except in the early entire loss of reaction of the muscles to
electricity, with those of complete section. Loss of sensation and
motion was immediate, complete, and prolonged, the limbs being lowered
in temperature, flaccid, and powerless. General systemic shock was also
severe. In the case either of plexus or multiple contusions, or where
the injury was more local, correspondingly complete signs were present
in the area supplied by the affected nerves.
In the cases in which the contusion was not of extreme degree,
hyperæsthesia often developed as a later sign, and was probably due to
the irritation of hæmorrhage, when the sensory portion of the nerve
began to regain functional capacity. The date of appearance of the
hyperæsthesia varied from a few days to a week or later. It might then
persist for weeks or many months.
In a few instances large blebs rose on the back of the hand, or patches
of vesicles appeared over the terminal distribution of the nerve,
pointing to early trophic changes.
The period of recovery varied greatly; in some instances of very
complete paralysis, function was regained and became apparently normal
at the end of three or four weeks; in others, even after severe wasting
of muscles for weeks, rapid improvement occurred often suddenly, while
in some there was no apparent recovery at the end of months. In cases of
long-deferred improvement, wasting of the muscles became a very
prominent feature; but this without complete loss of reaction of the
muscles to electrical stimulation.
Recovery of sensation usually preceded by some time that of motion, the
former often reappearing in some degree at an early date, and, even if
very modified in character, it formed a most useful and valuable aid
both in diagnosis and prognosis.
When in a position allowing of direct examination, the contused portion
of the nerve sometimes developed a palpable fusiform thickening,
manipulation of which might give rise to formication in the area of
distribution--a favourable prognostic sign.
Many of the cases bore a very marked resemblance in character to those
in which paralysis results from tight constriction of the limb, as in
the arm after the application of an Esmarch's tourniquet.
_Laceration._--If incomplete, the signs corresponded very nearly to
those of severe contusion, since partial section is impossible without
the occurrence of the latter. The condition indeed was only to be
distinguished by the partial nature of the recovery, and even this
latter might be only more prolonged.
The same remarks hold good with regard to perforation of the nerve
trunks; but, as regards function, these injuries are not so serious in
prognosis as very much more limited transverse divisions or mere
notching, and in some cases the disturbance of function was by no means
profound or prolonged.
Absolute loss of reaction to electrical stimulus from above was the only
pathognomonic sign of actual section, unless the position of the nerve
was such as to allow of palpation, when the presence of a bulbous end at
once settled the difficulty. In many cases of superficial tracks with
division of such nerves as the long or short saphenous, the early
development of bulbs in the course of the trunks gave positive
information, and these were often observed.
_Traumatic neuritis._--This was a common sequence of contusion of the
nerve itself, or of its subsequent inclusion in a cicatrix or callus. It
was evidenced by hyperæsthesia both superficial and deep, pain,
contracture, wasting of the muscles, local sweating, and the development
of glossy skin.
Examples of this condition were seen in the case of nearly every nerve
in the body. In frequency of occurrence, degree of severity, and in its
selection of individual nerves considerable variation was met with. With
regard to the two former points, personal idiosyncrasy, and degree of or
peculiarity in the nature of the injury, are the only explanations I can
suggest. Perhaps in some instances exposure to wet or cold in the early
stages of the injury was of some import. Thus, I saw several severe
cases of musculo-spiral neuritis in men who were wounded during the
trying and wet march on Bloemfontein. I did not observe that suppuration
or wound complications seemed important explanatory moments, as most of
the cases occurred in wounds that healed rapidly.
With regard to the question of selection; the same nerves that appear
particularly liable to suffer from idiopathic inflammations, toxic
influences, or to be the seat of ascending changes (e.g. ulnar,
musculo-spiral, and external popliteal), were those most often affected
by secondary neuritis. Many of the most severe cases I saw were in the
musculo-spiral nerve.
_Scar implication._--The signs of this most commonly commenced with
neuralgia, or painful sensations when such movements were made as to put
the cicatrix on the stretch. Although such neuralgia might not be
constant, it was often observed to be troublesome when the patients were
exposed to cold in sleeping out at night, or to extra fatigue, as in
long marches. The results in many cases stopped at this point, but the
size and wide distribution of certain nerves rendered even such slight
symptoms of importance; while in others well-marked signs of neuritis
declared themselves, such as glossy skin, pain, muscular wasting, and
paralysis.
_Ascending neuritis._--In a few cases I observed very remarkable
instances of ascending neuritis, after comparatively slight wounds. I
will quote three of these as illustrations and make no further remarks
as to the symptoms. It will be observed that one is a case of ulnar,
both the others of external popliteal, neuritis:--
(108) _Ulnar nerve: secondary ascending neuritis._--Boer
wounded at Elandslaagte. Wound of hand, implicating anterior
two-thirds of third metacarpal bone. This bone, together with
the middle finger, was removed, and healing took place by
granulation slowly.
The resulting gap allowed considerable overlapping of the
fingers, and shortening of the corresponding digit; the index
finger also became flexed as a result of destruction of the
extensor tendons. Three months later the man was still in
hospital in consequence of the tardiness with which the wound
had healed: at this time pain was noted, which became very
severe in the whole course of the ulnar nerve; superficial
hyperæsthesia and deep muscular tenderness developed, but no
wasting. Several crops of herpetic vesicles also developed over
the distribution of the radial nerve in the hand. This pain was
followed by spastic contracture, first of the ulnar fingers and
later of the wrist and elbow, which could only be straightened
by the application of considerable force. The limb was,
therefore, kept straight by the application of a splint; and
warm baths, and a blister applied over the course of the ulnar
nerve, were resorted to: under this treatment the condition
improved until the patient was well enough to be transferred as
a prisoner, and I saw him no more.
(109) _Peroneal nerve branches._--Wounded at Colenso. _Entry_,
at the anterior margin of the fibula 5 inches above the
external malleolus; the track crossed the anterior aspect of
the leg obliquely, to its _exit_ 1 inch above the centre of the
ankle joint. Incomplete paralysis of the peronei muscles
followed, combined with progressive wasting of the whole limb,
which at the end of a month was marked, and then commenced to
improve.
(110) In a second case the wound took a similar course in the
centre of the leg, crossing the line of the branches of the
musculo-cutaneous nerve. Motor paralysis of the peronei
followed, together with general lowering of tactile sensation
in the musculo-cutaneous area.
_Traumatic neurosis._--In connection with the cases just quoted, mention
must be made of the fact that the functional element was often somewhat
prominent. The influence of this factor was not to be neglected in case
108; again, its presence was a feature in cases 132 and 134, of injury
to the sciatic nerve and of peripheral injury to the seventh nerve (p.
355). A remark has been made as to the occurrence of functional
paraplegia on p. 337. Again, in the case of the organs of special sense.
Case 66, of injury to the occipital lobes, showed that a mixture of
organic and functional phenomena might be a source of error, even in the
determination of the visual field in the subject of an undoubted
destructive lesion. On more than one occasion an injury was accompanied
by loss of the power of speech; thus a patient who received a slight
wound of the neck did not speak again until the application of a battery
by my colleague, Mr. H. B. Robinson. A patient was also for a short time
an inmate of No. 1 General Hospital, Wynberg, who had become deaf and
dumb as a result of the explosion of a shrapnel shell over his head.
This patient also did not recover his powers until he returned to the
mother-country.
In many other cases of nerve concussion or contusion, the recovery of
power and sensation, or the disappearance of neuralgia or contractures,
was so sudden and rapid after prolonged continuance of the symptoms, as
to suggest a very strong functional element in their origin. The
influence of the general shock to the nervous system received by the
patients had an important bearing on these phenomena, and their interest
from a prognostic point of view was very great.
INJURIES TO SPECIAL NERVES
_Cranial nerves._--It will be convenient first to make a few remarks
concerning the nerves of special sense.
_Olfactory._--I observed temporary loss of smell on three occasions. In
two instances this accompanied transverse wounds of the bones of the
face in which the upper third of the nasal cavities was crossed; in the
third a track passing obliquely downwards from the frontal region passed
through the inner wall of the orbit, and crossed the nose at a lower
level. In view of the small area of the olfactory distribution which was
directly implicated, I was at first inclined to regard the loss of smell
as dependent on the presence of dried blood on the surface of the mucous
membrane, or on obstruction of the cavities from the same cause. Further
observation, however, appeared to show that it was due to concussion of
the branches of the olfactory nerve, since the loss of function
persisted when the cavities were manifestly clear.
In all these cases we were confronted with the same difficulty which was
experienced both in lesions of sight and hearing, the determination as
to whether the concussion was of the branches or of the olfactory bulb.
When the symptom was the accompaniment of a fracture of the roof of the
orbit, the possibility of concussion of the olfactory lobe was manifest.
In all, again, it was difficult to say what part the accompanying
concussion of the branches of the fifth nerve took in the production of
the symptom. In all three cases mentioned the return of function was
gradual, but apparently fairly complete at the end of three weeks. In
one it was noted that at first the patient was conscious of an odour
before he was able to discriminate its actual nature; later he could
determine the latter readily.
_Optic._--Some remarks concerning lesions of the optic nerve have
already been made under the heading of wounds of the orbit. Concussion
and contusion of the nerve both occurred, but I was unable to
differentiate between the effects of these on the nerve itself, apart
from the effects on the globe of the eye, which usually accompanied
wounds of the orbit.
In some cases the nerve was directly divided in orbital wounds, and
either pressure on or division of the nerve in the intra-cranial portion
of its course, or as it traversed the optic foramen, was not uncommon.
_Auditory._--Loss of hearing was also not infrequent; thus it
accompanied all three wounds of the mastoid process quoted under the
heading of the seventh nerve, also two cases of fracture of the
occipital bone near the ear quoted on p. 278. In all these instances it
was impossible to attribute the deafness to lesion of the nerve alone,
as the causative injury equally affected the internal ear, and in at
least two the bullet implicated the tympanum as well in its course. The
deafness was absolute in each case, and in none had any improvement
occurred at the end of nine months. Deafness was a symptom in a certain
number of the more severe cerebral injuries in which the course of the
bullet was not so near to the internal ear: probably some of these were
central in origin.
I only once observed any interference with the sense of taste.
_Remaining cranial nerves._--I have little to say regarding the _third_,
_fourth_, and _sixth_ nerves. In the case of the third nerve, ptosis was
occasionally seen in wounds of the skull involving the roof of the
orbit, but the relative parts taken by injury to nerve and laceration or
fixation of muscle respectively, were usually hard to determine. Again,
the fourth and sixth nerves may have been damaged in some of the more
extensive orbital wounds, especially those in which the globe suffered
injury, but the signs under such circumstances were difficult to
discriminate, and the injury was of slight practical importance, in view
of the major injury to the globe itself.
_Fifth nerve._--Concussion, contusion, or laceration of the different
branches of the three divisions of the fifth nerve were common in wounds
of the head, but most frequent in fractures of the upper or lower jaws.
Localised anæsthesia was common from one or other of these causes, but
for the most part transitory in the cases of contusion or concussion. I
saw no case of entire loss of function in any one division, symptoms
being mostly confined to certain branches, as the supra-orbital, the
temporo-malar, the dental branches of the second division, the
auriculo-temporal nerve, and the lingual, dental, and mental branches of
the third division. I did not observe any cases in which modification of
the special senses accompanied these injuries beyond those mentioned in
the remarks already made on the subject of anosmia, and one case in
which some modification of the sense of taste accompanied an injury to
the floor of the mouth. It was a matter of surprise, considering the
frequency with which subsequent neuritis was met with in the nerves
generally, that trifacial neuralgia in some form was not more often met
with. I never observed any serious case. Perhaps this is one of the
fields in which a longer after-period may increase our knowledge.
Lastly, I never observed motor paralysis in the case of the third
division, although sensory symptoms in some of the branches were common,
evident proof that injuries to the trunk were rare.
