In cases where inflammatory hernia cerebri developed, a secondary

exploration was often indicated for the removal of fragments of bone or

the evacuation of pus, otherwise the condition was best treated by dry

dressings and gentle support.

Abscess of the brain was treated by simple evacuation and drainage by

metal or rubber tubes: the operations were always of extreme simplicity,

since the abscess in every case I saw was in the direct line of the

wound track, and was readily opened by the insertion of a director or

blunt knife. The only trouble in the after treatment was that already

referred to, of preventing premature closure of the drainage opening.

I have made no special reference to the method of dressing, since it was

of the ordinary routine kind. The most important factor in success was

the efficient primary disinfection of the scalp; a piece of antiseptic

gauze and some absorbent wool, efficiently secured, was all that was

needed later.

As usual the consideration of the treatment of cases in which the bullet

was retained may be considered last. Such accidents were distinctly

rare. I operated in only one (No. 54, p. 260) in whom the indications

both for localisation and interference were obvious, since the bullet

had palpably fractured the bone, although it had not retained sufficient

force to enable it to leave the skull. In two other cases that I saw, in

one the bullet was lodged in the zygomatic fossa, in the second just

below the mastoid process. The former patient died; the latter exhibited

symptoms indicative of injury to the occipital lobe (No. 68), and was

successfully treated by Mr. J. E. Ker. I never happened to see a case in

which a retained bullet in the skull was localised by the X rays, but

such might have been possible in case No. 64, p. 275. In no case is

primary interference indicated, unless a fracture exists where the

bullet has tried to escape, or secondary symptoms develop pointing to

irritation.

Under ordinary circumstances, moreover, the indications for removal of a

bullet are not likely to be sufficiently imperative to necessitate the

operation being undertaken until the patient can be placed under the

best conditions that can be secured. This is the more advisable since

such operations need the infliction of an additional wound, require

great delicacy, and may be very prolonged in performance. The experience

of civil practice has already sufficiently proved the small amount of

inconvenience likely to follow the retention of a bullet in the skull.

I may again mention the fact that in explorations for the removal of

bone fragments, fragments of lead, from breaking or setting up of the

bullet, are sometimes found.

Taken as a whole, the operations on the head were extremely satisfactory

from a technical point of view; the large depressed pulsating cicatrix

so often left was the chief defect observed. The circumstances under

which many of the operations had to be performed militated strongly,

however, against the successful replacement of separated bone fragments,

which might have rendered the defects less serious.

Secondary operations for traumatic epilepsy scarcely come within the

scope of these experiences. In case 73, p. 292, it is of interest to

note the manner in which the cavity due to loss of brain substance was

filled up. No doubt a similar vicarious arachnoid space develops in all

cases in which a soft pulsating swelling fills an aperture in the bones

of the skull.

WOUNDS OF THE HEAD NOT INVOLVING THE BRAIN

_Mastoid process._--The most important wound of the cranium not already

mentioned was that involving the mastoid process and the bony capsule of

the ear. Wounds of the mastoid process obtained their chief interest in

connection with paralysis of the seventh nerve. This nerve rarely or

never escaped, and, as far as my experience went, the facial paralysis

was permanent (see cases 111-114, p. 355). I think the same prognosis

holds good with regard to the deafness resulting from these injuries,

and it is difficult to believe, with our experience of the effect of

vibration on other nerve centres and organs, that the internal ear could

ever escape permanent damage.

In a number of cases the tympanum itself, or the external auditory

meatus, was directly implicated in tracks; in these, also, loss of

hearing was the rule.

Wounds of the pinna when produced by undeformed bullets were usually of

the same slitlike nature remarked in perforations of the cartilages of

the nose, and healed with equal rapidity.

_Wounds of the orbit._--Injuries to the orbit were very numerous and

serious in their results, both to the globe of the eye and the

surrounding structures.

_Anatomical lesions._--The wound tracks, with regard to the injuries

produced, may be well classified according to the direction they took;

thus--vertical, transverse, and oblique.

Vertical wound tracks were on the whole the least serious, but this

mainly from the fact of limitation of the injury to one orbital cavity.

They were usually produced by bullets passing from above downwards

through the frontal region of the cranium, and were received by the

patients while in the prone position.

Transverse and oblique wounds owed their greater importance to the fact

that both eyes were more likely to be implicated.

Besides these tracks, which actually crossed the cavities, a number

involved the bony boundaries, producing almost as severe lesions in the

globe of the eye, many of the patients being rendered permanently blind.

The only difference in nature of such cases was the escape of orbital

structures, and this was of minor importance in the presence of the

graver lesion to vision. The following is an illustrative case:--

(74) Wounded at Colenso. _Entry_ (Mauser), 1 inch below the

centre of the margin of the right orbit; _exit_, behind the

right angle of the mandible. Fracture of lower jaw, and

development of a diffuse traumatic aneurism of the external

carotid artery. The common carotid artery was tied for

secondary hæmorrhage (Mr. Jameson) some three weeks later.

Vision was affected at the time of the accident; the fingers

could be seen, but not counted. After ligation of the carotid

the condition was possibly worse, and this needs mention as

transitory loss of power in the left upper extremity also

followed the operation.

Fractures of the bony wall were of every degree. The most severe that I

saw were two in which lateral impact by a bullet crossing the cranial

cavity caused general comminution of the whole orbital roof. Fissures of

the roof were common in connection with 'explosive' exit apertures in

the frontal region of the skull. Pure perforations usually accompanied

the vertical or transverse wounds of the cavity, fragments at the

aperture of entry then being projected into the orbit, sometimes

penetrating the muscles.

Occasionally the margin of the cavity was merely notched.

The ocular muscles were often divided more or less completely, and

occasionally some difficulty arose in determining whether loss of

movement of the globe in any definite direction depended on injury to

the muscle itself, or to the nerve supplying the muscle. The following

case illustrates this point:--

(75) _Entry_ (Mauser), 2 inches behind the right external

canthus; the bullet pierced the external wall and traversed the

floor of the right orbit beneath the globe, crossed the nasal

cavity, and a part of the left orbit; _exit_, at the lower

margin of the left orbit, beneath the centre of the globe of

the eye.

Complete loss of sight followed the injury, and persisted for

one week. Modified vision then returned.

Three weeks later there was diplopia; loss of function of the

right external and inferior recti, although the ball could be

turned downward to some extent by the superior oblique when the

internal rectus was in action. Movements of the left globe were

not seriously affected.

The pupils were immobile and moderately dilated, but atropine

had been employed two days previously.

A year later the condition was as follows: There is some

weakness of the right seventh nerve, as evidenced by want of

symmetry in all the folds of the face, and in narrowing of the

palpebral fissure.

When at rest the right eye is somewhat raised and turned

outwards. Active movements outwards or downwards are

restricted. There is diplopia, and the vision of the right eye

is much impaired; the man can see persons, but cannot count

fingers with certainty, although he sees the hand. Putting on

one side the loss of free movement, there is no obvious

external appearance of injury to the eye.

Mr. J. H. Fisher reported as follows:

Ophthalmoscopic examination shows the left eye and fundus to be

normal. The right disc is not atrophied, but the whole of the

lower half of the fundus is coated with masses of black retinal

pigment. There is atrophy in spots of the capillary layer of

the choroid, and the larger vessels of the deeper layer are

exposed between the interstices of the pigment masses. There is

no definite choroidal rupture. The lesion encroaches upon and

implicates the macular region.

The injury is a concussion one, not necessarily resulting from

contact, and certainly not due to a perforation. The loss of

movement and faulty position are the result of injury to the

muscles, and not to nerve implication.

The man complained that when he blew his nose the left eye

filled with water and air came out. The left nasal duct was

however shown to be intact, as water injected by the

canaliculus passed freely into the nose.

Intra-orbital bleeding, subconjunctival hæmorrhage with proptosis and

ecchymosis of the lids were usually well marked. The latter was

sometimes extreme.

Injury to the nerves was naturally of a very mixed character. In many

instances the branches of the first two divisions of the fifth nerve

were obviously implicated and regional anæsthesia was common. This was

often transitory when the result of vibratory concussion, contusion, or

pressure from hæmorrhage. In other cases it was more prolonged as a

result of actual division of the nerve. As is usually the case, when a

small area of distribution only was affected, sensation was rapidly

regained from vicarious sources, even when section had been complete.

As individual injuries, those to the optic nerve were the most

frequently diagnosed. I am sorry to be unable to attempt a

discrimination of injuries to the nerve alone from those in which both

nerve and globe suffered, but the globe can rarely have escaped injury,

either direct or indirect, when the bullet actually traversed the

orbital cavity. (A few further remarks concerning injuries to the optic

nerve will be found in Chapter IX.)

Injuries to the globe of the eye, either direct or indirect, accompanied

most of the orbital wounds.

In some the lesion was of the nature of concussion. In such the bone

injury was usually at the periphery of the orbit, or to the bones of the

face in the neighbourhood. The loss of vision might then be temporary,

persisting from two to ten days, then returning, often with some

deficiencies.

In other similar external injuries, the lesion of the globe was more

severe, and permanent blindness followed.

In variability of degree of completeness, these lesions of the globe

corresponded exactly with those produced in other parts of the nervous

system by bullets striking the bones in their vicinity, and they were no

doubt the result of a similar transmission of vibratory force.

In a third series of cases the globe suffered direct contusion, and in a

fourth was perforated and destroyed.

In cases in which permanent blindness was produced without solution of

continuity of the sclerotic coat, the nature of the lesion was probably

in most cases vibratory concussion and the development of multiple

hæmorrhages from choroidal ruptures of a similar nature to those seen in

the brain and spinal cord. The actual hæmorrhagic areæ varied in size;

but, as far as my experience went, gross hæmorrhages into the anterior

chamber did not occur without severe direct contact of the bullet.

In the vast majority of the cases blindness, whether transitory or

permanent, developed immediately on the reception of the injury, and was

possibly in its initial stage the result of primary concussion.

Cases were, however, seen occasionally in which the symptoms were less

sudden, of which the following is an example. I did not think that the

mode of progress seen here could be referred to simple orbital

hæmorrhage, although this existed, but rather to intravaginal hæmorrhage

into the sheath of the optic nerve. On external inspection the globes

appeared normal.

(76) Wounded at Paardeberg. _Entry_ (Mauser), over the centre

of the right zygoma; the bullet traversed the right orbit,

nose, and left orbit. _Exit_, immediately above the outer

extremity of the left eyebrow.

The patient stated that he could 'see' for thirty minutes with

the right eye and for an hour with the left, immediately after

the injury. He then became totally blind, and has since

remained so. During the next three weeks there were occasional

'flashes of light' experienced, but these then ceased.

At the end of three weeks the condition was as follows: Ocular

movements good in every direction except that of elevation of

the globe. The levator palpebræ superioris acted very slightly;

the right, however, better than the left.

There were marked right proptosis, less left proptosis, and

slight patchy subconjunctival hæmorrhage of both eyes. The

pupils were dilated, motionless, and not concentric.

The patient was invalided as totally blind (November, 1900).

Mr. Lang, who saw this patient on his return to England, kindly

furnishes me with the following note as to the condition. There was

extensive damage to both eyes, hæmorrhage, and probably retinal

detachment as well as choroidal changes.

