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Chapter II

Contents

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SECTION III

NEUROSURGERY

CHAPTER II

ACTIVITIES OF THE AMERICAN FIRST ARMY HOSPITAL AT DEUXNOUDS a

On September 26, 1918. Casual Team No. 538 was ordered to proceed to Deuxnouds and to take over the French ambulance in that village, it being the intention of the chief surgeon, First Army, to convert this ambulance into ahead hospital.

At noon of the 28th the first portion of the equipment of Mobile Hospital No. 6 arrived and continued to do so during the 29th and 30th. Because of the haste in opening, the taking over of the French hospital, and the functioning for the first time of a mobile unit fresh from its assembling point, many improvisations were necessary, and as complete records as might be desirable were not at all times obtained, especially in the first few days.

In the triage all lightly wounded were dressed and such as were non-operative immediately marked for evacuation. Operative cases were undressed, bathed, and placed on stretchers pending operation. About 90 per cent of the neurosurgical work was lone during the first two weeks.

Inasmuch as no systems of permanent records in evacuation hospitals had been established, it was necessary to improvise some method of keeping track of at least the most important cases received at this hospital. Each team was asked to keep a record in a duplicating book provided for them, of which one copy was placed with the field medical card or its equivalent. When a patient was evacuated, the records were passed through the office of the surgical chief, who abstracted the more essential points upon the patient's field medical card and saved the complete record to turn into the consulting surgeon's office. Unfortunately, when teams were ordered away, records were left in the hands of men who, although able and willing, had had no experience previously with the system of keeping them.

The total number of admissions up to the morning of October 15 was 815. Of these, 403 underwent operation. leaving 412 which were dressed in the triage at once and marked for evacuation. These cases then had passed through, in the majority of instances, triage at the field hospitals and evacuation hospitals without their dressings being changed and had come through to Deuxnouds before being recognized as nonoperable and evacuated. Of the 403 operations, 106 were craniotomies.

The operative capacity of the Deuxnouds hospital was, roughly, 100 cases per 24 hours, of which, from the experience gained there, one would expect 25 to be craniotomies and 15 dural penetrations. In addition, on the above basis,100 cases would be passed through the triage with a dressing and for immediate evacuation. If, as is generally estimated, 10 percent of the total casualties

a Based on report on head hospital at Deuxnouds, undated, made by Capt. S. C. Harvey, M. C., to the chief surgeon, A. E. F. Copy on file, Historical Division, S. G. O.


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involve the head, face, and neck, then this hospital was caring for its proportion of 2,000 casualties in 24 hours.

With the equipment the personnel could be expanded at least 50 percent, and in that case such a unit could handle 200 operations, admit 400 casualties, and handle its proportion of 4,000 in the 24 hours. This would make a total of 28,000 a week or, roughly, 100,000 a month, which perhaps is approximately the casualty rate for the fighting at this time in the First Army; that is to say, one well-developed unit of this type or two smaller ones should be able to handle wounds above the clavicle for one army as at present organized.

Frequently it is assumed that the retention of head cases will soon choke the bed capacity of a hospital. The normal intakes of this hospital estimated at 15 dural penetrations per day (these being the only cases retained) would provide at the maximum an accumulation of 100 per week. In two weeks this type of case is evacuated, so that at no time would more than 2,000 beds be occupied.

As a matter of experience, during the second week of function of this hospital, the beds occupied reached 290, but this was chiefly because of lack of evacuation, and in spite of this there was no choking of the hospital by retention of head cases.

CLINICAL DATA

Deaths.- In so far as neurosurgical conditions are concerned, the deaths from the opening of the hospital until its evacuation by Mobile Hospital No. 8.that is until about November 8, numbered 67, of which 25 died without operation and 42 following operation. These have been classified according to Cushing's classification, as follows:

DEATHS UNOPERATED

Cranial: Group I (general shock and sepsis from other wouiids).............................................1
II (previously operated)..................................................................................................1
IV (previously operated).................................................................................................1
V (all moribund on entrance)..........................................................................................5
VI (4 meningitis; 3 moribund on entrance)....................................................................7
Wounds of head (no data; moribund on entrance)....................................................................4
Dead on entrance (dural penetration; no further data)...............................................................1
Spinal cord ------------------------------------------------------------------------------------1
Total-------------------------------------------------------------------------------------------21

Of these, it may be noted that two (Group II and Group IV, respectively)previously had undergone operation. The records of these are as follows:

CASE 1.- A. I. J. F., No. 3270146. Wounded October 5, 1918. Field hospital (?).Copy of note: " (1) G. S. W. left arm; compound fracture. (2) G. S. W. head, left. Compound fracture of skull. 36 hours. Operation October 7: Cleaning, partial suture of scalp; no evidence of depression of skull. Amputation left arm after consultation. Hold." Entered Mobile Hospital No. 6, October 12. Amputation left forearm. Suture lacerated scalpwound, left occipital. Neurological examination negative; X ray negative. Dressing. One suture removed from scalp. Patient profoundly unconscious; manifestly moribund. Died October 13. Autopsy: Depressed fracture of the inner plate, left occipitoparietal, with large extradural hemorrhage; no dural penetration. Brain saved for section.


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This patient arrived profoundly unconscious, with notes of operation performed elsewhere and revealing no fracture. A negative X-ray and neurological examination of the patient confused the picture still further. In view of the moribund condition of the patient and the negative findings, it was not thought worth while to do an exploration. The surgeon who operated upon him would have been in a better position to judge of his condition and the advisability of further operative action. Consequently this case should not have been evacuated.

CASE 2.- J. G., No. 1624243. 79th Div. 314th Machine Gun Battery, B Co.,admitted to A. R. C. Hospital No. 114 with following note: "X-ray: F. B. 1 cm.right side of head, 4 cm. under skin mark, right temple. Large depressed fracture of skull; left parietal region. 22 hours after injury. Operation: Removal of depressed parts of bone.Brain irrigated and macerated brain tissue removed. F. B. not removed. Hold." Admitted to Mobile Hospital No. 6, October 6, 1918, 11.30 p. m. A. T. S. given. October 7:Unconscious; delirious; tosses about with left arm and hand. Incontinence of feces and urine. Complete right-sided hemiplegia. Right facial palsy. Large postoperative wound, left parietal region; crow-foot incision; sutures infected; spinal fluid oozing out. Three central sutures removed. Skin edges infected; decompressed area size of half dollar in left parietal; there has been considerable brain injury. No rigidity of neck; no Kernig; left Babinski plus. October 8, 1918. Considerable foul discharge. Neck rigidity marked. October 9, 1918. Meningitis. Foul discharge from wound; opened more; fragments of inner table which were loose, removed. October 10, 1918. Died 12.40 p. m. No autopsy.

