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in detail. Two-thirds of the cases, after an average periodof eight years, had materially better vision than before theoperation. In not one of them had he to deal with adetachment of the retina as a sequela to the operation,though it was well known to occur occasionally. He did notthink the operative treatment of high myopia tended tocounteract the increase in the long axis of the eyeball,though obviously the removal of the lens had the effect ofdiminishing the result of the lengthening of the axis of theeyeball on the refraction by about one-half.-An interestingdiscussion ensued, which was taken part in by Dr. T.HARRISON BUTLER, Mr. R. J. COULTER, Mr. ARNOLDLAWSON, Mr. JESSOP, Mr. W. T. HOLMES SPICER, Mr.ZORAB, and the PRESIDENT.

MEDICAL SOCIETY OF LONDON.

- DMCMMMM on Gunshot lTTOtcnds of the Head.A MEETING of this society was held on Nov. 15th, Dr. W.

PASTEUR, the President, being in the chair,Mr. PERCY SARGENT (Temporary Lieutenant-Colonel,

R A.M. C.), in opening a discussion on Gunshot Wounds ofthe Head, said that in the case of head injuries the needfor early operation was not so pressing as in abdominalinjuries. Head cases travelled well and did not appear tobe adversely affected by the journey. On the other hand,they did not bear transport well immediately after operation,and those operated upon ought to be kept where they werefor at least a week. In time of stress this was practicallyimpossible near the fighting line. He did not suggest thatearly and efficient cleansing of head wounds was not

important, but procedure directed to this end alone was onquite a different footing from an operation undertaken forthe relief of cerebral symptoms and for the removal ofbone fragments and missiles without the aid of an

X ray examination. Gunshot wounds must be regardedfrom two points of view : First, the neurological,and secondly, that of a compound fracture. Compoundfracture was an almost constant factor ; the cerebral injurymight be so slight that no evidence of its existence could bedetected, or the clinical signs might point to widespreaddisturbance of function of every sort and degree. In pointof severity there was no constant relationship between thecranial and the cerebral injury, and cerebral symptoms werenot wholly dependent upon the existence of a cranial lesion ;the two were co-existent but not interdependent. Once theblow had been struck, the relationship between cranial andcerebral injury ceased, and nothing that was done to thewound could influence those cerebral symptoms. So long asthe dura was uninjured this rule remained true. When, how-ever, the dura was lacerated so as to open up an avenue forinfection, then what was done to the wound, whilst not influ-encing the initial cerebral lesion, might, by diminishing thechances of intradural infection, prevent or minimise furtherthe destruction of brain tissue. In gunshot wounds of thehead subdural hemorrhage of such a degree as to cause, ofitself, symptoms of any severity, or to require operation, wasvery rare. In some six cases, which they had observed, it hadmanifested itself slowly, and had given rise to unmistakablesymptoms. Exploratory operations for possible haemorrhagehad no place in the treatment of gunshot wounds, especiallyas such wounds were invariably septic, while opening thedura in their presence carried with it very great danger ofmeningeal infection. If operation were undertaken it shouldbe done to assist healing of the wound and to minimise thedanger of the intracranial suppuration, which was the causeof death or of further disablement in nearly all those caseswhich survived the initial cerebral injury. He spoke of thedifferent kinds of cases met with. First, at the field ambu-lance and clearing stations many patients arrived with exten-sive defects in scalp, bone, and dura, from which largemasses of brain protruded and from which brain matter,blood, and cerebro-spinal fluid issued. Most of these wereeither deeply unconscious or very restless, and they diedin a few hours. Clearly this class of cases was excludedfrom the scope of operation. In some similar cases, however,careful examination revealed that although the amount ofbrain matter lost was large, yet the injury was less thanseemed at first sight. After a few hours, improvement began,the cerebral shock passed off, and recovery was not im-possible. These should have the wound cleaned under ananaesthetic, and perhaps its edges should be excised, but no

intra-cerebral manipulation involving a search for bonefragments or missiles should be undertaken, especially ifradiographic examination was not available. Secondly,there was the common case of a tangential wound with.cerebral laceration, where the scalp defect took theform either of two wounds separated by a bridge of skin orof an open gutter. These generally needed operation.Thirdly, the single penetrating wounds through which a.

