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.