It is impossible to convey by notes, especially such as can be placed on a field card, the completeness of an operation and the history of a case such as this. Any dural penetrations should always stay under the care of the man operating until either evacuated to the base or dead.

Of the five cases in Group V dying without operation, in three the foreign body had traversed or lodged in the region of the basal ganglia. In the remaining two the cranial damage was extensive, partly direct laceration of brain tissue and partly extensive "commotion" of the brain, such as is seen in profound concussion. They were all moribund on entrance. The following case is typical of this group:

CASE 3.- W. H., Pvt., No. 542269, 7th Inf., Co. H. Field Hospital No. 27, October 8, 1918. G. S. W. skull. Field Hospital No. 26, October 8, redressed, morphia, external heat, small piece of high explosive taken from right knee. Wound of thigh dressed. Mobile Hospital No. 6, October 8. Patient entered hospital in unconscious condition. No history other than above. Pulse 144; respiration rapid and with apparent beginning edema of lung. Wound: G. S. W. right anterior quadrant skull, about 4 cm. in length. Multiple C. S. W. right leg. X ray; foreign body 1 by 1½ 2 cm. inside skull, 7½ cm. under skin mark right anterior frontal region head on left side; 8 cm. under skin mark on middle anterior frontal region; plane passing on the line drawn will meet at a point giving the position of foreign body 1 by 1½ cm., 6 cm. under skin mark on upper inner surface of thigh, right. Foreign body A by A under skin mark on point of heel, right. October 9, 4.15 a. m. patient died. Autopsy: Penetrating wound right frontoparietal region. Extensive comminution of cerebrum with softening opposite side. Brain saved for section.

In Group VI, three patients entered in a moribund condition, the missile having, judging from its course, reached or traversed the ventricle. Four died of meningitis, one having a foreign body traversing the lateral horn of the left ventricle, unconscious on entering and developing infection in 24 hours; a second entering, unconscious, with foreign body localized in such a position


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as to indicate that it had traversed the ventricle, developed signs of meningitis in 24 hours and died on the seventh day after admission; a third had outspoken signs of meningitis; and the fourth, the foreign body had traversed one hemisphere from pole to pole, passing through the ventricle, while the man was profoundly unconscious and developed meningitis in 24 hours. A typical case is as follows:

CASE 4.- 145th Inf., Co. B, 37th Div. No notes from field hospital. Admitted to Mobile Hospital No. 6, September 30. Unconscious, with diagnosis of G. S. W., left parietal region. Condition good. Entrance wound in front of left ear just above zygoma. X ray: Foreign body 1/4 by 1 cm. lying below mark on right ear, right side of head to the table. Neurological examination: Complete right hemiplegia. October 1, 4 p. m.: Temperature, 100.6; pulse, 94; deeply unconscious. Fundus examination: Disks blurred; fields distended. Operation not considered advisable. October 3: Symptoms of meningitis. October 4: Semiconscious. October 7: Semiconscious; marked symptoms of meningitis. October 8: Died from meningitis. October 9: Autopsy. Penetrating wound left temporal region, entering tip of temporal lobe, entrance measuring 2 cm. in diameter, exuding quantity of pus and disorganized brain. Acute purulent meningitis especially marked over the base.

DEATHS OPERATED

Operated deaths are as follows:

Cranial: Group II.........................1
III.................................................2
IV...............................................17
V................................................. 3
VI.................................................5
VII................................................2
VIII...............................................2
IX ................................................2
Sinus (venous) ..............................1
Total...........................................35

The death in Group II was due to lobar pneumonia, shown at autopsy. There was also a linear fracture of the skull down to the right, but with no evidence of depression. A small and unimportant extradural clot was present. This fracture was not recognized at operation, and the skull consequently was not trephined.

The records of the patients in Group III who died are as follows:

CASE 5.- G. H. P., No. 65331, 103d Inf., Co. H. Admitted to Mobile Hospital No. 8, October 25, 5 p. m. Wounded 7 a. m., October 24. A. T. S. given. Unconscious 15 to 20 minutes after accident, with immediate paralysis left side of body. G. S. W., 12 by 3 cm., right parietal region, dirty and inflamed. G. S. W. right arm and elbow, outer surface, above and below knee, foul-smelling discharge suggesting gas infection. X ray head: Penetrating skull, right parietal. Numerous foreign bodies ½ by ¾ cm. in length in wound in skull. One foreign body 1 cm. long projects from the wound, to inner surface of the skull. No foreign body in brain. Right arm, leg, and thigh negative. Neurological examination: Paralysis left side of face, left arm, and left leg. Loss of sensation to touch and pin prick left arm and hand. Touch sensation in left hand present. Deep reflexes left arm, left leg hyperactive. Left epigastric, left cremasteric absent; right present. Spasticity left leg and left arm. Left Babinski. Pulse rate 100. October 25, 10.20 p. m.: Blood pressure, systolic 120, diastolic 80. Operation: Excision of scalp. Block removal decompressed skull fracture 3 cm. in diameter; dural penetration. Subdural blood clot and contused brain


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removed by suction. Dural wound left open. Partial closure of scalp. Local anesthesia, under primary ether. Arm and leg wounds excised for drainage. Pulse 150 and very weak, so that more extensive procedure could not be done. October 26, 8.45 a. m.: Convulsion, Jacksonian type, left side of face, left hand, duration 10 minutes. Dressings changed. Pulse 120. During the next 12 hours, patient had 6 of the localized convulsions. October 30: Continued and increasingly severe convulsions since operation, always involving left arm and left side of face. Left leg paralyzed; leg wound dirty and foul-smelling. General condition never good and became steadily worse. Right leg shows evidence of gas infection. Died at 7.30 p. m.

The severe shock and the sepsis resulting from wounds other than that of the skull seemed to preclude as extensive an operative procedure as was advisable in the first place, and also a secondary exploration to ascertain the cause of the irritative phenomena, which might otherwise have been done. A similar case with Jacksonian attacks, on secondary operation showed a tract in the cortex about 2 cm. deep under considerable pressure and tension. On relief of this, the convulsion subsided. No autopsy.

