving the mastoid process and the bony capsule of the ear. Wounds of the mastoid process obtained their chief interest in connection with paralysis of the seventh nerve. This nerve rarely or never escaped, and, as far as my experience went, the facial paralysis was permanent (see cases 111-114, p. 355). I think the same prognosis holds good with regard to the deafness resulting from these injuries, and it is difficult to believe, with our experience of the effect of vibration on other nerve centres and organs, that the internal ear could ever escape permanent damage.

In a number of cases the tympanum itself, or the external auditory meatus, was directly implicated in tracks; in these, also, loss of hearing was the rule.

Wounds of the pinna when produced by undeformed bullets were usually of the same slitlike nature remarked in perforations of the cartilages of the nose, and healed with equal rapidity.

_Wounds of the orbit._--Injuries to the orbit were very numerous and serious in their results, both to the globe of the eye and the surrounding structures.

_Anatomical lesions._--The wound tracks, with regard to the injuries produced, may be well classified according to the direction they took; thus--vertical, transverse, and oblique.

Vertical wound tracks were on the whole the least serious, but this mainly from the fact of limitation of the injury to one orbital cavity. They were usually produced by bullets passing from above downwards through the frontal region of the cranium, and were received by the patients while in the prone position.

Transverse and oblique wounds owed their greater importance to the fact that both eyes were more likely to be implicated.

Besides these tracks, which actually crossed the cavities, a number involved the bony boundaries, producing almost as severe lesions in the globe of the eye, many of the patients being rendered permanently blind. The only difference in nature of such cases was the escape of orbital structures, and this was of minor importance in the presence of the graver lesion to vision. The following is an illustrative case:--

(74) Wounded at Colenso. _Entry_ (Mauser), 1 inch below the
centre of the margin of the right orbit; _exit_, behind the
right angle of the mandible. Fracture of lower jaw, and
development of a diffuse traumatic aneurism of the external
carotid artery. The common carotid artery was tied for
secondary hæmorrhage (Mr. Jameson) some three weeks later.

Vision was affected at the time of the accident; the fingers
could be seen, but not counted. After ligation of the carotid
the condition was possibly worse, and this needs mention as
transitory loss of power in the left upper extremity also
followed the operation.

Fractures of the bony wall were of every degree. The most severe that I saw were two in which lateral impact by a bullet crossing the cranial cavity caused general comminution of the whole orbital roof. Fissures of the roof were common in connection with 'explosive' exit apertures in the frontal region of the skull. Pure perforations usually accompanied the vertical or transverse wounds of the cavity, fragments at the aperture of entry then being projected into the orbit, sometimes penetrating the muscles.

Occasionally the margin of the cavity was merely notched.

The ocular muscles were often divided more or less completely, and occasionally some difficulty arose in determining whether loss of movement of the globe in any definite direction depended on injury to the muscle itself, or to the nerve supplying the muscle. The following case illustrates this point:--

(75) _Entry_ (Mauser), 2 inches behind the right external
canthus; the bullet pierced the external wall and traversed the
floor of the right orbit beneath the globe, crossed the nasal
cavity, and a part of the left orbit; _exit_, at the lower
margin of the left orbit, beneath the centre of the globe of
the eye.

Complete loss of sight followed the injury, and persisted for
one week. Modified vision then returned.

Three weeks later there was diplopia; loss of function of the
right external and inferior recti, although the ball could be
turned downward to some extent by the superior oblique when the
internal rectus was in action. Movements of the left globe were
not seriously affected.

The pupils were immobile and moderately dilated, but atropine
had been employed two days previously.

A year later the condition was as follows: There is some
weakness of the right seventh nerve, as evidenced by want of
symmetry in all the folds of the face, and in narrowing of the
palpebral fissure.

When at rest the right eye is somewhat raised and turned
outwards. Active movements outwards or downwards are
restricted. There is diplopia, and the vision of the right eye
is much impaired; the man can see persons, but cannot count
fingers with certainty, although he sees the hand. Putting on
one side the loss of free movement, there is no obvious
external appearance of injury to the eye.