_Seventh nerve._--Facial paralysis was most commonly observed in cases
of wound of the mastoid process, apart from central cortical facial
paralyses, of which several are quoted in the chapter on injuries of the
head. All the wounds of the mastoid process were, in addition,
accompanied by absolute deafness. I am sorry to be unable to give any
details as to the electrical condition of the muscles in these cases,
but I believe that in the great majority the paralysis was mainly the
result of nerve concussion, since the perforations were clean in
character and not obviously accompanied by comminution. Pressure from
hæmorrhage into the Fallopian canal may, of course, have been present,
and in some instances, particularly those in which the bullet traversed
the tympanic cavity, spicules of bone may have caused laceration. In
every case, however, all the branches were equally affected; the
paralysis was absolute, and in none did any improvement occur while the
cases were under my observation.
The following are a few illustrative examples:--
(111) Boer wounded at Belmont. _Entry_, immediately above
zygoma; the bullet passed through the temporal fossa, fractured
the neck of the mandible, traversed the mastoid process, and
emerged at the lower margin of the hairy scalp, 1 inch from the
median line. Facial paralysis was complete, and there was no
improvement at the end of ten weeks.
(112) Wounded at Magersfontein. _Entry_, at the posterior
border of the left mastoid process, 1/2 an inch above the tip;
_exit_, through the right upper lip at the junction of the
middle and outer thirds. There was considerable hæmorrhage from
the left ear. The injury was followed by complete deafness, and
facial paralysis, which showed no sign of improvement.
There was complete anæsthesia over the area of distribution of
the third division of the fifth nerve; this improved rapidly,
and at the end of five weeks was hardly to be detected; neither
at that time could any impairment of power on the part of the
muscles of mastication be detected. No impairment of the sense
of taste was noted.
(113) _Entry_, above the anterior extremity of the zygoma,
bullet retained. Primary hæmorrhage from ear. Complete facial
paralysis and deafness. Anæsthesia over distribution of
temporal branch of temporo-malar nerve, part of supra-orbital
area, auriculo-temporal nerve, and small occipital cervical
nerve. The muscles of mastication acted well. Ecchymosis below
the right mastoid process.
(114) Wounded at Paardeberg. 300 yards. _Entry_, at the
posterior border of the right mastoid process, 3/4 of an inch
above the tip; _exit_, the inner third of the left upper
eyelid. (Eye destroyed.) Complete right facial paralysis; deaf,
on right side cannot hear tick of watch either held close or in
contact. Purulent otitis media.
In this place I might mention two other cases of lesion of the seventh
nerve secondary to wound of peripheral branches. In one a patient was
struck by several fragments of lead from a bullet which broke up against
a neighbouring stone. These for the most part lodged in the skin over
the left orbicularis muscle, but one also lodged in the conjunctiva and
was removed. Some ten days later the patient complained that he could
not lift the upper lid. The levator palpebræ was normal, but spasm of
the orbicularis held the eye firmly closed. The condition did not
improve, and the patient was invalided home. He recovered later.
In another patient a bullet entered above the right zygoma and traversed
the orbits, without wounding the globes. At the time no want of power of
the muscles of the face was noted, but a year later there was evident
weakness of the whole of the muscles of the right side of the face, with
loss of symmetry.
In the former case the functional element was strong, but in both an
ascending neuritis was probably present.
_Tenth nerve._--The pneumogastric was implicated in many wounds of the
neck. I never observed an uncomplicated case, but laryngeal paralysis
was temporarily present in two of the cases of cervical aneurism in
which the wound crossed above the level of origin of the recurrent
laryngeal branch, while in two others the recurrent branch itself was in
close contact with the wall of the aneurism (p. 135). In all such cases
signs of concussion or contusion of the nerve would be expected, judging
from the similar results observed in the brachial nerves when the
neighbouring artery was implicated. The only obvious symptoms occurring,
however, were laryngeal paralysis and acceleration of the pulse. As the
latter symptom was often observed in the cases of arterio-venous
communication, wherever situated, and as the sympathetic nerve also lay
in close contiguity to the wound track, it was difficult to ascribe it
with certainty solely to the vagus lesion. In the two cases of high
vagus injury the laryngeal paralysis steadily improved, and at the end
of six months was apparently well; in the two others it persisted at the
end of three months and a year respectively.
The nerve must have been very frequently damaged in wounds of the neck;
it is possible that this injury may have been an important factor in the
death of some of the patients with cervical wounds upon the field.
_Eleventh nerve._--I append the only case of localised spinal accessory
paralysis I observed. This was one of my earliest experiences, and when
I examined the neck, in the Field hospital, I assumed from the
completeness of the sterno-mastoid and trapezius paralysis that the
nerve was severed. The patient, however, made such a rapid recovery
that it became evident that the nerve had been contused only, and that
the recovery of function was not due, as is so often the case, to
vicarious compensation by the cervical supply to the muscles.
(115) _Entry_, immediately to the right of the fourth cervical
spinous process; _exit_, at the anterior border of the left
sterno-mastoid opposite the angle of the mandible. The left
shoulder was depressed, the head inclined to the injured side.
There was evident spinal accessory paralysis, and marked
hyperæsthesia of the whole left upper extremity, most severe in
the circumflex area. The hyperæsthesia gradually disappeared in
a few days, and was clearly due to concussion and possibly
slight contusion of the cervical nerve roots. The spinal
accessory paralysis improved, so that the patient returned to
the front at the end of a month: when I saw him some four
months later the shoulders were held quite symmetrically.
The _twelfth nerve_ was occasionally damaged in wounds of the floor of
the mouth. I saw no case of permanent paralysis.
_Injury to the systemic nerves._ _Cervical plexus._--Evidence of injury
to the superficial branches of the cervical plexus was not rare; thus I
saw cases of small occipital anæsthesia, and great occipital neuralgia,
but none of motor paralysis from injury to the deeper muscular branches.
I take it that the smallness of the branches, and the multiple supply
possessed by many of the muscles of the neck, would both take part in
rendering certain evidence of the injury of an individual motor nerve
rare.
_Brachial plexus._--Injury to this plexus in the neck was common; the
main peculiarity observed was the partial nature of the damage
inflicted.
Thus injury to a single nerve, or to a complex of two or more, was far
more common than one implicating the whole plexus. Again, while complete
paralysis might affect one set of nerves, another might simply exhibit
signs of irritation in the form of hyperæsthesia or pain.
The wounds producing these injuries varied much in direction; thus some
crossed the neck transversely, some were obliquely transverse, while
others took a more or less vertical course.
These same remarks hold good in the case of the nerves of the arm. In
the upper half, especially, complex injury was not rare, while in the
lower third affection of individual nerves was more common. Another
important difference must be mentioned in regard to the upper and lower
segments of the course of the brachial nerves; they are not only more
widely distributed below, but also more fixed in position, a fact
antagonistic to the escape of the nerve by displacement and liable to
expose it to more severe contusion.
The latter point holds good in the forearm also; here, individual
injuries often occurred.
While at work in the Field hospital alone I gained the impression that
the musculo-spiral nerve would not retain the unenviable character of
being the most vulnerable nerve of the upper extremity, since the
chances of each individual nerve seemed about equal, putting the
question of the long course of the musculo-spiral nerve against the
humerus out of question. This expectation was, however, not confirmed,
since the musculo-spiral itself, if not primarily affected, was so often
the seat of secondary mischief in fractures of the humerus. The
posterior interosseous branch seemed to exhibit a similar vulnerability
to slight injuries, to be referred to later under the external popliteal
of the lower extremity. Again, in complex injuries of the brachial
plexus, or nerve trunks, the musculo-spiral branch rarely escaped being
a member, if not individually singled out.
Of the _thoracic nerves_ I have little to say. They must have been often
injured in the thoracic wounds, yet, as far as my experience went,
intercostal neuralgia was uncommon, or at any rate not a special
feature. One observation of interest, however, does exist; in the cases
in which the ribs were fractured by bullets travelling across them
within the thorax, pain was distinctly a prominent feature. This was no
doubt referable to the facts that in such instances the intercostal
nerves were especially liable to direct injury, and that this was often
multiple. On one occasion a crop of herpetic vesicles developed along
the course of a dorsal nerve in an injury implicating a single
intercostal space posteriorly.
_Lumbar plexus._--Although not quite so well arranged to escape bullet
wounds as the thoracic nerves, the lumbar, by reason of their deep
position and the comparatively wide area they cover, together with the
rarity of wounds taking a sufficiently longitudinal direction to cross
the course of more than one or two branches, were also comparatively
rarely damaged. I never saw an uncomplicated case of anterior crural
paralysis, and rarely cruralgia. I think this is to be explained in two
ways: first, that the trunk course of the nerve is short; secondly, that
it lies in the inguinal fossa. The second fact is of importance, since
wounds in this region were in my experience responsible for a
considerable percentage of the deaths on the field or shortly
afterwards. Such deaths probably occurred from internal hæmorrhage from
the iliac arteries, and it was in such cases that the anterior crural
nerve stood in greatest danger of injury. I also never saw a case of
localised obturator paralysis. On the other hand, anæsthesia or
hyperæsthesia in the area of distribution of the lumbar nerves in the
groin, the external cutaneous and the long saphenous in the thigh, were
not uncommon. Hyperæsthesia developed in more than one case in which
injury to the psoas had led to hæmorrhage into the muscle sheath.
_Sacral plexus._--The sacral plexus is far more liable to extensive
direct injury than either of the two preceding. Its cords are larger,
gathered up into a much smaller space, and more liable to injury, from
the fact that the slope in which they lie is more readily followed by a
bullet track. Again, the cords rest for a considerable portion of their
course on a bony bed, a particularly dangerous position in gunshot
wounds, since the nerves are not only exposed to the danger of direct
wound, or pressure from bony spicules, but also readily receive
transmitted vibrations secondary to impact of the bullet with the bone.
None the less I had few occasions to observe extensive injuries of the
plexus. In one instance damage particularly affecting the lumbo-sacral
cord occurred, but this was complicated by signs of irritation of the
anterior crural and obturator nerves, as the result of retro-peritoneal
hæmorrhage and injury to the psoas muscle. Two cases in which the
sacro-coccygeal plexus suffered isolated injury on account of their
characteristic nature as gunshot injuries will be shortly quoted:
(116) _Sacro-coccygeal plexus._--_Entry_, at the junction of
the middle and posterior thirds of the left iliac crest; the
bullet passed obliquely downwards through the pelvis to lodge 3
inches below the right trochanter major. Incontinence of soft
fæces persisted for five weeks, and retention of urine during
three weeks.
This patient subsequently died on the homeward voyage, but I am
unable to say from what cause.
(117) _Entry_, over third sacral vertebra; _exit_, 2 inches
from the median line, and 1-1/2 inch above Poupart's ligament
on the anterior abdominal wall. Incontinence, with involuntary
passage of fæces, persisted during the first twenty-four hours,
and for two days the urine had to be withdrawn with a catheter.
No further signs of nerve injury were noted.
The same explanation of the comparative rarity of injuries to the sacral
plexus that has been already given in the case of the anterior crural
nerve holds good--viz. that in a great many of the pelvic wounds
involving the plexus early death followed from the severity of the
concurrent injuries.
Injuries to the great sciatic nerve outside the pelvis, or to one of its
constituent elements, on the other hand, formed one of the most familiar
of the nerve lesions. The wounds giving rise to these were of the most
diverse character; some crossed the buttock in a vertical, transverse,
or oblique direction; others travelled through the thigh in
corresponding directions, while a third series involved both buttock and
thigh.
The size of the great sciatic nerve renders complete laceration by a
bullet of small calibre a matter almost of impossibility; hence complete
division may almost be left out of consideration in the case of this
nerve. On the other hand, partial division, perforation, and severe
contusion are each and all favoured by the same factor.
With an extended thigh the nerve is in a state of comparatively slight
tension, and this may be still lessened if the knee be flexed. This
factor, together with the density of the sheath of the nerve, favours
the possibility of displacement, and this occurrence is more likely in
the lower segment than in the upper, which is comparatively fixed in
position.
