Wounds of the Neck

(74) Wounded at Colenso.Entry(Mauser), 1 inch below the centre of the margin of the right orbit;exit, behind the right angle of the mandible. Fracture of lower jaw, and development of a diffuse traumatic aneurism of the external carotid artery. The common carotid artery was tied for secondary hæmorrhage (Mr. Jameson) some three weeks later.Vision was affected at the time of the accident; the fingers could be seen, but not counted. After ligation of the carotid the condition was possibly worse, and this needs mention as transitory loss of power in the left upper extremity also followed the operation.

Vision was affected at the time of the accident; the fingers could be seen, but not counted. After ligation of the carotid the condition was possibly worse, and this needs mention as transitory loss of power in the left upper extremity also followed the operation.

Fractures of the bony wall were of every degree. The most severe that I saw were two in which lateral impact by a bullet crossing the cranial cavity caused general comminution of the whole orbital roof. Fissures of the roof were common in connection with 'explosive' exit apertures in the frontal region of the skull. Pure perforations usually accompanied the vertical or transverse wounds of the cavity, fragments at the aperture of entry then being projected into the orbit, sometimes penetrating the muscles.

Occasionally the margin of the cavity was merely notched.

The ocular muscles were often divided more or less completely, and occasionally some difficulty arose in determining whether loss of movement of the globe in any definite direction depended on injury to the muscle itself, or to the nerve supplying the muscle. The following case illustrates this point:—

(75)Entry(Mauser), 2 inches behind the right external canthus; the bullet pierced the external wall and traversed the floor of the right orbit beneath the globe, crossed the nasal cavity, and a part of the left orbit;exit, at the lower margin of the left orbit, beneath the centre of the globe of the eye.Complete loss of sight followed the injury, and persisted for one week. Modified vision then returned.Three weeks later there was diplopia; loss of function of the right external and inferior recti, although the ball could be turned downward to some extent by the superior oblique when the internal rectus was in action. Movements of the left globe were not seriously affected.The pupils were immobile and moderately dilated, but atropine had been employed two days previously.A year later the condition was as follows: There is some weakness of the right seventh nerve, as evidenced by want of symmetry in all the folds of the face, and in narrowing of the palpebral fissure.When at rest the right eye is somewhat raised and turned outwards. Active movements outwards or downwards are restricted. There is diplopia, and the vision of the right eye is much impaired; the man can see persons, but cannot count fingers with certainty, although he sees the hand. Putting on one side the loss of free movement, there is no obvious external appearance of injury to the eye.

Complete loss of sight followed the injury, and persisted for one week. Modified vision then returned.

Three weeks later there was diplopia; loss of function of the right external and inferior recti, although the ball could be turned downward to some extent by the superior oblique when the internal rectus was in action. Movements of the left globe were not seriously affected.

The pupils were immobile and moderately dilated, but atropine had been employed two days previously.

A year later the condition was as follows: There is some weakness of the right seventh nerve, as evidenced by want of symmetry in all the folds of the face, and in narrowing of the palpebral fissure.

When at rest the right eye is somewhat raised and turned outwards. Active movements outwards or downwards are restricted. There is diplopia, and the vision of the right eye is much impaired; the man can see persons, but cannot count fingers with certainty, although he sees the hand. Putting on one side the loss of free movement, there is no obvious external appearance of injury to the eye.

Mr. J. H. Fisher reported as follows:

Ophthalmoscopic examination shows the left eye and fundus to be normal. The right disc is not atrophied, but the whole of the lower half of the fundus is coated with masses of black retinal pigment. There is atrophy in spots of the capillary layer of the choroid, and the larger vessels of the deeper layer are exposed between the interstices of the pigment masses. There is no definite choroidal rupture. The lesion encroaches upon and implicates the macular region.The injury is a concussion one, not necessarily resulting from contact, and certainly not due to a perforation. The loss of movement and faulty position are the result of injury to the muscles, and not to nerve implication.The man complained that when he blew his nose the left eye filled with water and air came out. The left nasal duct was however shown to be intact, as water injected by the canaliculus passed freely into the nose.

The injury is a concussion one, not necessarily resulting from contact, and certainly not due to a perforation. The loss of movement and faulty position are the result of injury to the muscles, and not to nerve implication.

The man complained that when he blew his nose the left eye filled with water and air came out. The left nasal duct was however shown to be intact, as water injected by the canaliculus passed freely into the nose.

Intra-orbital bleeding, subconjunctival hæmorrhage with proptosis and ecchymosis of the lids were usually well marked. The latter was sometimes extreme.