CASE 6.- H. P., No. 2257218, 361st Inf., Co. C, Pvt. Admitted to Mobile Hospital No. 6, October 4, 1918. Wounded October 3, 3 p. m. Was not rendered unconscious and was able to walk. X-ray examination: Foreign body 8 by 5 cm., 20 mm. from mark on posterior surface of right thigh. Forehead shows no foreign body. Wound of head 3 cm. above right eyebrow, 1 cm. in diameter. Neurological examination: Right pupil greater than left; pupils react to light, otherwise negative. Operation: October 4, 5.50 p. m. Block excision of block and bone. Internal plate, 2 by 1½ cm., which had been driven inward and striking into dura, removed. Escape of large amount of clear, cerebrospinal fluid. No contusion of underlying brain noted. Dura and scalp closed with silk. October 7: Scalp wound infected; opened. October 8: Kernig positive. Neck stiff; lumbar puncture done, 20 c. c. cloudy fluid removed. October 9: Lumbar puncture, with removal of cloudy fluid. October 10: At midnight patient died of meningitis. Autopsy: Scalp wound only slightly infected. Dura tight. Spreading from this is an acute, purulent meningitis, most marked over the right cerebrum and base.

In Group IV, there were 17 deaths, of which 1 had signs of meningitis on admission; 1 died of severe and generalized gas burns; 3 of meningitis; 8 encephalitis; and 4 directly as a result of very extensive intracranial damage, although this in some cases may have been complicated by infection. In other words. 11 out of the 17 cases were amenable to operative treatment.

In the cases of meningitis, two showed signs in 24 hours, making it seem possible that the meninges were infected previous to operation, while the third flared tip on the fifth day following a very extensive herniation and encephalitis. In the first two, the scalp was closed tightly and not opened at any time. The third was leit open because of the size of the scalp defect.

Four of the eight cases classified as dying of encephalitis had such an ex tensive intracranial damage that their condition was obviously practically hopeless for operation. One of these died of a gas infection of the brain.

The following is a typical case:

CASE 7.- M. K., Pvt., No. 1630902, 30th Inf., Co. I. Evacuation Hospital (A. R. C.) No. 114, October 11. G. S. W. head. Admitted to Mobile Hospital No. 6, October 12, A. T. S. given. History: G. S. W. head, October 11, 4 p. m. Conscious, no vomiting. Paralysis, left; spastic. Condition fair. Wound 2½ by 6 cm., right parietal, parallel with sagittal suture to the right of mid line over parietal region. Ragged, dirty, depressed fragment 1 by ½ cm. Stellate fracture radiating from depression. X-ray examination: No


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foreign body. Fracture of skull through inner table beneath wound. Neurological examination: Spastic left hemiplegia, arm and face; arm less than lower limb. Knee jerks diminished, left. Ankle-clonus, left. Operation: De bridement, two sutures in the dura; closure with no drainage. October 13: Wound dressed; considerable discharge. Patient stuporous October 14: Wound shown increasing sanguinio-purulent discharge. No rigidity marked. Unconscious. October 15: Condition serious. Much foul discharge from wound. Unconscious; no rigidity; Kernig. October 16: Nystagmus to the left. Condition worse. Convulsion this morning at 9; this afternoon at 1.30. Died at 5.30 p. m. Autopsy, October,17: Wound, vertex, of the skull, right parietal region, softened brain substance exuding--Three radiating lines of fracture from bone defect. Opening in the dura measures 3 by 5cm. Brain is so softened that its removal intact is almost impossible. Right parietal lobe entirely replaced by softened hemorrhagic mass.

The remaining four cases represent errors of treatment, and these are reported in detail:

CASE 8.- F. S., Pvt., No. 2965964, .314th F. A., Co. E. Wounded October 7, 1918. French field hospital, October 7, 1918. A. T. S. given. G. S. W. head. Entered Mobile Hospital No. 6, October 7, midnight. History indefinite; patient's statements uncontrolled and unreliable. Given his name, organization, State, etc., but readily forgets and repeats. Recognizes objects and names; knows he is in hospital and has been wounded. Wound: Small penetrating, left posterio-parietal, measuring 2½ by ¼ cm. X-ray examination negative, for foreign body. Area of increased density size of nickel, suggestive of intracranial hemorrhage under wound. Operation: De bridement of scalp; fractured bone 6 by 5 cm. had been driven into the dura and brain. Removal of bone fragments, enlarging the opening to the size of a dollar, under local anesthesia. October 10: Visual fields somewhat limited, homonomously to the right. October 11: Patient much more alert. Visual fields probably normal. October 17: Sutures removed. Slight amount of sero-purulent material. October 24: Died at 7.15 p. m. Progressive cerebral herniation and signs of encephalitis.

The condition of this patient previous to the operation seemed quite favorable, but for some unknown reason the block operation with wide exposure was not done, consequently thorough d ebridement was not accomplished. Intection ensued in the presence of inadequate drainage, followed by1 progressive encephalitis and death.

CASE 9.- F. D., No. 2557608, 138th Reg. Admitted to Mobile Hospital No. 6 September 30, 1918. Unable to talk. Slip with him says wounded in action: Day not known. Marked S. W. of skull. Condition: Unconcious on admission. An hour later could be rouse. Could not speak, but some attempts to obey simple orders, such as moving arm and leg. Wound: Severe, penetrating, over left parietal region. Bone fragments driven inwards and down outwards. Neurological examination: Complete right hemiplegia. Right pupil larger than left. Right ankle-clonus. Right knee jerks greater than left. No Babinski. X-ray findings negative. Operation: Déebridement ; removal of shattered bone. No foreign body. October 2: Dressing, some herniation. October 3: Dressing; herniation increased; slight hemorrhage. October 4: Severe hemorrhage. Herniation of almost entire left lobe. Discharge of blood spinal fluid on slightest cough. Died at 1.30 p. m., October 4.

CASE 10.- Pvt. No. 17X1329, Co. L, 313th Inf. Wounded, October 1, 1918. G. S. W. head: (1) frontoparietal; no foreign body or fracture. (2) G. S. W. 5 cm. in length, left Rolandic area; indriven bone. Admitted to Mobile Hospital No. 6 October 2, 1918. Neurological examination: Spastic paralysis right side. Right facial paralysis. Operation: De bridement. No foreign body found. Subdural clots. Bone fragments removed. Closure incomplete. October 3: Slight hemorrhage from dural vessels; brain hernia. Vessel cauterized; actual cautery. October 4: Patient died, 5.45 a. m.

In both of these cases, the dressings were carelessly done, with compression and damage to the herniating cerebral tissue, followed by hemorrhage. This was controlled only after further rough usage, resulting in the shutting


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off of blood supply to considerable areas of herniating cerebrum. Such a condition so handled is, of course, always progressive and followed by death.