Clinical experience appeared to illustrate the importance of these
anatomical factors, as the worst cases of sciatic injury that I saw were
in connection with wounds of the buttock or the junction of that segment
of the trunk with the thigh.
The most striking observation with regard to the injuries of the great
sciatic nerve was the comparatively frequent escape of the popliteal
element and the severe lesion of the peroneal. This was so pronounced as
to amount to as high a proportion of peroneal symptoms as 90 per cent.,
and often when the whole nerve was implicated the popliteal signs were
of the irritative, the peroneal of the paralytic type. When bullets
crossed the popliteal space, given wounds of equal severity in
corresponding degrees of contiguity to the respective nerves, the
peroneal element always suffered in greater degree. Again, the peroneal
nerve symptoms were more obstinate and prolonged, and instances of
ascending neuritis were more common than in the case of any other nerve
of the lower extremity, and the trophic wasting of muscles was more
marked.
The peroneal nerve, therefore, acquires the same unenviable degree of
importance in the lower extremity enjoyed by the musculo-spiral in the
upper. Here, again, we are confronted with the fact that the peroneal
element of the great sciatic nerve is the more prone to idiopathic
inflammations or toxic influences, and hence we can only assume it to
possess a special vulnerability. The peroneal element is of course
somewhat the more exposed, as lying posterior; but it seems unreasonable
to assume that so large a proportion of the injuries can implicate the
posterior segment of the nerve as to make the startling difference in
the incidence of degeneration explicable. In this relation we may bear
in mind that the muscles supplied by this nerve suffer most in the
degeneration subsequent to anterior polio-myelitis, and again that in
cerebral hemiplegia or spinal-cord injuries they are the last to
recover. Unfortunately no explanation of these remarkable facts, so
forcibly impressed by the large series of cases with peroneal symptoms
seen in a short time, is forthcoming.
I may dismiss the other branches of the sacral plexus in a few words.
The small sciatic was occasionally injured in its course in the buttock,
and the small saphenous in the leg. When either element of the latter
was injured, it was surprising how sharply the imperfections in the
anæsthesia corresponded with the composite character of the nerve.
CASES OF NERVE INJURY
The following cases are added mainly to give some idea of the
comparative frequency with which the individual nerves were injured, and
also to exemplify the more common forms of complex injury met with.
Circumstances, unfortunately, did not always allow of extended
observation at the time, and I have not been very fortunate in my
attempts to obtain subsequent information on this series since my
return. A certain amount of prognostic information is, however,
furnished by some of the records, and I am very much indebted to my
colleague, Dr. Turney, for help in this matter.
(118) _Brachial plexus._--_Entry_, 2 inches above the clavicle
at the anterior margin of the trapezius; _exit_, first
intercostal space, 1 inch from the sternal margin. Heavy dull
pain developed at once, extending down the upper extremity. A
fortnight later this pain still persisted; there was lowered
sensation in the ulnar area with formication, also lowered
sensation in the internal cutaneous area of distribution;
sensation in the lesser internal cutaneous area was normal. The
patient went home with the nerve symptoms well at the end of a
month.
(119) _Brachial plexus injury._--Wounded at Magersfontein.
_Entry_, at the anterior border of the sterno-mastoid opposite
the pomum Adami; _exit_, through the ninth rib below and 1/2 an
inch external to the scapular angle. Emphysema and considerable
blood extravasation developed in the posterior triangle of the
neck, also loss of power in the musculo-spiral distribution,
but no anæsthesia. At the end of the first fortnight there was
evident wasting of the muscles, but some power was returning in
the triceps. At the end of a month the man left for England,
with fair power in the triceps, but well-marked wrist-drop. A
year later the wrist-drop still persisted.
(120) _Plexus injury._--Wound of _entry_, over pomum Adami;
_exit_, below scapular spine, about centre. Complete median and
musculo-spiral paralysis.
(121) _Median, musculo-cutaneous, and musculo-spiral
nerves._--The wound traversed the axilla from just beneath the
anterior fold; three weeks later a firm mass in the axilla
corresponded to the wound track. Hyperæsthesia developed in the
area of median distribution, with deep pain in the muscles.
There was rigidity of the biceps cubiti and slight wasting in
the radial extensors. The patient improved slowly, and
eventually was discharged and passed out of sight.
(122) _Brachial nerves._--Wounded at Paardeberg. Range 500
yards. _Entry_, at the front of the arm, 2 inches below the
junction of the anterior axillary fold; _exit_, a little lower,
at the back of the arm, in the line of junction of the
posterior axillary fold.
Considerable shock attended the primary injury; when reaction
had taken place, complete motor and sensory paralysis was noted
of the whole upper extremity, with the exception of some power
of movement of the posterior interosseous group of muscles.
Three weeks later the patient could extend the wrist, but
sensation was imperfect in the arm, and completely absent in
the forearm and hand. The track was now hard and palpable, but
there was no hyperæsthesia in any area; when the track was
manipulated slight formication in the hand was experienced. The
biceps and triceps were equally paralysed. There was no wasting
in any of the muscles.
(123) _Brachial nerves._--Wounded at Modder River. _Entry_,
through the anterior axillary fold at its junction with the
arm; _exit_, on the posterior wall of the thorax, 1/2 an inch
from the median line at a level with the angle of the scapula.
Complete musculo-spiral paralysis; hæmothorax. Three weeks
later, radial sensation returned; but the triceps was very
weak, and wrist-drop was complete. There was some wasting of
the muscles supplied by the median and ulnar nerves, and
complete obliteration of the radial pulse. A year later the
musculo-spiral paralysis still persisted.
(124) _Musculo-spiral and median._--Wounded at Magersfontein.
_Entry_, 3 inches below the anterior axillary fold, on the
inner aspect of the arm; track passed obliquely downwards
behind the humerus to a point on the outer aspect of the arm
1-1/2 inch below the level of the entry. The humerus escaped
injury. Musculo-spiral paralysis was complete; hyperæsthesia in
the distribution of the median followed some days later. One
month subsequently radial sensation had returned, and a feeling
of numbness had taken the place of the median hyperæsthesia.
The triceps and marginal muscles were much wasted, and only
interosseous extension was possible in the fingers.
(125) _Brachial nerves._--Wounded at Magersfontein. _Entry_ and
_exit_, in the upper third of the arm internal to the humerus.
Complete median paralysis, anæsthesia in the ulnar area, and in
the radial supply to the dorsum of the middle and ring fingers.
Could flex, extend, and adduct and abduct the wrist; some power
of flexion in index finger, in others none. The flexion of the
wrist was dependent on the ulnar supply to the muscles of the
forearm. No wasting of the interossei, skin normal except for a
large trophic blister on the dorsum of the hand. Little
improvement had taken place in this patient at the end of a
year.
(126) _Brachial nerves._--Wounded at Magersfontein. The wound
traversed the lower part of the upper third of the arm,
fracturing the humerus. Immediate complete loss of power in the
arm was experienced, together with loss of all sensation. Three
weeks later the humerus was united; the fracture was evidently
the result of passing contact, and not of direct impact. The
paralysis was still complete in the distribution of the median,
ulnar, and musculo-spiral nerves. There was considerable
wasting of the hand and forearm, and a good deal of thickening
in the lower third of the arm.
Four months after the original injury, the nerves were explored
by Mr. Eve, who kindly gives me the following information. All
the nerves and vessels of the arm were united into one firm
bundle by cicatricial tissue. When dissected clear, the median
nerve was found to be thickened and enlarged for about 1-1/2
inch of its length; the ulnar was not completely freed, but was
found to be continuous and indurated; the musculo-spiral was
also intact, but at its entrance into the humeral groove a mass
of callus was felt. A sclerosed and thickened portion of the
median nerve 3-1/2 inches in length was resected, also 1 inch
of sclerosed ulnar nerve, and both were sutured. The
musculo-spiral nerve was left for future exploration. A small
traumatic aneurism was found on the brachial artery, and the
vessel was ligatured above it.
Ten months later no improvement in the median or ulnar nerves.
Electrical reaction present in musculo-spiral group of
muscles.
(127) _Musculo-spiral._--Transverse wound through arm posterior
to humerus. Slight suppuration. Triceps weakened only, complete
paralysis of radial extensors and posterior interosseous group.
Radial sensation lowered only.
(128) _Musculo-spiral._--_Entry_, 2 inches above and 1/2 an
inch behind the external humeral condyle; _exit_, at the inner
edge of the biceps, 1/2 an inch lower in the arm than the
entry. It is doubtful whether the paralysis was noted at first,
but a few days later complete posterior interosseous paralysis
and lowered radial sensation were remarked. No change except a
deepening of the anæsthesia, and the development of formication
on manipulation of the wound occurred, and at the end of three
weeks the nerve was exposed (Mr. Watson), and it was found that
a notch had been cut in its outer border, which had opened out
into a V shape. The margins of this notch were refreshed and
the gap closed. Ten days later radial sensation was fairly
good, but the motor symptoms remained unchanged. Nine months
later steady but very slow improvement was reported.
(129) _Ulnar and musculo-cutaneous nerves._--_Entry_, back of
forearm; the bullet passed between the bones and was retained
at the posterior aspect of the arm. Three weeks later the hand
was glossy and stiff, the fingers extended and adducted, the
thumb was held stiffly in the palm with no power of extension.
The forearm was held semiprone, and the elbow flexed by a rigid
biceps. Six months later the same position was maintained, but
the contracture disappeared under an anæsthetic.
(130) _Median and posterior interosseous._--_Entry_, over the
external margin of the radius at the centre of the forearm;
_exit_, at the inner margin of the olecranon 1-1/2 inch below
the tip. Lowered cutaneous sensation in median distribution,
and loss of median flexion of wrist and fingers. Complete
wrist-drop. The triceps supinator longus and extensor carpi
radialis longior were perfect. Twelve days later the wrist
could be raised into a direct line with forearm, but there was
no change in the median symptoms. A week after this the
anæsthetic median area became hyperæsthetic both as to skin and
on deep pressure over the muscles.
(131) _Sacral plexus. Great sciatic nerve._--Wounded at Modder
River. _Entry_, in left loin; _exit_, at lower margin of
buttock. The wound was followed immediately by complete
peroneal paralysis, both motor and sensory. Fourteen days later
hyperæsthesia developed in the area of distribution of the
internal popliteal nerve, the superficial pain being greatest
in the sole; the muscles of the calf were also very tender on
manipulation. The pain increased, and at the end of twenty-four
days the patient's sufferings were so great that Mr. Thornton
cut down upon and exposed the nerve. It was found embedded in
firm cicatricial tissue close to the sciatic notch; this
compressed the nerve to such a degree that a waist was apparent
upon it.
The nerve was freed and resumed its normal outline. For a few
days the patient was much relieved, but the neuralgia then
returned in greater intensity than ever. Morphia was injected
hypodermically, and other hypnotics employed, but with little
effect, the patient developing the hysterical condition so
common in the subjects of severe sciatica. Some five weeks
later a sudden improvement took place, the morphia was
decreased, and the patient became sufficiently well to return
to England, but there was still deep tenderness in the calf,
and well-marked hyperæsthesia of the sole.
A year later the patient had been discharged from the Service,
but was earning his living in a shop. He walked fairly well,
but still with foot-drop, and complained of tenderness in the
sole. I am indebted to Dr. Turney for the following report on
the condition of the muscles.
Calf muscles practically normal. In the anterior tibial and
peroneal groups the faradic irritability is much diminished,
that in the peroneus longus being the lowest of all.
Contraction can be induced in the extensor longus hallucis,
extensor longus digitorum, and peroneus brevis; but reaction is
doubtful in the case of the tibialis anticus and peroneus
longus.
With the galvanic current contraction is sluggish, and the
irritability diminished. No serious changes are present except
in the peroneus longus. ACC > KCC at 10 M. A.
(132) _Great sciatic._--_Entry_, at outer aspect of the thigh,
just above the centre; _exit_, at the junction of the inner and
posterior aspects of thigh, about 2 inches lower. The wound was
produced by a ricochet bullet, and beyond the perforation of
the sciatic nerve the femur was fractured obliquely (see plate
XVI.). Hyperæsthesia of the sole was noted early, and when I
saw the patient three months later, there was wasting of the
muscles of the leg, and foot-drop, although he walked with a
stick.
