advisedly, since what may be called the formal operation of trephining is seldom necessary except in the case of the small openings due to wounds received from a very long range of fire; in all others there is no difficulty, but very great advantage, in making such enlargement of the bone opening as is necessary with Hoffman's forceps.

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

The flap having been raised, if the wound be a small perforation, a 1/2-inch trephine crown may be taken from one side; but it is rare for the opening to be so small that the tip of a pair of Hoffman's forceps cannot be inserted. The trephine is more often useful in cases of non-penetrating gutter fractures where s.p.a.ce 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 pa.s.sing 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 circ.u.mstances 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 circ.u.mstances, 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 herniae 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 haemorrhages, were far more often the cause of the paralysis than surface haemorrhage, since the latter was rarely found in large quant.i.ty. 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 circ.u.mstances, 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 circ.u.mstances 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 s.p.a.ce 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 cla.s.sified 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 pa.s.sing from above downwards through the frontal region of the cranium, and were received by the patients while in the p.r.o.ne 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 ill.u.s.trative 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 haemorrhage (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 ill.u.s.trates 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 ma.s.ses 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 ma.s.ses. 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 ca.n.a.liculus pa.s.sed freely into the nose.

Intra-orbital bleeding, subconjunctival haemorrhage 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 anaesthesia was common. This was often transitory when the result of vibratory concussion, contusion, or pressure from haemorrhage. 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.