Mr. J. H. Fisher reported as follows:

Ophthalmoscopic examination shows the left eye and fundus to be
normal. The right disc is not atrophied, but the whole of the
lower half of the fundus is coated with masses of black retinal
pigment. There is atrophy in spots of the capillary layer of
the choroid, and the larger vessels of the deeper layer are
exposed between the interstices of the pigment masses. There is
no definite choroidal rupture. The lesion encroaches upon and
implicates the macular region.

The injury is a concussion one, not necessarily resulting from
contact, and certainly not due to a perforation. The loss of
movement and faulty position are the result of injury to the
muscles, and not to nerve implication.

The man complained that when he blew his nose the left eye
filled with water and air came out. The left nasal duct was
however shown to be intact, as water injected by the
canaliculus passed freely into the nose.

Intra-orbital bleeding, subconjunctival hæmorrhage with proptosis and ecchymosis of the lids were usually well marked. The latter was sometimes extreme.

Injury to the nerves was naturally of a very mixed character. In many instances the branches of the first two divisions of the fifth nerve were obviously implicated and regional anæsthesia was common. This was often transitory when the result of vibratory concussion, contusion, or pressure from hæmorrhage. In other cases it was more prolonged as a result of actual division of the nerve. As is usually the case, when a small area of distribution only was affected, sensation was rapidly regained from vicarious sources, even when section had been complete.

As individual injuries, those to the optic nerve were the most frequently diagnosed. I am sorry to be unable to attempt a discrimination of injuries to the nerve alone from those in which both nerve and globe suffered, but the globe can rarely have escaped injury, either direct or indirect, when the bullet actually traversed the orbital cavity. (A few further remarks concerning injuries to the optic nerve will be found in Chapter IX.)

Injuries to the globe of the eye, either direct or indirect, accompanied most of the orbital wounds.

In some the lesion was of the nature of concussion. In such the bone injury was usually at the periphery of the orbit, or to the bones of the face in the neighbourhood. The loss of vision might then be temporary, persisting from two to ten days, then returning, often with some deficiencies.

In other similar external injuries, the lesion of the globe was more severe, and permanent blindness followed.

In variability of degree of completeness, these lesions of the globe corresponded exactly with those produced in other parts of the nervous system by bullets striking the bones in their vicinity, and they were no doubt the result of a similar transmission of vibratory force.

In a third series of cases the globe suffered direct contusion, and in a fourth was perforated and destroyed.

In cases in which permanent blindness was produced without solution of continuity of the sclerotic coat, the nature of the lesion was probably in most cases vibratory concussion and the development of multiple hæmorrhages from choroidal ruptures of a similar nature to those seen in the brain and spinal cord. The actual hæmorrhagic areæ varied in size; but, as far as my experience went, gross hæmorrhages into the anterior chamber did not occur without severe direct contact of the bullet.

In the vast majority of the cases blindness, whether transitory or permanent, developed immediately on the reception of the injury, and was possibly in its initial stage the result of primary concussion.

Cases were, however, seen occasionally in which the symptoms were less sudden, of which the following is an example. I did not think that the mode of progress seen here could be referred to simple orbital hæmorrhage, although this existed, but rather to intravaginal hæmorrhage into the sheath of the optic nerve. On external inspection the globes appeared normal.

(76) Wounded at Paardeberg. _Entry_ (Mauser), over the centre
of the right zygoma; the bullet traversed the right orbit,
nose, and left orbit. _Exit_, immediately above the outer
extremity of the left eyebrow.

The patient stated that he could 'see' for thirty minutes with
the right eye and for an hour with the left, immediately after
the injury. He then became totally blind, and has since
remained so. During the next three weeks there were occasional
'flashes of light' experienced, but these then ceased.

At the end of three weeks the condition was as follows: Ocular
movements good in every direction except that of elevation of
the globe. The levator palpebræ superioris acted very slightly;
the right, however, better than the left.

There were marked right proptosis, less left proptosis, and
slight patchy subconjunctival hæmorrhage of both eyes. The
pupils were dilated, motionless, and not concentric.

The patient was invalided as totally blind (November, 1900).

Mr. Lang, who saw this patient on his return to England, kindly furnishes me with the following note as to the condition. There was extensive damage to both eyes, hæmorrhage, and probably retinal detachment as well as choroidal changes.