Injury to the nerves was naturally of a very mixed character. In many instances the branches of the first twodivisions of the fifth nerve were obviously implicated and regional anæsthesia was common. This was often transitory when the result of vibratory concussion, contusion, or pressure from hæmorrhage. In other cases it was more prolonged as a result of actual division of the nerve. As is usually the case, when a small area of distribution only was affected, sensation was rapidly regained from vicarious sources, even when section had been complete.

As individual injuries, those to the optic nerve were the most frequently diagnosed. I am sorry to be unable to attempt a discrimination of injuries to the nerve alone from those in which both nerve and globe suffered, but the globe can rarely have escaped injury, either direct or indirect, when the bullet actually traversed the orbital cavity. (A few further remarks concerning injuries to the optic nerve will be found in Chapter IX.)

Injuries to the globe of the eye, either direct or indirect, accompanied most of the orbital wounds.

In some the lesion was of the nature of concussion. In such the bone injury was usually at the periphery of the orbit, or to the bones of the face in the neighbourhood. The loss of vision might then be temporary, persisting from two to ten days, then returning, often with some deficiencies.

In other similar external injuries, the lesion of the globe was more severe, and permanent blindness followed.

In variability of degree of completeness, these lesions of the globe corresponded exactly with those produced in other parts of the nervous system by bullets striking the bones in their vicinity, and they were no doubt the result of a similar transmission of vibratory force.

In a third series of cases the globe suffered direct contusion, and in a fourth was perforated and destroyed.

In cases in which permanent blindness was produced without solution of continuity of the sclerotic coat, the nature of the lesion was probably in most cases vibratory concussion and the development of multiple hæmorrhages from choroidal ruptures of a similar nature to those seen in the brain and spinal cord. The actual hæmorrhagic areæ varied in size; but, as far as my experience went, gross hæmorrhages intothe anterior chamber did not occur without severe direct contact of the bullet.

In the vast majority of the cases blindness, whether transitory or permanent, developed immediately on the reception of the injury, and was possibly in its initial stage the result of primary concussion.

Cases were, however, seen occasionally in which the symptoms were less sudden, of which the following is an example. I did not think that the mode of progress seen here could be referred to simple orbital hæmorrhage, although this existed, but rather to intravaginal hæmorrhage into the sheath of the optic nerve. On external inspection the globes appeared normal.

(76) Wounded at Paardeberg.Entry(Mauser), over the centre of the right zygoma; the bullet traversed the right orbit, nose, and left orbit.Exit, immediately above the outer extremity of the left eyebrow.The patient stated that he could 'see' for thirty minutes with the right eye and for an hour with the left, immediately after the injury. He then became totally blind, and has since remained so. During the next three weeks there were occasional 'flashes of light' experienced, but these then ceased.At the end of three weeks the condition was as follows: Ocular movements good in every direction except that of elevation of the globe. The levator palpebræ superioris acted very slightly; the right, however, better than the left.There were marked right proptosis, less left proptosis, and slight patchy subconjunctival hæmorrhage of both eyes. The pupils were dilated, motionless, and not concentric.The patient was invalided as totally blind (November, 1900).

The patient stated that he could 'see' for thirty minutes with the right eye and for an hour with the left, immediately after the injury. He then became totally blind, and has since remained so. During the next three weeks there were occasional 'flashes of light' experienced, but these then ceased.

At the end of three weeks the condition was as follows: Ocular movements good in every direction except that of elevation of the globe. The levator palpebræ superioris acted very slightly; the right, however, better than the left.

There were marked right proptosis, less left proptosis, and slight patchy subconjunctival hæmorrhage of both eyes. The pupils were dilated, motionless, and not concentric.

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

Mr. Lang, who saw this patient on his return to England, kindly furnishes me with the following note as to the condition. There was extensive damage to both eyes, hæmorrhage, and probably retinal detachment as well as choroidal changes.