CASE 11.- F. C., Sgt. No. 2307026, Co. G, 127th Inf. G. S. W. head. Wounded October 4, 4.30 p. m. Hit by piece of high explosive. Unconscious for hour and a half. Vomited directly on regaining consciousness, but not since. At Field Hospital No. 27. A. T. S. given. Entered Mobile Hospital No. 6 October 6, 1918, midnight. Wound: Gutter wound over right median frontal, apparently tangential. Dirty and protruding cranial tissue. General condition good. Pulse 60. Weakness of arm and hand. Positive Babinski, left; cremasteric, left; less than right. No other signs. Operation: Wound in bone removed en bloc. Three bone fragments removed, completing half mosaic. Cortical bleeding started by an attempt to remove bone fragment; controlled by cotton and finally by a small facial slip. Scalp sutured. October 6, 3.10 p. m.: Left lower fascialis weak. Pupils equal and react to light and accommodation. Left arm paralyzed except for very slight movement of forearm. Left leg very weak; no Babinski or Oppenheim. Reflexes: Knee jerks, left greater than right; no clonus. Vomiting. Wound dressed; blood under scalp expressed; seems clean. Pulse rapid. October 7: Neck stiff. Optic neuritis. Unconscious. Pulse 116.Temperature 100.6; respiration 30. October 8: Condition much worse this morning; com-plete left hemiplegia; stuporous. Died at 10.05 a. m.

The tearing of the deep cortical vessel, and the consequent hematoma along the tract, destroyed what small chance of recovery this patient had. Examination of wound post mortem showed a gas infection involving the greater part of the right frontal lobe, patient having died of a gas encephalitis.

In Group V, three eases died following operation. One of these entered with a foreign body 5 by 3 cm. in left parietal region and a herniation already present measuring 6 by 8 by 4 cm. Patient was unconscious and hemiplegic. An unsuccessful attempt at removal of foreign body was made. Wound was dressed; patient died within 48 hours.

The records of the remaining two cases are given in detail.

CASE 12.- J. E., Pvt. No. 2256961, 361st Inf., Co. A. Wounded October 1, 191g. Entered Mobile Hospital No. 6, October 3, 1918, 10.45 a. m. Penetrating wound right occipital region. X-ray examination: Penetrating wound: Foreign body 1 1/cm. in the brain. Mid line 7 cm. back of external auditory meatus. No localizing neurological sign. Operation: Block removal of fracture area through tripod incision. Foreign body lying about 8 cm. under the surface removed; several bone fragments also. Scalp closed tightly. October 5: Incontinence of urine; temperature 100F.; no nausea or headache. Deep reflexes very sluggish; drowsy. Disorientated for time and place. Knows he was in 361st. Inf., does not remember any circumstances of accident. October 7: Temperature ranged to 102 F. Patient vomiting to-day. Fungus formation, with broken-down wound. Scalp resutured, with anterior drain. October 8: Bloody discharge but wound holding. Opisthotonos; positive Kernig; patient has developed meningitis. October 9: Died at 7.40 a. m.

CASE 13.- Pvt. No. 1458990, 152d Inf. G. S. W. head. Entered Mobile Hospital No. 61 October 1, 1918, 12.05 a. m. Extensive gutter wound of left side of head from above left orbit upward and outward to left external auditory meatus. No neurological signs except for motor aphasia.
Operation: Local anesthesia. D bridement: Removal of bone fragments and pieces of shrapnel from brain. Closed in layers. October 7: Lower end of wound incision opened. Brain irrigated with saline. Fungus cleaned away. Scalp wound sutured tightly. October 10: Wound suppurating; dressed daily and irrigated with sterile salt solution. Draining profusely. Condition fair. October 12: Redressed. Free drainage, with suppuration of wound. Condition improved. October 13: Redressed. Some improvement. Temperature normal. Draining freely. October 14: Redressed. Wound condition same; still draining freely. Temperature 102.6 F. Suspicious Kernig. No opisthotonos. October 16: Died 4.30 p. m.


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These cases are of special interest because once having been sutured and having broken down, they were again closed over the hernia. The conception in the operator's mind of the condition being that it was a purely mechanical thing, it was not appreciated that while cranial herniation is due to increased intracranial pressure, this may be either the result of edema from mechanical disturbances, or, what is more important in war injuries, from infection. If the herniation is due to a purely mechanical cause, under proper dressing itwill shortly subside even if the scalp is left open. If, however, it is due to infection, as in any other region of the body, the infected area must be adequately drained. Both of these cases, as might have been expected under the treatment used, did badly.

Of the five deaths in Group VI, three were instances where the projectiles traversed the entire hemisphere passing through the ventricle in its course. Such injury-according to Cushing's experience, confirmed by this data-results uniformly in death. In time of rush such cases should be marked inoper-able. An instance of this class is the following:

CASE 14.- E. W., Pvt. No. 1937561, 26th Inf., Co. G. G. S. W. right side of head, severe. Entered Mobile Hospital No. 6 October 11. History of being wounded October 9, 4.55 p. m. States that he was struck by shrapnel. Not unconscious. Helmet broken. Very severe headache, and nauseated. Left hand has been weak since injury. No speech difficulty. Wound: Right frontal region, just back of hair line. Brain substance oozing. X ray shows machine-gun bullet lying near junction of temporal and occipital lobes on the right. Neurological signs: Left facial weakness. Left arm and hand extremely weak; left leg somewhat so. Slight diminution of sensation left. No astereognosis: Complete left homonymous hemianopsia. Reflexes, biceps, more lively right than left. Knee jerks, present right, absent left. Few clonic jerks each side. Operation: Novocaine and morphia. Complete removal of fractured skull. Débridement of scalp and track; through irrigation. Foreign body, machine-gun bullet; removal of right hemisphere, location 4½ cm. from point just above right external auditory canal and about 9 cmn. from the point of entrance in the right frontal lobe. Irrigated with sterile saline. Bone fragments removed; scalp sutured; patient's condition good. October 13: Dressed, wound clean. Temperature 101.4 F.;delirious; stiff neck and double Kernig. Left hemiplegia present. October 14: Died 2.15 a. m. Autopsy: Penetrating wound, deep, right frontal lobe. Brain saved for section.

The two remaining cases were instances of indriven bone fragments reaching the ventricle, and they died of meningitis. About one in four of such wounds recover and they are, therefore, distinctly operable.

In Group VII, two cases died, both having a wound involving the orbital contents, frontal sinus, and frontal lobe. The extensive mortality accompanying this type of injury suggests more radical measures, which were not under-taken in this hospital, namely, evisceration of the orbit and establishing wide and thorough drainage.

Two cases with traversing wounds of Group VIII died following operation, one of the cerebellum and one of an occipital lobe, the latter dying from a generalized gas infection, apparently arising from the foreign body which lodged deeply in the neck muscles and was not removed. In the former the foreign body traversed the right lobe of the cerebellum, almost completely destroying it, encephalitis of the cerebellum resulting in death in six days.