The quotation of a few illustrative examples typical of the ordinary

orbital injuries may be of interest:--

(77) _Vertical wound._--_Entry_, into left orbit in roof

posterior to globe, and internal to optic nerve; _exit_, from

orbit through junction of inner wall and floor into nose.

Complete blindness followed the injury, but upon the second day

light was perceived on lifting the upper lid. There was marked

proptosis, subconjunctival ecchymosis, swelling and ecchymosis

of the upper lid, and ptosis. Anæsthesia in the whole area of

distribution of the frontal nerve.

At the end of three weeks, fingers could be recognised, but a

large blind spot existed in the centre of the field of vision.

The general movements of the globe were fair, but the upper lid

could not be raised. The proptosis and subconjunctival

hæmorrhage cleared up.

Little further improvement occurred; six months later the

patient could only count the fingers excentrically. A very

extensive scotoma was present. The optic disc was much

atrophied, the calibre of the arteries diminished and the veins

full (Mr. Critchett). The ptosis persisted. It was doubtful in

this case whether the ptosis depended on injury to the nerve of

supply, or on laceration and fixation of the levator palpebræ

superioris. The latter seemed the more probable, as the

superior rectus acted. The absence of any sign of gross

bleeding into the anterior chamber is opposed to the existence

of a perforating lesion of the globe in this case.

(78) _Entry_ (Mauser), from cranial cavity, just within the

centre of the roof of the right orbit; _exit_, from the orbit

by a notch in the lower orbital margin internal to the

infra-orbital foramen; track thence beneath the soft parts of

the face to emerge from the margin of the upper lip near the

left angle of the mouth. Collapse of globe, proptosis,

subconjunctival hæmorrhage, oedema and ecchymosis of lids.

Shrunken ball removed on twenty-fourth day (Major Burton,

R.A.M.C.).

(79) _Entry_ (Mauser), at the posterior border of the left

mastoid process, 3/4 inch above the tip; _exit_, in the inner

third of the left upper eyelid. Globe excised at end of seven

days. Facial paralysis and deafness.

(80) _Entry_ (Mauser), from cranial cavity through centre of

roof of orbit; _exit_, through maxillary antrum. Total

blindness. Movements of ball good, no loss of tension.

Proptosis, subconjunctival hæmorrhage, ecchymosis of eyelids.

No improvement in sight followed. One month later the globe

suppurated and was removed. The bullet had divided the optic

nerve and contused the ball.

_Prognosis and treatment of wounds of the orbit._--Except in those cases

in which return of vision was rapid, the prognosis was consistently bad

in the injuries to the globe. When the globe was ruptured it, as a rule,

rapidly shrank. The case (80) quoted above is the only one in which I

saw secondary suppuration.

With regard to active treatment, the majority of the cases were

complicated by fracture of the roof of the orbit, and in many instances

concurrent brain injury was present. In all of these, as a general rule,

it was advisable to await the closure of the wound in the orbital roof

prior to removal of the injured eye, if that was considered necessary.

The only exception to this rule was offered by instances in which the

bullet passed from the orbit into the cranium; in these primary removal

of fragments projecting into the frontal lobe was preferable. As already

indicated, such wounds were comparatively rare except in the case of

bullets coursing transversely or obliquely.

The wounds were, as a rule, followed by considerable matting of the

orbital structures.

_Wounds of the nose._--I will pass by the external parts, with the

remark that perforating wounds of the cartilages were remarkable for

their sharp limitation and simple nature. I remember one case shown to

me in the Irish Hospital in Bloemfontein by Sir W. Thomson, in which at

the end of the third day small symmetrical vertical slits in each ala

already healed were scarcely visible. This case very strongly impressed

one with the doctrine of chances, since on the same morning I was asked

to see a patient in whom a similar transverse shot had crossed both

orbits, destroying both globes and injuring the brain.

A retained bullet in the upper portion of the nasal cavity has already

been referred to (fig. 60). This accident was naturally a rare one; in

that instance the bullet had only retained sufficient force to insert

itself neatly between the bones.

Wounds crossing the nasal fossæ were comparatively common. The

interference with the sense of smell often resulting is discussed in

Chapter IX.

_Wounds of the malar bone_ were not infrequent. The small amount of

splintering was somewhat remarkable considering the density of structure

of the bone. In this particular the behaviour of the malar corresponded

with what was observed in the flat bones in general. A case quoted in

Chapter III. p. 87, illustrates the capacity of the hard edge of the

bone to check the course of a bullet, and cause considerable deformity

and fissuring of the mantle.

_Wounds of the jaws. Upper jaw._--A large number of tracks crossing the

antrum transversely, obliquely, or vertically were observed. In the

first case the nasal cavity, in the others the orbital or buccal cavity,

were generally concurrently involved. It was somewhat striking that I

never observed any trouble, immediate or remote, from these perforations

of the antrum. If hæmorrhage into the cavity occurred, it gave rise to

no ultimate trouble. I never saw an instance of secondary suppuration

even in cases where the bullet entered or escaped through the alveolar

process with considerable local comminution. The branches of the second

division of the fifth nerve were sometimes implicated. In one instance a

bullet traversed and cut away a longitudinal groove in the bones,

extending from the posterior margin of the hard palate, and terminating

by a wide notch in the alveolar process.

A good example of a troublesome transverse wound of the bones of the

face is afforded by the following instance:--

(81) _Entry_ (Mauser), through the left malar eminence, 1 inch

below and external to the external canthus; _exit_, a slightly

curved tranverse slit in the lobe of the right ear.

The injury was followed by no signs of orbital concussion, and

no loss of consciousness. There was free bleeding from both

external wounds and from the nose. The sense of smell was

unaffected, but taste was impaired, and there was loss of

tactile sensation in the teeth on the left side also on the

hard palate. There was no evidence of fracture of the neck of

the mandible, nor of the external auditory meatus, but there

was considerable difficulty in opening the mouth widely or

protruding the teeth. The latter difficulty persisted for some

time, and was still present when I last saw the patient.

_Mandible._--Fractures of the lower jaw were frequent and offered some

peculiarities, the chief of which were the liability of any part of the

bone to be damaged, and the absence of the obliquity between the cleft

in the outer and inner tables so common in the fractures seen in civil

practice.

The neck of the condyle I three times saw fractured; in each instance

permanent stiffness and inability to open the mouth resulted. This

stiffness was of a degree sufficient to raise the question whether the

best course in such cases would not be to cut down primarily and remove

a considerable number of loose fragments, and thus diminish the amount

of callus likely to be thrown out.

Fractures of the ascending ramus and body were more frequent. They were

accompanied by considerable comminution, but all that I observed healed

remarkably well, and in good position, in spite of the fact that many of

the patients objected to wear any form of splint.

The most special feature was the occurrence of notched fractures,

corresponding to the type wedges described in Chapter V. When these

fractures were at the lower margin of the bone, the buccal cavity

occasionally escaped in spite of considerable comminution, the latter

confining itself to the basal portion of the bone.

When the base of the teeth, or the alveolus, was struck, a wedge was

often broken away, and from the apex of the resulting gap a fracture

extended to the lower margin of the bone.

When fractures of the latter nature resulted from vertically coursing

bullets, much trouble often ensued. I will quote two cases in

illustration:--

(82) Wounded at Rooipoort. _Entry_ (Mauser), through the lower

lip; the bullet struck the base of the right lateral incisor

and canine teeth, knocked out a wedge, and becoming slightly

deflected, cut a vertical groove to the base of the mandible;

_exit_, in left submaxillary triangle. The bullet subsequently

re-entered the chest wall just below the clavicle, and escaped

at the anterior axillary fold. The appearance of these second

wounds suggested only slight setting up of the bullet; the

original impact was no doubt of an oblique or lateral

character.

The injury was followed by free hæmorrhage and remarkably

abundant salivation (I was inclined to think that the latter

symptom was particularly well marked in gunshot fractures of

the body of the mandible), and very great swelling of the floor

of the mouth.

The patient could not bear any form of apparatus, but was

assiduous in washing out his mouth, and made a good recovery,

the fragments being in good apposition.

(83) _Entry_ (Mauser), over the right malar eminence; the

bullet carried away all the right upper and lower molars,

fractured the mandible, and was retained in the neck.

A fortnight later an abscess formed in the lower part of the

neck, which was opened (Mr. Pooley), and portions of the mantle

and leaden core, together with numerous fragments of the teeth,

were removed. The bullet had undergone fragmentation on impact,

probably on the last one (teeth of mandible), and still

retained sufficient force to enter the neck.

This case affords an interesting example of transmission of force from

the bullet to the teeth, and bears on the theory of explosive action.

In the treatment of fractures of the upper jaw, interference was rarely

needed. In the case of the mandible, a remark has already been made as

to the advisability of removing fragments when the neck of the condyle

has suffered comminution. The removal of loose fragments is necessary in

all cases in which the buccal cavity is involved. Experience in fracture

of the limbs has shown a tendency to quiet necrosis when comminution was

severe, in spite of primary union. This is no doubt dependent on the

very free separation of fragments on the entry and exit aspects from

their enveloping periosteum. In the case of the mandible, considerable

necrosis is inevitable, and much time is saved by the primary removal of

all actually loose fragments.

A splint of the ordinary chin-cap type with a four-tailed bandage meets

all further requirements, but the patients often object to them. Cases

in which the fragments could be fixed by wiring the teeth were not

common, as the latter had so frequently been carried away. The usual

precautions as to maintaining oral asepsis were especially necessary.

The results of fractures of the mandible were, in so far as my

experience went, remarkably good, as deformity was seldom considerable.

The absence of obliquity and the effect of primary local shock were no

doubt favourable elements, little primary displacement from muscular

action occurring.

Wounds of the _cheek_ healed readily, and the same was noticeable of the

lips. Wounds of the _tongue_ healed with remarkable rapidity when of the

simple perforating type, often with little or no swelling or evidence of

contusion. At the end of a few days it was often difficult to localise

them.

In connection with this subject a remarkable case which occurred at the

fighting at Koodoosberg Drift is worthy of mention, although the

projectile was a shell fragment and not a bullet of small calibre.

(84) A Highlander was the unfortunate possessor of an entire

set of upper teeth set in a gold plate. A small fragment of a

shell perforated the upper lip by an irregular aperture, and

struck the teeth in such a manner as to turn the posterior edge

of the plate towards the tongue, which latter was cut into two

halves transversely through to the base.

The patient asserted that the plate had been driven down his

throat, but nothing was palpable either in the fauces or on

external examination of the neck. He spoke distinctly, but

there was dysphagia as far as solids were concerned.

On the second day swelling of the neck due to early cellulitis

developed, especially on the left side, and signs of laryngeal

obstruction became prominent. Chloroform was administered, but

on the introduction of the finger into the fauces, respiration

failed and a hasty tracheotomy had to be performed. No foreign

body was palpable with the finger in the pharynx.

Tracheitis and septic pneumonia developed, and the man died of

acute septicæmia thirty-six hours later. Death occurred just as

the Division received marching orders, and no _post-mortem_

examination was made. As a result of palpation at the time of

the tracheotomy, the probabilities seemed against the presence

of the tooth plate in the pharynx, but the absence of positive

evidence scarcely allows the case to be certainly classed as

one of cellulitis and septicæmia secondary to wound of the

tongue.

