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.