Two deaths are recorded in Group IX, one being the type of basal fracture commonly seen in civil life, and the other a fracture of the petrous portion of the temporal bone, with cerebrospinal fluid from the ear.


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Of these crises involving a venous sinus, one died. In this case the approach was made with an inadequate exposure resulting in profuse hemorrhage, packing, and death on the fifth day, which, however, was probably due to the effect of the missile ranging forward and inward to the basal ganglia.

PATIENTS EVACUATED

The following records are of cases that were evacuated in good condition: Cranial-Group I, 69; Group II, 32: Group III, 14; Group IV, 6; Group V, 11; Group VI, 1; Group VII, 1; Group VIII, 2. Sinus (venous): 4. Total: 140.

CRANIAL

Group 1
.- The majority of cases in this group were scalp wounds in which the injury had extended to the bone. In a few, however, the pericranium was not lacerated. It would seem, particularly in times of rush, that the patients in whom the laceration did not extend to the bone might be evacuated without operation. It is realized that there might well be a depressed fracture underneath such a lesion, but with the absence of neurological symptoms and the lack of a tract leading from the external wound to the depressed fracture, there would be few if any cases which would afterward show either neurological signs or infection of the fracture and the underlying cranial structures. In other words, in proper hands, a more conservative position might be taken as regards the operating on scalp wounds.

Group 11
.- Every case of this group should be explored and trephined. Experience with this hospital confirmed what already was well known, that is, that even the simplest linear fracture or even abrasion of the skull may overlie serious intracranial damage. If the pathway from the external wound to the fracture is continuous, then infection will in many cases--even with the simple depressed fracture without dural penetration-lead to a meningitis or an abscess in the contused adjacent cortex.

Group III.- The majority of cases reported in this group showed only a small puncture of the dura or slight laceration. An occasional one, however, had a short tract of contused tissue. The question always arises as to whether the best procedure is to close the dura at once with silk sutures, thus hoping to avoid infection of the underlying tissues, or to leave it open, arranging for drainage. From a study of the cases in this hospital, as well as experience elsewhere, it seems that every patient in whom the dura is sutured does badly. There is a tendency to the damming back of the infection in the subdural tissues, leading to meningitis or cortical abscess. Where the dura has been left open, such infected material evacuates itself beneath the scalp, and if the scalp is drained into the dressing no progressive infection arises and the wound heals with little reaction. As a general policy it would seem advisable in cases of this type to leave the dura open and, in addition, to drain the scalp with a small rubber-tissue wick. A case of this type is as follows:

CASE 15.- S. D. Pvt., No. 552003, 38th Inf., Co. K. Wounded: October 9, 10 a. m. machine-gun bullet, which made two holes in his helmet. Unconscious five minutes after injury. Wound 10 by 2 cm. over the right parietal eminence, the large diameter being


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anteposterior. X-ray examination showed metallic dust in the wound. Shadow suggesting fracture of the inner table. Admitted, Mobile Hospital No. 6, October 9, 6.30 p. m. A. T. S. given. Neurological symptoms: Right pupil larger than the left. Right cremasteric reflex present, more sluggish than left. Left knee jerk more active than right. Left Babinski. Pulse 80. Operation: Tripod incision, with wide incision of wound. Scalp wound did not extend down to skull, but upon examining skull a line of fracture extending backward toward the occipital lobe was present, with no depression of the external plate. Upon opening the skull, two pieces of internal plate measuring 1½ cm. in diameter were found pressing deeply against the dura. One of these lay partially through a small tear in the dura. These were removed. The exposed dura pulsated and there seemed to be no undue tension. It was, therefore, not opened further. The scalp was now closed with S. W. G. sutures. Local anesthesia. October 11: Wound dressed. Looks all right. Pupils equal No Babinski. Diminished sensation left hand and left forearm. Perception of pin prick. Loss of muscle sense and astereognosis. October 13: Stitches removed. Wound healed. October 17: Both pupils dilated equally . React to light. No neurological symptoms. Evacuated sitting.

This case was evacuated to Base Hospital No. 56-A. His condition upon arrival was good, and from there he left on November 14. Wound healed; no. symptoms; recommended for convalescent camp.

In some eases, classified as Group III, there was no penetration of dura from the original injury, but there were marked neurological signs, and the appearance of the dura at time of operation indicated hemorrhage and contusion in the adjacent cortex. In three such cases the dura was opened and the damaged tissue beneath evacuated by irrigation and by having the patient cough, and the dura subsequently sutured. These cases did very well. It seems that with a relatively clean external wound excised thoroughly with a block removal of the bone, carried out with the necessary technique, a sufficiently clean operation field can be obtained, so that the dura may be safely opened and sutured.

In contradistinction to the type of cases referred to above, where the original injury, has punctured the dura, the contused cortex beneath the intact dura is sterile and if the technique is good, after the evacuation of this contused tissue, the dura may logically be sutured over what is a sterile field. Drainage may be advisable down to the dura to take care of the oozing and any possible contamination of the scalp incision. A case of this type is as follows:

Case 16.- L.F., No. 2255444, 347th Reg. Machine Gun Bat., Co. D. Wounded: September 29. 4 p. m. Gunshot, wound head and left buttocks. A. T. S. given. X-ray examination: Head negative. Admitted to Mobile Hospital No. 6, October 3, 12 p. m. Wound on vertex of skull lying in direction of Rolandic fissure, 8 by 1 cm. On left side. The inne angle of the wound extended 20 mm. to the left of median line. Neurological examination: Unable to move ankles and toes, right and left. Right cremasteric sluggish; left active. Right leg rather spastic; deep reflexes right leg hyperactive. Sustained right ankle-clonus. Right Babinski. Operation: Isle-of-Man incision; block removal of bone. Dura injured but not penetrated. There was evidence of underlying contusion of the bone. Dura opened just to the right of the longitudinal sinus, and upon having patient cough a quantity of softened contused brain substance and a clot size of the thumb was expressed. This seemed to be in the leg area. Dura closenl. Scalp wound sutured. October 11: Convalescence uneventful. Neurological examination shows equal pupils, the left eve perhaps a shade smaller. Both react to light and accommodation but right more slowly. Visual field normal; retina normal. October 24: Patient can move toes and feet of both legs. Motions limited in power in toe and ankle-joint . Knee motions of both legs normal. Right ankle-clonus; none on left. Babinski is present on neither side. Evacuated.


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This case is of particular interest from the neurological standpoint, because the clinical pictures correspond to the longitudinal sinus syndrome described by Sargent and Holmes. The damage to the cortex was so apparent that the dura was incised and the blood clots evacuated. The subsequent history showed a very distinct improvement in the neurological signs.

