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).

[Ill.u.s.tration: FIG. 66.--Gutter Fracture of the second degree.

Perforating the skull in the centre of its course. External table alone carried away at either end.]

Bevelling at the expense of the outer table at both entry and exit ends of the course existed, but in either case a portion of the inner table was also detached and depressed. Sometimes the depressed portion of the inner table was mainly composed of one elongated fragment; this was either when the bullet had not implicated a great thickness of the outer table, or had pa.s.sed with great obliquity through especially dense bone (see fig. 70). When the bullet had pa.s.sed 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).

[Ill.u.s.tration: FIG. 67.--Diagrammatic transverse sections of complete Gutter Fracture. _A._ External table destroyed, large fragment of internal table depressed. (Low velocity or dense bone.) _B._ Comminution and pulverisation of both tables centre of track. _C._ Depression of inner table (low velocity)]

The nature of the injury to the bone when the flight of the bullet actually involved the whole thickness of the calvarium was comparable to that seen in the case of the long bones when struck by a bullet travelling at a moderate rate (see plate XIX. of the tibia, or what is ill.u.s.trated 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 ill.u.s.trated by skiagrams Nos. III. and XXIII. of the clavicle and fibula is a close one.

[Ill.u.s.tration: FIG. 68.--Superficial Perforating Fracture. Ill.u.s.trating lifting of roof at both entry and exit openings]

I will add here a case of coexistent gutter fracture and perforating wound of the skull, the conditions of the bone in which will ill.u.s.trate the behaviour of the outer and inner tables respectively, when struck with moderate force.

[Ill.u.s.tration: FIG. 69.--Diagrammatic longitudinal section of Fracture shown in fig. 68]

[Ill.u.s.tration: FIG. 70.--Fragment forming the main part of the floor of Gutter Fracture in the squamous portion of the temporal bone. (Low velocity, hard bone)]

(54) Wounded at Thaba-nchu. Guedes bullet. _Entry_ behind left ear, just above posterior root of zygoma; gutter fracture; bullet retained within skull. Above and corresponding to right frontal eminence there was a haematoma, 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 pa.s.sed 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 haemorrhage extending over the whole base of the brain.

[Ill.u.s.tration: FIG. 71.--Scale of outer table of Frontal Bone and Diploe. Exact size, from fracture shown in fig. 72]

[Ill.u.s.tration: FIG. 72.--Perforating Fracture of Frontal Bone from within Separation of plate outer table. (Low velocity.) 1/2]

The injury to the _cranial contents_ varied with the degree of bone injury. Haemorrhage 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 haemorrhage, 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 haemorrhage, although many fractures crossing the line of distribution of the large branches came under observation. Case 60, p.

274, ill.u.s.trated the fact that the osseous lesions of lesser apparent degree are sometimes the more to be feared in the matter of haemorrhage, 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 ill.u.s.trative of these injuries are included under the heading of symptoms.

It will be, of course, appreciated that the coa.r.s.e 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 cla.s.ses. The damage consisted in direct superficial laceration and contusion, and beyond the limits of the area of actual destruction, abundant parenchymatous haemorrhages more or less broke up the structure of the brain, such haemorrhages 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 cla.s.ses, 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 cla.s.sical 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 pa.s.sing 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 cla.s.sed 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 pa.s.sed 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 fossae were met with far less frequently, partly I think because vertical wounds pa.s.sing 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 ill.u.s.trate 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 pa.s.sage 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 cla.s.s 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 ma.s.s of brain debris, 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 cla.s.s 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 a.s.sumed.

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 ill.u.s.tration 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 haemorrhage, 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 s.p.a.ce 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, haemorrhage 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 s.p.a.ce 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 haemorrhages 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 circ.u.mstances: first, the rarity of injuries giving rise to meningeal haemorrhage; 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 haemorrhage 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.