WOUNDS OF THE NECK

Wounds of the neck were not unfrequent and were of the gravest

importance; there can be little doubt that they accounted for a

considerable proportion of the deaths on the field. On the other hand,

the neck as a region offered some of the most striking examples of

hairbreadth escape of important structures. Consideration of a number of

the vascular lesions (see cervical aneurisms, p. 135) also shows

conclusively that in no region did the small size of the bullet more

materially influence the result, since no doubt can exist that all these

wounds would have proved immediately fatal if produced by projectiles of

larger calibre.

In this place only a few general considerations will be entered into, as

most of the important cases are dealt with under the general headings of

vessels, nerves, and spine; but it is convenient to include here the few

remarks that have to be made concerning the cervical viscera.

The wounds of the soft parts might course in any direction, but vertical

tracks from above downwards were rare. In point of fact, these occurred

only in connection with perforations of the head, and as vertical wounds

of the latter were received in the prone position, usually when the head

was raised, the necessary conditions for longitudinal tracks were seldom

offered. One case of a complete vertical track in the muscles of the

back of the neck has been already quoted (No. 69, p. 286).

Tracks coursing upwards from the trunk were somewhat more frequent in

occurrence; thus a considerable number traversing the thorax were seen.

In such instances the aperture of exit was generally situated in the

posterior triangle, and some of the brachial nerves often suffered.

The commonest forms of wound were the transverse or the oblique. A large

number of cases with such tracks will be found among the cases of injury

to the cervical vessels and nerves. In some instances the course was

restricted to the neck alone, in others the trunk or upper extremity was

also implicated.

The favourable influence of the arrangement of the structures of the

neck, which allows of the ordinary displacement excursions necessary for

deglutition, respiration, and their cognate movements, was very strongly

marked. Thus in several cases the bullet traversed the neck behind the

pharynx and oesophagus without injuring either viscus, and the escape

of the main vessels and nerves was equally striking. In such wounds the

wedge-like bullet without doubt separated and displaced all these

structures, causing mere superficial contusion.

In connection with the latter statement, the rarity of direct sagittal

wounds in the hospitals should be mentioned. This is probably to be

explained by the facts that wounds in the mid-line of the neck

implicated the cervical spinal cord, and that sagittal wounds

implicating the vessels were apt to lead more directly to the surface,

and thus external hæmorrhage was favoured. A few examples of cervical

tracks will suffice to illustrate these remarks:--

(85) _Entry_ (Lee-Metford), below angle of scapula; _exit_,

centre of posterior triangle. Injury to the lung, and

hæmothorax. No damage to neck structures.

(86) _Entry_ (Mauser), over Pomum Adami; _exit_, below right

scapular spine. Median and musculo-spiral paralysis.

(87) _Entry_, a large oval aperture through ninth right rib,

1/2 an inch external to scapular angle; _exit_, anterior border

of sterno-mastoid opposite Pomum Adami. Second entry, opposite

angle of mandible; exit, in centre of cheek.

Wound of lung. Musculo-spiral paralysis still persisting at the

end of nine months.

(88) _Entry_ (Mauser), 2 inches above left clavicle at margin

of trapezius; _exit_, 1 inch from sternum in left first

intercostal space. Contusion of brachial plexus, with mixed

signs, which disappeared in two months. No signs of vascular

injury.

See also cases of cervical aneurism, &c.

_Wounds of the pharynx._--I saw only three cases of wound of the

pharynx; in each the injury was in the nasal or buccal segment of the

cavity, and in each the soft palate was injured, in two instances the

wound being a small perforation.

All three cases belong to the somewhat miraculous class. The first (89)

was the only one in which the wound gave rise to subsequent trouble. The

second was under the charge of Mr. Bowlby, and will no doubt be more

fully recounted by him, as interesting signs of injury to the cervical

cord were present. In the third the occipital neuralgia was the only

troublesome symptom.

In both cases 90 and 91 the high position of the wound in the fixed

portion of the pharynx no doubt accounted for the absence of any

infective trouble.

(89) _Wounds of the pharynx._--_Entry_ (Lee-Metford),

immediately below the tip of right mastoid process; the bullet

traversed the neck, entering the pharynx close to the right

tonsil, crossed the cavity of the pharynx and the mouth,

emerging through the left cheek. Great swelling of the fauces

and dysphagia persisted for some days after the injury, and

there was considerable hæmorrhage.

Infection of the posterior portion of the track from the

pharynx resulted, and suppuration continued for some weeks: a

small sequestrum eventually needed to be removed from the tip

of the transverse process of the atlas.

(90) _Entry_ (Mauser), through mouth; the bullet pierced the

soft palate and the posterior wall of the pharynx, and passed

out between the transverse process of atlas and the occiput. No

serious pharyngeal symptoms.

(91) _Entry_ (Mauser), through the mouth, knocking out the left

upper canine and bicuspid teeth. Perforation of the soft palate

just to the right of the base of the uvula and the posterior

wall of the pharynx; _exit_, 1-1/2 inch internal to and 1/2 an

inch below the tip of the right mastoid process. Hæmorrhage

persisted for half an hour, and the patient could not swallow

solids for a week. Great occipital neuralgia followed the

wound.

_Wounds of the larynx._--I saw only one wound of the larynx (see No. 10,

p. 135). In this instance the thyroid cartilage was wounded on either

side at the level of the Pomum Adami. Transitory hæmorrhage and signs of

oedema were the only signs referable to the wound, but in addition the

bullet contused the left vagus and gave rise to temporary laryngeal

paralysis. The same course was observed in a second case of perforation

of the larynx of which I was told.

_Wounds of the trachea._--The two cases recounted below are the only

tracheal injuries I met with; in one the oesophagus was also

implicated. This patient died from mediastinal emphysema. In the second

case the wide development of emphysema was prevented by the early

introduction of a tracheotomy tube.

(92) _Entry_ (Mauser), on the outer side of the right arm,

3-1/2 inches below the acromion; _exit_, 3 inches below the tip

of the left mastoid process, through the sterno-mastoid. Thirty

six hours later there was very free hæmorrhage into the right

posterior triangle, emphysema at the episternal notch,

dysphagia, and complete obliteration of the cardiac area of

dulness. Respiration was rapid (40) and extremely noisy. Pulse

130, small and weak.

A tracheotomy was performed (Mr. Stewart), but the patient died

an hour later. When the operation was performed a considerable

amount of mucus from the oesophagus was discovered in the

wound. The bullet had passed obliquely between trachea and

oesophagus, wounding both tubes.

(93) _Entry_, at the centre of the margin of the left

trapezius; _exit_, in mid line of the neck over the trachea.

Dyspnoea was noted the next morning, which increased during a

journey in a wagon. On the third day the dyspnoea was more

troublesome and emphysema began to develop in the neck. A

tracheotomy was performed (Mr. Hunter), and the tube was kept

in for four days. No further trouble was experienced, and the

wound shortly closed, and the patient, a surgeon, returned to

his duties. Temporary signs of median nerve concussion and

contusion were noted.

CHAPTER VIII

INJURIES TO THE VERTEBRAL COLUMN AND SPINAL CORD

Every degree of local injury to the constituent vertebræ and the

contents of the spinal canal was met with considerable frequency. Pure

uncomplicated fractures of the bones were of minor importance, except in

so far as they exemplified the general tendency to localised injury in

small-calibre bullet wounds. Injuries implicating the spinal medulla, on

the other hand, were proportionately the most fatal of any in the whole

body to the wounded who left the field of battle or Field hospital

alive, and these cases formed one of the most painful and distressing

features of the surgery of the campaign.

The prognostic gravity of any spinal injury depended upon two factors:

first, the obvious one of relative contiguity or direct implication of

the cord or nerves in the wound track; secondly, the degree of velocity

retained by the bullet at the moment of impact with the spine.

Observation of the serious ill effects produced by bullets passing in

the immediate proximity of large strongly ensheathed peripheral nerves

surrounded by soft tissue, such as those of the arm or thigh, would lead

one to expect that a comparatively thin-clad bundle of delicate nerve

tissue like the spinal cord, enclosed in a bony canal so well disposed

for the conveyance of vibrations, would suffer severely, and such proved

to be the case.

_Fractures in their relation to nerve injury_ will be first dealt with,

and secondly injuries to the cord itself.

Isolated fractures of the processes were not uncommon, the determination

of the injury to anyone being naturally dependent on the position and

direction taken by the wound track.

For implication of the _transverse processes_ sagittal wounds coursing

in varying degrees of obliquity were mainly responsible. Such injuries

might be unaccompanied by any nerve lesion. Thus a Boer received a

Lee-Metford wound at Belmont which passed from just below the tip of the

right mastoid process across the pharynx and through the opposite cheek.

No bone damage was at first suspected; suppuration in the neck, however,

followed infection from the pharynx, and when a sinus which persisted

was opened up later, a number of small comminuted fragments were found

detached from the transverse process of the axis. In other cases more or

less severe symptoms of nerve lesion were observed, varying from

transient hyperæsthesia, due to implication of the issuing nerves, to

symptoms of spinal hæmorrhage, such as are portrayed in the following:--

(94) A private in the Black Watch was wounded at Magersfontein

from within a distance of 1,000 yards. Among other wounds, one

track entered 1 inch to the right of the second lumbar spinous

process, and emerged 1 inch internal to the right anterior

superior iliac spine. There were signs of wound of the kidney,

and in addition, retention of urine, incontinence of fæces,

complete motor and sensory paralysis of the right lower

extremity, and total absence of all reflexes. Anæsthesia

existed over the whole area of skin supplied by the nerves of

the sacral plexus, hyperæsthesia over that supplied by the

lumbar nerves.

On the tenth day subsequent to the injury, the hyperæsthesia in

the area of lumbar supply was replaced by normal sensation,

motor power began to be slowly regained in the muscles supplied

by the anterior crural and obturator nerves, and the patellar

reflex returned. At this time lowered sensation returned in the

area supplied by the sacral plexus, but no improvement in motor

power took place, and no control was regained over the bladder

and rectum.

During the succeeding week some sciatic hyperæsthesia

developed, but on the twenty-eighth day the patient developed

secondary peritonitis from other causes and died on the

thirty-first. A fracture of the transverse process existed, but

unfortunately the spinal canal was not opened for examination

and no details can be given as to the condition of the cord.

(See case 201, p. 463.)

Fractures of the _spinous processes_, or those involving both the

process and laminæ, were not uncommon. Isolated separation of the

spinous process was usually the result of wounds crossing the back

obliquely or transversely. Examples of this injury were numerous,

especially in the dorsal region, as being the most prominent,

particularly when the patients assumed the prone position when advancing

on the enemy.

Cervical injuries, owing to the comparatively sheltered position of the

more deeply sunk spines, and from the fact that the head was usually

under cover of a stone or ant-heap, were less common; in one instance

hyperæsthesia was noted in one upper extremity as the result of a

crossing bullet having struck the fourth cervical spine. In a man

wounded at Paardeberg Drift the bullet entered at the centre of the

buttock, traversed the bones of the pelvis, and, leaving that cavity

above the crest of the ilium, crossed the spine to emerge in the

opposite loin. Suppuration occurred, and when the wound was laid open

the third and fourth lumbar spinous processes were found to be loosened,

but still connected to the surrounding soft parts. There were no nerve

symptoms in this case; these would not have been expected, since by the

time that the bullet had traversed the bones of the pelvis its velocity

must have been considerably lessened, even if high at the moment of

primary impact. In another case a dorsal spine, together with its

lamina, was separated and moveable; the only nerve symptoms were slight

pain and a crop of herpes on the line of distribution of the

corresponding intercostal nerve, the bullet having probably struck the

nerve in passing across the intercostal space. In one instance of a

retained bullet lying beneath the skin of the back, its passage between

two contiguous dorsal spines without fracture of either was determined

during an extraction operation.