Group IV.- The treatment carried out at this hospital in cases of this group in which there was extensive damage of the cortex with indriven bone fragments, was less successful than that in any other group. There were several factors which accounted for this. The great majority--one might, say practically all of these cases--were the result of tangential wounds in which the damage to the brain was not only direct from laceration by the indriven bone, but also in many cases from the concussion and general commotion of the adjacent area of the cerebrum. If one could have a blow of the same intensity delivered without any fracture of the skull, there would undoubtedly be severe concussion and in some instances a fatal issue from the intensity of the intracranial damage by "commotion"; secondly, it is in these cases that the pathway of infection from the scalp to the intracranial contents is most widely open. Almost without exception, they arrived with gutter wounds, funnel-shaped; and with cranial contents extruding and overflowing the scalp. In such a case-as was the rule at this hospital--if from 24 to 48 hours was taken from the time of the wound to reach the operating table, there is almost sure to be infection in the scalp, in the extruding cranial contents and within the cerebrum itself, about the indriven fragments of bone. It is, then, nearly as important that this particular type of cranial injury should reach the surgeon's hands in a few hours. Unfortunately, the general idea that all head cases travel well before operation has led to the opinion that there is no urgency in forwarding these cases to their operative destination.

If one were fortunate enough to be so situated as to receive these cases in three or four hours after injury then any who would die after operation would in any event have died of the severity of the intracranial damage. If one waited 10 hours, the majority perhaps of these could be ruled out. Their condition would be very apparently moribund, or they would have begun to improve sufficiently to justify operation. On the other hand, if one waited longer than 15 hours, the danger of propagation of infection in the intracranial structures increases rapidly. It, would seem, then, that the optimum time for operation, reasoning purely from the clinical side, would be between 10 and 15 hours after the injury.

It is in this group that the most detailed and careful technique is necessary. It would hardly seem necessary to emphasize the fact that the cerebral tissue must be treated with care, but from observation of the work done at this hospital bv teams which had had some neurological training only two operators were among these teams who had a proper respect for the tissues upon which they were working. It is impossible--contrary to the general opinion-to train the average surgeon, however good he may be in general work, in the space of one or two weeks to the necessary fastidious reflexes which are so essential to the successful treatment of these cases. Of six patients evacuated in good


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condition three had been operated upon by one team, the operator of which was most conservative in his method of handling the brain tissue.

It would seem that greater emphasis should be laid upon the steps necessary in cleaning up this type of wound. After the preliminary de bridement of the superficial structures, repeated coughing and straining of the patient will, as suggested by Cushing, evacuate the contused tract of fragments of bone and sometimes a foreign body, without any further manipulation. It is only after this procedure has been carried to the point where no further results are obtained that one should introduce the catheter. Often it will be found if this is done that the catheter's most important use is as a probe for the discovery of fragments of bone still remaining in the tract. Again, it can not be too strongly emphasized that the catheter in the hands of many without a wholesome fear of the brain tissue may lead to irreparable damage. Indeed in some hands it is as dangerous as the finger and may be thrust very readily into the ventricle, converting the chances of recovery from 60 to 70 percent to about 20 percent.

One feels very definitely, after an experience with cases of the type and age received at this hospital, in which infection of the scalp or its intracranial contents is very problematical, that such wounds should be left open for free drainage. It might almost be stated as an axiom that a herniating wound is an infected wound and no amount of mechanical operative manipulation will control such a herniation. The only possible control is drainage, which from the time of operative procedure will in many cases prevent the extension of infection and sometimes even the formation of a hernia. Without drainage there would be an initial herniation and blocking off of the septic material, encephalitis, and the progressive picture which is all too familiar to the cranial surgeon.

The dogmatic statement arising early in the war of 1914-1918, that a cranial wound must be sutured, arose at least in part from the fact that drainage with glass or rubber tubes and dressing of exposed cranial contents with gauze or other adherent material led to fungus formation. A quite different treatment, in which the extruding cranial contents are carefully protected from compression by a "dough-nut" and from adhesion and the tearing of the blood vessels by protective tissues led to the impression that a great number of herniae will subside in the course of two weeks, and that a still greater number, if this type of dressing is used as a preventive measure, will never occur at all.

The following case is typical of those which recovered in Group IV:

CASE 17.- F. S., Pvt., 127th Inf., Co. F. G. S. W. head. Admitted to Mobile Hospital No. 6, October 5. History: Wounded October 4, 9 a. m., by shrapnel. Remembers getting hit; was unconscious for a few minutes. Has suffered since from very severe headaches. Has not vomited. Noticed he saw things double, that he could not see to the left, has been drowsy, has been unable to walk alone. Admitted about 10 p. m. Punctured overtip of left occipital lobe. X-ray examination negative for foreign body. Neurological examination: Headache severe, especially occipital; complete right homonymous hemianopsia. Reflexes all increased; questionable Babinski on the right side. Operation: October 5: 4 a. m.: Tripod incision. Block removal of the fractured area; dura penetrated. Blood clots oozing from cortex, fragments of bone also. One fragment removed 6 cm. from dorsal surface. Careful toilet. Closure with drain. At end of operation, headache had


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ceased; temperature 7S, pulse 80; diplopia also present. October 11: Wound dressed. Clean; no leak; temperature normal. Right hemianopsia possilbly less complete. October 16: Fundi normal. Oetober 18: Dressed. Stitches out. Small area of necrosis in center of wound. No discharge. Hemianopsia as before. October 20: Dressed. Slight granulation of wound. Condition good. October 21: Granulating area practically closed and dry. Wound clean. Right hemianopsia niow incoImpletc and improved. Reflexes normal Evacuated.

Group V.-It is a surprising fact that in this group of cases, where the foreign body was retained within the cranium, the results were distinctly better than in the preceding group. A missile striking the skull at an angle, especially after penetrating the helmet, is frequently deflected and does not penetrate, but by its implact drives hone fragments into the cranium over a large area with great laceration. If, on the other hand, it strikes at an approximate right angle and penetrates, especially if it is of small size, the greater part of the damage is produced by the missile itself, the number of bone fragments is small, and consequently the sum total of the damage done is less than in the tangential blow. Then, too, the penetrating wound frequently produces a punctate wound of entrance with infection; this infection, however, from thescalp surface is not as rapid as through the gutter-shaped wound of the Group IV class.

As regards treatment the same procedures apply as noted under the preceding group. A word should be added, however, in respect to the extraction of foreign bodies. The first reaction on the part of an inexperienced operator is that every foreign body should be removed or an attempt made at its removal. This was the experienee in this hospital. One should have definitely in mind the course of the missile, the anatomical structures it has crossed and their function, and above all the relation of the tract and the missile to the ventricle. It is obvious that a tract crossing the neighborhood of the basal ganglia and the internal capsules can be probed or explored with safety in few if any cases. The slight increase in damage produced by the exploratory instrument, no matter how careful one is, may lead to hemorrhage or edemia, or introduce infection in areas where encephalitis will be at once fatal.