The quotation of a few illustrative examples typical of the ordinary orbital injuries may be of interest:—

(77)Vertical wound.—Entry, into left orbit in roof posterior to globe, and internal to optic nerve;exit, from orbit through junction of inner wall and floor into nose.Complete blindness followed the injury, but upon the second day light was perceived on lifting the upper lid. There was marked proptosis, subconjunctival ecchymosis, swelling and ecchymosis of the upper lid, and ptosis. Anæsthesia in the whole area of distribution of the frontal nerve.At the end of three weeks, fingers could be recognised, but a large blind spot existed in the centre of the field of vision. The general movements of the globe were fair, but the upper lid could not be raised. The proptosis and subconjunctival hæmorrhage cleared up.Little further improvement occurred; six months later the patient could only count the fingers excentrically. A very extensive scotoma was present. The optic disc was much atrophied, the calibre of the arteries diminished and the veins full (Mr. Critchett). The ptosis persisted. It was doubtful in this case whether the ptosis depended on injury to the nerve of supply, or on laceration and fixation of the levator palpebræ superioris. The latter seemed the more probable, as the superior rectus acted. The absence of any sign of gross bleeding into the anterior chamber is opposed to the existence of a perforating lesion of the globe in this case.(78)Entry(Mauser), from cranial cavity, just within the centre of the roof of the right orbit;exit, from the orbit by a notch in the lower orbital margin internal to the infra-orbital foramen; track thence beneath the soft parts of the face to emerge from the margin of the upper lip near the left angle of the mouth. Collapse of globe, proptosis, subconjunctival hæmorrhage, œdema and ecchymosis of lids.Shrunken ball removed on twenty-fourth day (Major Burton, R.A.M.C.).(79)Entry(Mauser), at the posterior border of the left mastoid process, 3/4 inch above the tip;exit, in the inner third of the left upper eyelid. Globe excised at end of seven days. Facial paralysis and deafness.(80)Entry(Mauser), from cranial cavity through centre of roof of orbit;exit, through maxillary antrum. Total blindness. Movements of ball good, no loss of tension. Proptosis, subconjunctival hæmorrhage, ecchymosis of eyelids. No improvement in sight followed. One month later the globe suppurated and was removed. The bullet had divided the optic nerve and contused the ball.

(77)Vertical wound.—Entry, into left orbit in roof posterior to globe, and internal to optic nerve;exit, from orbit through junction of inner wall and floor into nose.

Complete blindness followed the injury, but upon the second day light was perceived on lifting the upper lid. There was marked proptosis, subconjunctival ecchymosis, swelling and ecchymosis of the upper lid, and ptosis. Anæsthesia in the whole area of distribution of the frontal nerve.

At the end of three weeks, fingers could be recognised, but a large blind spot existed in the centre of the field of vision. The general movements of the globe were fair, but the upper lid could not be raised. The proptosis and subconjunctival hæmorrhage cleared up.

Little further improvement occurred; six months later the patient could only count the fingers excentrically. A very extensive scotoma was present. The optic disc was much atrophied, the calibre of the arteries diminished and the veins full (Mr. Critchett). The ptosis persisted. It was doubtful in this case whether the ptosis depended on injury to the nerve of supply, or on laceration and fixation of the levator palpebræ superioris. The latter seemed the more probable, as the superior rectus acted. The absence of any sign of gross bleeding into the anterior chamber is opposed to the existence of a perforating lesion of the globe in this case.

(78)Entry(Mauser), from cranial cavity, just within the centre of the roof of the right orbit;exit, from the orbit by a notch in the lower orbital margin internal to the infra-orbital foramen; track thence beneath the soft parts of the face to emerge from the margin of the upper lip near the left angle of the mouth. Collapse of globe, proptosis, subconjunctival hæmorrhage, œdema and ecchymosis of lids.

Shrunken ball removed on twenty-fourth day (Major Burton, R.A.M.C.).

(79)Entry(Mauser), at the posterior border of the left mastoid process, 3/4 inch above the tip;exit, in the inner third of the left upper eyelid. Globe excised at end of seven days. Facial paralysis and deafness.

(80)Entry(Mauser), from cranial cavity through centre of roof of orbit;exit, through maxillary antrum. Total blindness. Movements of ball good, no loss of tension. Proptosis, subconjunctival hæmorrhage, ecchymosis of eyelids. No improvement in sight followed. One month later the globe suppurated and was removed. The bullet had divided the optic nerve and contused the ball.

Prognosis and treatment of wounds of the orbit.—Except in those cases in which return of vision was rapid, theprognosis was consistently bad in the injuries to the globe. When the globe was ruptured it, as a rule, rapidly shrank. The case (80) quoted above is the only one in which I saw secondary suppuration.

With regard to active treatment, the majority of the cases were complicated by fracture of the roof of the orbit, and in many instances concurrent brain injury was present. In all of these, as a general rule, it was advisable to await the closure of the wound in the orbital roof prior to removal of the injured eye, if that was considered necessary. The only exception to this rule was offered by instances in which the bullet passed from the orbit into the cranium; in these primary removal of fragments projecting into the frontal lobe was preferable. As already indicated, such wounds were comparatively rare except in the case of bullets coursing transversely or obliquely.