When the prone position was assumed by the men, more or less

longitudinal wounds in the course of the spine were naturally liable to

occur. These tracks assumed somewhat greater importance than the

transverse ones, because the injury to bone was more often multiple, and

the laminæ were frequently implicated. The relative importance of such

injuries was dependent on the velocity of the bullet and the depth at

which it travelled. As an instance of a more serious character the

following may be given:--

(95) In a Highlander wounded at Magersfontein, probably at a

range within 1,000 yards, the bullet entered at the right side

of the sixth cervical vertebra; tracking downwards, it loosened

the laminæ of the fifth and sixth dorsal vertebræ from the

pedicles, and separated the tip of the seventh spine. The

bullet was extracted from beneath the skin at the latter spot,

its force having been no doubt exhausted by the resistance of

the firm neural arches supported by the weight of the man's

body. Symptoms of total transverse lesion of the cord followed,

and the patient died at the end of fifty-four days. The bone

had not apparently been sufficiently depressed to exert

continuous pressure, but the cord was diffluent and actually

destroyed over an area corresponding with the fourth, fifth,

sixth, and seventh dorsal segments.

I saw no instance of wound of the _neural arch_ from a direct shot in

the back in any of our men, neither was I ever able to detect an injury

to the articular processes as a localised lesion.

Injuries to the _centra_ were very frequent, but differed

extraordinarily in their importance. Perforation by bullets travelling

at a relatively low grade of velocity, but still one sufficient to allow

them to pass through the body, produced in many instances no symptoms

whatever when the track did not lie in immediate contiguity to the

spinal canal or perforate it.

In all the wounds which I had the opportunity of examining post mortem,

the fracture was of the nature of a pure perforation of the cancellous

tissue of the centrum, with no comminution beyond slight splintering of

the compact tissue at the aperture of exit. In one instance the bullet

passed in a coronal direction so close to the back of the centrum as to

leave a septum of only the thickness of stout paper between the track

and the spinal canal. In this case signs of total transverse lesion were

present. I never happened to meet with a case in which the canal was

encroached upon from the front by displaced bone. In some cases at the

end of six weeks there was difficulty in determining the position of the

openings, and section of the bone was necessary in order to assure

oneself as to the direction of the track.

In some instances the centra were pierced in the coronal direction with

varying degrees of obliquity; in others the direction was more sagittal;

in two of the latter the bullet was retained in the spinal canal. The

tracks were sometimes confined to one vertebra, but often implicated

two. In others the bullet passed longitudinally through the thorax,

grooving or perforating one or more centra.

The accompanying evidences of nerve injury varied from nil to those of

pressure or irritation of the nerve roots, transient signs of spinal

concussion, signs of contusion and hæmorrhage, or to evidence of total

transverse lesion. Instances of all these conditions will be quoted

under the heading of injuries to the cord or nerves.

_Signs of injury to the vertebræ._--Separation of the spinous processes

was often indicated by slight deformity, either evident or palpable,

local pain, tenderness, mobility, and crepitus. In some cases these

local signs were reinforced by evidence of cord injury. Fractures

involving the laminæ differed merely in the degree to which the above

signs were developed. Fractures of the transverse processes were

generally only to be assumed from the position and direction of the

wounds, the assumption being sometimes strengthened in probability by

evidence of injury to the cord and nerves.

Fractures of the centra were also frequently only to be assumed from the

direction of the wound tracks, and possibly from evidence of nerve

injury. When no paralysis supervened, interference with the movements of

the back, or pain, was so slight as to be inappreciable, especially in

the presence of concurrent injury to other parts, which was seldom

absent. I only once saw any angular deformity from this injury, and that

slight, and not apparent before the end of three weeks. In this

particular a very striking difference exists between injuries from

small-calibre bullets and larger ones such as the Martini-Henry. In the

only instance of Martini-Henry fracture of the spine that came under my

notice, the centrum was severely comminuted and deformity was obvious.

Still, as in so many particulars, the difference was only one of degree,

since comminution of the centra in gunshot wounds has always been

observed to be slight in nature compared with what is met with in the

compression fractures of civil life.

A few words will suffice to dismiss the questions of diagnosis,

prognosis, and treatment of the above injuries. The diagnosis depended

on attention to the signs above indicated, the prognosis almost entirely

on the concurrent injury to the nervous system, which will be considered

later, and the treatment consisted in enforcing rest alone.

INJURIES TO THE SPINAL CORD ACCOMPANYING SMALL-CALIBRE BULLET WOUNDS OF

THE VERTEBRÆ

_Anatomical lesions._--In introducing the subject of the nature of the

lesions of the spinal cord and membranes, I should again enforce the

statement that their character and degree, in comparison with the slight

accompanying bone damage, are pathognomonic of gunshot wounds, and that

these characters find their completest exemplification in injuries

produced by bullets of small calibre, endowed with a high grade of

velocity. Again, that the varying degrees of damage depend comparatively

slightly on the position of the bone lesion, apart from actual

encroachment on the canal, while the degree of velocity retained by the

bullet at the moment of impact is all-important. In no other way are the

divergent results to be explained which follow an apparently identical

injury, in so far as extent, position, and external evidence of damage

to the spinal column are concerned.

Injuries to the nerve roots of the nature of concussion and contusion,

are dealt with in Chapter IX.

_Pure concussion_ of the spinal cord may, I believe, be studied from a

better standpoint in the case of small-calibre bullet injuries than in

any others, since in many instances it is, I think, possible to exclude

any complications such as wrenches and strains of the vertebral column,

and ascribe the symptoms to the pure effect of extreme vibratory force

communicated to the cord by its enveloping bony canal. The condition

must be considered under the two headings of slight and severe.

In _slight concussion_ the usually transient effects of the injury, and

its happy tendency not to destroy life, place us in a state of

uncertainty as to the occurrence of anatomical changes, since no

opportunity of post-mortem examination occurred. The clinical condition

included under this term corresponds with that implied in 'spinal

concussion' in civil practice. One point of extreme interest, whether

the subjects of small-calibre bullet spinal concussion will in the

future suffer from the remote effects common to similar sufferers in

civil life from other causes such as railway collisions, still remains

for future determination. An ample field for such observations has at

any rate been created by the present war.

In _severe concussion_ a far more highly destructive action is exerted.

This condition may be followed by complete disorganisation of the cord,

accompanied or not by multiple parenchymatous hæmorrhages into its

substance. Either or both of these pathological conditions are produced

by the impact of the bullet with the spine, given a sufficiently high

degree of velocity, and it is difficult to separate clinically the

resulting symptoms. This is a matter perhaps of less importance, since

it stands to reason that a vibratory force, capable of rupturing the

spinal capillaries, would at the same time damage the nervous tissue.

In speaking of concussion of this degree, it should be clearly

recognised that a general condition, such as is indicated by the use of

the term 'concussion of the brain,' is in no wise implied. The condition

is really far more nearly allied to one of contusion, a strictly

localised portion of the spinal cord undergoing the destructive process

which affects the segments below only in so far as it interrupts the

normal channels of communication with the higher centres.

Case 102 is an instance of such a lesion, the post-mortem examination

showing clearly that the spinal canal was not encroached upon by the

bullet. The cord in this instance appeared little changed

macroscopically, and this fact was observed in other instances, both

during operations and post mortem.

_Contusion._--This condition is very closely allied to the last. In

cases 101 and 103 the spinal canal was as little encroached upon as in

102, but the bullet struck the somewhat elastic neural arch in each

case, and post mortem an adhesion between the cord and the enveloping

dura opposite the point at which impact of the bullet was closest

suggests that, in spite of the escape of the bone from fracture, it may

have been momentarily depressed to a sufficient degree to contuse the

cord, or the latter may have suffered a _contre-coup_ injury. For these

reasons the inclusion of the cases as instances of pure concussion is

not warranted. In both Nos. 99 and 100 the neural arch had actually

suffered fracture, and although the bone was not depressed or exercising

pressure at the time of the autopsies, it was no doubt driven in

temporarily at the moment of impact of the bullet.

At the post-mortem examinations of injuries of this nature it was common

to find one to four segments of the spinal cord completely disorganised.

At the end of some five weeks, the common duration of life, the

structure of the cord was represented by a semi-diffluent yellowish

material, the consistence of which was so deficient in firmness as to

allow the partial collapse of the membranes covering the affected

portion, so as to exhibit a definite narrowing when the whole was held

up (see fig. 79). In such cases traces of extra- or intra-dural

hæmorrhage sometimes still persisted.

_Hæmorrhage._--This occurred as surface extravasation and in the form of

parenchymatous hæmorrhages. I saw the former both in the extra-dural and

peri-pial forms, but never in sufficient quantity to exert a degree of

pressure calculated to produce symptoms of total transverse lesion. Here

again, however, it is difficult to speak with confidence since the

conditions which regulate the tension within the normal spinal canal are

so complicated and liable to variation, that it is very difficult to

estimate the effect of any given hæmorrhage discovered.

My friend Mr. R. H. Mills-Roberts described to me one fatal case under

his care in the Welsh Hospital in which extra-dural hæmorrhage was so

abundant as, in his opinion, to have taken a prominent part in the

production of the paralytic symptoms.

Examples of both extra- and intra-dural (peri-pial) hæmorrhage are

afforded by cases 99, 102, and 103; in none was it large in amount or

widely distributed. The condition was probably also frequently

associated in varying degree with that to be immediately described

below.

_Intra-medullary hæmorrhage_ (_hæmato-myelia_).--The importance of this

condition is lessened in small-calibre bullet injuries by the fact

already alluded to, that it is almost invariably accompanied by

concussion changes. In one instance in which death took place at the end

of eight days, partly as the result of concurrent injury, in a man in

whom signs of total transverse lesion of the cord were present, the

substance of the cord was found to be closely scattered over with

hæmorrhages of various sizes and extending for a longitudinal area of

some three inches.

As to the frequency with which hæmorrhage into the substance of the cord

occurred, I regret to be unable to give an opinion. In the late

post-mortem examinations I witnessed, a yellow discoloration of the

softened cord was the only macroscopic evidence of hæmorrhage.

Hæmorrhages of this nature may, however, account for the grave paralytic

symptoms in some cases of partial or total transverse lesion not due to

direct compression or laceration.

The conditions of concussion, contusion, or hæmatomyelia were, I

believe, responsible for at least nine-tenths of the cases in which a

total transverse lesion was indicated by the symptoms. The extreme

importance of realising this fact and the rarity of the production of

symptoms by continuing compression both from the prognostic and the

therapeutic point of view is obvious.

The analogous injuries termed generally in Chapter IX. nerve contusion,

although frequently accompanied by tissue destruction, may be followed

by reparative change, and are capable of complete or almost complete

spontaneous recovery; while the lesions in the spinal cord are

permanent, and complete recovery is only witnessed in the parts affected

by the remote pressure or irritation from blood extravasation, or in

those influenced by concussion.

