Chapter VII · (continued 2)

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 œdema. 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 1½ 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.

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, œdema 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 Chapter III. p. 87, illustrates the capacity of the hard edge of the bone to check the course of a bullet, and cause considerable deformity and fissuring of the mantle.

Wounds of the jaws. Upper jaw.—A large number of tracks crossing the antrum transversely, obliquely, or vertically were observed. In the first case the nasal cavity, in the others the orbital or buccal cavity, were generally concurrently involved. It was somewhat striking that I never observed any trouble, immediate or remote, from these perforations of the antrum. If hæmorrhage into the cavity occurred, it gave rise to no ultimate trouble. I never saw an instance of secondary suppuration even in cases where the bullet entered or escaped through the alveolar process with considerable local comminution. The branches of the second division of the fifth nerve were sometimes implicated. In one instance a bullet traversed and cut away a longitudinal groove in the bones, extending from the posterior margin of the hard palate, and terminating by a wide notch in the alveolar process.

A good example of a troublesome transverse wound of the bones of the face is afforded by the following instance:—

(81) Entry (Mauser), through the left malar eminence, 1 inch below and external to the external canthus; exit, a slightly curved tranverse slit in the lobe of the right ear.

The injury was followed by no signs of orbital concussion, and no loss of consciousness. There was free bleeding from both external wounds and from the nose. The sense of smell was unaffected, but taste was impaired, and there was loss of tactile sensation in the teeth on the left side also on the hard palate. There was no evidence of fracture of the neck of the mandible, nor of the external auditory meatus, but there was considerable difficulty in opening the mouth widely or protruding the teeth. The latter difficulty persisted for some time, and was still present when I last saw the patient.

Mandible.—Fractures of the lower jaw were frequent and offered some peculiarities, the chief of which were the liability of any part of the bone to be damaged, and the absence of the obliquity between the cleft in the outer and inner tables so common in the fractures seen in civil practice.

The neck of the condyle I three times saw fractured; in each instance permanent stiffness and inability to open the mouth resulted. This stiffness was of a degree sufficient to raise the question whether the best course in such cases would not be to cut down primarily and remove a considerable number of loose fragments, and thus diminish the amount of callus likely to be thrown out.

Fractures of the ascending ramus and body were more frequent. They were accompanied by considerable comminution, but all that I observed healed remarkably well, and in good position, in spite of the fact that many of the patients objected to wear any form of splint.

The most special feature was the occurrence of notched fractures, corresponding to the type wedges described in Chapter V. When these fractures were at the lower margin of the bone, the buccal cavity occasionally escaped in spite of considerable comminution, the latter confining itself to the basal portion of the bone.

When the base of the teeth, or the alveolus, was struck, a wedge was often broken away, and from the apex of the resulting gap a fracture extended to the lower margin of the bone.

When fractures of the latter nature resulted from vertically coursing bullets, much trouble often ensued. I will quote two cases in illustration:—

(82) Wounded at Rooipoort. Entry (Mauser), through the lower lip; the bullet struck the base of the right lateral incisor and canine teeth, knocked out a wedge, and becoming slightly deflected, cut a vertical groove to the base of the mandible; exit, in left submaxillary triangle. The bullet subsequently re-entered the chest wall just below the clavicle, and escaped at the anterior axillary fold. The appearance of these second wounds suggested only slight setting up of the bullet; the original impact was no doubt of an oblique or lateral character.

The injury was followed by free hæmorrhage and remarkably abundant salivation (I was inclined to think that the latter symptom was particularly well marked in gunshot fractures of the body of the mandible), and very great swelling of the floor of the mouth.

The patient could not bear any form of apparatus, but was assiduous in washing out his mouth, and made a good recovery, the fragments being in good apposition.

(83) Entry (Mauser), over the right malar eminence; the bullet carried away all the right upper and lower molars, fractured the mandible, and was retained in the neck.

A fortnight later an abscess formed in the lower part of the neck, which was opened (Mr. Pooley), and portions of the mantle and leaden core, together with numerous fragments of the teeth, were removed. The bullet had undergone fragmentation on impact, probably on the last one (teeth of mandible), and still retained sufficient force to enter the neck.

This case affords an interesting example of transmission of force from the bullet to the teeth, and bears on the theory of explosive action.

