Fig. 65.Fig. 65.
Diagrammatic transverse sections of varying condition of bones in Gutter Fractures of the first degree.A.With no loss of substance.B.With comminution
(53)Superficial gutter fracture in parietal region. Convulsive twitchings. Secondary paralysis.—Wounded at Modder River. Range, 400 yards. A scalp wound 3 inches in length ran vertically downwards, commencing 1 inch from the median line, and situated immediately over the upper third of the right fissure of Rolando. The patient was unconscious for several hours after the injury, and later suffered with severe headache, and twitchings in the left shoulder and arm.The wound healed, but a well-marked groove was palpable in the bone beneath, and the twitchings persisted. The latter came on about every twenty minutes, and loss of power in the left upper extremity, and to a less degree in the lower, developed. The memory was defective, and the patient suffered at times with headache. The pupils were equal but sluggish in action. No changes were discovered in the fundus beyond a well-developed myopic crescent at the lower and outer part of the left disc (Mr. Hanwell).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.
(53)Superficial gutter fracture in parietal region. Convulsive twitchings. Secondary paralysis.—Wounded at Modder River. Range, 400 yards. A scalp wound 3 inches in length ran vertically downwards, commencing 1 inch from the median line, and situated immediately over the upper third of the right fissure of Rolando. The patient was unconscious for several hours after the injury, and later suffered with severe headache, and twitchings in the left shoulder and arm.
The wound healed, but a well-marked groove was palpable in the bone beneath, and the twitchings persisted. The latter came on about every twenty minutes, and loss of power in the left upper extremity, and to a less degree in the lower, developed. The memory was defective, and the patient suffered at times with headache. The pupils were equal but sluggish in action. No changes were discovered in the fundus beyond a well-developed myopic crescent at the lower and outer part of the left disc (Mr. Hanwell).
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).
Fig. 66.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
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 passed with great obliquity through especially dense bone (see fig. 70). When the bullet had passed more deeply the inner table was comminuted into numberless fragments. I have frequently seen 50 or 60 removed. Where such trackscrossed 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).
Fig. 67.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 illustrated 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 thesurface, 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 illustrated by skiagrams Nos. III. and XXIII. of the clavicle and fibula is a close one.
Fig. 68.Fig. 68.
Superficial Perforating Fracture. Illustrating 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 inwhich will illustrate the behaviour of the outer and inner tables respectively, when struck with moderate force.
Fig. 69.Fig. 69.
Diagrammatic longitudinal section of Fracture shown in fig. 68
Fig. 70.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.Entrybehind left ear, just above posterior root of zygoma; gutter fracture; bullet retained within skull. Above and corresponding to right frontal eminence there was a hæmatoma, 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 passed 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 2p.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, wasdiscovered. 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 apost-mortemexamination, and found considerable pulping of the tip of the right frontal and left temporo-sphenoidal lobes, and a thick layer of hæmorrhage extending over the whole base of the brain.
(54) Wounded at Thaba-nchu. Guedes bullet.Entrybehind left ear, just above posterior root of zygoma; gutter fracture; bullet retained within skull. Above and corresponding to right frontal eminence there was a hæmatoma, 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 passed 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 2p.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, wasdiscovered. 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 apost-mortemexamination, and found considerable pulping of the tip of the right frontal and left temporo-sphenoidal lobes, and a thick layer of hæmorrhage extending over the whole base of the brain.
Fig. 71.Fig. 71.
Scale of outer table of Frontal Bone and Diploë. Exact size, from fracture shown in fig. 72
Fig. 72.Fig. 72.—Perforating Fracture of Frontal Bone from within Separation of plate outer table. (Low velocity.) 1/2
The injury to thecranial contentsvaried with the degree of bone injury. Hæmorrhage 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 ifnot 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 hæmorrhage, 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 hæmorrhage, although many fractures crossing the line of distribution of the large branches came under observation. Case 60, p. 274, illustrated the fact that the osseous lesions of lesser apparent degree are sometimes the more to be feared in the matter of hæmorrhage, 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 illustrative of these injuries are included under the heading of symptoms.