I include below short abstracts of all the cases of lesion of the spinal

cord which terminated fatally, in which I had the opportunity of

witnessing the post-mortem conditions. In a considerable proportion of

the cases at the end of six weeks the spinal cord was softened over an

area of from two to four segments in such degree as to have practically

lost all continuity. Although the autopsies were made on patients who

had died slowly and in summer weather, often twelve to sixteen hours

after death, I think it can be but fair to assume, when the consistency

of the remaining portion of the spinal cord is considered, that the

softening was only in slight degree if at all exaggerated by post-mortem

change. Again symptoms of secondary myelitis and meningitis had been

observed in some of the fatal cases prior to death.

I had but one opportunity of observing a case in which a retained bullet

exercised compression, and none in which this was due to displaced bone

fragments. I also only once came across a case of complete section, but

no doubt both bone pressure and section may have occurred with greater

frequency amongst patients dying on the field or shortly after. The case

of section is illustrated in fig. 80. It will be noted that, although

the section is complete, the bullet lies to one side of the canal, and

hence the bullet, as fixed in its course by the bone of the centrum,

directly struck but half of the whole width of the cord.

It was striking how little secondary change in the cord had occurred in

the neighbourhood of the spot of division. This well illustrates the

comparatively slight vibratory effect of a bullet travelling with a

degree of velocity insufficient to completely perforate the vertebral

column.

_Symptoms of injury to the spinal cord._--In _slight spinal concussion_

these exactly resembled those of the more severe lesions, except in

their transitory nature. They consisted in loss of cutaneous

sensibility, motor paralysis, and vesical and rectal incompetence. The

phenomena persisted from periods of a few hours to two or three days,

return of function being first noticeable in the sensory nerves, and

often with modification in the way of lowered acuteness, or minor signs

of irritation, such as formication, slight hyperæsthesia or pain,

pointing to a combination with the least extensive degrees of

hæmorrhage; later, motor power was rapidly regained. The subjects of

such symptoms often suffered from weakness and unsteadiness in movement

for some days or weeks; a sharp line of discrimination between such

cases and those described in the next paragraphs is manifestly

impossible.

_Spinal hæmorrhage._--The symptoms of this condition developed

differently according to whether concurrent concussion existed.

Occasionally very typical instances of pure hæmorrhage were observed

with transient symptoms:--

(96) A private in the Yorkshire Light Infantry was wounded at

Modder River; the bullet entered between the eleventh and

twelfth ribs, just posterior to the left mid-axillary line,

emerging in the posterior axillary fold, at its junction with

the right side of the trunk. On the second day after the injury

the lower extremities became drawn up, the knees and hips

assuming a flexed position, and this was followed shortly by

the advent of complete motor and sensory paraplegia,

accompanied by retention of urine. Two days later, the patient

again passed water normally, and gradual and rapid return of

both sensation and motor power took place. At the end of

fourteen days no trace of the condition remained, and the

patient was shortly after sent home.

The symptoms, however, were rarely so simple as in this example; it was

very much more common to meet with an admixture of signs of primary

concussion, or at any rate symptoms of radiation. The following is an

extreme but excellent example of more complicated and prolonged effects:

(97) A lance-corporal of the Black Watch was wounded at

Magersfontein at a range of from 400 to 500 yards. The bullet

entered over the left malar bone 2-1/2 inches from the outer

canthus, while the aperture of exit was 2-1/4 inches above the

inferior angle of the right scapula, 3/4 of an inch anterior to

its axillary margin.

Very shortly after the injury complete motor and sensory

paralysis developed in both upper extremities, followed by the

development of a similar condition in the left lower limb, and

retention of urine and fæces, but the latter unaccompanied by

the marked abdominal intestinal distension so characteristic in

cases of total transverse lesion. The right side of the chest

continued to work well, but the intercostals of the left side

were paralysed. No disturbance of the normal action or

condition of the pupils was noted. After the first few days the

condition began to improve.

Three weeks later, the chest was moving symmetrically and well,

sensation and motor power had returned in considerable degree

in the left lower extremity, with marked increase in both the

plantar and patellar reflexes; sensation had returned in both

upper extremities, a slight amount of motor power was regained

in the right, but the left remained entirely flaccid and

incapable of movement.

At the end of a month power was regained over both bladder and

rectum, some slight movement of the left thumb was possible,

and a certain degree of hyperæsthesia developed over the back

of the forearm.

At the end of six weeks there was little further alteration,

but that in the direction of improvement. There was some

wasting of the muscles of the left upper extremity, and this

was most marked in the muscles supplied by the ulnar nerve.

At the end of ten weeks the patient had been up some days; he

could stand and walk, but was unable to rise from the sitting

posture without help. The plantar and patellar reflexes were

much exaggerated, and there was ankle clonus, most marked in

the left limb. The right upper extremity was normal, but weak;

there was wrist-drop on the left side and the deltoid was

wasted and powerless; on the other hand the fingers could be

flexed, and although the elbow could not be, there were signs

of returning power in the biceps, and some movements of the

shoulder could be performed by the capsular muscles. It was

remarkable that common sensation was more acute in the left

than the right lower extremity, but I attributed this to the

remains of hyperæsthesia on the left side. The patient left for

home shortly after the last note.

In both these cases the absence of marked hyperæsthesia or pain points

to medullary hæmorrhage (hæmato-myelia) as the pathological condition

produced by the injury. In this particular they contrast well with case

94 quoted on page 315, where the degree of both hyperæsthesia and pain

indicated a combination of pressure and irritation of the nerve roots by

surface hæmorrhage on the affected side. In case 97 the persistence for

four weeks of paralysis of the bladder and rectum suggested medullary

hæmorrhage in addition, while the return of patellar reflex in the

paralysed limb negatived the occurrence of an extensive destructive

lesion.

In view of the extreme interest of these cases I will shortly detail one

other in which the cauda equina alone was affected.

I must confess my inability to place the case definitely in the

category either of concussion or medullary hæmorrhage. As so often

happened, both conditions probably took part in the lesion. The

immediate development of the primary symptoms is no doubt to be referred

to concussion, while the patchy nature of the prolonged lesion and

gradual recession of the symptoms point to the presence of hæmorrhages.

We find here the link most nearly connecting the spinal cord and the

peripheral systemic nerves. Such a case goes far to show that the

condition which I have in the next chapter often referred to as nerve

contusion may in fact be produced by an injury far short of actual

contact.

(98) A trooper in the Imperial Yeomanry, while advancing in the

crouching attitude, was struck by a bullet from his left front,

at an estimated distance of 300 yards. The bullet traversed the

right arm anteriorly to the humerus, entered the trunk in the

line of the posterior axillary fold, 1-1/2 inch below the level

of the nipple, crossed the thoracic and abdominal cavities,

deeply striking the lumbar spine, and finally lodged beneath

the skin over the venter of the left ilium. The skin was

broken, but the force of the bullet was not sufficient to cause

it to pass through, and it was later expressed from the wound

by the surgeon. The bullet was a Mauser, and not in any way

deformed, although it must at any rate have struck the spine

and perforated the ilium.

Immediate paraplegia resulted, both sensation and motor power

were completely abolished, but there was no trouble either with

the bladder or rectum. No symptoms of injury to either thoracic

or abdominal viscera were noted.

Three days after the injury sensation and some return of motor

power were observed in the left extremity, and some power of

movement in the toes of the right foot.

During the next eight weeks steady but slow improvement took

place; during the last three weeks of this period he made the

voyage to England. Ever since the injury some elevation of

temperature was noted, a rise at night to 100° or at times to

102°; for this no definite cause was discovered. In the tenth

week the condition was as follows: The temperature has become

normal. The patient has lost flesh to a considerable extent

since the reception of the injury. The lower extremities are

much wasted, especially the peroneal muscles. Patellar reflexes

can be obtained, but the knee jerks are uncertain. Unevenly

distributed paralysis exists in both lower extremities.

Left--Sensation fairly good throughout. Quadriceps very weak;

does not react to electrical stimulation. Calf muscles act

fairly. Anterior tibial and musculo-cutaneous groups are

paralysed. Right--Quadriceps acts better than on left, muscles

below the knee paralysed, and in the same area there is

complete absence of sensation. The patient complains of

shooting pains in both legs, and there is some deep muscular

tenderness.

Three weeks later an abundant crop of vesicles appeared over

the front of the right thigh and leg, above and below the knee.

Sensation in the limb at the same time returned to a

considerable degree, anæsthesia persisting on the outer aspect

of the thigh only.

At the end of four months very considerable improvement had

taken place, but there was no return of motor power in the

right leg, or the muscles supplied by the peroneal nerve in the

left leg. There was some general oedema of the legs,

especially of the right, possibly in connection with the

herpetic eruption which was now disappearing. Muscular

tenderness had disappeared. There was also definite improvement

in the size and tone of the peroneal muscles, although no motor

power was regained.

At the end of five months, slight gradual improvement was still

taking place, but the loss of power was nearly as extensive as

when the last note was taken. The skin of the right leg was

glossy, that of the left apparently normal. At times some

hyperæsthesia of the soles was noted, and the plantar reflex

was very brisk.

The right anterior tibial and musculo-cutaneous groups of

muscles reacted to the strongest faradic current, not to any

galvanic current below 20-25 m.a., contraction very sluggish.

The same muscles in the left leg also reacted to the strongest

faradic current, but only locally, with no sort of effect on

the tendons. Similar contractions could be induced in the right

quadriceps, but none in the left (Dr. Turney).

Appreciation of heat and cold applied to the skin was fair,

but, in the case of heat, distinctly slow in the right leg and

foot.

At the end of seven months improvement was still taking place;

the patient could now stand, walk a little with crutches, and

even ascend and descend a staircase.

* * * * *

_Severe concussion, contusion, or medullary hæmorrhage

producing signs of total transverse lesion, and complete

transverse section._--The symptoms of these conditions will be

taken together, because, with very slight variations, they may

be considered as lesions of equal degree as to severity, bad

prognosis, and unsuitability for active interference.

All were characterised by the exhibition of the same essential

phenomena, symmetrical abolition of sensation and motor power

on either side of the body, absence of any signs of irritation

in the paralysed area, and loss of patellar reflex. In a small

number of the cases of medullary hæmorrhage some return of

sensation was observed prior to death; in a still smaller,

traces of motor power, and in one or two irritability of the

muscles or feeble reflexes pointed to the fact that destruction

of the cord was not absolute. As abstracts of a series of cases

are appended on page 330, it is only necessary to add a few

remarks as to any slight peculiarities which seemed directly

dependent on the mode of causation.

It may be first stated that these severe injuries were

accompanied by signs of a very high degree of shock. In fact,

the shock observed in them was more severe than in any other

small-calibre bullet injuries that I witnessed. The patients

lay still with the eyes closed, great pallor of surface,

sometimes moaning with pain, the sensorium much benumbed, or

occasionally early delirium was noted. The pulse was small,

often slow and irregular, and the respiration shallow. The

originally quiet state was often changed to one of great

restlessness of the unparalysed part of the body, with the

appearance of reaction.

The degree of primary pain varied greatly, but as a rule it was

considerable; in some cases it was excruciating in the parts

above the level of the totally destructive lesion, and commonly

of the zonal variety. A hyperæsthetic zone at the lower limit

of sensation usually existed.

In the majority of the cases pain must have depended on

meningeal hæmorrhage. In one of the cases related, positive

evidence was offered as to this particular by the autopsy,

although this was made as long as six weeks after the original

injury, since no other source of pressure or irritation was

discovered. When I first saw this patient some twenty-four

hours after the injury he was moaning with pain, although a

strong and plucky man; I hastened to give him an injection of

morphia, and assured him that it would relieve his suffering:

as I left I heard him say to his neighbour: 'That is no use;

they gave me three last night, and I was no better,' and his

remark proved true.