In the treatment of fractures of the upper jaw, interference was rarely needed. In the case of the mandible, a remark has already been made as to the advisability of removing fragments when the neck of the condyle has suffered comminution. The removal of loose fragments is necessary in all cases in which the buccal cavity is involved. Experience in fracture of the limbs has shown a tendency to quiet necrosis when comminution was severe, in spite of primary union. This is no doubt dependent on the very free separation of fragments on the entry and exit aspects from their enveloping periosteum. In the case of the mandible, considerable necrosis is inevitable, and much time is saved by the primary removal of all actually loose fragments.

A splint of the ordinary chin-cap type with a four-tailed bandage meets all further requirements, but the patients often object to them. Cases in which the fragments could be fixed by wiring the teeth were not common, as the latter had so frequently been carried away. The usual precautions as to maintaining oral asepsis were especially necessary.

The results of fractures of the mandible were, in so far as my experience went, remarkably good, as deformity was seldom considerable. The absence of obliquity and the effect of primary local shock were no doubt favourable elements, little primary displacement from muscular action occurring.

Wounds of the cheek healed readily, and the same was noticeable of the lips. Wounds of the tongue healed with remarkable rapidity when of the simple perforating type, often with little or no swelling or evidence of contusion. At the end of a few days it was often difficult to localise them.

In connection with this subject a remarkable case which occurred at the fighting at Koodoosberg Drift is worthy of mention, although the projectile was a shell fragment and not a bullet of small calibre.

(84) A Highlander was the unfortunate possessor of an entire set of upper teeth set in a gold plate. A small fragment of a shell perforated the upper lip by an irregular aperture, and struck the teeth in such a manner as to turn the posterior edge of the plate towards the tongue, which latter was cut into two halves transversely through to the base.

The patient asserted that the plate had been driven down his throat, but nothing was palpable either in the fauces or on external examination of the neck. He spoke distinctly, but there was dysphagia as far as solids were concerned.

On the second day swelling of the neck due to early cellulitis developed, especially on the left side, and signs of laryngeal obstruction became prominent. Chloroform was administered, but on the introduction of the finger into the fauces, respiration failed and a hasty tracheotomy had to be performed. No foreign body was palpable with the finger in the pharynx.

Tracheitis and septic pneumonia developed, and the man died of acute septicæmia thirty-six hours later. Death occurred just as the Division received marching orders, and no post-mortem examination was made. As a result of palpation at the time of the tracheotomy, the probabilities seemed against the presence of the tooth plate in the pharynx, but the absence of positive evidence scarcely allows the case to be certainly classed as one of cellulitis and septicæmia secondary to wound of the tongue.

Wounds of the Neck

Wounds of the neck were not unfrequent and were of the gravest importance; there can be little doubt that they accounted for a considerable proportion of the deaths on the field. On the other hand, the neck as a region offered some of the most striking examples of hairbreadth escape of important structures. Consideration of a number of the vascular lesions (see cervical aneurisms, p. 135) also shows conclusively that in no region did the small size of the bullet more materially influence the result, since no doubt can exist that all these wounds would have proved immediately fatal if produced by projectiles of larger calibre.

In this place only a few general considerations will be entered into, as most of the important cases are dealt with under the general headings of vessels, nerves, and spine; but it is convenient to include here the few remarks that have to be made concerning the cervical viscera.

The wounds of the soft parts might course in any direction, but vertical tracks from above downwards were rare. In point of fact, these occurred only in connection with perforations of the head, and as vertical wounds of the latter were received in the prone position, usually when the head was raised, the necessary conditions for longitudinal tracks were seldom offered. One case of a complete vertical track in the muscles of the back of the neck has been already quoted (No. 69, p. 286).

Tracks coursing upwards from the trunk were somewhat more frequent in occurrence; thus a considerable number traversing the thorax were seen. In such instances the aperture of exit was generally situated in the posterior triangle, and some of the brachial nerves often suffered.

The commonest forms of wound were the transverse or the oblique. A large number of cases with such tracks will be found among the cases of injury to the cervical vessels and nerves. In some instances the course was restricted to the neck alone, in others the trunk or upper extremity was also implicated.

The favourable influence of the arrangement of the structures of the neck, which allows of the ordinary displacement excursions necessary for deglutition, respiration, and their cognate movements, was very strongly marked. Thus in several cases the bullet traversed the neck behind the pharynx and œsophagus without injuring either viscus, and the escape of the main vessels and nerves was equally striking. In such wounds the wedge-like bullet without doubt separated and displaced all these structures, causing mere superficial contusion.

