_Punctured wounds_ may be inflicted on the vault by stabs with a knife or dagger, or by other sharp objects, such as the spike of a railing. More frequently a pointed instrument, such as a fencing foil, the end of an umbrella, or a knitting needle, is thrust through the orbit into the base of the brain. Occasionally the base of the skull has been perforated through the roof of the pharynx, for example, by the stem of a tobacco-pipe. All such wounds are of necessity compound, and the risk of infection is considerable, particularly if the penetrating object is broken and a portion remains embedded within the skull. The infective complications of such injuries are described later. _Bullet wounds_ have many features in common with punctured wounds. There is more contusion of the brain substance, disintegrated brain matter is usually found in the wound of entrance, and the bullet often carries in with it pieces of bone, cloth, or wad, thus adding to the risk of infection. Aseptic foreign bodies, especially bullets, may remain embedded in the brain without producing symptoms. The _treatment_ of punctured wounds consists in enlarging the wounds in the soft parts, trephining the skull, and removing any foreign body that may be in it, purifying the track, and establishing drainage. AFTER-EFFECTS OF HEAD INJURIES Various after-effects may follow injuries of the head. Thus, for example, _chronic interstitial changes_ (sclerosis) may spread from an area of cicatrisation in the brain; or _softening_ may ensue, either in the form of pale areas of necrosis (white softening) or of hæmorrhagic patches (red softening). The symptoms vary with the area implicated. _Adhesions_ between the brain and its membranes may produce severe headache and attacks of vertigo, especially on the patient making sudden exertion. After a head injury, the patient's whole mental attitude is sometimes changed, so that he becomes irritable, unstable, and incapacitated for brain-work--_traumatic neurasthenia_. In some cases self-control is lost, and alcoholic and drug habits are developed. #Traumatic epilepsy# may ensue as a result of some circumscribed cortical lesion, such as a spicule of bone projecting into the cortex, the presence of adhesions between the membranes and the brain, a cicatrix in the brain tissue leading to sclerosis or a hæmorrhagic cyst in the membranes or cerebral tissue.