In high dorsal and cervical injuries the temperature rose high,

in one case to 108° F.; I had no opportunity, however, of

observing the temperature in any case immediately before and

after death. During the hot weather the profuse sweating of the

upper part of the body contrasted very strongly with the dry

skin of the paralysed part.

The heart's action was often particularly irregular in the

dorsal injuries, and the respiration slow and irregular; as

these cases, however, were often complicated by severe

concurrent injuries to internal organs, the irregularities

could hardly be ascribed to the spinal-cord lesion alone. In

cases of pure diaphragmatic respiration, the rate did not as a

rule exceed the normal of 16 or 20 to the minute, and it was

quite regular; this was noted soon after the injury and

persisted throughout the course of the cases. As is usually the

case, both respiration and the heart's action were most

embarrassed in the cases in which abdominal distension was a

prominent feature. In some of the neck cases the Cheyne-Stokes

type of respiration was very strongly marked.

In cases of low dorsal injury intestinal distension was

extreme, and I think more troublesome than the same condition

as seen in civil practice. The distension was accompanied by

most persistent vomiting, continuing for days, and in the cases

that lived for some time severe gastric crises of the same type

occurred in some instances.

Priapism was a common symptom; but, as is seen from the cases

quoted, was rarely due to any gross direct laceration of the

cord.

Trophic sores were both early to develop, and extensive;

primary decubitus occurred in all the cases I saw, and steady

extension followed. In one case a remarkable symmetrical

serpiginous ulceration developed in the area of distribution of

the cutaneous branches of the external popliteal nerve on the

outer side of the leg.

The paralysis in nearly every case was of the utterly flaccid

type, and wasting of the muscles was early and extreme. This

was occasionally accentuated by the supervention of myelitis.

Opportunities for making observations on the quantity of urine

secreted were not great, and I can offer no remark as to the

occurrence of polyuria. In one rapidly fatal case, however,

suppression of urine occurred.

(99) _Lumbar region. Transverse lesion._--Range under 1,000

yards. Wound of _entry_ (Mauser), over the seventh rib 1 inch

from the left posterior axillary fold; _exit_, over the centre

of the right iliac crest. Complete symmetrical motor and

sensory paralysis of lower extremities, entire abolition of

reflexes, retention of urine.

On the ninth day there was some return of sensation in the

lower extremities, and a cremasteric reflex was to be obtained.

A large bedsore had developed over the sacrum. No further

change occurred in the lower extremities. The patient became

progressively emaciated and exhausted, cystitis persisted, the

bedsore deepened. The man eventually developed signs of a large

basal abscess in the left lung, and died on the forty-second

day.

At the _post-mortem_ a fracture of the first lumbar lamina was

discovered, with some splintering of the bone; the lumbar

spinous process was attached and in its normal position.

Opposite the centre of the cauda equina were the remains of a

considerable hæmorrhage, both extra- and intra-dural, the

nerves appearing somewhat compressed, but of normal

consistency. The muscles of the back were infiltrated with

putrid pus on both sides. A pulmonary abscess cavity the size

of a hen's egg occupied the upper part of the lower lobe of the

left lung. The kidneys were congested, and the bladder

thickened and chronically inflamed.

(100) _Cervico-dorsal region. Total transverse lesion._--Wound

of _entry_ (Mauser), to the right of the sixth cervical

vertebra: the bullet was removed on the field from the left of

the seventh dorsal spinous process, which was somewhat

prominent. Complete motor and sensory paralysis extended

upwards to the third intercostal space; the breathing was

almost entirely diaphragmatic. Retention of urine. Entire

abolition of reflexes in lower limbs and trunk. Hyperæsthesia

was present in both upper extremities, with a zone of

hyperæsthesia around the chest. The patient suffered greatly

for some weeks from pain in the hyperæsthetic area, he

developed severe cystitis and later incontinence of urine. A

large trophic sacral bed-sore steadily increased in depth and

size.

About ten days before death, which occurred on the fifty-third

day from exhaustion and septicæmia, the patient complained of

pains in his legs; but there was no return of sensation,

motion, or reflexes.

At the _post-mortem_, the seventh dorsal spinous process was

found to be loose and the laminæ of the fifth, sixth, and

seventh vertebræ were separated from the pedicles, and somewhat

depressed on the left side. These laminæ were adherent to the

dura, as were also a few small separated bony spiculæ. There

was no sign of old hæmorrhage. The spinal cord was practically

gone between the levels of the fourth and seventh dorsal

vertebræ, and diffluent from myelitis up to the third cervical.

(101) _Dorsal region; total transverse lesion._--Wound of

_entry_ (Mauser), in the left supra-spinous fossa of the

scapula; _exit_, between the eleventh and twelfth ribs of the

right side. Complete motor and sensory paralysis, with absence

of reflexes from mid-dorsal region downwards. Upper

intercostals working. Retention of urine, penis turgid.

Sensation perfect to lower extremity of sternum. Early trophic

sacral bed-sores developed and steadily increased in depth and

extent, slighter ones developed on the heels. The paralysis was

flaccid throughout. The patient gradually emaciated with fever,

and died on the seventy-eighth day.

At the _post-mortem_ the wound proved not to have penetrated

the thorax, and both the vertebral spines and laminæ were

intact, no trace of bony injury being discoverable. Opposite

the sixth dorsal vertebra, for a distance of 1-1/2 inch, the

cord and dura were adherent, and over the same area the cord

was represented by soft custard-like material. There was no

sign of old hæmorrhage.

(102) _Dorsal region; total transverse lesion; slight

extra-dural hæmorrhage._--Wound of _entry_ (Mauser), at the

posterior aspect of the right shoulder; _exit_, 2 inches to the

left of the spine below the ninth rib.

Complete motor and sensory paralysis below the site of the

lesion, with absence of superficial and deep reflexes.

Retention of urine. Great abdominal distension, pain, and

vomiting. Bed-sores over the sacrum developed on the third day;

meanwhile the vomiting continued on and off for a week, and

very severe girdle pain persisted.

One month later when seen at the Base hospital considerable

improvement had occurred. Sensation had returned in both lower

limbs; but flaccid paralysis persisted and both were wasted,

especially the left. There was no return of reflexes in the

lower limbs, the urine was passed in gushes, and the patient

was cognisant when these occurred. The sacral bed-sores were,

however, very extensive and becoming larger and deeper.

At the end of the fifth week slight power was regained in the

flexors and abductors of the right thigh, and the same muscles

of the left limb could be made to contract feebly. Meanwhile

the patient suffered with severe fever, accompanied by frequent

rigors and profuse sweats; the bed-sore continued to extend,

and the urine was foul and contained pus.

The patient continued in a similar condition, progressive

emaciation and exhaustion taking place, and at the end of six

weeks he died.

At the _post-mortem_ the bullet was found to have tracked

beneath the right scapula, entering the chest by the fifth

intercostal space and lacerating the right lung; thence it

entered the eighth dorsal centrum and tunnelled both this and

the ninth diagonally, to escape beneath the ninth rib. On

opening the spinal canal the tunnel was found to be separated

only by the compact tissue of the centrum from the cavity,

while a thin extra-dural hæmorrhage separated the dura from the

bones anteriorly. The spinal cord exhibited no sign of pressure

and was firm and continuous, but up to the lower limit of the

dorsal region there was septic myelitis and meningitis, the

result of pus having tracked up the canal from the sacral

bedsore. Suppurative cystitis and pyelitis were present. The

patient was the subject of an old urethral stricture which had

given rise to trouble during treatment.

(103) _Dorsal region; total transverse lesion; slight

intra-dural hæmorrhage._--Wound of _entry_ (Mauser), below

spine of scapula, close to right axilla; _exit_, 2-1/2 inches

to left of tenth dorsal spinous process.

Complete motor and sensory paralysis below ensiform cartilage,

with well-marked hyperæsthetic zone around trunk. All reflexes

absent. Retention of urine. Incontinence of fæces. Bed-sores in

sacral region developed during the first two days, and

seventeen days later well-developed serpiginous trophic sores

developed on the outer side of each leg and continued to

increase slowly until death. The paralysis remained of the

absolutely flaccid variety. Great emaciation occurred,

accompanied by hectic fever, the temperature ranging from

normal to 102.5°. During the third week double pleurisy

developed.

At the _post-mortem_ no bone injury could be detected. The cord

and dura-mater were adherent over an area corresponding to the

fifth to the eighth dorsal vertebræ, and opposite the seventh

the cord was soft and of the consistence of butter. A small

intra-dural hæmorrhage was still evident below the main lesion,

not extensive enough to give rise to serious compression.

General adhesions in each pleura. Cystitis.

[Illustration: FIG. 79.--Appearance of Spinal Cord enclosed in membranes

in case 103 after removal from the canal. When the membranes were opened

a white custard-like substance took the place of the cord. Slight

evidence of extra-dural hæmorrhage existed]

(104) _Dorsal region; section of cord; retained bullet._--Wound

of _entry_ (Mauser), in seventh right intercostal space, 4-1/2

inches from the dorsal spinous processes, oval in outline;

bullet retained.

Complete motor and sensory paralysis, with absence of reflexes

below umbilicus. Retention of urine, incontinence of fæces.

Large sacral bed-sore developed rapidly. Right hæmothorax.

The patient emaciated rapidly, and for the last fourteen days

the temperature ranged to 104°, the bed-sore steadily

increasing in size. Death occurred on the forty-second day.

At the _post-mortem_ a Mauser bullet was found embedded in the

centrum of the twelfth dorsal vertebra. The bullet was slightly

curved; its anterior extremity had passed across the spinal

canal, and wounding the dura posteriorly rested against the

left lamina. The plating of the mantle of the bullet was

stripped from half the area of the tip. The dura was not

adherent, and the cord was softened for half an inch above the

point of section; above this it was normal, the vessels

coursing normally to the softened spot. Below the point of

section the cord was blanched, but offered no other macroscopic

evidence of disease. No evidence of either intra- or

extra-dural hæmorrhage was detectible.

[Illustration: FIG. 80.--Complete division of Spinal Cord. The bullet is

retained, and from its position can be seen to have struck the right

half of the cord only. The nickel plating of half of the tip of the

bullet is stripped off. Case No. 104]

The right pleura contained a large quantity of dark cocoa-like

fluid. Extensive adhesions were present in both pleural

cavities. The spleen was much enlarged. At the base of the

bladder a large submucous hæmorrhage had occurred, the

blood-clot had assumed a dark orange colour, and on first

opening the viscus the appearance was that of a mass of fæces.

The mucous lining elsewhere was slaty grey, with small

hæmorrhages. The kidneys were large, but no abscesses or

pyelitis were present.

(105) _Cervico-dorsal region; total transverse lesion._--Wound

of _entry_ (Mauser), opposite right sixth cervical transverse

process; _exit_, on left side of third dorsal spinous process.

Slight grasping power was present in the hands, and the patient

could hold his arms across his chest. Complete motor and

sensory paralysis, with absence of all reflexes below. The

pupils were moderately contracted. Retention of urine. On the

second day blebs appeared on each buttock, and the patient

complained of very severe pain in the neck: the temperature

rose to 103°, and on the third day he died suddenly. No

_post-mortem_ examination was made.