It will be, of course, appreciated that the coarse 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 classes. The damage consisted in direct superficial laceration and contusion, and beyond the limits of the area of actual destruction, abundant parenchymatous hæmorrhages more or less broke up the structure of the brain, such hæmorrhages 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 classes, 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 classical 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 passing 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 classed 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 passed 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 fossæ were met with far less frequently, partly I think because vertical wounds passing from the vertex to the base in these regions were with few exceptions rapidly fatal, and partly from thefact 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 illustrate 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 passage 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 thebone 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 class 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 mass of brain débris, 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 class the actual opening was smaller, but the whole scalp was swollen and œdematous, 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 assumed.
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 illustration 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, whilethe 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 hæmorrhage, 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 space 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, hæmorrhage 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 space 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 expectedfrom 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 hæmorrhages 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 1½ 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 circumstances:first, the rarity of injuries giving rise to meningeal hæmorrhage; 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 hæmorrhage 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.
The pupils were rarely unequal, and at the stage in which these patients were first seen were usually moderately contracted. Wide dilatation was uncommon throughout.
The pulse was with very few exceptions slow, sometimes irregular. In some instances, when the wounds had been thought suitable for exploration, the slow pulse was altered after operation to a rapid one, and death usually quickly supervened.
Respiration was irregular, sometimes sighing; in the late stage often of the Cheyne-Stokes type; actual stertor was exceptional, but the respiration was often noisy.
The temperature was often raised from an early stage to 99° or 100°, and if the patient survived a day or two, it often rose to 103° or 104°. How far the secondary risedepended on sepsis it was not always easy to determine. The urine was usually retained.
Cases presenting the above characters were usually those suffering from lesions such as are described in class I., and mostly died in twenty-four to forty-eight hours. The correspondence of the train of symptoms with those due to combined brain destruction and severe concussion is at once apparent.
To illustrate the nature of the symptoms in patients suffering from the less extensive forms of injury, such as those included in classes II. and III. under the heading of anatomical lesion, the relation of a short series of histories will be advisable. I may first premise, however, that the special characteristics of these were in some instances the almost entire absence of primary symptoms of gravity; in others general symptoms of a severity out of apparent proportion to the external lesion; while in all destructive lesions, very widely distributed radiation symptoms developed, often disappearing with great rapidity.
The symptoms consisted in those of concussion, irritation, local pressure, and actual destruction.
The symptoms of concussion were either general, and then usually transient, or local paralysis of the radiation variety, which also rapidly improved.
Signs of irritation consisted in irritability of temper, drowsiness, closure of the eyes and objection to light, contracted pupils sometimes unequal, a tendency to the assumption of the flexed position at all the joints, twitchings, and sometimes convulsions. Sometimes these appeared early as a direct result of mechanical irritation from bone fragments or blood-clot; sometimes only in the course of a few days, as a result of irritation of parts recovering from the radiation effects which had prevented earlier nervous reaction. Possibly in some cases the symptoms of irritation depended upon an increase in the amount of hæmorrhage, and in others upon the development of local inflammatory changes.
Local pressure, or actual destruction of brain tissue, was evidenced by temporary paralysis in the former, permanent loss of function in the latter, condition.
Fractures of the anterior fossa of the skull were attended by very marked evidence of orbital hæmorrhage, as subconjunctival ecchymosis (rarely pure), increased tension, and proptosis.
Injuries to the cranial nerves at the base, with the single exception of lesion of the optic nerves, which was not rare, were in my experience uncommon in the hospitals—a fact pointing to the very fatal nature of direct basal injuries, except in the anterior fossa of the skull. Signs indicative of injury to the olfactory lobe were occasionally observed.
I should, perhaps, again insist here on the rarity with which acute diffuse septic infection occurred in cases of these degrees of severity, also on the fact that interference with the wounds in the way of secondary exploration, even when they were manifestly the seat of local infection, was followed almost without exception by good immediate results; and, lastly, that when suppuration did occur, it was usually strictly local in character. The influence of the climate of South Africa and our surroundings has already been discussed, but whether climate, condition of the patients, or peculiarity in the nature of causation of the wounds was responsible, in no series of cases was the absence of acute inflammatory troubles more striking than in this one of brain injuries.