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

Wounds of the nose.—I will pass by the external parts, with the remark that perforating wounds of the cartilages were remarkable for their sharp limitation and simple nature. I remember one case shown to me in the Irish Hospital in Bloemfontein by Sir W. Thomson, in which at the end of the third day small symmetrical vertical slits in each ala already healed were scarcely visible. This case very strongly impressed one with the doctrine of chances, since on the same morning I was asked to see a patient in whom a similar transverse shot had crossed both orbits, destroying both globes and injuring the brain.

A retained bullet in the upper portion of the nasal cavity has already been referred to (fig. 60). This accident was naturally a rare one; in that instance the bullet had only retained sufficient force to insert itself neatly between the bones.

Wounds crossing the nasal fossæ were comparatively common. The interference with the sense of smell often resulting is discussed in Chapter IX.

Wounds of the malar bonewere not infrequent. The small amount of splintering was somewhat remarkable considering the density of structure of the bone. In thisparticular the behaviour of the malar corresponded with what was observed in the flat bones in general. A case quoted in Chapter III. p. 87, illustrates the capacity of the hard edge of the bone to check the course of a bullet, and cause considerable deformity and fissuring of the mantle.

Wounds of the jaws. Upper jaw.—A large number of tracks crossing the antrum transversely, obliquely, or vertically were observed. In the first case the nasal cavity, in the others the orbital or buccal cavity, were generally concurrently involved. It was somewhat striking that I never observed any trouble, immediate or remote, from these perforations of the antrum. If hæmorrhage into the cavity occurred, it gave rise to no ultimate trouble. I never saw an instance of secondary suppuration even in cases where the bullet entered or escaped through the alveolar process with considerable local comminution. The branches of the second division of the fifth nerve were sometimes implicated. In one instance a bullet traversed and cut away a longitudinal groove in the bones, extending from the posterior margin of the hard palate, and terminating by a wide notch in the alveolar process.

A good example of a troublesome transverse wound of the bones of the face is afforded by the following instance:—

(81)Entry(Mauser), through the left malar eminence, 1 inch below and external to the external canthus;exit, a slightly curved tranverse slit in the lobe of the right ear.The injury was followed by no signs of orbital concussion, and no loss of consciousness. There was free bleeding from both external wounds and from the nose. The sense of smell was unaffected, but taste was impaired, and there was loss of tactile sensation in the teeth on the left side also on the hard palate. There was no evidence of fracture of the neck of the mandible, nor of the external auditory meatus, but there was considerable difficulty in opening the mouth widely or protruding the teeth. The latter difficulty persisted for some time, and was still present when I last saw the patient.

(81)Entry(Mauser), through the left malar eminence, 1 inch below and external to the external canthus;exit, a slightly curved tranverse slit in the lobe of the right ear.

The injury was followed by no signs of orbital concussion, and no loss of consciousness. There was free bleeding from both external wounds and from the nose. The sense of smell was unaffected, but taste was impaired, and there was loss of tactile sensation in the teeth on the left side also on the hard palate. There was no evidence of fracture of the neck of the mandible, nor of the external auditory meatus, but there was considerable difficulty in opening the mouth widely or protruding the teeth. The latter difficulty persisted for some time, and was still present when I last saw the patient.

Mandible.—Fractures of the lower jaw were frequent and offered some peculiarities, the chief of which were the liability of any part of the bone to be damaged, and the absence of the obliquity between the cleft in the outer and inner tables so common in the fractures seen in civil practice.

The neck of the condyle I three times saw fractured; in each instance permanent stiffness and inability to open the mouth resulted. This stiffness was of a degree sufficient to raise the question whether the best course in such cases would not be to cut down primarily and remove a considerable number of loose fragments, and thus diminish the amount of callus likely to be thrown out.

Fractures of the ascending ramus and body were more frequent. They were accompanied by considerable comminution, but all that I observed healed remarkably well, and in good position, in spite of the fact that many of the patients objected to wear any form of splint.

The most special feature was the occurrence of notched fractures, corresponding to the type wedges described in Chapter V. When these fractures were at the lower margin of the bone, the buccal cavity occasionally escaped in spite of considerable comminution, the latter confining itself to the basal portion of the bone.

When the base of the teeth, or the alveolus, was struck, a wedge was often broken away, and from the apex of the resulting gap a fracture extended to the lower margin of the bone.