These symptoms persisted, and on his return to England an
exploration was made by Sir Thomas Smith, and the two fragments
of mantle seen in the skiagram were removed from the substance
of the sciatic nerve. Eight months after the injury, the
patient still walked with foot-drop; there was modified
sensation in the musculo-cutaneous area, and a feeling as if
the bones of the foot were uncovered when he walked. The
circumference of the affected leg was more than 1 inch less
than that of the sound one. Steady but slow improvement was
taking place.
(133) _Great sciatic_.--In a third patient with a buttock
track, the symptoms were identical with those observed in case
131. In this an exploration showed that the nerve had been
perforated. Although the symptoms were never so severe as in
No. 131, yet recovery was very much slower and less complete,
the muscular weakness remained more marked, and the skin
exhibited more evidence of trophic lesion. Some contracture of
the knee and rigid foot-drop took place, and at the end of
twelve months the patient walked poorly with a stick.
Improvement is, however, continuing.
(134) _Great sciatic_.--Wounded at Ladysmith. _Entry_,
immediately below left buttock fold; _exit_, at anterior aspect
of thigh, 3-1/2 inches below Poupart's ligament. The left leg
was paralysed, and patient was sent down to the Base, where he
remained two months. The wound closed by primary union, the
paralysis improved, and the man rejoined his regiment. After he
had been in camp four days, his leg gave way, and he returned
to hospital, where he contracted enteric fever. Later, he was
sent home, and eight months after the reception of the injury
his condition was as follows:
Left lower limb somewhat wasted, a diminution of 1 inch in the
circumference of the leg and 1/2 an inch in the thigh being
found. The patient walks with foot-drop, and the flexor muscles
of the knee are weak. On examination the peroneal muscles
reacted but sluggishly to faradic irritation. There is complete
anæsthesia of the foot to above the ankle, and up to the knee
tactile sensation and appreciation of pain were dulled. The
left plantar reflex was absent, the right slight, the left
patellar reflex was abnormally brisk. There was neither ankle
nor patellar clonus, and the other reflexes were present and
normal. The gait was spastic, and the patient was more troubled
by a contraction of the calf muscles, which prevented his
putting the heel to the ground, than by the foot-drop.
Beyond these local phenomena there was marked tremor of the
upper extremities on any exertion, and slight lateral
nystagmus. The patient was not sure that this had not been
present ever since he recovered from the enteric fever, but it
was sufficiently marked to give rise to the suspicion of the
development of disseminated sclerosis.
The patient was a hard-headed, sensible man. He remained in the
hospital under the care of Dr. Turney, to whom I am indebted
for notes of the case, forty-six days. During this period he
was treated by faradic electricity, and, with some checks,
notably the development of passive effusion into the left
knee-joint, and a fugitive attack of redness over the dorsum of
the foot, both suggesting trophic changes, steadily improved.
The anæsthesia became limited to the outer half of the leg, at
the end of one month was limited to the dorsum of the foot
only, and at the end of six weeks entirely disappeared.
Meanwhile the tendency to drawing up of the heel by the calf
muscles became less, and the gait improved. The man left the
hospital at the end of two months, very satisfied with his
condition, although the tremor of the hands was still present
in a lessened degree.
(135) _External popliteal._--Wounded at Magersfontein, 250-300
yards. _Entry_, at the outer side of the thigh, 5 inches above
the lower extremity of the external condyle; _exit_, at the
inner margin of the adductors, at a level 4 inches higher in
the thigh. The track crossed behind the femur. Complete
peroneal motor paralysis and anæsthesia, except in the hinder
part of the region supplied by the mixed external saphenous.
Slight hyperæsthesia of the sole. Improving at the end of three
weeks, but paralysis still nearly complete.
(136) _External popliteal._--Wounded at Magersfontein. _Entry_,
5 inches below the highest part of the right iliac crest, on
outer aspect of hip; _exit_, at the posterior margin of the
gracilis, 2 inches from the perineum. Complete peroneal
paralysis followed, which rapidly improved, and on the
twenty-second day was nearly well.
(137) _Internal popliteal. Secondary anæsthesia_.--_Shell_
wounds of the right popliteal space. Wounded at Belmont.
Anæsthesia of the outer side of the calf, the leg and sole of
foot. No motor paralysis. As cicatrisation progressed, the
anæsthesia became more marked and was complete over the whole
of the external saphenous area.
(138) _Internal popliteal._--Wounded at Paardeberg. 400-500
yards. _Entry_, about the centre of the outer half of the
patella; _exit_, at the centre of the calf, about 2 inches from
the popliteal crease. Five days after the injury severe burning
pain developed in the sole. A fortnight later the pain was much
less severe, but varied in degree with the heat of the weather,
being worse when cool. At this date, however, rubbing became
comforting.
(139) _External popliteal._---Wounded at Magersfontein.
_Entry_, 1 inch above the upper end of the internal margin of
the patella; _exit_, at the margin of leg, just below the outer
tuberosity of the tibia. Complete peroneal paralysis followed
the injury. A month later the nerve was bared and found
slightly thickened. An improvement in cutaneous sensation
followed quickly, and a much slower improvement in the motor
power commenced.
(140) _External popliteal nerve._--Wounded at Beacon Hill. A
_bayonet_ entered over upper quarter of fibula, and passed
between the bones of leg into the calf. An aneurismal varix of
the calf vessels developed, also incomplete peroneal paralysis.
The scar was raised from the nerve (Major Simpson, R.A.M.C.)
six weeks later, and at the end of a fortnight the power and
sensation were both much improved and the patient returned to
England.
(141) _External popliteal._--Wounded at Modder River. _Entry_,
1/2 an inch above the internal border of the patella; _exit_,
1-1/2 inch from the head of the fibula and over that bone. The
wound was followed by peroneal paralysis. Six weeks later
sensation was still diminished in the anterior tibial and
musculo-cutaneous nerve areas, and marked foot-drop, little
improved, persisted. The patient came to England, and at the
end of twelve months is reported as very little improved.
(142) _Anterior tibial._--_Entry_, 1 inch in front and below
the external malleolus; _exit_, at the centre of the sole, just
anterior to the bases of the metatarsal bones. Wasting and
paralysis of extensor brevis digitorum.
(143) _Small sciatic and small saphenous._--Wounded at
Magersfontein. 200 yards. Two wounds: (i) _Entry_, below the
centre of the twelfth rib on the left side; _exit_, immediately
to the left of the buttock furrow at upper part, (ii) _Entry_,
in the right loin, midway between the last rib and iliac crest;
_exit_, just within the centre of the left buttock; the two
wounds crossed diagonally. Hyperæsthesia in area of
distribution of small saphenous and small sciatic nerves, which
rapidly improved.
(144) _Lumbar plexus._--Boer, wounded at Magersfontein.
_Entry_, eleventh interspace, posterior axillary line; _exit_,
tenth interspace, right mid-axillary line. Impaired sensation
in area of distribution of external cutaneous and crural branch
of genito-crural nerves. At the end of a fortnight anæsthesia
was less apparent, but a feeling of numbness persisted, which
soon disappeared.
_Prognosis and treatment._--In considering the prognosis in cases of
nerve injury, several of the points already raised as to the nature of
the lesion are of importance. Short of actual section, it may be broadly
stated that no lesion is too serious to render ultimate recovery
impossible.
In cases in which the injury has been produced by a bullet fired at a
short range, or in which contact with the nerve has been close, the
return of functional activity is very slow. In such instances the
condition probably resembles that in which a divided nerve has been
sutured, with the additional disadvantage that a considerable portion of
the nerve, both above and below the point actually struck, has been
destroyed as far as the conduction of nervous impulses is concerned.
This may reasonably be concluded in the light of the evidence offered by
the injuries of the spinal cord, in which several segments usually
suffered if the velocity of the bullet was great, and also if the fact
is remembered that, when thickening takes place, a considerable length
of the nerve is usually implicated.
Recovery is notably slow in the case of certain nerves, _e.g._
musculo-spiral and peroneal, even when the injury has not been of
extreme severity. Again, these same nerves are apparently more seriously
affected by moderate degrees of damage than are others.
As favourable prognostic elements we may bear in mind: low velocity on
the part of the travelling bullet, and with this a lesser degree of
contiguity of the track to the nerve. The early return of sensation is a
favourable sign, and in this relation the development of hyperæsthesia,
whether preceded by anæsthesia or no, points to the maintenance of
continuity of, and a moderate degree of damage to, the nerve. The early
return of sensation, even if modified in acuteness, was always a very
hopeful sign; also the production of formication in the area of
distribution of the nerve on manipulation of the injured spot. As in the
case of nerve injuries of every nature, the disposition and temperament
of the patient exerted considerable influence on the course of the
cases.
Complete section of the nerves in these bullet wounds only obtained
special importance in two ways: first, in that a considerable portion of
the trunk might be shot away in oblique tracks, and, secondly, in that
very severe contusion might affect the nerve for a considerable
distance beyond the point actually implicated. In point of fact,
complete section when treated by suture was often more rapidly recovered
from than an injury in which only a portion of the width of a trunk was
divided. This was no doubt to be explained on the theory that the
contiguous portion of the nerve suffered less when tension and
resistance were lessened by complete severance of the cord.
_The treatment_ of slight nerve contusion was simple; rest alone was
necessary, and in the course of hours or days paralysis was recovered
from. The symptoms were most troublesome in patients of a neurotic
temperament, or those who had suffered from severe systemic shock.
In severe concussions and contusions the first care had to be devoted to
the discrimination of the lesion from that of division. A period of rest
then needed to be followed by one of massage and movement, to maintain
the nutrition of the muscles. In a considerable portion of the cases a
stage of neuritis had to be expected. In all cases, either of severe
concussion, contusion, or complete section, accompanied by the fracture
of a bone, especial care was necessary that the bandaging and fixation
of the limb were not sufficiently tight to add the dangers of muscular
ischæmia to those of the nerve injury already present.
Neuritis, whether dependent on local injury, implication in the scar,
pressure from callus, or of the ascending variety, needed the same
treatment: rest, preservation of the limb from cold or damp, and the
local application of anodynes, as belladonna, or hot laudanum
fomentations. In some cases a general anodyne, as morphia, was
preferable; then always to be used with caution, as the patients soon
craved inordinately for it, and were unwilling to give it up. Later,
local blisters in the line of the nerve trunk, careful massage and
exercise when muscular and cutaneous tenderness had subsided, the
application of the continuous current to the nerves, and perhaps
faradisation of the muscles, were all useful.
Splints were often temporarily required to resist contracture, or the
assumption of false positions; in either case they needed to be
frequently removed, and movement &c. made, in order to avoid any chance
of troublesome stiffness.
_Operative treatment._--Early interference was only warranted by
positive knowledge that some source of irritation or pressure could be
removed; thus a bone spicule, or a bullet, or part of one, particularly
portions of mantles.
In case of contusion the expiration of three months is the earliest date
at which any operation should be taken into consideration, and
interference is only then advisable if there is good prospect of freeing
the nerve from compressing adhesions. The two strongest indications for
operation are (1) signs pointing to the secondary implication of the
nerve in a cicatrix, especially when these are of such a nature as to
indicate local tension, fixation, or pressure; (2) the possibility of
the irritation being the result of the presence of some foreign body,
such as a bone spicule, or portions of a bullet mantle; in such cases
the X rays will often give useful help.
With regard to the early exploration of cases of traumatic neuralgia, it
may be pointed out that when this was undertaken the results were as a
rule very temporary. In many cases in which the measure was resorted to,
either no macroscopic evidence of injury to the nerve was discovered, or
a bulbous thickening was met with of such extent as to make excision
inadvisable, even if it were considered otherwise the most suitable
treatment.