On the other hand, where the tract passes through cortical or immediately subcortical areas or through the so-called "silent areas," more extensive exploration can be attempted. The danger of opening the ventricle is perhaps the greater one and can not be too strongly emphasized. It should be constantly reiterated that the opening of the ventricle changes the mortality from 30 to 40 percent to 70 to 80 percent at least. The employment of special localization methods, such as a Hirtz compass, in the experience gained at this hospital is only a temptation to excess of exploration, and the same to a lesser degree may be true of the use of the magnet. Such procedures in the hands of experienced and conservative operators in some cases would be invaluable, but in the hands of the average operator would be more dangerous than useful. Illustrative cases of this group are the following:

CASE 18.- J. M. L. Pvt. No. 372132, 130th Machine Gun Bat., Co. B. Entered Mobile Hospital No. 6 October 1, 1918, at 12.01 a. m. Diagnosis: Multiple G. S. W. History: Wounded September 30, shrapnel wound of head; left arm. Wounded between 6


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and 7 a. m. Not unconscious, missile passing beneath helmet; walked to the first aid post alone; not much headache; no diplopia or pressure symptoms. Wound: Point of entrance right occipitoparietal region. X-ray examination: Foreign body 1¼ by 1 cm., lying 2 ½ cm. beneath mark on hair back of left ear. No fluroscopic cvidlence of fracture. Neurological symptoms: None. Operation: Oetober 1, 2 p. m. Block removal of fractured skull area. Foreign body removed from right occipital lobe. Wound cleaned. Foreign body was just below the dura; not much cortical laceration; dura left open. Scalp closed tightly. Temperature normal. Left forearm had through and through shrapnel wound; fracture of both bones and loss of bone substance. Débridement: Thomas extension splint. October 4: Wound healing per primam. October 6: Wound healing cleanly. Temperature 98.6. October 8: Wound healed; temperature normal; no headache; reflexes normal; no Babinski; no hemianopsia. Stitches partially removed. October 11: Remaining sutures removed. No headache. Reflexes normal; arm doing nicely with daily saline irrigations. October14: Head dressed; wound clean and healed; now 14 days old; dressing applied. No diplopia hemianopsia. Knee jerks active and equal. No Babinski; no motor or sensory disturbances. Left arm wound clean and granulating. Has had daily saline irrigations. Some movement with thumb and first finger. Evacuated lying.

CASE 19.- R. L. Sgt. No. 558198, 48th Inf., Co. H. Admitted to Mobile Hospital No. 6, October 18, 8.30 p. m., from Neurological Hospital No. 1. History and notes of neurological hospital: Entered hospital October 1; wounded September 27. Age 26 years. Family history negative. Past history: Graduate, clerical; works at 18 dollars a week. Not interested in sports. Enlisted October, 1917. Arrived France May 23, 1918. In at end of Chateau Thierry operation. Had a severe emotional shock then; saw one of his men hit, went to his assistance. found his head blown off. Nauseated for two days. Carried on in Verdin Sector for two days. At the end of second day, September 27, shell exploded near and he was hit by some of the pieces; received three slight wounds in left arm; one piece of the shell pierced helmut and gave him a slight wound over the parietal region. Blow from this was quite forceful and staggered himn, bit did not lose consciousness. Believes he bled from the right ear. Was brought back. When first seen wore an anxious expression and was apparently quite confused. October 2: Seen in convulsion, tonic. Mouth was half open; no frothing at the mouth. Physical examination: Deep reflexes exaggerated and exhaustible. Left ankle-clonus, otherwise signs negative. October 17: Later the man gave a clearer account and verified facts above mentioned. In addition, he says there seemed to he about two days he can not. account for. Remembers coming to this hospital and that when he was being brought into the hospital he had a convulsion. He noticed that his left arm at and leg were beginning to twitch and his throat tightening and remembers no more. He has had same sensation twice since. The past three or four days he has had severe headache, but is better to-day. Pulse 48 to 60, remittent. All neurological signs negative except that superficial, epigastric, and cremasteric reflexes are slightly more active. Eye grounds: Disc margins are both indistinct and decidely hazy; vessels seem normal. Diagnosis: (1) Psychoneurosis; hysterical. (2) Observation for epilepsy; traumatic. First diagnosis was made on first seeing the patient, ut was later changed. Summary: Right head injury, September 27. Two or more convulsions since. Now severe headache. Slow pulse and hazy eye grounds. Entered Mobile Hospital No. 6, October 18. Wound: There is a small healed scar in the right parietal region 1 cm. long over the parietal eminence. Neurological examination: Right pupil measures 5 mm. in diameter, left 3 mm. in diameter. Right optic disc 1½ mm; swelling of lef lid. There is a small retinal hemorrhage to the right eye. Left facial nerve slightly affected during expression. Left arm and hand movements somewhat ataxic. There is also partial loss of muscle sense in the left hand. X-ray examination: Fracture of skull anteriorally; right antrum cloudy. Foreign body 2 by 3 mm. under mark right side of head (this was about 3 cm. anterior to the wound). Operation: October 18: Straight line incision as for decompression. Small bone defect measuring 1 cm. in diameter excised en bloc. Small opening 1 cm. in diameter in the dura through which brain under pressure was protruding. On coughing, patient squeezed out a blood clot size of a large bean. Subcortical collection of old bloody fluid about 15 cc. in amount. This was removed from the region of the track and also small amount of contused brain was


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removed by suction. Foreign body w as not removed, although an attempt was made with the magnet. Dura left open; scalp closed. October 19: Headache very much better. Neurological signs as previously noted. October 25: Edema of optic disks subsiding; headache practically disappeared. Neurological signs clearing up. This case was later evacuated in good condition.

