ses recurring symptoms pointed to the continued presence of bone
fragments; these were usually indicated by signs of irritation, or often
of local inflammation, in the latter case infection taking the greater
share in the causation. Such cases needed secondary exploration, and the
wonderful success of this operation, even when the wound was evidently
infected, was perhaps one of the most striking experiences of the
surgery in general.

I should add a word here as to the most satisfactory time for the
performance of these operations; as in all cases the earlier they could
be undertaken the better, but in the head injuries the advantages of
early interference were more evident than in any other region. This
depended on the fact that, as in civil practice, the scalp is one of the
most dangerous regions as far as auto-infection of the wound is
concerned, and one of the most difficult to cleanse, except by thorough
shaving. Beyond this the extreme simplicity of the operative procedure
needed, called for few precautions beyond those for asepsis, and very
little armament in the way of instruments, &c.

When on the march from Winberg to Heilbron with the Highland Brigade we
had some five days' continuous fighting, and on this occasion several
perforating fractures of the skull were brought in. The coldness of the
nights at that time made evening operations an impossibility; hence the
operations on these men were performed at the first dressing station, in
the open air, at the side of the ambulance wagons, often during the
progress of fighting around. Of several cases so operated on, all healed
by primary union without a bad symptom of any kind, except one (see p.
249), in whom a very large entrance opening over the right cortical
motor area led down to an extensive destruction of the brain,
complicated by a fracture of the base in the middle fossa. This wound,
from the first considered hopeless, became septic during the four days'
travelling in an ambulance wagon that was necessary, and the man died at
the end of fourteen days. As the whole cortical motor area was
destroyed, death was, perhaps, the end most to be desired; but the fight
that this man made for recovery, and the fact that his death, after all,
was due to general infection and not to any local extension of the
injury, very strongly impressed me with the possibility of recovery,
even in such extensive cases, if only an aseptic condition can be
maintained. I saw man