Even when complete section of the nerve was assured by the absence of
any power of reaction to stimulation by electricity from above on the
part of the muscles, operation was better not undertaken until
cicatrisation had reached a certain stage. If done earlier than at the
end of three weeks, the sutured spot became implicated in a hard
cicatrix, and any advantage to be obtained by early interference was
lost. When partial division of a trunk was determined, the same date was
the most favourable one for exploration, the gap in the nerve being
freshened and closed by suture. There is little doubt, however, that in
some cases such injuries were recovered from spontaneously.
In view of the uniformly bad results observed in the case of the seventh
nerve, I am inclined to think that the above rules might be tentatively
relaxed, and the nerve primarily explored by an operation resembling
that for mastoid suppuration. It is of course doubtful whether the
trouble does not generally result from the vibratory concussion alone;
but as this is not certain, and the operation would only have to be
performed on patients already permanently deaf, it might be worth while
at any rate opening the Fallopian canal with the object of relieving
tension. It is not probable that in any of the cases quoted much
splintering of the bone had occurred, as the wounds appeared to be of
the nature of pure perforations.
CHAPTER X
INJURIES TO THE CHEST
In regard to Prognosis wounds of the chest furnished the most hopeful
class of the whole series of trunk or visceral injuries. Cases of wound
of the heart and great vessels afforded the only exceptions to an almost
universally favourable course, both as regards life and the
non-occurrence of serious after-effects.
This was mainly explicable on two grounds: first, the sharply localised
character of the lesion produced by the bullet of small calibre; and,
secondly, the fact that the lung, the most frequently injured organ, is
not materially affected by the grade of velocity with which the bullet
strikes. In point of fact, wounds of this organ probably afford an
instance in which high grades of velocity are distinctly favourable to
the nature of the injury, and this is possibly true in the case of
wounds of the chest-wall also.
The significance of the calibre of the bullet in wounds of the chest is
evident. The late Mr. Archibald Forbes, in one of his letters from the
seat of the Franco-German war, remarked that in crossing a battlefield
it was easy to recognise the patients who had suffered a wound of the
lung from the fact that the whistle of the air entering and leaving the
chest was plainly audible. This was, indeed, not uncommonly the case in
wounds produced by the older bullets of large calibre, but with the
employment of the smaller projectile it has become an experience of the
past. Some evidence as to the comparative severity of wounds produced by
the larger forms of bullet was, moreover, afforded by the present
campaign, since Martini-Henry wounds were occasionally met with. Of some
instances observed by myself, in one, external hæmorrhage was a
prominent symptom; in another, a piece of lung was prolapsed from a
wound in the back, and twice I observed pneumothorax, an uncommon
sequela to wounds from bullets of small calibre.
It may be remarked, however, that all these more serious injuries were
recovered from, also that when we consider that the patients were
comparatively young and healthy subjects, the favourable prognosis was
what might have reasonably been expected. When, as occasionally
happened, a patient of more mature years, with enlarged facial
capillaries, received a wound of the lung, the course was in no way so
favourable as that witnessed in the case of the younger men.
In support of this opinion I may add that wounds from shrapnel and
fragments of shell also did remarkably well, although they sometimes
gave rise to more troublesome symptoms than did wounds produced by
bullets of the Mauser type. Again, these injuries as a whole were of
nothing like so serious a nature as the lacerations of the lung produced
by fractured ribs, which we commonly have to treat in civil practice,
and are not accustomed to regard as especially dangerous.
It is also a striking fact that the most common and troublesome
complication of wounds of the chest, hæmothorax, was usually the result
of the wound of the chest-wall and not of the lung. I preface these
remarks to the detailed account of the thoracic injuries, because I
think the favourable course usually taken by patients with wounds of the
lung has been accorded somewhat greater prominence than the
circumstances warranted.
_Non-penetrating wounds of the chest-wall._--Surface wounds were not
very common, and were chiefly of interest in so far as they illustrated
the very superficial course that may be occasionally taken by a bullet
without breach of the integument, and as sometimes affording opportunity
for the exercise of diagnostic skill when the track traversed the
axilla.
The most common situation for tracks taking a long course on the surface
of the thoracic skeleton was the back. Such wounds were usually received
while the patients were prone on the ground; thus I might instance a
case in which the bullet entered the posterior aspect of the shoulder 3
inches above the spine of the scapula, passed downwards, pierced that
process, and emerged 2 inches below the inferior angle of the bone.
Wounds of a similar nature coursing in transverse and oblique
directions, and not implicating bone, were also seen. Those implicating
the vertebræ have been already dealt with. The scapular region was also
a favourite one for the lodgment of retained bullets, some resting in
the supra- and infra-spinatus muscles, others lying beneath the bone
itself.
On the anterior aspect of the chest, bullets coming from the front
sometimes traversed and fractured the clavicle, and then took a short
course downwards, emerging over the ribs or sternum. Figure 81
represents a particularly long track in this region. In other cases the
precordial region was crossed, but I never witnessed any serious effect
on the heart's action in any such injury at the time the patients came
under my notice.
Wounds received with the arm outstretched and traversing the axilla
sometimes gave considerable trouble in excluding with certainty a
perforation of the thoracic cavity. Thus a bullet entered below the
centre of the right clavicle and emerged 2-1/2 inches below, above the
angle of the scapula, at its axillary margin. The arm was outstretched
at the moment of the reception of the injury; but when the wound was
viewed with the limb placed alongside the trunk, it seemed almost
impossible that the chest cavity could have escaped. In some cases of
this kind the difficulty was at once cleared up by noting evidence of
injury to the axillary nerves.
A word will suffice as to the treatment of these wounds. The only
special indication was to keep the scapula at rest for a sufficient
period. I have dealt with the anatomy of them at such length only
because in their extreme form they are so highly characteristic of the
nature of the injuries which may be produced by bullets of small
calibre.
_Penetrating wounds of the chest._--Tracks crossing the thoracic cavity
in every direction were common. When the erect attitude was maintained,
frontal and sagittal wounds, pure or oblique, were received; when the
prone position was assumed, longitudinal tracks, either purely or
obliquely vertical, were the rule. Experience of wounds of the latter
class was extensive in the present campaign, from the fact that so many
of the advances were made in prone or crawling attitudes. The vertical
and transverse tracks each possessed the special characteristic of
frequently implicating both the thoracic and abdominal cavities, but the
vertical were often prolonged into the neck, or even downwards through
the pelvis. The vertical wounds in addition sometimes exhibited one very
important feature, the fracture of several ribs from within, often at a
very considerable distance from the aperture of either entry or exit.
[Illustration: FIG. 81.--Superficial Track in anterior Wall of Trunk]
_Characters of the apertures of entry and exit._--As has already been
mentioned, the chest-wall was one of the situations in which the
aperture of entry was often large, and the oval form due to obliquity of
impact on the part of the bullet was particularly well marked. The exit
wounds were often smaller than those of entry, especially if the bullet
emerged by an intercostal space; even when the ribs were comminuted, the
fragments were, as a rule, too small to occasion more than a slightly
enlarged and irregular aperture. Taken as a class, however, and putting
aside explosive exit wounds, wounds of the chest afforded more numerous
examples of irregular outline and variation in size than were met with
in any other region of the body.
When the tracks penetrated the broad upper intercostal spaces, an
interesting feature, due to the tense and rigid nature of the muscles
closing the intervals, and their large admixture of fibrous tissue, was
sometimes noticed. The bullet, especially if passing obliquely, was apt
to cut a slit in the muscles far exceeding in size the opening in the
overlying integument, with the result of leaving a palpable subcutaneous
defect. Under these circumstances the yielding spot was often noticed to
rise and fall with the movements of respiration, external palpation met
with an absence of normal resistance, and there was impulse on coughing.
_Fractures of the ribs._--These injuries were produced in either
transverse or longitudinal coursing tracks, their special feature being
a sharp localisation of the lesion of the bone.
In tracks crossing the chest transversely the injury to the ribs might
consist in notching, perforation, or complete solution of continuity,
sometimes with fine comminution. In the incomplete injuries some
importance attached to the localisation of the lesion to the upper or
lower border of the rib, in so far as the intercostal artery was
concerned. Comminution at the wound of entry was, as a rule, not so
extensive as at the aperture of exit, and in any case was less apparent,
since the fragments were driven inward. The wider comminution at the
exit aperture depends on the lesser degree of support afforded by the
thoracic coverings to the convex outer surface of the rib, and on the
fact that the velocity of the bullet has been lowered by its passage
through the opposite rib and the chest cavity.
The splinters of comminuted ribs are small, and wide-reaching fissures
rare. These characters depend on the elastic nature of the resistance
offered by the curved rib to the passage of the bullet, which is
calculated to preserve the bone from the full force of impact, except at
the point actually impinged upon.
Fractures of the ribs, produced from within by bullets taking a
longitudinal course through the thorax, were still more special in
character. They were also more important, as giving rise to troublesome
symptoms.
In these, again, the degree of injury to the bones varied considerably.
In some cases the bones were merely grooved internally, without any
external deformity; in other cases a sort of green-stick fracture was
produced, accompanied by the projection of a tender salient angle
externally; in others complete solution of continuity was effected.
Another feature of importance was the occasional implication of several
ribs. In this case the symptoms accompanying the injury were very much
more like those observed in the corresponding injuries resulting from
indirect violence seen in civil practice.
Injuries to the _costal cartilages_ closely resembled those to the ribs.
Perforation, bending from injury to the inner aspect, and comminution
were observed. The latter condition differed from the similar one seen
in the case of the ribs only in so far as the tougher consistence of the
cartilage did not lend itself to such free comminution, and the
splinters remained in great part attached. The nature of the fractures,
in fact, somewhat resembled that seen on breaking a piece of cane.
I saw no fracture of the _sternum_ except of the nature of a pure
perforation; these were not uncommon in the hospitals, either in the
upper or the extreme lower portions of the bone. Fractures in other
portions were no doubt usually associated with fatal injuries to the
heart. The openings were usually so small as to be difficult of
palpation, and I never had the opportunity of examining one _post
mortem_.
Perforations of the body of the _scapula_ were common, but they were of
little importance in symptoms or prognosis.
_Symptoms of fracture of the ribs._--Fractures accompanying transverse
wounds of the chest were characterised by the insignificance of the
symptoms produced. Every common sign of fracture of the rib was in fact
absent. Neither pain, stitch on inspiration, nor crepitus, either
audible or palpable, was, as a rule, present. This absence of signs was
accounted for by the nature of the lesion: thus in perforations or
notchings there was no loss of continuity, while in the freely
comminuted fractures the loss of continuity was so absolute as to allow
no possibility of the main fragments rubbing together. Again, part of
the symptoms attending these injuries, as seen in civil practice,
depends upon contusion and laceration of the surrounding structures--a
condition precluded by the localised nature of the application of the
violence by a bullet of small calibre. In order to establish a
diagnosis, therefore, we were in many cases reduced to palpation, and
occasionally to direct examination of the wound.
Fractures accompanying longitudinal tracks formed a class rather apart
in the matter of symptoms. In these mere groovings might also be
accompanied by no signs, or at the most by slight local pain and
tenderness. When, however, the grooving was sufficiently deep to be
accompanied by deformity, or a complete solution of continuity was
effected, the signs were often severe. The tender salient angle, or, in
the absence of this, a highly tender localised spot, often pointed to
the less severe injuries, and when the fractures were complete or
multiple, pain was a very prominent symptom, both constant and in the
form of inspiratory stitch. The severity of the pain was probably to be
in part ascribed to implication of the intercostal nerves, which in
these injuries was direct and often multiple. Again, severe contusion or
actual laceration of the nerves, with resulting anæsthesia, was less
common than when the bullet directly implicated the nerves in transverse
wounds. Free comminution and absolute solution of continuity were also
less common than in the fractures accompanying transverse wounds; hence
pain from rubbing of the fragments on inspiratory movement or palpation
was more common, and crepitus, either on auscultation or palpation, was
more often met with. Patients with this class of fracture often suffered
greatly from painful dyspnoea, and were unable to assume the supine
position.