missile might or might not have entered, determinable onlyby X rays, usually required operation. Fourthly, came casesin which a bullet had traversed the cranial cavity from sideto side. They showed that at certain ranges, where thevelocity was still sufficiently high to allow the bullet to>traverse the cranial cavity and to emerge therefrom, as wel.bas in cases in which. the velocity was so low that the bulletwas retained within the skull after traversing the brain,no explosive effect could be demonstrated, for patientsin both classes often exhibited no symptoms or neuro-

logical signs whatever. They rarely required operation,and many recovered by dressing merely. Fifthly, there-was a large group with injuries to the superior longitudinalsinus. Operation upon them had given very bad results, andthey should be left alone unless some other condition was.added. Sixthly were the minor injuries in which a fral t’lre-existed without laceration of the dura. Traumatic epilepsyin such cases resulted from the subcranial damage sustainedat the time, rather than to the mere presence of the injuredbone, and consequently if all such were operated upon,many of the operations were unnecessary. Mr. Sargent.operated upon depressed fractures, as a rule, only whenthey were of considerable extent, and when the brokenbone, exposed at the bottom of a septic scalp wound,threatened to become necrosed and delay healing. Dis-

cussing whether operation should be performed immediatelyor after an interval, he said that immediate operationcould only be required in the very rare cases in which pro-gressive hemorrhage threatened life from cerebral com-

pression. At a later date progressive neurological symptomswhen due to heamorrhage or suppuration might call for

operative relief, and therefore the question arose whether-these later complications could be avoided by earlier opera-tion. Early experience in the war showed that a large-proportion so treated died later from meningitis because-of the ease with which the subarachnoid space can be-infected and the tendency to the formation of hernia.

Subsequent experience had shown that delay lessenedthese dangers. There was some risk in allowing bone

fragments to remain buried in the brain, because an infec-tive encephalitis might spread from such a focus and

might reach the ventricles. The two dangers-those of

meningitis and hernia-attendant upon the earlier operation,and that of ventricular infection which beset delay, had to-be balanced against one another, but his experience from alarge number of cases had shown that the former pre-dominated. The best time for operation was from two to-four days from the date of the wound, during which timethe’ patient could be transferred to the base, an X rayexamination made, the head shaved, and the wound andscalp thoroughly cleansed. Such evidence as he hadobtained seemed to show that bullets and fragments of shellwere best left alone, unless they were so situated as to be

easily removed with the bone and fragments, or unless theysubsequently caused symptoms directly referable to theirpresence. The symptoms which existed at first were not.due to the mere presence of a foreign body ; they dependedupon the damage done during its introduction, andits removal would not only fail to effect an improve-ment, but by causing additional damage would be morelikely to aggravate the symptoms. Such foreign bodies werenot always septic. If septic complications occurred laterthey were more likely to arise in some part of the track ofthe missile, where hairs and other septic material had beenimplanted, than to take the form of abscess or diffusecerebral softening. The question of removal was furtherinfluenced by the nature, position, and number of themetallic foreign bodies. Many lay in positions consideredinaccessible to surgery. More than one patient had died asthe direct result of operating for removal of such foreignbodies, and many patients in whom removal had not beenattempted had been sent to England with good prospects ofrecovery, and had since been progressing favourably,their wounds having completely healed. In all woundsin which the dura had been torn and the brain

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lacerated, the primary object of any operation was toremove infective material and to provide efficient drainage.When the dura was not lacerated it was an exceedingly ’,4angerous proceeding to incise it, and one which was uncalledfor except in a very small number of cases. It was unjustifi-able unless there were an extensive subdural hoemorrhage.When the missile or bone fragments had caused a laceration- of the dura it was similarly dangerous and almost as

unnecessary to enlarge the dural opening. If these cases- exhibited signs of a dangerous degree of intracranial pressure.4umbar puncture or a contralateral decompression operationafforded a much safer and an efficacious mode of relief.- Glancing wounds with laceration of the dura and brain,being commonly produced by rifle bullets, were compara-tively clean, and the bony fragments were not driven in toany great depth. On the other hand, when the splintered bone4iad been removed the dural tear and lacerated brainwere often seen to be considerable in extent, and if-such an area of damaged brain were left exposed, suppurationwas prolonged and hernia cerebri was likely to form. Mr.:Sargent then described the means which had been devisedfor covering in this damaged brain, whilst providing for freedrainage. Briefly, the gap which resulted from excision of- the original wound was closed by a flap of muscle or of peri-- cranial or aponeurotic tissue. The operation was modified tosuit the case of a penetrating wound in which the dural openingwas small, but where the cerebral laceration extended rela-tively deeply and bony fragments had been driven in for adistance of from 1 to 2 inches.

Dr. GORDON HOLMES (Temporary Lieutenant-Colonel,R.A.M.C.), who had collaborated with Mr. Sargent in hiswork in France, said that the main aim had been to establish.efficient drainage. Infection was always present by thetime the patients could be dealt with. Such remarks as they<could make were only of relative value for those working athome, as the conditions and objects were different. It wastheir object to place the patients in such a condition that theycould be safely evacuated to England. They had found itadvisable either to leave head cases alone or only to operatein the presence of clear and emphatic indications. Foreign’bodies were well left alone. Many head injuries could bedealt with more successfully at home, after the scalp hadhealed. It was more dangerous to operate with the idea of,preventing problematical secondary effects than to refrainfrom operating.