I observed two similar cases in the Field Hospital at Orange River, the

patients dying on the third day; pain and high temperature were

prominent symptoms in both. In one patient early delirium was present.

(106) _Dorsal region; Martini-Henry wound._--Wound of _entry_,

oval, 1 inch × 3-1/4 inches; long axis obliquely crossing

infra-spinous fossa of right scapula; bullet retained

(Martini-Henry). Spine of third dorsal vertebra loose, and a

distinct thickening to its right side. Complete symmetrical

paralysis extending up to upper extremities. No sensation on

surface of trunk below cervical area. Respiration entirely

diaphragmatic. Retention of urine, penis turgid. Total absence

of reflexes, superficial and deep. Reddening of buttocks, but

no bullæ.

General hyperæsthesia of upper extremities, with severe

spasmodic attacks of pain.

On the third day an exploration was decided upon, in view of

the local deformity, and the severe pain in the upper

extremities. The third dorsal spine was found to be loose, as a

result of bilateral fracture of the neural arch; the bullet had

crossed the right limit of the spinal canal, and destroyed the

body of the vertebra, and passing onwards had entered the left

pleural cavity, into which air entered freely from the

operation wound.

The patient was relieved from his pain by the exploration, and

lived four days. On the second day after operation, however,

the temperature rose to 107°, while on the last two days the

temperature was normal in the mornings, rising to 105° in the

evenings. No alteration resulted in the trunk symptoms.

_Diagnosis._--The pure question of the fact of injury of the spinal cord

needs no discussion; but it is necessary to make some remarks on the

discrimination between concussion, contusion and hæmorrhage, meningeal

and medullary hæmorrhage, the latter condition and compression, and on

partial and complete severance of the cord.

The sharp discrimination of cases of concussion from those of slight

medullary hæmorrhage was necessarily impossible. I think the only points

of any importance in diagnosing pure concussion were the transitory

nature of the symptoms, and the uniformity of recovery, without

persistence of any signs of minor destructive lesion. In medullary

hæmorrhage the tendency for a certain period was towards increase in

gravity in the signs. It goes almost without saying that the latter

point was seldom accurately determined in patients struck on the field

of battle; these perhaps lay out for hours before they were brought in,

and when they were placed in the Field hospital the rush of work did not

usually allow the careful observation necessary to clear up this

difference in the development of the symptoms. Nevertheless it is

preferable to consider the cases in which transitory symptoms persist

for a period of hours, or even a couple of days, as instances of pure

concussion, unless the existence of this condition can be disproved by

actual observation.

Extra-medullary hæmorrhage, accompanied by only slight encroachment on

the spinal canal, certainly results with some frequency from

small-calibre wounds. Some of the quoted cases show this decisively by

_post-mortem_ evidence, others by such clinical signs of irritation as

pain and hyperæsthesia. I think its presence may also be assumed in

cases of total transverse lesion due to medullary hæmorrhage or severe

concussion, accompanied by well-marked pain and hyperæsthesia above the

level of paralysis. As affecting treatment, however, determination of

its presence is of small importance.

The important conditions for discriminative diagnosis are those of local

compression, actual destructive lesion, whether from concussion changes,

contusion, or medullary hæmorrhage, and partial and total section of the

cord.

First, with regard to compression of the cord, the possible sources are

three; (i) extra-dural hæmorrhage, which may, I think, be dismissed with

mention as rarely capable of producing severe symptoms. (ii) The

displacement of bone fragments. This is of less importance than in civil

practice, because an injury by a bullet of small calibre, capable of

seriously displacing fragments, has probably at the same time produced

grave changes in the cord. In the presence of severe immediate symptoms

we may tentatively assume that a simultaneous destructive lesion has

been produced. In such injuries pain, combined with a tendency to

improvement in the paralytic symptoms and return of reflexes, is the

only point in favour of bone pressure, unless considerable deformity of

the spinal column can be detected by palpation or examination with the

X-rays.

(iii) Pressure from the bullet. This is the most important form of

compression, because the mere fact of retention of the bullet is

evidence of a low degree of velocity, and therefore opposed to the

existence of the most severe form of intramedullary lesion. In a case of

apparent transverse lesion with retained bullet, shown to me at No. 3

General Hospital by Mr. J. E. Ker, the pain was very severe, and so

greatly aggravated by movement that an anæsthetic had to be administered

prior to the renewal of some necessary dressings. The general condition

of this patient precluded a projected operation, and after death the

bullet was found to be pressing laterally upon a cord not materially

altered on macroscopic inspection. In the case of retained bullet

recorded (No. 104), the slight degree to which the severed ends of the

cord appeared altered has been already remarked upon.

Beyond this we are helped by the position of the aperture of entry, and

its shape, as evidence of the direction in which the bullet passed, the

presence of pain, and positive proof may be obtained by examination with

the X-rays.

Lastly, we come to the discrimination of total or partial section,

destruction by vibratory concussion or contusion, and severe

intramedullary hæmorrhage. Except in the case of partial section with

localised symptoms, which must be rare, I believe this to be impossible

from the primary symptoms, although some indication of possible

encroachment on the canal may be obtained from careful consideration of

the course of the wound, as evidenced by the position and shape of the

openings, the position of the patient's body at the time of reception of

the injury being taken into consideration. Later we may get some aid

from the possible improvement in the symptoms in the case of hæmorrhage.

In cases with signs of total transverse lesion, however, the

discrimination of the conditions is of little practical importance,

since either is equally unfavourable and unsuitable for surgical

treatment.

In closing these remarks reference must be made to the occasional

occurrence of paraplegic symptoms of an apparently purely functional

nature. I saw these on one or two occasions, of which the following is

a fair example. A man was wounded in the lower extremity and fell. When

brought into the hospital he complained of loss of power in the legs and

inability to straighten his back. No very definite evidence was present

of serious impairment either of motor or sensory nerves, and the man was

got up and walked with crutches. While moving about the hospital camp,

another man pushed him down, and the patient then became completely

paraplegic. He was placed in bed, and the next day moved his limbs

without any difficulty, and gave rise to no further anxiety.

_Prognosis._--In slight concussion the importance of prognosis is as to

remote effects, and upon this no opinion can be given at the present

time. The same may be said concerning cases in which transient symptoms

followed the slighter degrees of surface and medullary hæmorrhage. In

the case of the latter, however, I think it would be rash to give a too

confident opinion as to the future non-occurrence of secondary changes.

Severe concussion is probably irrecoverable.

Meningeal hæmorrhage of either form is one of the slighter lesions, and

less dangerous, both as an immediate condition and as to the

probabilities of after trouble. None the less the possibilities of

secondary chronic meningitis, or chronic trouble from adhesions, must be

kept in mind.

Cases of medullary hæmorrhage with incomplete signs are favourable in

prognosis, as far as life is concerned; as to complete recovery,

however, this is hardly possible; in many cases serious functional

deficiency at any rate will remain, while in others the healing of the

lacerated tissue and subsequent contraction can scarcely fail to

influence unfavourably an already imperfect recovery.

I think it must be a rare occurrence for pressure from bone fragments to

be able to be regarded as a favourable prognostic condition, since in

the very large majority of cases the velocity of the bullet causing the

injury will have been such as to inflict irreparable damage on the cord.

Still, cases may occasionally be met with where the velocity has been

sufficiently low, or contact with the bone slight enough, to allow of

the comparative escape of the cord. In this relation cases in which the

bullet is retained, especially if the symptoms of transverse lesion are

incomplete, may be regarded as relatively favourable.

Cervical and high dorsal injuries, as in civil practice, offered the

worst prognosis. In cases in which symptoms of total transverse lesion

were present, as far as my experience went, it was, however, only a

matter of importance as to the prolongation of a miserable existence.

All the patients eventually died; those with higher lesions at the end

of a few days; the lower ones, at the completion on an average of six

weeks of suffering.

The actual causes of death resembled exactly those met with in civil

practice, except in so far as it was more often influenced or determined

by concurrent injuries, a complication so characteristic of modern

gunshot wounds. Thus exhaustion, septicæmia from absorption from

suppurating bed-sores or from severe cystitis, secondary myelitis, and

pulmonary complications, carried off most of the patients.

_Treatment._--The general treatment of the cases demanded nothing

special to military surgery, except in so far as it was modified by the

disadvantage to the patient of necessarily having to be transported,

often for some distance. The ill effects of this, particularly in cases

of hæmorrhage, are obvious, but in so far as fracture was concerned the

question of transport did not acquire the importance that it does in

civil practice, since the nature of the fractures and their strict

localisation did not render movement either painful or particularly

hurtful. It was indeed striking how little pain movement, made for the

purposes of examination, caused these patients. The treatment of

bed-sores, cystitis, or other secondary complications possessed no

special features.

The importance of insuring rest in the early stages of the cases of

hæmorrhage is self-evident; hence, if the possibility exists of not

moving the patient, its advantage cannot be too strongly insisted upon.

Again, if transport is inevitable, the shorter distance that can be

arranged for the better. It should be borne in mind, also, that from the

peculiar nature of causation of the injuries, stretcher or wagon

transport for short distances is preferable to the vibratory movements

of a long railway journey. Beyond this the administration of opium, and

in some cases the assumption of the prone position, are both useful in

the recent or possibly progressive stage of hæmorrhage.

Lastly, as to active surgical treatment by operation. In no form of

spinal injury is this less often indicated, or less likely to be useful.

It is useless in the cases of severe concussion, contusion, or medullary

hæmorrhage which form such a very large proportion of those exhibiting

total tranverse lesion, and equally unsuited to cases of partial lesion

of the same character. Extra-medullary hæmorrhage can rarely be

extensive enough to produce signs calling for the mechanical relief of

pressure; the section of the cord cannot be remedied. In one case with

signs of total transverse lesion, in which a laminectomy was performed,

no apparent lesion was discovered, and this would frequently be the

case, since the damage is parenchymatous. The experience was indeed

exactly comparable to that which followed early exposure of the

peripheral nerves.

Only three indications for operation exist. 1. Excessive pain in the

area of the body above the paralysed segment; operation is here of

doubtful practical use, except in so far as it relieves the immediate

sufferings of the patient.

2. An incomplete or recovering lesion, when such is accompanied by

evidence furnished by the position of the wounds, pain, and signs of

irritation of pressure from without, or possibly palpable displacement

of parts of the vertebra, that the spinal canal is encroached upon by

fragments of bone.

3. Retention of the bullet, accompanied by similar signs to those

detailed under 2.

In both the latter cases the aid of the X-rays should be invoked before

resorting to exploration.

Operation, if decided upon, in either of the two latter circumstances,

may be performed at any date up to six weeks; but if pressure be the

actual source of trouble, it is obvious that the more promptly operation

is undertaken the better for early relief and ulterior prognostic

chances.

In only one case of the whole series I observed did it seem possible to

regret the omission of an exploration.

CHAPTER IX

INJURIES TO THE PERIPHERAL NERVE TRUNKS

The occurrence of these injuries has undoubtedly increased in frequency

with the employment of bullets of small calibre, and no other class of

case more strikingly illustrates the localised nature of the lesions

produced by small projectiles of high velocity. Again, no other series

of injuries affords such obvious indications of the firm and resistent

nature of the cicatricial tissue formed in the process of repair of

small-calibre wounds, and in none is the advantage of a conservative and

expectant attitude so forcibly impressed upon the surgeon. Implication

of the nerves may be primary, or secondary to an injury which left them

originally unscathed.