_External hæmorrhage_ of severity was rare from these thoracic wounds;
in many cases it did not amount to more than local staining of the
shirt; altogether I saw only one or two cases where any serious bleeding
occurred. Internal hæmorrhage into the pleura, in consequence of the
position of the intercostal arteries, was common, and often abundant;
this will be treated of under the heading of hæmothorax.
_Treatment of fractured ribs._--Transverse wounds of the thorax, with no
symptoms of fractured ribs, needed to be dealt with as wounds of the
soft parts alone.
In multiple fractures accompanying longitudinal tracks, bandaging or
strapping for the purpose of fixation was necessary to relieve pain. A
few fragments of bone sometimes needed primary removal, and occasionally
small sequestra were removed at a later date; but necrosis was rare,
unless some complication led to the development of a fistula.
Retained bullets were occasionally met with in the chest wall. In such
cases the last remaining energy of the bullet often seemed to have been
spent in diving under the margin of a rib and turning longitudinally up
or down. Removal was sometimes necessary, either from the prominence
produced, the presence of pain, or the continuance of suppuration. Some
of the specimens removed offered interesting evidence of the capacity of
the ribs to withstand considerable violence from a bullet. These were
slightly bent, and marked by a half-spiral groove. I saw such bullets
removed from the thoracic and the abdominal wall, and the evidence
seemed rather against the groove having been produced prior to their
entrance into the body.
[Illustration: FIG. 82.--Spirally grooved Mauser Bullet]
_Wounds of the diaphragm._--Perforations of the diaphragm were very
frequent, and as a rule of small significance. When, however, the course
taken by the bullet was parallel with that of the slope of the
diaphragm, a more or less extensive slit was the result. I saw such a
wound still gaping, and 2 inches in length, in the body of a patient
who died three weeks after the infliction of a fatal abdominal injury.
In several other obliquely transverse thoracic wounds there was reason
to assume the existence of similar slits. Certain signs were more or
less constant under these circumstances. These consisted in shallow
respiration, often accompanied by a groan or the slightest degree of
hiccough on inspiration, and considerable increase in respiratory
frequency. In one patient the respirations were at first 48, only
dropping to 36 some seventy hours after the reception of the injury. In
some of the cases in which the abdominal cavity was implicated, wound to
the diaphragm seemed a more likely explanation of early, frequent, and
painful vomiting than did visceral injury. The possibility of the later
development of diaphragmatic herniæ in some of these patients will have
to be borne in mind in the future.
_Visceral injuries._--The frequent escape of the thoracic viscera from
injury, putting aside the lungs which fill so great a part of the
cavity, was very remarkable. I never saw a case in which I could assume
injury to any of the posterior mediastinal viscera, although such may
have occurred on the field of battle. An injury to the oesophagus, for
instance, would almost of necessity be accompanied by wound of either
one of the large vessels, even the thoracic aorta, or the spinal column.
I was somewhat surprised, however, to learn on enquiry from surgeons who
had seen a large number of the dead and dying on the field, that
thoracic wounds, putting aside those that directly implicated the heart,
were responsible for but a small proportion of the fatalities.
The escape of the posterior mediastinal viscera, the great vessels, and
the heart, is, I believe, to be explained by the fact that all are
supported and held in position by the loose meshed mediastinal tissue,
which allows for their displacement after the manner observed in the
case of the vessels and nerves lying in the loose tissue of the great
vascular clefts.
_Wounds of the heart._--Perforating wounds of the heart were probably
fatal in all instances, in spite of the fact that, in some patients who
survived, the position of wound apertures on the surface of the body
made it difficult to believe that the heart had not been penetrated.
(See cases below.)
In the case of this organ, we must bear in mind its constant variations
in bulk, its elastic compressibility, and its variations in position in
systole and diastole. The variations in bulk and position would be
capable of explaining the escape of the organ from injury at some
particular moment, when a second shot apparently through the same wound
track might implicate it. Beyond this, reasoning from the case of
analogous hollow viscera, as the arteries or the intestine, a bullet
might readily score the surface of the heart without perforating its
cavity.
Such accidents were observed. Thus, in a case examined by Mr. Cheatle,
the patient died of suppurative pericarditis, secondary to a wound of
which the external apertures had closed. In this patient both auricle
and ventricle were scored externally by the passage of the bullet.
I am, however, disinclined to allow that many patients survived direct
blows on the heart, since I believe that in the majority if not in all
cardiac wounds the actual cause of death was not hæmorrhage, but sudden
stoppage of the heart's action. This is to be inferred from the fact
that severe external hæmorrhage did not occur; in some cases the shirt
was hardly stained, and in all death occurred in the course of a very
few minutes. Again, in none of the patients whom I saw who had received
possible wounds of the heart-wall were there evident signs of
hæmo-pericardium. In view of the difficulty of detecting this condition
from physical signs, this argument is naturally not of great weight, but
must be allowed.
One or two death scenes from cardiac wound were described to me. In one
the patient muttered 'They have got me this time,' and died quietly; in
a second the patient's face became ghastly pale, he lay on his back with
the knees flexed, clutching the ground, gasping for breath, and died
only after some minutes of evident great agony. The absence of any
_post-mortem_ details as to the condition of the heart in these injuries
is much to be regretted.
(145) _Entry_, in the seventh left intercostal space, in the
posterior axillary line; _exit_, immediately below the ninth
costal cartilage, close to the position of the gall bladder.
This track in all probability involved the diaphragm twice,
both lungs and pleuræ, and passed immediately beneath the
heart. The liver was also perforated, but the spleen and
stomach probably escaped as far as could be judged from the
symptoms. The patient afterwards developed a pneumo-hæmo-thorax
on the right side. The immediate symptoms were great distress
in breathing and rapid irregular pulse. The difficulty in
respiration was probably in part accounted for by the injuries
to the lung and diaphragm. The pulse remained from 112 to 120
for three days, at first soft and hardly perceptible, later
very irregular, and dropping one every fifth or sixth beat; and
it seemed fair to attribute this to the shock to the nervous
mechanism of the heart. The patient recovered from the chest
injury.
In some other patients in whom the track passed close below the
heart a disturbance of the pulse rate was noted, but this was
in some cases a slowing, not below 48, in others quickening to
100, with irregularity both in force and beat.
(146) _Entry_, in the fourth right interspace, 3 inches from
the middle line; _exit_, in the seventh left interspace, in the
mid-axillary line. This wound was received at a distance of
500-600 yards, but the bullet penetrated both sides of a stout
silver cigarette case and some cigarettes before entering the
body. There were minor signs of pulmonary injury, 'coughing day
and night,' and slight discoloration of the sputum on three or
four occasions. The respirations were quickened to 32, and as
much as ten days after the injury the pulse only beat 48 to the
minute; it then rose to 56, but beat in a very deliberate
manner.
In other cases the signs were almost nil.
(147) _Entry_, in the fourth right intercostal space 3/4 of an
inch from the sternum; _exit_, in the sixth left interspace in
the posterior axillary line. This patient had no symptoms,
beyond quickening of the pulse to 100, and a 'feeling of
tightness at the heart.' He shortly returned to active duty.
(148) _Entry_, situated in the third right interspace 3 inches
from the sternal margin; _exit_, in the fourth left space 2-3/4
inches from the sternal margin. In this case the bullet without
doubt passed through the anterior mediastinum, and slight
injury to the lung was evidenced by transient hæmoptysis.
Some remarks regarding wounds of the thoracic vessels have already been
made in Chapter IV., where instances of injury to the innominate and
left subclavian arteries are recounted. The escape of the large trunks
was generally quite as astonishing as in other parts of the body,
especially in the superior mediastinum.
(149) _Entry_, over the first right intercostal space beneath
the centre of the clavicle; _exit_, at left anterior axillary
fold. The great vessels must have been crossed here in
immediate contact, and considerable hæmorrhage from the wound
of entry caused great anxiety; this ceased spontaneously,
however, and, beyond transient hæmoptysis and a right
pneumo-thorax, no further trouble occurred.
(150) _Entry_, in the ninth interspace, just anterior to the
anterior axillary line; _exit_, through the right half of the
sternum, 1/2 an inch below the upper border. No primary
hæmorrhage of importance followed, but I believe this patient
subsequently died. The wound was received at a range of within
fifty yards.
_Wounds of the lungs._--Numerically, pulmonary wounds formed the most
important series of visceral injuries met with in the thorax, the
frequency of incidence corresponding with the proportionate sectional
area occupied by the organs. Although these injuries did well, and
needed little interference on the part of the surgeon, many points of
interest were raised by them.
Thus the comparative importance of the wound in the chest-wall to that
in the lung itself, was scarcely what, without actual experience, would
have been expected, the former proving so very much the more important
element of the two.
The question of velocity on the part of the bullet took a very secondary
position in these injuries. I saw a number of cases in which the
patients estimated the range at which they received their wounds as from
30 to 50 yards, and although some of the wounds were of a severe type,
the increased gravity depended rather on the injury to the chest-wall
than to that of the lung. If the bullet passed by the intercostal space,
avoiding the rib, I very much doubt if the relative velocity was of any
importance, further than from the fact that a sufficiently low degree to
allow of lodgment of the bullet was distinctly unfavourable.
In view of the general lack of significance in these injuries it was
interesting to note how very definite was the ill effect of early
transport on the after course. This depended on the frequent development
of parietal hæmothorax in patients who were not kept absolutely at rest.
The tracks produced in the lungs by the bullets were very minute, and in
the few cases in which opportunity arose for their examination _post
mortem_ some little time after the infliction of the wound, there was
great difficulty in localising them. The slight damage incurred by the
pulmonary tissue is due to its elasticity and non-resistent character.
Pulmonary hæmothorax was distinctly rare. Reasoning from the analogous
wounds of the liver, tracks scoring the surface of these organs might be
much more to be feared than clean perforations. The elasticity of the
lung tissue, however, must make such lesions rare. In point of fact,
there is no reason why a perforation by a bullet of small calibre should
be much more feared than a puncture from an exploring trocar, and the
danger of the two wounds is probably very nearly the same.
The only points of importance as to the particular region of the lung
traversed were the distance from the periphery as affecting the probable
size of the vessels injured, and perhaps the implication of the base or
apex of the organ respectively. I am under the impression that wounds in
the apical region were somewhat more liable to be followed by the
development of pneumothorax, and possibly hæmothorax, while wounds at
the base gained their chief importance from the frequency of concurrent
injury to the abdominal viscera. I had no experience of the immediate
results of wound of the great vessels at the root of the lung, but
assume that they led to speedy death.
_Symptoms of wound of the lung._--I shall describe the whole complex
usually observed, although it is obvious that the wound of the
chest-wall is responsible for a large proportion of the signs.
The majority of these injuries were accompanied by a certain degree of
systemic shock, and this was more marked in wounds received at a short
range. The shock was, however, rather to be attributed to the injury to
the chest-wall and thoracic concussion than to that to the lung itself.
I think it may also be stated that few patients were inclined to walk
or remain in the erect position after receiving these wounds; this
feature was also noted in horses in whom a bullet passed through the
lungs.
The remarks made as to the pain accompanying fractures of the ribs apply
equally here. Pain was not a prominent symptom, except in so far as the
actual impact caused temporary suffering. It was striking how often
patients who received wounds through the arm prior to the same bullet
traversing the chest appreciated the chest wound only, yet the chest
might pass unnoticed when a still more sensitive part was struck later,
as has been already mentioned in the section on wounds in general.
Dyspnoea was not a prominent primary symptom. The patients sometimes
had 'all the wind knocked out of them' at the moment of impact, but when
seen at the Field hospitals a short time later, the respirations were
shallow, but easy and regular, and only moderately quickened; thus 24
was a not uncommon rate. Naturally if accumulation of blood in the
pleura began early and continued, these remarks do not hold good; and
again in some older men of full-blooded type and the subjects of
recurrent attacks of bronchitis, a considerable degree of pain,
dyspnoea, and even cyanosis was sometimes present soon after the
injury. The complication of wound of the diaphragm has already been
referred to in this relation.