Group VI-An example of a favorable case of this group is the following:

CASE 20.- F. M., Cpl., No. I897372, Machine Gun Co., 325th Inf. Entered Mobile Hospital No. 6, October 12. Wounded October 11, 4 p. m. by shrapnel; unconscious 12 to15 minutes; nausea and vomiting; weakness left leg immediately. Blurred vision; bright flashes of light. Persistent headache. Wound: Lacerated wound 2 cm. in diameter over left parietooccipital region. X-ray examination: Foreign body, 5/10 by 3/10 cm., 1 cm. under skin mark just above ear. Neurological examination: Right hand and arm spastic and weak. Loss of sensation of right upper extremity as well as lower; no Babinski. Patella clonus on the right. Knee jerks hyperactive, but equal. Left homonymous hemianopsia. Operation: Small laceration of the scalp. Two by three cm., excised. Bone removed en bloc. Dura punctured and three indriven fragments removed. Foreign body found in scalp. Large masses of blood oozed from cortex, cerebral fluid leaking in small amounts. Irrigation of wound produced severe headaches. It was thought that the fluid entered the ventricle. Scalp closed tightly; dura left open. October 14: Wound clean; temperature normal; nosubjective changes. October 16: Fundi normal; wound clean; several sutures removed. October 18: Remaining sutures removed; temperature 98.4. Has had occasional headache, and temperature reached 100 last night. Profuse discharge from scalp wound. October 22:Complains of slight headache; no ocular symptoms or nausea; hemiplegia improving. Sense of position and common sensation absent. Heat and cold preserved. No fever for past three days. Wound draining slightly; condition good. October 24: Redressed. Condition improved. October 25: Dressed. Drainage has stopped. Wound healed. Neurological condition improving. On evacuation, condition good.

Group VII.-A case which recovered in this group is as follows:

CASE 21.- W. D. P., Pvt., No. 573950, 12th Machine Gun Battalion, Co. C. Admitted to Mobile Hospital No. 6, October 2, 1918, at 4.15 p. m. History: Wounded October 2, at 10 a. m., machine-gun bullet, penetrating right tipper eyelid. Complete collapse of right eye, bullet apparently having passed posteriorly. X-ray examination: Machine-gun bullet lying in the cranial cavity, 1 inch to the right of median line over roof of the orbit and hack of the posterior border of the orbital cavity, directly at the intersection of lines from two skin marks. Neurological examination: No signs. Operation: Enucleation of right eve removal of contused brain tissue; bone fragments and bullet from a bione defect in supraorbital plate very deep down in frontal lobe. Plastic closures of structures about the right orbit. October 17: Convalescence uneventful; no neurological signs; evacuated.

Group VIII.- Two cases of traversing wounds in this group recovered, and will be given in detail.

CASE 21.- L. S., Pvt., No. 2661431, 59th Inf., Co. B. Admitted to Mobile Hospital No. 6. September 30. History: Wounded September 29. Point of entrance left frontal; point of exit right frontal about 2 inches above the external orbital process. Lacerated wound at higher point about 2 cm. in diameter, both outside of the hair line. Not unconscious; walked in, complaining only of some frontal headache. Neurological examination negative. Operation: Wounds excised and connected, with thorough d ebridement. Dura penetrated and brain oozing out. Edges cleaned, and toilette of entire wound; drainage at either entd and with sutture of scalp between. October 11: Neurological note says headaches the whole time and eyes burn; otherwise feels well. He states at this time that he remembers everything from the time he was hit; did not vomit; walked to dressing station; had no pain, but was dazed and his head began to ache soon after. Is perfectly rational at present; relevant and coherent; euphoria; no irritability. October 14: Sutures removed; wound healing. October 17: Couvalescence has been uneventful. Evacuated.


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CASE 22.- J. G., Pvt., No. 1448900, 37th Inf. Admitted Mobile Hospital No. 6, September 30. History: Wounded by machine-gun bullet September 28. Condition stuporous: answers questions slowly; retarded; no aphasia. Wound: Point of entrance left occipitoparietal; point of exit right occipitoparietal, both 2 inches above left occipital protuberance and 3 inches to the right. No foreign body. Neurological examination: No evidence of cranial nerve injury; complains of loss of vision in the right eye; distinguishes light, right eye; recognizes objects with left eye. Operation: Débridement scalp and bone both exit and entrance. Suture. October 4: Pupillary examination, normal. Fundus: Slight but definite hyperemia; no swelling; vision both eyes nil. October 6: Slight convulsion, seizure lasting five minutes. Says he can hear well. October 9: Thinks he can distinguish light. Wound clean. October 13: Vision improving; distinguishes objects both right and left eye October 17: Wound healed. Vision and memory returned. Cerebration keener. Evacuated.

SINUS (VENOUS)

The following case is illustrative of a wound which involved the longitudinal sinus:

CASE 23.- Pvt., No. 220739, 362d Inf., Co. G. Entered Mobile Hospital No. 6, September 29. History: Wounded, September 28. Shrapnel passing through helmet; not unconscious; did not vomit. Slight headache. Condition: Walked into the hospital; headache only at present. Wound: Slight lacerated wound over sagittal suture at the occipitoparietal junction. X-ray examination negative. Neurological examination negative. Operation: Excision of scalp wound, small indentation of external table measuring 2 cm. in diameter; square piece of bone removed en bloc over area 5 cm. in diameter. Depressed fracture inner table; small fragments piercing longitudinal sinus with a linear tear about 1 cm. in length; no clot. Bleeding controlled by cotton and a slip of muscle placed directly over the tear. Scalp sutured tightly. October 2- Wound healing primum; no neurological signs. No headache. Patient evacuated.

SUMMARY

The following table gives the complete data as regardis the cranial injuries handled ly this hospital:

CHART

The advantage of such a specialized unit as this may be summarized as follows: 1. Refinement of technique, approximating that really necessary to do even fairly satisfactory work, is possible. 2. Changes in technique, and the adoption of adjuncts, such as X ray are rapidly possible in a group with a centralized control, such as this. 3. The training of surgical teams, and the insistence upon the most fastidious technique can be accomplished readily only in such a hospital. 4. It is possible to get "team play'" between the


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ophthalmologists, maxillofacial surgeons, X-ray department, pathologists, etc.,in one hospital; it is exceedingly difficult to do so in all of a dozen or more hospitals.

The disadvantages, as they appear in this experience, were principally those of transportation and triage. This hospital was situated at such a distance from the front that during a major portion of the fighting, cases reached it upon an average of 36 hours after injury. In addition, there were too many steps in transportation; that is, all cases would be evacuated through one and sometimes through two hospitals, at which points there would be a delay of sometimes 12 or even 24 hours. These cases did not suffer from length of transportation to any great degree, but they did suffer, as shown by data, especially those under Group IV, by the prolonging of the preoperative period, during which infection was uncontrolled. It should always be stated as a corollary to the axiom, "Head cases bear transportation well before operation," that a delay of 24 hours increases the chances of infection and decreases the chances of survival almost as markedly as it does in penetrating wounds of the abdomen. This is shown by the high mortality in Group IV, where the wounds were open, cranial contents extruding, and infection had a wide pathway of entrance, whereas in the other groups in which the point of penetration was smaller, and the path of infection more devious, the mortality was as low, and even lower, than the ideal figure given in "Instructions to the Neurological Surgical Teams."