Frontal injuries were those most frequently unaccompanied by primary symptoms of severity; slowing of the pulse—this often fell to 40—and occasional irregularity, were almost the only constant signs of cerebral damage. Some patients temporarily lost consciousness, others rose at once and walked to the dressing station, and in few cases was any psychical disturbance noted in the early stages.
I think, however, it may be affirmed that frontal injuries, accompanied by trivial signs, resulted without exception from the passage of bullets travelling at a low rate of velocity. Thus in several of the instances here related the patients at the time of reception of the wound were under the impression that they were entirely beyond the range of fire, and in one, in which well-marked signs of concussion followed, the bullet, which had traversed the head, retained only sufficient force to perforate the skin of the neck and bury itselfin the posterior triangle without even fracturing the clavicle, against which it impinged. In men struck at a shorter range, signs of concussion, often followed by transient radiation signs of injury to the parietal lobe, were common. These signs were, I think, not as a rule due to surface hæmorrhage, since they were of a purely paralytic nature and not irritative. Several cases with partial or complete hemiplegia, hemiplegia and aphasia, or facial paralysis are recorded below.
(56)Frontal injury.—Wounded at Magersfontein. In prone position when struck, distance 700 to 800 yards.Entry(Mauser), at the margin of the hairy scalp above and to the left of the frontal eminence; course, through anterior third of left frontal lobe, roof of orbit, obliquely across line of optic nerve, inner wall of orbit, nose, right superior maxilla piercing alveolar process, and passing superficial to inferior maxilla:exit, one inch anterior to angle of jaw. The bullet again entered the posterior triangle of the neck, struck the right clavicle, and turned a somersault, so that its base lay deepest in the wound.The patient was unconscious for a short time, suffered with general headache and giddiness, and was somewhat irritable. On the third day the pulse was 70, temperature normal, and he was sent to the Base. There was considerable proptosis, œdema and discoloration of the eyelid, and subconjunctival ecchymosis, but the movements of the eyeball could be made and light could be distinguished. The sense of smell was apparently absent. A week later the headache was gone, the pulse numbered 80 to 90, the temperature was normal, he slept well, sat up in bed and smoked, took his food well, and exhibited no cerebral symptoms. He could detect the smell of tobacco, but not as a definite odour.No further symptoms were noted, the sense of smell returned, the swelling of the eyelid and proptosis decreased, but the upper lid could not be raised. When the lid was drawn up, there appeared to be vision at the margins of the field with a large central blind spot. The patient left for England at the end of a month apparently well.(57)Gutter fracture of frontal bone.—Wounded at Paardeberg.Entry(Mauser), 3/4 of an inch within the margin of hairy scalp above outer extremity of right eyebrow; gutter fracture;exit, 2 inches nearer middle line, at the same distance from the margin of the hairy scalp. The patient was knocked head over heels, his main feeling being a sense of dulness in the right great toe. He sat upand got a first field dressing applied, then lay down, but as he was still under fire, he retired 1,000 yards to the collecting station; here he dressed some patients, and later mounted an ambulance wagon and was driven to the Field hospital. The next day he helped with the work of the hospital, amongst other things controlling the artery during an amputation of the arm. He then took a three days' and nights' journey to Modder River in a bullock wagon, during which journey he had a fit, which was general, the thumbs being turned in and a wedge being necessary between the teeth to prevent him biting his tongue.On the sixth day the wound was examined, and between this and the tenth day he had several fits of the same nature as the first, accompanied by stertorous breathing and profuse sweating. On the tenth day Mr. Cheatle opened up the wound and removed numerous fragments of bone, leaving a clean gutter 2 inches by 3/4 of an inch. After the operation no further fits occurred, and eight days later he was conscious, but was excitable and talked at random. On the twentieth day he arrived at the Base after 30 hours' railway journey (623 miles). He was then quite rational, but unable to make any demands on his memory and very sensitive to noise; at times he wandered in the evenings and his temperature rose as high as 100°. The wound was open and granulating, the floor pulsating freely.Three weeks later the wound was still open, and the skin dipped in at the lower margin. The mental condition was much improved, although attempts at giving a history of his case were obviously tiresome.The wounds in the leather headband of this patient's helmet were interesting, the round aperture of entry in the exterior of the helmet being followed by a starred exit aperture in the leather band, the second entry opening in the leather band being again circular, and the external opening in the puggaree a transverse slit.