Local respiratory immobility of the thoracic parietes and consequent
asymmetry of movement were constant. This was especially a marked
feature when the upper part of the chest was implicated on one side
only. It rather corresponded, however, to the local shock observed in
wounds of the limbs than to the instinctive immobility accompanying
fractures of the ribs; since, as already explained, small-calibre bullet
wounds of the ribs are not necessarily painful on movement, and the sign
existed even when the bullet had passed by an intercostal space. This
sign was naturally a transitory one.
Hæmoptysis was a fairly constant sign, but sometimes quite absent when
no doubt could exist as to the perforation of the lung. As a rule, a
considerable quantity of blood might be coughed up shortly after the
injury; but I never knew this to be sufficient in amount to give rise
to any misgivings as to danger from the hæmorrhage. After the first
evacuation of blood from the wounded lung, the sign varied much; in the
majority of instances the patients continued to expectorate small
quantities of blood mixed with mucus, for some three or four days, the
blood gradually assuming a coagulated condition. Sometimes only the
primary hæmoptysis was noted, and still more rarely the expectoration of
clots was continued for a week, or even longer. This probably depended
partly on personal idiosyncrasy, partly on the size of the vessels which
had been implicated in the track.
Cough was not commonly the troublesome symptom noted in the contused
wounds of the lung seen in civil practice accompanying fracture of the
ribs. Moist sounds were usually audible on auscultation, but in many
cases over a very limited area and only on the first few days.
Cellular emphysema was distinctly rare, and usually limited in extent:
thus I saw it in the posterior triangle of the neck alone in an apical
wound; over about a third of the upper part of the thorax in another
wound through the second intercostal space, and in this case oddly
enough the emphysema was the only sign of injury to the lung; and very
occasionally widely distributed--in the latter case there were also
usually multiple fractures of the ribs. Neither issue of air from the
external wound nor frothy blood was ever seen with small-calibre wounds,
but I saw one instance in a case of Martini-Henry wound.
_Pneumothorax_ was also rare. I saw pneumothorax three times out of
about half a dozen Martini-Henry wounds, but I do not think it occurred
as often in 100 small-calibre wounds. The Martini-Henry wounds all
recovered; but convalescence was very prolonged, and the same remark to
a less degree holds good in the small-calibre cases.
That the slow recovery in cases of pneumothorax in the Martini-Henry
wounds was due mainly to the size of the opening in the thoracic
parietes was, I think, proved by the fact that in the small-calibre
bullet wounds, followed by the development of pneumothorax, the external
wounds were usually large and irregular in type; also, that in the only
pneumothorax which I saw produced during an extraction operation, the
air was very rapidly absorbed. In the latter case, however, there was
little reason to conclude that wound of the lung had occurred primarily,
and certainly no opening existed at the time the thorax was incised.
_Hæmothorax._--This was the most frequent and also the most interesting
of the complications of wound of the chest. In 90 per cent. or more of
the cases, the hæmorrhage was of parietal source, and due either to
direct injury to the intercostal vessels by the bullet or to laceration
by spicules of comminuted ribs. For this reason, the passage of the
bullet whether by an intercostal space, or through a rib, provided the
wound was not at the posterior part of the space where the artery
crosses, was a point of considerable prognostic importance. Exclusion of
the lung as the source of hæmorrhage was, I think, amply justified by
the absence of continuous recurrent or progressive hæmoptysis in the
majority of the cases, and by the very small trace of injury found in
the lungs of patients who died some weeks after the injury. In such it
was difficult to discriminate the tracks at all. I only happened to see
one case where free hæmoptysis, during the course of development of a
hæmothorax, pointed to the lung as the source of the blood.
Hæmorrhage into the pleural cavity occurred in some degree in a very
large proportion of the chest wounds, but it was especially interesting
to note how greatly its extent was influenced by the amount of transport
to which the patients were subjected in the early stages after the
injury. During the early part of the campaign, on the western side, I
saw a large number of chest wounds, and had I been asked my opinion as
to the relative frequency of occurrence of hæmothorax I should have
placed it at about 30 per cent. The patients in these early battles
needed little wagon transport, and when sent down to the Base travelled
in comfortable ambulance trains. After the commencement of the march
from Modder River to Bloemfontein, however, these conditions were
changed, and all the chest as other cases were exposed to the necessity
of three days and nights' journey to the Stationary hospitals and
afterwards to the long journey to Cape Town. Of these patients, at
least 90 per cent. suffered with hæmothorax of varying degrees of
severity.
In some cases, the least common, signs of considerable intra-pleural
hæmorrhage immediately followed the wound; in others, the accumulation
of blood was gradual, and only manifest in any degree at the end of
three or four days, when it became stationary if the patient was kept at
rest. In a second series the hæmorrhage was of the recurrent variety;
these cases differing little in character from those of slight
continuous hæmorrhage. In a third, the bleeding was definitely of a
secondary character, corresponding with one of the classes of secondary
hæmorrhage described in Chapter IV., and occurring on the eighth or
tenth day from giving way of an imperfectly closed wounded vessel. In
either of the two latter classes the development of the hæmothorax often
corresponded with a journey, or with allowing the patient to get up.
The general course of these effusions was towards spontaneous absorption
and recovery. Coagulation of the blood took place early, the fluid serum
separated, and tended to undergo absorption with some rapidity, leaving
a small amount of coagulum at the base, which evidenced its presence for
many weeks by a persistence of a certain degree of dulness on
percussion. Early coagulation, I think, accounted for the usual absence
of gravitation ecchymosis as a sign.
The course to recovery was sometimes broken by signs of slight pleuritic
inflammation, which, as affecting the amount of effusion, will be spoken
of under the heading of symptoms. In some cases the amount of blood was
so great as to necessitate means being taken for its removal; in these a
reaccumulation often took place. Occasionally an empyema followed in
cases thus treated.
The nature of the blood evacuated on tapping varied much. In very early
aspirations unchanged blood was often met with, but clot sometimes made
evacuation difficult and necessitated a second puncture. In the tappings
done at the end of a week or more a dark porter-like fluid was common,
while when suppuration was imminent a brick-red-coloured grumous fluid
replaced normal blood. In the cases where early incision was resorted
to, blood both fluid and in clots was often mixed with a certain
proportion of lymph flakes, perhaps indicating the part taken by
inflammatory reaction to the irritation of the clot in producing the
rise of temperature.
_Symptoms of hæmothorax._--In the more severe cases of primary bleeding
the symptoms did not, as a rule, reach their full height until the third
or fourth day after the injury. The patients then often suffered
severely. The pulse and temperature rose, and to general symptoms of
loss of blood were added: occasional lividity of countenance; severe
dyspnoea, accompanied by inability to lie on the sound side or to
assume the supine position; absence of respiratory movement on the
injured side; pain, restlessness, cough, and sometimes continuance of
hæmoptysis, small clots usually being expectorated.
Accompanying these symptoms were the usual physical signs of fluid in
the pleura in differing degrees and combination. Dulness of varying
extent up to complete absence of resonance on one side, often
accompanied in the incomplete cases by well-marked skodaic resonance
anteriorly. Loss of vocal resonance, and fremitus; oegophony, tubular
respiration over the root of the lung or at the upper limit of the
dulness, and more or less extensive displacement of the heart. Obvious
increase in girth, fulness of the intercostal spaces, or gravitation
ecchymosis was rare. The latter was most common in instances in which
multiple fracture of the ribs existed (see fig. 83). I think the rarity
of the last sign must have been due to the early coagulation of the
blood, and its retention by the pleura, as I saw well-marked gravitation
ecchymosis in one or two cases of mediastinal hæmorrhage.
The above complex of symptoms was common to all the cases, but in the
slighter ones they gave rise to little trouble, and cleared up with
great rapidity.
[Illustration: FIG. 83.--Gravitation Ecchymosis in a case of Hæmothorax,
accompanying fracture of three ribs from within. The influence of the
fractures on the development of the ecchymosis is shown by the linear
arrangement of the discoloration]
The most interesting feature was offered by the temperature, as this was
very liable to lead one astray. A primary rise always occurred with the
collection of blood in the pleura, this reaching its height on the third
or fourth day, usually about 102° F. in well-marked cases; it then fell,
and in favourable instances remained normal. In a large number of cases,
however, where the amount of blood was considerable, this was not the
case, the primary fall not reaching the normal, and a second rise
occurred which reached the same height as before or higher. The second
rise was accompanied by sweating, quickened pulse, and the probability
of the development of an empyema had always to be considered. I believe
in most cases this secondary rise was an indication of a further
increase in the hæmorrhage, for the dulness usually increased in extent,
and such rises were often seen when the patient had been moved or taken
a journey. Again, the temperature often fell to normal after
paracentesis and removal of the blood, to rise again with a fresh
accumulation, which was not uncommon. I have already mentioned the large
proportional incidence of hæmothorax observed in the patients who had
to travel down from Paardeberg, and I might instance another case
related to me by Dr. Flockemann of the German ambulance, which was very
striking. A Boer, wounded at Colesberg, developed a hæmothorax which
quieted down, and he was removed to Bloemfontein; on arrival at the
latter place the temperature rose, and other signs of fever suggested
the development of an empyema; an exploring needle, however, only
brought blood to light. After a short stay at Bloemfontein the symptoms
entirely subsided, and the man was sent to Kroonstadt, when an exactly
similar attack resulted, again quieting down with rest.
Similar recurrent attacks of hæmorrhage and fever occurred, however, in
patients confined to their beds without moving after the first journey.
Some temperature charts, in illustration of this point, are added to the
cases quoted later. The explanation of the recurrent hæmorrhages is, I
think, to be found in the reduction of the intra-thoracic pressure with
coagulation and shrinkage of the clot in the pleura in the patients kept
quiet in bed, while in the patients who had to travel it was probably
the result of direct mechanical disturbance.
In many of these cases a pleural rub was audible at the upper margin of
the dulness with the development of the fresh symptoms. Whether this was
due to actual pleurisy or to the rubbing of surfaces rough from the
breaking down of slight recent adhesions which had formed a barrier to
the effusion, I am unable to say, but the signs were fairly constant. In
some instances the increase in the amount of fluid was, no doubt, due to
pleural effusion resulting from irritation from the presence of
blood-clot, or perhaps the shifting of the latter; in these the
secondary rise of temperature may well be ascribed to the development of
pleurisy.
I am inclined to believe, however, that the primary rise of temperature
was similar to that seen when blood accumulates in the peritoneal cavity
as the result of trauma, and the secondary rises in most cases to those
which we saw so frequently accompanying the interstitial secondary
hæmorrhages spoken of in Chapter IV., and are to be explained on the
theory of absorption of a blood ferment. The secondary rises always
occurred with a fresh effusion, often of blood, occasioning an
extension, which broke down probable light adhesions and exposed a fresh
area of normal pleural membrane to act as a surface for absorption.
It is, of course, manifest that the fever might also be ascribed to the
infection of the clot or serum from without, and in the first cases I
saw I was inclined to take this view, since we had in every case the
primary wounds of chest-wall, and possibly of lung, and in some the
addition of a puncture by an exploring needle between the first and
second rise. After a wider experience, however, I abandoned the
infection theory, as it seemed opposed by the very infrequent sequence
of suppuration. The effect of simple removal of the blood or serum was
also often so striking as to strongly suggest that it alone was
responsible for the fever. Exactly the same result, moreover, followed
evacuation of the interstitial blood effusions already mentioned
elsewhere.
The common course of all the cases of hæmothorax was to spontaneous
recovery, the rapidity of the subsidence of the signs depending mainly
on the quantity of the primary hæmorrhage, and the occurrence of further
increases. The blood serum tended to collect at the upper limit of the
original blood effusion (as was often proved on tapping), and this was
first absorbed; the clot deposited on the pleural surface and at the
basal part of the cavity was, however, not absorbed with the same
rapidity. In the majority of the patients when they left the hospitals,
at the end of six weeks on an average, some dulness and deficiency of
vesicular murmur always remained, and the clot and the surrounding
surface, irritated by its presence, will, no doubt, be responsible for
permanent adhesions in many cases. That such adhesions do form in the
majority of cases I feel certain, as, although these patients when they
left the hospital were to all intents and purposes apparently well, few
of them could undertake sustained exertion without getting short of
breath, and sometimes suffering from transitory pain, and for this
reason it became customary to invalid them home.