The quotation of a few illustrative examples typical of the ordinary orbital injuries may be of interest:--

(77) _Vertical wound._--_Entry_, into left orbit in roof
posterior to globe, and internal to optic nerve; _exit_, from
orbit through junction of inner wall and floor into nose.

Complete blindness followed the injury, but upon the second day
light was perceived on lifting the upper lid. There was marked
proptosis, subconjunctival ecchymosis, swelling and ecchymosis
of the upper lid, and ptosis. Anæsthesia in the whole area of
distribution of the frontal nerve.

At the end of three weeks, fingers could be recognised, but a
large blind spot existed in the centre of the field of vision.
The general movements of the globe were fair, but the upper lid
could not be raised. The proptosis and subconjunctival
hæmorrhage cleared up.

Little further improvement occurred; six months later the
patient could only count the fingers excentrically. A very
extensive scotoma was present. The optic disc was much
atrophied, the calibre of the arteries diminished and the veins
full (Mr. Critchett). The ptosis persisted. It was doubtful in
this case whether the ptosis depended on injury to the nerve of
supply, or on laceration and fixation of the levator palpebræ
superioris. The latter seemed the more probable, as the
superior rectus acted. The absence of any sign of gross
bleeding into the anterior chamber is opposed to the existence
of a perforating lesion of the globe in this case.

(78) _Entry_ (Mauser), from cranial cavity, just within the
centre of the roof of the right orbit; _exit_, from the orbit
by a notch in the lower orbital margin internal to the
infra-orbital foramen; track thence beneath the soft parts of
the face to emerge from the margin of the upper lip near the
left angle of the mouth. Collapse of globe, proptosis,
subconjunctival hæmorrhage, oedema and ecchymosis of lids.

Shrunken ball removed on twenty-fourth day (Major Burton,
R.A.M.C.).

(79) _Entry_ (Mauser), at the posterior border of the left
mastoid process, 3/4 inch above the tip; _exit_, in the inner
third of the left upper eyelid. Globe excised at end of seven
days. Facial paralysis and deafness.

(80) _Entry_ (Mauser), from cranial cavity through centre of
roof of orbit; _exit_, through maxillary antrum. Total
blindness. Movements of ball good, no loss of tension.
Proptosis, subconjunctival hæmorrhage, ecchymosis of eyelids.
No improvement in sight followed. One month later the globe
suppurated and was removed. The bullet had divided the optic
nerve and contused the ball.

_Prognosis and treatment of wounds of the orbit._--Except in those cases in which return of vision was rapid, the prognosis was consistently bad in the injuries to the globe. When the globe was ruptured it, as a rule, rapidly shrank. The case (80) quoted above is the only one in which I saw secondary suppuration.

With regard to active treatment, the majority of the cases were complicated by fracture of the roof of the orbit, and in many instances concurrent brain injury was present. In all of these, as a general rule, it was advisable to await the closure of the wound in the orbital roof prior to removal of the injured eye, if that was considered necessary. The only exception to this rule was offered by instances in which the bullet passed from the orbit into the cranium; in these primary removal of fragments projecting into the frontal lobe was preferable. As already indicated, such wounds were comparatively rare except in the case of bullets coursing transversely or obliquely.

The wounds were, as a rule, followed by considerable matting of the orbital structures.

_Wounds of the nose._--I will pass by the external parts, with the remark that perforating wounds of the cartilages were remarkable for their sharp limitation and simple nature. I remember one case shown to me in the Irish Hospital in Bloemfontein by Sir W. Thomson, in which at the end of the third day small symmetrical vertical slits in each ala already healed were scarcely visible. This case very strongly impressed one with the doctrine of chances, since on the same morning I was asked to see a patient in whom a similar transverse shot had crossed both orbits, destroying both globes and injuring the brain.

A retained bullet in the upper portion of the nasal cavity has already been referred to (fig. 60). This accident was naturally a rare one; in that instance the bullet had only retained sufficient force to insert itself neatly between the bones.

Wounds crossing the nasal fossæ were comparatively common. The interference with the sense of smell often resulting is discussed in Chapter IX.

_Wounds of the malar bone_ were not infrequent. The small amount of splintering was somewhat remarkable considering the density of structure of the bone. In this particular the behaviour of the malar corresponded with what was observed in the flat bones in general. A case quoted in