(58)Transverse superficial perforating frontal injury.—Wounded at Graspan. Aperture ofentry(Lee-Metford), at upper and outer part of left frontal eminence;exit, at margin of hairy scalp over outer third of right eyebrow. On the second day the patient complained of giddiness and headache; the pulse was 60. He was then walking about. The wounds were explored and typical entry and exit apertures discovered in the frontal bone from which cerebral matter was protruding. Both openings were enlarged (Mr. S. W. F. Richardson) with Hoffman's forceps, and a considerable number of splinters of the inner table were removed from the aperture of entry.The headache gradually passed off, but there was throbbing about the scar, and pulsation was visible for some three weeks, after which no further symptoms were observed.(59)Oblique frontal gutter fracture.—Wounded at Magersfontein.Entry(Mauser), 1/2 an inch to right of median line of forehead, 3/4 of an inch from the margin of the hairy scalp;exit, about 3/4 of an inch anterior to the lower extremity of the right fissure of Rolando. Weakness of left facial muscles, especially of angle of mouth. No further motor symptoms. Wounds explored (Mr. Stewart); numerous fragments of bone and some pulped cerebral matter were removed. Patient developed no further signs; the paralysis, although improved, did not completely disappear. The man a year later was still on active duty, the paralysis almost well, and no further ill effects of the injury remained.
(56)Frontal injury.—Wounded at Magersfontein. In prone position when struck, distance 700 to 800 yards.Entry(Mauser), at the margin of the hairy scalp above and to the left of the frontal eminence; course, through anterior third of left frontal lobe, roof of orbit, obliquely across line of optic nerve, inner wall of orbit, nose, right superior maxilla piercing alveolar process, and passing superficial to inferior maxilla:exit, one inch anterior to angle of jaw. The bullet again entered the posterior triangle of the neck, struck the right clavicle, and turned a somersault, so that its base lay deepest in the wound.
The patient was unconscious for a short time, suffered with general headache and giddiness, and was somewhat irritable. On the third day the pulse was 70, temperature normal, and he was sent to the Base. There was considerable proptosis, œdema and discoloration of the eyelid, and subconjunctival ecchymosis, but the movements of the eyeball could be made and light could be distinguished. The sense of smell was apparently absent. A week later the headache was gone, the pulse numbered 80 to 90, the temperature was normal, he slept well, sat up in bed and smoked, took his food well, and exhibited no cerebral symptoms. He could detect the smell of tobacco, but not as a definite odour.
No further symptoms were noted, the sense of smell returned, the swelling of the eyelid and proptosis decreased, but the upper lid could not be raised. When the lid was drawn up, there appeared to be vision at the margins of the field with a large central blind spot. The patient left for England at the end of a month apparently well.
(57)Gutter fracture of frontal bone.—Wounded at Paardeberg.Entry(Mauser), 3/4 of an inch within the margin of hairy scalp above outer extremity of right eyebrow; gutter fracture;exit, 2 inches nearer middle line, at the same distance from the margin of the hairy scalp. The patient was knocked head over heels, his main feeling being a sense of dulness in the right great toe. He sat upand got a first field dressing applied, then lay down, but as he was still under fire, he retired 1,000 yards to the collecting station; here he dressed some patients, and later mounted an ambulance wagon and was driven to the Field hospital. The next day he helped with the work of the hospital, amongst other things controlling the artery during an amputation of the arm. He then took a three days' and nights' journey to Modder River in a bullock wagon, during which journey he had a fit, which was general, the thumbs being turned in and a wedge being necessary between the teeth to prevent him biting his tongue.
