Surgical Experiences in South Africa, 1899-1900 Part 26

My sight is about the same. There is no improvement in the right eye, and the doctor at Stoke said that the left eye was not as it ought to be and might get worse.

I ofttimes go to take up a thing, but find I am not near to it, though it appears to me so.

I have no pain to speak of in the head, though at times a shooting pain.

I have a continual noise in the left ear as if of a locomotive blowing off steam, and a deafness in the left ear which I had not before being wounded.

I am extremely indebted to my friend Mr. J. Errington Ker for the notes of the above case, so successfully treated by him.

(69) _Injury to occipital lobe._--Wounded at Modder River.

Scalp wound in occipital region. Two days later on arrival at the Base the patient was extremely restless and in a condition of noisy delirium. The wound was explored (Mr. J. J. Day) and a vertical gutter fracture discovered 1/2 an inch above and to the left of the occipital protuberance. The gutter was 1-1/2 inch in length and finely comminuted, the dura wounded, and the left occipital lobe pulped. A number of fragments of bone (one lodged in the wall of, but not penetrating, the lateral sinus) and pulped brain were removed. No improvement took place in the general condition, but the patient lived twenty-two days, during which time he coughed up a large quant.i.ty of gangrenous lung tissue and foul pus.

At the _post-mortem_ examination a wound track was found extending to the crest of the left ilium, where the bullet was lodged. The patient was no doubt lying with his head dipped into a hole scooped out in the sand (a common custom) when struck; the bullet then traversed the muscles of the neck, entered the upper opening of the thorax, where it struck the bodies of the second and third dorsal vertebrae, one third of the bodies of each of which were driven into an extensive laceration of the lung; it then grooved the inner surfaces of the eighth and ninth ribs, fractured the tenth and eleventh, and pa.s.sing the twelfth traversed the deep muscles of the back to the pelvis. Beyond the injury to the occipital lobe, the cerebellum was found to be lacerated and extensively bruised and ecchymosed.

_Complications._--_Hernia cerebri_ as a primary feature has already been mentioned as one of the peculiarities of some explosive wounds. In the later stages of the cases in which primary union did not take place the development of granulation tumours was often seen, sometimes in connection with slight local suppuration, sometimes over a cerebral abscess. In some cases a wound which had once closed reopened and a hernia developed. This sequence was chiefly of prognostic significance as an indication of intra-cranial inflammation, usually of a chronic character, and affecting rather the lowly organised granulation tissue formed in the cavity than the brain itself. When primary union of the skin flap and wound failed, the process of definitive closure of the subjacent cavity was always a very prolonged one, and it was in such cases that a great proportion of the so-called herniae developed.

_Abscess of the brain._--Local abscesses formed in a considerable proportion of the cases where serious damage to the brain had occurred, in whatever region this happened to be. I never saw one develop in cases where primary union had taken place, even when bone fragments had not been removed; neither did I ever see an abscess situated at a distance from the original injury. I take it that the latter is to be explained by the early date of the suppuration, and the fact that in the great majority of small-calibre wounds the exit opening exists in the situation of the contre-coup damages of civil practice.

The main feature in the symptoms when abscesses developed was the insidious mode of their appearance, usually at the end of fourteen to twenty-one days, and their comparative mildness.

Very slight evidences of compression were observed; thus, varying degrees of headache, drowsiness, irritability of temper or depression, twitchings, or in some cases Jacksonian seizures, combined with slow pulse and slight rises of temperature. I never happened to see complete unconsciousness. The slight evidence of compression was perhaps explained in most cases by the large bony defect in the skull, which acted as a kind of safety-valve. Again the firm nature of the cicatricial tissue which formed at the periphery of the injury and extended up to the skull and there formed a more or less firm attachment, also preserved the actual brain tissue to some degree from either pressure or direct irritation. After evacuation of the pus, the usual difficulty was experienced in ensuring free drainage, and definitive healing and closure of the cavities was very slow. The following two cases will ill.u.s.trate the character of the cases of cerebral abscess we met with:--

(70) _Fronto-parietal abscess._--Wounded at Magersfontein (Mauser). _Entry_, 1-3/4 inch above the line from the lower margin of the orbit to the external auditory meatus, and 1-3/4 inch behind the external angular process; _exit_, a little posterior to the left parietal eminence. There was right hemiplegia. The wounds were explored, and a large number of fragments of bone and pulped brain were removed, especially from the anterior wound. No great improvement followed, and the patient was sent to the Base. At this time there was a large hernia cerebri at the anterior wound which was suppurating.

A further operation was here performed (Mr. J. J. Day). The hernia cerebri was removed, also several fragments of bone which were found deeply imbedded in the brain. The patient then improved, but a month later his temperature rose, and on exploration an abscess was discovered in the frontal lobe and drained.

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 haemorrhage, or rapid intracranial oedema. 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 1-1/2 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 s.p.a.ce was opened up. The s.p.a.ce was crossed by a number of strands of connective tissue, and the cavity had no epithelial lining. The fluid ran out freely, and the s.p.a.ce 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 const.i.tutional 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 pa.s.sing water involuntarily.

On the third morning two similar fits occurred, the first a severe one, during which the patient pa.s.sed 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 cla.s.s 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 circ.u.mstances be deviated from. An expectant att.i.tude, 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'