_Nature of the anatomical lesions._--In degree these vary in

mathematical progression, but the extent of the lesion is not always

readily differentiated by the early clinical manifestations, and again

the actual damage is not to be estimated by the gross apparent

anatomical lesion alone; but, in addition, consists in part in changes

of a less easily demonstrable nature, varying with the velocity with

which the bullet was travelling and the consequent comparative degree of

vibratory force to which the nerve has been subjected. In these

injuries, as in those of every part of the nervous system, the degree of

velocity appears to gain especial importance both in regard to the

general symptoms and the local effect on the functional capacity of the

nerve.

This is perhaps a fitting place for the introduction of a few further

remarks as to the significance of the term 'concussion' in connection

with the injuries produced by bullets of small calibre, since the most

striking exemplification of the results following the transmission of

the vibratory force of the projectile is afforded by the behaviour of

the comparatively densely ensheathed and supported peripheral nerves.

As already pointed out in Chapters VII. and VIII. the chief concussion

effects on the nervous tissue of the brain and spinal cord are of a

destructive nature, far exceeding those accompanying the injuries

designated by the same term seen in the ordinary accidents met with in

civil practice, and this damage is comparatively localised in extent.

In the case of the peripheral nerves I have still employed the terms

'concussion' and 'contusion' to designate certain groups of symptoms and

clinical phenomena, but any sharp distinction between the two conditions

on a morbid anatomical basis is impossible. The results of severe

vibratory concussion may, in fact, be more generally destructive than

those of contusion, and the subsequent effects more prolonged. A certain

length of the affected nerve is apparently completely destroyed as a

conductor of impulses, the connective-tissue element alone remaining

intact. Under these circumstances a nerve, the subject of the most

serious degree of vibratory concussion, which, if cut down upon, may

exhibit no macroscopic change, may take a longer period to recover than

one in which the presence of considerable local thickening points to

direct contact with the bullet, with resulting hæmorrhage into the nerve

sheath and perhaps partial gross rupture of nerve fibres.

The therapeutic and prognostic importance of the above remarks, if

correct, is obvious. The course of the nerve is preserved by its intact

connective-tissue framework, and ultimate recovery by a regeneration of

the nerve fibres is more likely to be complete, and will be just as

rapid, if nature be relied on and the nerve be left untouched by the

hand of the surgeon.

It is, I think, undeniable that nerve trunks may escape severe or

irrecoverable injury by lateral displacement. The mere fact that the

trunk itself may be perforated by a slit in its long axis would suggest

the possibility of displacement of the whole structure, and this no

doubt occurred with some frequency. Displacement would naturally be most

frequent in the case of nerves, such as those of the arm, which run long

courses in comparatively loose tissue. In a remarkable case already

narrated, an exploratory operation showed the musculo-spiral nerve in

the upper part of the arm to have been driven into a loop which

projected into, and provisionally closed, an opening in the brachial

artery.

I. _Simple concussion._--Anatomically, or histologically, no information

exists as to the changes which give rise to the often transitory

symptoms dependent on this condition. We are reduced to the same

theories of molecular disturbance and change which have been invoked to

account for similar affections of the central nervous system. The

causation of concussion is, however, materially influenced in its degree

by the velocity of flight of the bullet and consequent severity of the

vibratory force exerted. Hence actual contact of the bullet with the

nerves is not necessary for its production, as is seen in the temporary

complete loss of functional capacity in the limbs in many cases of

fracture, where the vibrations are rendered still more far-reaching and

effective as the result of their wider distribution from the larger

solid resistance afforded by the bone. The relative density and

resistance offered by the different parts of the bone acquire great

significance in this relation, since local shock due to nerve concussion

is far more profound when the shafts are struck than when the cancellous

ends furnish the point of impact.

The form of concussion which most nearly interests us in this chapter is

that affecting single nerve trunks in wounds of the soft parts alone,

and here the passage of the bullet is, as a rule, so contiguous to the

nerve that there is difficulty in drawing a strict line of demarcation

between such cases and those dealt with in the next paragraph.

II. _Contusion._--Clinically this was the form of nerve injury both of

greatest comparative frequency and of interest from the points of view

both of diagnosis and prognosis.

The seriousness of a contusion depends on two factors: first, the

relative degree of violence exerted upon the nerve, which is dependent

on the force still retained by the travelling bullet; and, secondly, on

the extent of tissue actually implicated. The range of fire at which the

injury was received determines the importance of the first factor; the

second varies with the degree of exactness with which the nerve is

struck, and on the direction taken by the bullet. Naturally transverse

wounds affect a small area; while an oblique or longitudinal direction

of the track may indefinitely increase the extent of injury to the nerve

trunk, and hence acquire prognostic significance in direct ratio to the

amount of tissue which needs to be regenerated.

As to the actual anatomical lesion resulting in the cases which we

designated clinically as contusion I can give no information. On many

occasions when the symptoms were considered of such a nature as to

render an exploration advisable, no macroscopic evidence of gross injury

was obtained. It was therefore impossible to draw a definite line of

demarcation between such cases and those which we considered merely

concussion. It could only be assumed that the vibration transmitted to

the nerve had occasioned such changes as to destroy its capacity as a

conductor of impressions.

In some cases the presence of a certain amount of interstitial blood

extravasation was suggested clinically by early hyperæsthesia and signs

of irritation; in others the paralysis was of such a degree as to lead

to the inference that a complete regeneration of the existing nerve

would be necessary prior to the restitution of functional capacity.

In a certain proportion of the injuries the development of a distinct

fusiform swelling in the course of the nerve pointed to the existence of

considerable tissue damage, while in others this was evidenced

clinically by early signs of neuritis.

III. _Division or laceration._--The varying mechanical conditions

affecting the last class of injury play a similar rôle here. Thus the

degree of laceration depends on the direction of the wound track, and as

all lacerations are accompanied by contusion, the relative velocity

retained by the travelling bullet assumes the same importance.

I saw every degree of injury to the trunks, from notching to complete

solution of continuity, and in some cases destruction and disappearance

of pieces from one to two or more inches in length. Such lesions as the

latter were most common in the forearm. In this segment of the limbs

tracks of varying degrees of longitudinal obliquity are readily

produced, whether the patient be in the upright or prone position,

since the upper extremities are commonly in forward action whichever

position is assumed.

The most peculiar form of injury consisted in perforation of the trunk

without gross destruction of its fibres, and without in many cases

prolonged or permanent loss of functional capacity. I cannot speak with

any confidence as to the comparative frequency of occurrence of this

form of injury, but judging by the analogous perforations of the

vessels, it is probably not uncommon in trunks large enough to allow of

its production. The trunk nerves of the arm, and the great sciatic

nerve, were probably the most frequent seats of such wounds. As,

however, a very short experience of the futility of early interference

in the case of nerve lesions warned me against exploration before a date

at which observations of this nature were unsatisfactory, I gained less

experience on this point than I could have wished.

In the case of completely divided nerves the development of a bulbous

enlargement on the proximal end was constant, and very marked in degree.

I saw few cases in which primary effects could be certainly referred to

pressure or laceration by bone spicules, excepting in some fractures of

the humerus, and perhaps some injuries of the seventh nerve accompanying

perforating wounds of the mastoid process.

IV. _Secondary implication of the nerves._--This was a striking

characteristic in many at first apparently simple wounds of the soft

parts. In such cases it was due to implication of the contiguous trunk

in the process of cicatrisation, and its importance varied with the size

of the nerve in question. In the smaller sensory trunks it was often

evidenced by the occurrence of neuralgic pain, especially liable to be

influenced by climatic changes; in the larger, by signs of more or less

severe motor, sensory, and trophic disturbance. Musculo-spiral paralysis

from implication in, or pressure from, callus in cases of fracture of

the humerus was very frequent. This would naturally be expected from the

extreme degree the comminution of the bone often reached, and the

consequently large amount of callus developed.

The effect of cicatrisation of the tissues surrounding the nerves

varied somewhat according to the degree of fixation of the individual

nerve implicated. Thus if a nerve lay in a fixed bed some form of

circular constriction resulted; if, on the other hand, the nerve was

readily displaceable, the cicatrix often drew it considerably out of its

course; in either case symptoms corresponding with those of pressure

resulted.

_Symptoms of nerve lesion_.--These differed little in character from

those common to such injuries in civil practice, except in the relative

frequency with which they assumed a serious aspect. After all in civil

practice nerve concussion is most familiar to us in the degree common

after knocking the elbow against a hard object, and the same may be said

in regard to the allied injury of contusion. It is in small-calibre

bullet wounds alone that the occurrence of such severe and sharply

localised injury to deep parts as was observed is possible.

_Concussion_.--Temporary loss of function was often observed in the

limbs, corresponding to the distribution of one or more nerve trunks

when wound tracks had passed in their vicinity. Interference with

function sometimes amounted to loss of sensation alone: in others to

loss of both sensation and motor power. Such symptoms were of a

transitory character, lasting for a few days or a week; if both

sensation and motion were impaired, sensation was usually the first to

be regained. In these cases secondary trouble was not uncommon, since

the near proximity of the track to the originally affected nerve offered

every chance for implication of the latter in the resulting cicatrix.

This sequence was often observed, and its symptoms are described under

the heading of secondary implication below. Equally striking were the

instances of concussion in the case of the nerves of special sense and

their end organs, temporary loss of smell, vision, or hearing being not

uncommon, often passing off in the course of a few days with no apparent

ulterior ill-effect.

One of the most interesting illustrations of the occurrence of

concussion was furnished by cases in which complete paralysis of a limb

rapidly cleared up with the exception of that corresponding to a single

individual nerve of the complex apparently originally implicated.

Instances of severe contusion or division of one nerve of the arm, for

instance, accompanied by transient signs of concussion of varying

degrees of severity in all the others, were by no means uncommon.

_Contusion_.--The symptoms of contusion were somewhat less simple,

since, in addition to lowering or loss of function, signs of irritation

were often observed. In the slighter cases irritation was often a marked

feature, as was evidenced by hyperæsthesia and pain combined with loss

of power. In cases in which pain and hyperæsthesia were primary

symptoms, these were often transitory. I will quote an illustrative case

which, though affecting the nerve roots, is characteristic of the

effects of slight contusion in the case of the nerve trunks in any part

of their course:--

(107) _Contusion of cervical nerve roots_.--Range probably

about 1,000 yards. Wounded at Belmont. Aperture of _entry_

(Lee-Metford), immediately posterior to the right fifth

cervical transverse process; _exit_, immediately anterior to

the space between the third and fourth left cervical transverse

processes. The movements of the neck were perfect, there was

neither pain nor difficulty in swallowing. Extreme

hyperæsthesia was present in both palms and down the front of

the forearms. The grip in either hand was weak, this being

possibly explained in part by the hyperæsthesia of the palms,

as all movements of the upper extremities could be made,

although not with full power. On the fourth day the condition

was much improved on the left side, and at the end of a week

the left upper extremity was normal; the right (side of entry,

and therefore exposed to greater force from the bullet)

improved more slowly, becoming normal only at the end of three

weeks.

I observed an identical case of injury to the cervical roots, and many

similar instances in injuries of the nerve trunks of the limbs in which

the course was exactly parallel. In the more severe, pain was often

added to hyperæsthesia.