On the sixth day the wound was examined, and between this and the tenth day he had several fits of the same nature as the first, accompanied by stertorous breathing and profuse sweating. On the tenth day Mr. Cheatle opened up the wound and removed numerous fragments of bone, leaving a clean gutter 2 inches by 3/4 of an inch. After the operation no further fits occurred, and eight days later he was conscious, but was excitable and talked at random. On the twentieth day he arrived at the Base after 30 hours' railway journey (623 miles). He was then quite rational, but unable to make any demands on his memory and very sensitive to noise; at times he wandered in the evenings and his temperature rose as high as 100°. The wound was open and granulating, the floor pulsating freely.
Three weeks later the wound was still open, and the skin dipped in at the lower margin. The mental condition was much improved, although attempts at giving a history of his case were obviously tiresome.
The wounds in the leather headband of this patient's helmet were interesting, the round aperture of entry in the exterior of the helmet being followed by a starred exit aperture in the leather band, the second entry opening in the leather band being again circular, and the external opening in the puggaree a transverse slit.
(58)Transverse superficial perforating frontal injury.—Wounded at Graspan. Aperture ofentry(Lee-Metford), at upper and outer part of left frontal eminence;exit, at margin of hairy scalp over outer third of right eyebrow. On the second day the patient complained of giddiness and headache; the pulse was 60. He was then walking about. The wounds were explored and typical entry and exit apertures discovered in the frontal bone from which cerebral matter was protruding. Both openings were enlarged (Mr. S. W. F. Richardson) with Hoffman's forceps, and a considerable number of splinters of the inner table were removed from the aperture of entry.
The headache gradually passed off, but there was throbbing about the scar, and pulsation was visible for some three weeks, after which no further symptoms were observed.
(59)Oblique frontal gutter fracture.—Wounded at Magersfontein.Entry(Mauser), 1/2 an inch to right of median line of forehead, 3/4 of an inch from the margin of the hairy scalp;exit, about 3/4 of an inch anterior to the lower extremity of the right fissure of Rolando. Weakness of left facial muscles, especially of angle of mouth. No further motor symptoms. Wounds explored (Mr. Stewart); numerous fragments of bone and some pulped cerebral matter were removed. Patient developed no further signs; the paralysis, although improved, did not completely disappear. The man a year later was still on active duty, the paralysis almost well, and no further ill effects of the injury remained.
In the fronto-parietal or parietal regions, signs of damage to the cortical motor area were seldom absent, sometimes evanescent, at others prolonged. In some cases the signs were permanent and followed by evidence of local sclerosis.
The motor area on both sides of the brain was sometimes implicated; thus in a child shot at Kimberley the bullet entered in the right frontal region, and emerged to the left of the line connecting bregma and inion a little behind its centre. Paralysis of both lower extremities resulted, power rapidly returning in the right, while incomplete paralysis persisted in the left.
In only one instance (see case 73, p. 292) was any permanent sensory defect observed, and the mental condition of this patient would have certainly suggested a functional explanation for its presence, had it not been for the accompanying inequality in the axillary surface temperatures.
In a second case (No. 67) blunting of sensation followed a definite lesion of the inferior parietal lobule. In this instance an occipital lesion was associated with the parietal.