Professor WILSON and Colonel Sir VICTOR HORSLEY,A.M. S., sent a contribution to the discussion. In their viewthe principles which should guide the treatment of headinjuries in the field practically resolved themselves into thoseunderlying our means, general or special, of preventing thespread of microbic invasion of the brain from the trackof the projectile and the surfaces of the wound. Such meansmust depend upon our determination of two points: (a) Whatspecies of microbe were found in such wounds; and (b) whatwas the nature of the lesion they respectively produced."They had made, with the kind assistance of LieutenantG. B. Bartlett, pathologist to the 21st General Hospital,Alexandria, many observations and determinations of theinfections in a number of gunshot injuries of the head in thehospitals at Alexandria. From the cultures obtainedfrom these cases they had carried out a series of experi-mental subdural inoculations in rabbits. Their conclusionstabularised were briefly as follows :-

TABLE I.

In each case the pathogenic activity of the microbe (obtaine3 Iby aspiration with all precautions from the softened brainbeneath the hernia cerebri, &c.) was established experi-mentally. The kind of cerebral lesions and the pathologicalchanges observed clinically were reproduced with completefidelity in the experimental inoculations with pure culturesand could be tabularised as shown in Table II. Fromthe facts thus collectively stated it would follow that :(a) In all cases of gunshot injuries of the head a bacterio-logical diagnosis should be made. (b) That all cases of

gunshot injury of the head should be disinfected actively andcompletely from the earliest possible moment-i.e., byex-cision of the primary wound, no closure of the wound, and byfrequently repeated dressings soaked with antiseptic lotions ;and that in any case in which streptococcal infection wasfound the free use of antistreptococcal serum was essential.

TABLE II.

Mr. L. B. RAWLING (Temporary Major, R.A.M.C.)agreed that as his work was in England he was speak-ing from a totally different experience. He deplored thelack of cooperation between the surgeons abroad andthose at home, the absence of notes of the cases whichwere sent home, and the impossibility of knowing whatsurgeon had operated previously, and thus of communi-cating with him. He considered that a certain proportionof those seen should have been operated upon earlier. The

majoritv of the scalp incisions and the stitches were suppu-rating when the patients arrived. The cases with the lesserincisions were apparently more favourable than those inwhich larger ones had been made, and those in which thewound had been extended in various directions better thanthose with a large flap. The infectivity of the wound wassuch that primary excision was unsuitable. Those withsmaller osseous defects were better .than those with larger.He had found that if the hernise of the brain were shaved offthe condition recurred, and that the second protrusionwas often worse than the first. The second protrusiongenerally included a distended horn of the lateralventricle. He had consequently given up the method,and regarded the expectant attitude as the correctone. He had encountered foreign bodies in the hernias,and could not but think that they should have been removed.This often had to be done afterwards, as they kept up thesuppuration. He dissented from those surgeons who

approved of the finger as a means of detecting what lay atthe bottom of the wound and disapproved of the probe.The latter was preferable to the finger. Deeply-seatedbodies obviously must be left. He had contented himselfwith removal of the more superficial, and the results hadbeen favourable. His experience of paralysis followingthese injuries was that it only improved up to a

certain stage. The outlook after cerebral injuries wassomewhat gloomy, but excellent results had followedthose in the frontal and temporo-sphenoidal regions.Every fracture of the external table was associatedwith a greater fracture of the internal, injury of thefrontal sinus excepted. A common occurrence was for thepatient to appear very well, but a small superficial septicwound existed, and a probe showed that a fracture waspresent. The pulse-rate was slow in proportion to thetemperature, the blood pressure raised, headache was

present, and the mental condition was not quite sound.One could not tell without exploration how serious the

injury was. He urged that these cases should be operatedupon sooner, and not left until they arrived in this country.

Mr. WILFRED TROTTER (Temporary Captain, R.A.M.C.)said that the point which had struck him most in theopening paper was that it was possible to leave so muchof the nature of a foreign body in the brain. It mightbe the best procedure for a short time, but not for anindefinite period. He had been impressed by the frequencywith which serious lesions developed and remained latent inthe central nervous system. In view of this it was a mere

assumption that patients who appeared well soon after theinjury or who improved some months later could be regardedas cured. If the slightest evidence of a lesion persisted itshould be dealt with. It was often assumed that hemiplegiawas due to loss of brain substance, but probably any exten-sive hemiplegia denoted some haemorrhage or skull injury.

After Captain SIDNEY SMITH, R.A.M.C. (T.F.), and Mr.W. PEARSON (Temporary Major, R.A.M.C.) had spoken, Mr.SARGENT and Dr. GORDON HOLMES briefly replied.