In connection with the latter statement, the rarity of direct sagittal wounds in the hospitals should be mentioned. This is probably to be explained by the facts that wounds in the mid-line of the neck implicated the cervical spinal cord, and that sagittal wounds implicating the vessels were apt to lead more directly to the surface, and thus external hæmorrhage was favoured. A few examples of cervical tracks will suffice to illustrate these remarks:—

(85) Entry (Lee-Metford), below angle of scapula; exit, centre of posterior triangle. Injury to the lung, and hæmothorax. No damage to neck structures.

(86) Entry (Mauser), over Pomum Adami; exit, below right scapular spine. Median and musculo-spiral paralysis.

(87) Entry, a large oval aperture through ninth right rib, 1/2 an inch external to scapular angle; exit, anterior border of sterno-mastoid opposite Pomum Adami. Second entry, opposite angle of mandible; exit, in centre of cheek.

Wound of lung. Musculo-spiral paralysis still persisting at the end of nine months.

(88) Entry (Mauser), 2 inches above left clavicle at margin of trapezius; exit, 1 inch from sternum in left first intercostal space. Contusion of brachial plexus, with mixed signs, which disappeared in two months. No signs of vascular injury.

See also cases of cervical aneurism, &c.

Wounds of the pharynx.—I saw only three cases of wound of the pharynx; in each the injury was in the nasal or buccal segment of the cavity, and in each the soft palate was injured, in two instances the wound being a small perforation.

All three cases belong to the somewhat miraculous class. The first (89) was the only one in which the wound gave rise to subsequent trouble. The second was under the charge of Mr. Bowlby, and will no doubt be more fully recounted by him, as interesting signs of injury to the cervical cord were present. In the third the occipital neuralgia was the only troublesome symptom.

In both cases 90 and 91 the high position of the wound in the fixed portion of the pharynx no doubt accounted for the absence of any infective trouble.

(89) Wounds of the pharynx.—Entry (Lee-Metford), immediately below the tip of right mastoid process; the bullet traversed the neck, entering the pharynx close to the right tonsil, crossed the cavity of the pharynx and the mouth, emerging through the left cheek. Great swelling of the fauces and dysphagia persisted for some days after the injury, and there was considerable hæmorrhage.

Infection of the posterior portion of the track from the pharynx resulted, and suppuration continued for some weeks: a small sequestrum eventually needed to be removed from the tip of the transverse process of the atlas.

(90) Entry (Mauser), through mouth; the bullet pierced the soft palate and the posterior wall of the pharynx, and passed out between the transverse process of atlas and the occiput. No serious pharyngeal symptoms.

(91) Entry (Mauser), through the mouth, knocking out the left upper canine and bicuspid teeth. Perforation of the soft palate just to the right of the base of the uvula and the posterior wall of the pharynx; exit, 1½ inch internal to and 1/2 an inch below the tip of the right mastoid process. Hæmorrhage persisted for half an hour, and the patient could not swallow solids for a week. Great occipital neuralgia followed the wound.

Wounds of the larynx.—I saw only one wound of the larynx (see No. 10, p. 135). In this instance the thyroid cartilage was wounded on either side at the level of the Pomum Adami. Transitory hæmorrhage and signs of œdema were the only signs referable to the wound, but in addition the bullet contused the left vagus and gave rise to temporary laryngeal paralysis. The same course was observed in a second case of perforation of the larynx of which I was told.

Wounds of the trachea.—The two cases recounted below are the only tracheal injuries I met with; in one the œsophagus was also implicated. This patient died from mediastinal emphysema. In the second case the wide development of emphysema was prevented by the early introduction of a tracheotomy tube.

(92) Entry (Mauser), on the outer side of the right arm, 3½ inches below the acromion; exit, 3 inches below the tip of the left mastoid process, through the sterno-mastoid. Thirty six hours later there was very free hæmorrhage into the right posterior triangle, emphysema at the episternal notch, dysphagia, and complete obliteration of the cardiac area of dulness. Respiration was rapid (40) and extremely noisy. Pulse 130, small and weak.

A tracheotomy was performed (Mr. Stewart), but the patient died an hour later. When the operation was performed a considerable amount of mucus from the œsophagus was discovered in the wound. The bullet had passed obliquely between trachea and œsophagus, wounding both tubes.

(93) Entry, at the centre of the margin of the left trapezius; exit, in mid line of the neck over the trachea. Dyspnœa was noted the next morning, which increased during a journey in a wagon. On the third day the dyspnœa was more troublesome and emphysema began to develop in the neck. A tracheotomy was performed (Mr. Hunter), and the tube was kept in for four days. No further trouble was experienced, and the wound shortly closed, and the patient, a surgeon, returned to his duties. Temporary signs of median nerve concussion and contusion were noted.