(60)Parietal gutter fracture.—Wounded at Magersfontein. A scalp wound 3 inches in length ran transversely across the right parietal bone at the level of the lower third of the fissure of Rolando. A second wound of entry was found crossing the third dorsal spine; the bullet was retained and was palpable over the right scapula. There was left facial paralysis, weakness and numbnessof both upper extremities, especially of the left, and some difficulty in swallowing. The man was sent to the Base, where he arrived on the fourth day. The symptoms had then become much more marked, consciousness was incomplete, and articulation slow and imperfect. There was complete left hemiplegia, and deviation of the tongue to the right. The pulse was 40. An exploration (Mr. J. J. Day) showed that an oval plate of the outer table of the parietal bone had been struck off. A trephine was applied to the exposed diploë and a crown of bone removed; considerable comminution of the inner table had occurred, several large fragments having perforated the dura-mater. The latter did not pulsate; it was therefore freely incised, and many more fragments of bone and a large quantity of blood-clot removed.The first effect of the operation was slight, but ten days later rapid improvement commenced, the first sign being acceleration of the pulse, which rose to 70. On the eighteenth day the original symptoms still remained to a diminished extent, but a fortnight later there remained traces of the facial weakness only, and there was little difference in the grip of the two hands. The patient was shortly afterwards sent home. Ten months later he returned to South Africa on active service.(61)Fronto-parietal gutter fracture.—Wounded at Graspan.Entry(Mauser), 1 inch within the margin of the hairy scalp, 1/2 an inch to the left of the median line;exit, 3½ inches posterior in same line. Complete right-sided hemiplegia. The wounds were explored on the fourth day (Major Moffatt, R.A.M.C.) and a gutter fracture involving the frontal and parietal bones exposed. The dura-mater was lacerated and brain matter from the frontal lobe escaped freely. A large number of bone fragments were removed. On the fourth day after the operation, the patient became unconscious with right-sided twitchings, but rapidly improved, and at the end of three weeks, except for slight headache, he was well, the power of the right side being good. Ten months later he rejoined his regiment in South Africa, no apparent ill effects remaining.(62)Fronto-parietal perforating fracture.—Wounded at Magersfontein.Entry, within the margin of the hairy scalp;exit, behind and below the left parietal eminence, the track crossing about the centre of the fissure of Rolando. Right hemiplegia, the lower half of the face only being involved. The wounds were explored and a large number of fragments of bone and a quantity of pulped cerebral matter removed. Six days later the hemiplegia persisted, speech was slow, headache was troublesome and the pulse not above 45. After this, gradual improvement took place,and a month later the lower extremity and face had regained good power. The upper extremity remained flaccid and paralysed, except for some slight power of movement of the shoulder.(63)Fronto-parietal perforating fracture.—Wounded at Magersfontein.Entry(Mauser), 2½ inches from the median line, 3½ inches from the occipital protuberance;exit, 3/4 of an inch from the median line, 4½ inches from the glabella; sanious fluid escaped from both ears. There was left facial paralysis, complete paralysis of the left upper extremity, and partial paralysis of the left lower extremity. The patient was deaf, drowsy, and the pulse 45.Exploration showed the entry wound to be in the parietal, the exit to involve both parietal and frontal bones. The openings were enlarged, and a number of fragments of bone, together with pulped cerebral matter and blood-clot, were removed. The wound healed, except at the front part, where a small prominence suggested a hernia cerebri.The patient improved slowly; fourteen days after the operation he could hear well, and the flow from the ears had ceased. The facial weakness was slight, the upper extremity was still powerless, but he could move the lower and draw it up in bed. At the end of six weeks the wound had healed, and he was got up and dressed.At the end of two months he was well enough to be sent home; there was only a trace of facial weakness; the right upper extremity, however, was powerless and slightly rigid, occasional twitchings occurring in it. Considerable power had been regained in the lower extremity, so that the patient could walk with help, but foot-drop persisted; the gait was spastic in character, the reflexes were much exaggerated, and there was marked clonus. The patient was sensible, but his manner suggested some mental weakness. Both the openings in the skull were closed by very firm material, apparently bony.This patient became a Commissionaire some ten months later. His mental condition is normal, and loss of memory seems confined to the events immediately following the injury. The lower extremity has improved, but the upper is useless.(64)Parietal injury: retained bullet.—Wounded at Paardeberg. Aperture ofentry(Mauser), 1 inch diagonally below and anterior to left parietal eminence. No exit. The patient was trephined by the surgeons of the German ambulance at Jacobsdal.Sixteen days later he arrived at the Base. A circular pulsating trephine opening was then to be felt beneath the flap, but no information was forthcoming as to the bullet. The patient couldspeak, but lost words and the gist of sentences; he could remember nothing as to himself since the day of the injury. There was right facial weakness; he could not close the right eye or whistle, but there was little apparent want of symmetry; there was weakness in the grip of both hands, more marked on the right side; both lower extremities could be moved. The reflexes were normal, although the left limb was slightly rigid. The pupils were equal, reflex normal; slight nystagmus. Pulse 72, small and regular. Temperature normal. Rapid improvement followed.During the fourth week the temperature rose to 103°, and remained elevated for six days, but no local or general signs appeared; at the end of five weeks there was little evidence of the paralysis remaining. The patient was discharged from the service on his return home.