In a small proportion of the cases empyema followed; but I never saw
this in any case that had neither been tapped nor opened, and I saw
only one patient die from a chest wound uncomplicated by other injuries.
This case was an interesting one of recurrent hæmorrhage followed by
inflammatory troubles:--
[Illustration: TEMPERATURE CHART 2.--Secondary Hæmorrhages in a case of
Hæmothorax. Case No. 151]
(151) The wound was received at short range, probably at from
100 to 200 yards. _Entry_, 1 inch from the left axillary margin
in the first intercostal space; _exit_, at the back of the
right arm 1-1/2 inch below the acromial angle; both pleuræ were
therefore crossed. The patient expectorated at first fluid,
then clotted, blood in considerable quantity. When brought into
the advanced Base hospital on the third day, there were signs
of blood in the left pleura, cellular emphysema over the right
side of the chest, and signs of collapse of the right lung. The
temperature chart gives shortly the course of the case: the
right pneumo-thorax cleared up spontaneously, also the
emphysema; but the left pleura needed tapping to relieve
symptoms of pressure on four occasions, the 13th, 15th, 19th,
and 25th days respectively. On the first two occasions blood
was removed, on the third blood serum only, and on the last
pus. The patient was relieved after each aspiration; after the
third, the temperature fell to normal, the general condition
also improved, and he promised to do well. None the less,
reaccumulation took place, the evacuated fluid assumed an
inflammatory character, and an incision to evacuate pus was
eventually followed by death on the twenty-seventh day. The
amount of hæmoptysis throughout was considerable, and the case
was possibly one of pulmonary hæmothorax, as after death no
source of hæmorrhage could be localised in the intercostal
space. The track in the lung was almost healed, and although a
part of it allowed the introduction of a probe for about an
inch, it could be traced no further even on section of the
organ, and no special vessel could be located as the original
bleeding spot.
_Empyema._--I may here add the little that I have to say on this
subject. During the whole campaign the single case of primary empyema
that I saw was the one recorded below, which deserves special mention as
illustrating the disadvantage of extracting bullets on the field. Under
the conditions which necessarily accompanied this operation the
ensurance of asepsis was impossible, and the additional wound no doubt
proved the source of infection.
(152) _Entry_, at the posterior margin of the sterno-mastoid
muscle, 2 inches above the clavicle; the bullet came to the
surface beneath the skin over the fifth rib, in the nipple line
of the right side. There was never any hæmoptysis, but the
patient suffered with some dyspnoea throughout. After a three
days' stay in the Field hospital, where the subcutaneous bullet
was removed, the patient was transported by wagon and train to
the Base, a journey of about 600 miles.
On the fifth day pus escaped from the extraction wound, and
when the case was examined at the Base, the temperature was
101°, the pulse over 100, the respirations 30, and the whole
side of the chest was dull, with the exception of a patch of
boxy resonance over the apex anteriorly. On the following day
the chest was drained, and a considerable amount of pus
evacuated, which was mixed with breaking-down blood-clot. A
fortnight later a second operation had to be performed to
improve the drainage, and the patient made a tedious recovery.
The following case well illustrates the symptoms in a severe case of
hæmothorax, and empyema following aspiration:--
(153) The patient was wounded at Paardeberg at a range of from
500 to 700 yards. _Entry_, just to the left of the episternal
notch; _exit_, in the fifth left interspace posteriorly, midway
between the spine and vertebral margin of the scapula. A
quantity of bright blood was brought up at once, and later
blood was coughed up in clots.
There was no great pain at the moment of the injury; the man
again got up to the firing line, and later walked two miles to
the Field hospital without aid. He remained here a week, when
he was sent down to the Base, and during the first three days'
journey in the wagon he began to get worse. On the fourth day
cough began to be very troublesome.
When he arrived at the Base, fifteen days after the original
injury, there was much dyspnoea; the temperature was 102°,
and the pulse 110. The left side of the chest was dull
throughout; an aspirating needle was introduced, and a pint of
very dark liquid blood drawn off. The whole of the blood was
not removed on account of the very severe cough and pain which
the evacuation occasioned. The man appeared to steadily improve
until three weeks later, when the temperature, which throughout
had been uneven, became consistently high, and signs of fluid
at the base increased. An aspirating needle was introduced, and
16 ounces of pus were drawn off. Two days later a piece of rib
was resected (Mr. Pegg) and another pint of pus evacuated.
After this, rapid improvement took place, and in ten days the
man was able to be up and dressed, although a small amount of
discharge still persisted. He eventually made an excellent
recovery.
Secondary empyemata not uncommonly followed incision of the chest, or
excision of a rib for draining a hæmothorax. These operations in the
early part of the campaign were more freely undertaken on the
supposition that rise of temperature and other symptoms of fever pointed
to incipient breaking down of the clot. Subsequent experience showed
this not to be the case, and early operations for drainage ceased to be
undertaken. In these operations a primary difficulty was met with in
effectively clearing out the clot, a drain had to be left, and
suppuration occurred later in a considerable proportion. The
suppurations were most troublesome; local adhesions formed, and the pus
collected in small pockets, which were difficult to find and to drain,
and even when the collections seemed to have been successfully dealt
with at the time, residual abscesses often followed at a very late date.
Thus, I saw a case with a contracted chest and a fresh abscess the day
before I left Cape Town, in whom I had advised and witnessed an
operation for the evacuation of clot in the presence of signs of fever a
week after my arrival in the country, nine months previously. I saw
another case where general infection followed incision of a hæmothorax,
but the patient fortunately recovered.
The question of _pleurisy_ has already been mentioned in connection with
hæmothorax; it no doubt accounted for secondary effusion in some cases,
and beyond this I have nothing to add to what has been there said.
_Pneumonia_ was rare; there were occasionally signs of consolidation,
but, I think, quite as often in the opposite lung as in the one injured.
I never saw a fatal case, and I am inclined to think that when it
occurred it was as often the result of cold and exposure as of the
injury to the lung. Abscess of the lung I only saw once, and that in a
case in which the injury to the chest was complicated by paraplegia from
spinal injury and septicæmia, and it was possibly pyæmic.
_Diagnosis._--No difficulties special to small-calibre wounds were
experienced, except such as have been already dealt with. The only class
of case which frequently gave rise to difficulty was hæmothorax. Here
two points especially needed consideration. (1) _The source of the
hæmorrhage as parietal or visceral._ As has been already foreshadowed,
this was mainly to be decided by the amount and persistence of the
hæmoptysis, but naturally free hæmoptysis did not negative concurrent
parietal bleeding. Then the actual source of the bleeding other than
from the lung had to be considered; in the great majority of cases the
intercostal vessels were responsible, and attention to the course of the
tracks often allowed this to be definitely decided upon.
A case included in the chapter on Injuries to the Blood Vessels (No. 5,
p. 127) is of great interest in this particular; in that instance
feebleness of the radial pulse, together with the position of the wound,
was a valuable indication of injury to the subclavian artery, but
weakened somewhat by the fact of retention of the bullet, and hence
uncertainty as to the exact course that it had taken, and as to whether
the bullet itself was not responsible for pressure on the vessel. Such
indications, however, should make one very chary of interference with a
hæmothorax, even with extremely urgent symptoms, in the light of our
present knowledge of the nature of the lesions to the great vessels
produced by small-calibre bullets, and their tendency to be incomplete.
(2) _The imminence of suppuration or its actual occurrence._--In most
cases it sufficed to preserve an expectant attitude, and in the
persistence or increase of symptoms, to have recourse to an exploratory
puncture as the best means of solution of the difficulty.
_Prognosis._--The prognosis both as to life and as to subsequent
ill-effects was remarkably good; in many cases of uncomplicated injury
to the lung the patients rejoined their regiments at the end of a month
or six weeks. In the more serious cases complicated by the collection of
blood in the pleura, convalescence was more prolonged, and an average
time of six to eight weeks often elapsed before the patients could be
safely discharged from hospital. In the more serious a certain amount of
dulness always persisted at this time over the base of the lung, and the
chest was usually somewhat contracted on the injured side, with evidence
in the way of decreased vesicular murmur that the lung was still not
free from compression. With regard to the persistence of dulness on
percussion, it is well to bear in mind that a thin layer of blood
apparently produces as serious impairment of resonance as a much larger
quantity of serum. The signs appeared to favour the view that the space
necessary for the location of the hæmorrhage had been obtained at the
expense of the lung rather than by distension of the thoracic parietes,
and also, I think, denoted the presence of adhesions. Possibly they will
entirely disappear with the return of full excursion movements of
respiration, the latter being often still somewhat restricted when the
patients left hospital. All the patients with such signs were liable to
attacks of pain and shortness of breath on actual bodily exertion. I
happened to meet with an officer, the subject of a Lee-Metford wound of
the thorax, sustained five years previously, and he told me that he was
nine months before he could take active exercise without feeling short
of breath.
As to the cases of hæmothorax and empyema which needed drainage, all did
well; but expansion of the lung was much less satisfactory than would
have been expected, probably on account of especially firm adhesions.
The importance of concurrent injury I need hardly dwell on; but I might
add that perforation of one or both arms, the most common one, did not
materially affect the general statements above made.
_Treatment._--In the early stages of the pulmonary wounds rest was the
all-important indication, and when this was assured few serious cases of
hæmothorax occurred. Beyond simple rest, the administration of opium
with a view to checking internal hæmorrhage was used with good effect.
The wounds needed simple dressing only.
The treatment of hæmothorax at a later date, however, was of much
interest and difficulty. I think the following lines may be laid down
for guidance in such cases:--
(i) Hæmothorax, even of considerable severity, will undergo spontaneous
cure. An early rise of temperature may be disregarded.
(ii) Tapping the chest is indicated when pressure signs on the lung are
sufficiently severe to cause serious symptoms, and the removal of the
blood undoubtedly shortens the period of recovery, as well as relieves
symptoms.
In such cases the collection of blood has usually been rapid and
continuous; hence a fresh hæmorrhage is always probable when the local
pressure has been removed. Tapping therefore should not necessarily mean
complete evacuation, and should be followed by careful firm binding up
of the chest, the administration of opium, and the most stringent
precautions for rest.
(iii) Tapping may be needed as a diagnostic aid, and in such
circumstances as much fluid as can be removed should be evacuated with
the same precautions as mentioned in the last paragraph.
(iv) Tapping may be indicated for the evacuation of serum expressed from
the blood-clot, or due to pleural effusion, on the same lines as in any
other collection of fluid in the pleural cavity.
(v) Early free incision is, as a rule, to be steadfastly avoided. Some
cases already quoted fully illustrate its disadvantages.
(vi) Cases in which an incision and the ligature of a parietal artery
are indicated are very rare. I never saw such a one myself.
(vii) If a hæmothorax suppurates, it must be treated on the ordinary
lines of an empyema. In view of the constant formation of adhesions and
difficulty in drainage, a portion of a rib should always be resected in
order to ensure sufficient space for after-treatment. The cavities, as a
rule, are better irrigated, the usual precautions being taken where
there is any reason to fear that the lung is still in communication with
the cavity.
Care in carrying out asepsis in tapping, which should be performed with
an aspirator, need hardly be more than mentioned. It will be noted that
in some of the cases quoted suppuration followed tapping, but it must be
remembered that in these the two primary wounds already existed as
possible channels of infection.
Retained bullets of small calibre in the thoracic cavity were not
common, unless the lodgment had occurred in the bodies of the vertebræ.
I saw very few. Shrapnel bullets and fragments of shells, however, were,
in proportion to the frequency of wounds from such projectiles, more
commonly retained. The rules to be followed in such cases do not
materially deviate from those to be observed in the body generally.