(60)Parietal gutter fracture.—Wounded at Magersfontein. A scalp wound 3 inches in length ran transversely across the right parietal bone at the level of the lower third of the fissure of Rolando. A second wound of entry was found crossing the third dorsal spine; the bullet was retained and was palpable over the right scapula. There was left facial paralysis, weakness and numbnessof both upper extremities, especially of the left, and some difficulty in swallowing. The man was sent to the Base, where he arrived on the fourth day. The symptoms had then become much more marked, consciousness was incomplete, and articulation slow and imperfect. There was complete left hemiplegia, and deviation of the tongue to the right. The pulse was 40. An exploration (Mr. J. J. Day) showed that an oval plate of the outer table of the parietal bone had been struck off. A trephine was applied to the exposed diploë and a crown of bone removed; considerable comminution of the inner table had occurred, several large fragments having perforated the dura-mater. The latter did not pulsate; it was therefore freely incised, and many more fragments of bone and a large quantity of blood-clot removed.
The first effect of the operation was slight, but ten days later rapid improvement commenced, the first sign being acceleration of the pulse, which rose to 70. On the eighteenth day the original symptoms still remained to a diminished extent, but a fortnight later there remained traces of the facial weakness only, and there was little difference in the grip of the two hands. The patient was shortly afterwards sent home. Ten months later he returned to South Africa on active service.
(61)Fronto-parietal gutter fracture.—Wounded at Graspan.Entry(Mauser), 1 inch within the margin of the hairy scalp, 1/2 an inch to the left of the median line;exit, 3½ inches posterior in same line. Complete right-sided hemiplegia. The wounds were explored on the fourth day (Major Moffatt, R.A.M.C.) and a gutter fracture involving the frontal and parietal bones exposed. The dura-mater was lacerated and brain matter from the frontal lobe escaped freely. A large number of bone fragments were removed. On the fourth day after the operation, the patient became unconscious with right-sided twitchings, but rapidly improved, and at the end of three weeks, except for slight headache, he was well, the power of the right side being good. Ten months later he rejoined his regiment in South Africa, no apparent ill effects remaining.
(62)Fronto-parietal perforating fracture.—Wounded at Magersfontein.Entry, within the margin of the hairy scalp;exit, behind and below the left parietal eminence, the track crossing about the centre of the fissure of Rolando. Right hemiplegia, the lower half of the face only being involved. The wounds were explored and a large number of fragments of bone and a quantity of pulped cerebral matter removed. Six days later the hemiplegia persisted, speech was slow, headache was troublesome and the pulse not above 45. After this, gradual improvement took place,and a month later the lower extremity and face had regained good power. The upper extremity remained flaccid and paralysed, except for some slight power of movement of the shoulder.
(63)Fronto-parietal perforating fracture.—Wounded at Magersfontein.Entry(Mauser), 2½ inches from the median line, 3½ inches from the occipital protuberance;exit, 3/4 of an inch from the median line, 4½ inches from the glabella; sanious fluid escaped from both ears. There was left facial paralysis, complete paralysis of the left upper extremity, and partial paralysis of the left lower extremity. The patient was deaf, drowsy, and the pulse 45.
Exploration showed the entry wound to be in the parietal, the exit to involve both parietal and frontal bones. The openings were enlarged, and a number of fragments of bone, together with pulped cerebral matter and blood-clot, were removed. The wound healed, except at the front part, where a small prominence suggested a hernia cerebri.
The patient improved slowly; fourteen days after the operation he could hear well, and the flow from the ears had ceased. The facial weakness was slight, the upper extremity was still powerless, but he could move the lower and draw it up in bed. At the end of six weeks the wound had healed, and he was got up and dressed.
At the end of two months he was well enough to be sent home; there was only a trace of facial weakness; the right upper extremity, however, was powerless and slightly rigid, occasional twitchings occurring in it. Considerable power had been regained in the lower extremity, so that the patient could walk with help, but foot-drop persisted; the gait was spastic in character, the reflexes were much exaggerated, and there was marked clonus. The patient was sensible, but his manner suggested some mental weakness. Both the openings in the skull were closed by very firm material, apparently bony.
This patient became a Commissionaire some ten months later. His mental condition is normal, and loss of memory seems confined to the events immediately following the injury. The lower extremity has improved, but the upper is useless.
(64)Parietal injury: retained bullet.—Wounded at Paardeberg. Aperture ofentry(Mauser), 1 inch diagonally below and anterior to left parietal eminence. No exit. The patient was trephined by the surgeons of the German ambulance at Jacobsdal.
Sixteen days later he arrived at the Base. A circular pulsating trephine opening was then to be felt beneath the flap, but no information was forthcoming as to the bullet. The patient couldspeak, but lost words and the gist of sentences; he could remember nothing as to himself since the day of the injury. There was right facial weakness; he could not close the right eye or whistle, but there was little apparent want of symmetry; there was weakness in the grip of both hands, more marked on the right side; both lower extremities could be moved. The reflexes were normal, although the left limb was slightly rigid. The pupils were equal, reflex normal; slight nystagmus. Pulse 72, small and regular. Temperature normal. Rapid improvement followed.
During the fourth week the temperature rose to 103°, and remained elevated for six days, but no local or general signs appeared; at the end of five weeks there was little evidence of the paralysis remaining. The patient was discharged from the service on his return home.
In the upper part of the occipital region glancing or superficial injuries were comparatively favourable; those near the base, especially if perforating, were very dangerous. Two such cases are referred to elsewhere. Case 69 is included as the only example of cerebellar injury I happened to see who lived any appreciable time after the accident.
The main interest in these cases centres in the defects produced in the area of the visual field. I am extremely indebted to my colleague, Mr. J. H. Fisher, who has kindly determined this for me in three of the following cases. It will be noted that in two instances the injury was to the left occipital lobe. In these the resulting hemianopsia was of the pure lateral homonymous character, and in both the visual symptoms were accompanied by a certain degree of amnesic aphasia (65 and 68).
In 65 the injury was definitely unilateral, and at the time of the operation I decided that at least an inch and a half of the posterior extremity of the left occipital lobe was totally destroyed.
In 68 the lesion was probably confined to the left lobe, but it is impossible to exclude slight injury to the right lobe also. In this instance amnesic aphasia was a far more marked symptom than in 65, and the position of the lesion suggested damage both to the visual and auditory word centres.
Cases 66 and 67 are instances of damage to both occipital lobes. In 66, although the wound was a glancing one, and did not perforate, it was so near the median line, and accompanied by such severe damage to the bone, that a symmetrical lesion of the cuneate and precuneate lobules of both right and left sides is to be inferred. In 67 the great longitudinal fissure was traversed by the bullet obliquely. It is of great interest to observe that in each of these cases the lesion of the visual field was a horizontal one and affected the lower half in place of assuming a lateral distribution.
In all four cases the primary effect of the occipital injury was the same—viz. absolute blindness—while the return of vision in each was of the nature of the dawning of light. I regret that I am unable to furnish any detail as to increase of the field of vision in the progress of the cases, but circumstances rendered continuous observation of the patients impossible.
In each case deafness was apparently the direct result of concussion of the ear on the side corresponding to the wound. Deafness of the opposite ear was never noted.
In case 67 some general blunting of sensation was noted in the paralysed upper extremity, and in this patient, no doubt, injury to the inferior parietal lobule accompanied the occipital lesion.