When fractures of the latter nature resulted from vertically coursing bullets, much trouble often ensued. I will quote two cases in illustration:—

(82) Wounded at Rooipoort.Entry(Mauser), through the lower lip; the bullet struck the base of the right lateral incisor and canine teeth, knocked out a wedge, and becoming slightly deflected, cut a vertical groove to the base of the mandible;exit, in left submaxillary triangle. The bullet subsequently re-entered the chest wall just below the clavicle, and escaped at the anterior axillary fold. The appearance of these second wounds suggested only slight setting up of the bullet; the original impact was no doubt of an oblique or lateral character.The injury was followed by free hæmorrhage and remarkably abundant salivation (I was inclined to think that the latter symptom was particularly well marked in gunshot fractures of the body of the mandible), and very great swelling of the floor of the mouth.The patient could not bear any form of apparatus, but was assiduous in washing out his mouth, and made a good recovery, the fragments being in good apposition.(83)Entry(Mauser), over the right malar eminence; the bullet carried away all the right upper and lower molars, fractured the mandible, and was retained in the neck.A fortnight later an abscess formed in the lower part of the neck, which was opened (Mr. Pooley), and portions of the mantle and leaden core, together with numerous fragments of the teeth, were removed. The bullet had undergone fragmentation on impact, probably on the last one (teeth of mandible), and still retained sufficient force to enter the neck.

The injury was followed by free hæmorrhage and remarkably abundant salivation (I was inclined to think that the latter symptom was particularly well marked in gunshot fractures of the body of the mandible), and very great swelling of the floor of the mouth.

The patient could not bear any form of apparatus, but was assiduous in washing out his mouth, and made a good recovery, the fragments being in good apposition.

(83)Entry(Mauser), over the right malar eminence; the bullet carried away all the right upper and lower molars, fractured the mandible, and was retained in the neck.

A fortnight later an abscess formed in the lower part of the neck, which was opened (Mr. Pooley), and portions of the mantle and leaden core, together with numerous fragments of the teeth, were removed. The bullet had undergone fragmentation on impact, probably on the last one (teeth of mandible), and still retained sufficient force to enter the neck.

This case affords an interesting example of transmission of force from the bullet to the teeth, and bears on the theory of explosive action.

In the treatment of fractures of the upper jaw, interference was rarely needed. In the case of the mandible, a remark has already been made as to the advisability of removing fragments when the neck of the condyle has suffered comminution. The removal of loose fragments is necessary in all cases in which the buccal cavity is involved. Experience in fracture of the limbs has shown a tendency to quiet necrosis when comminution was severe, in spite of primary union. This is no doubt dependent on the very free separation of fragments on the entry and exit aspects from their enveloping periosteum. In the case of the mandible, considerable necrosis is inevitable, and much time is saved by the primary removal of all actually loose fragments.

A splint of the ordinary chin-cap type with a four-tailed bandage meets all further requirements, but the patients often object to them. Cases in which the fragments could be fixed by wiring the teeth were not common, as the latter had so frequently been carried away. The usual precautions as to maintaining oral asepsis were especially necessary.

The results of fractures of the mandible were, in so far as my experience went, remarkably good, as deformity was seldom considerable. The absence of obliquity and the effect of primary local shock were no doubt favourable elements, little primary displacement from muscular action occurring.

Wounds of thecheekhealed readily, and the same was noticeable of the lips. Wounds of thetonguehealed with remarkable rapidity when of the simple perforating type, often with little or no swelling or evidence of contusion. At the end of a few days it was often difficult to localise them.

In connection with this subject a remarkable case which occurred at the fighting at Koodoosberg Drift is worthy of mention, although the projectile was a shell fragment and not a bullet of small calibre.

(84) A Highlander was the unfortunate possessor of an entire set of upper teeth set in a gold plate. A small fragment of a shell perforated the upper lip by an irregular aperture, and struck the teeth in such a manner as to turn the posterior edge of the plate towards the tongue, which latter was cut into two halves transversely through to the base.The patient asserted that the plate had been driven down his throat, but nothing was palpable either in the fauces or on external examination of the neck. He spoke distinctly, but there was dysphagia as far as solids were concerned.On the second day swelling of the neck due to early cellulitis developed, especially on the left side, and signs of laryngeal obstruction became prominent. Chloroform was administered, but on the introduction of the finger into the fauces, respiration failed and a hasty tracheotomy had to be performed. No foreign body was palpable with the finger in the pharynx.Tracheitis and septic pneumonia developed, and the man died of acute septicæmia thirty-six hours later. Death occurred just as the Division received marching orders, and nopost-mortemexamination was made. As a result of palpation at the time of the tracheotomy, the probabilities seemed against the presence of the tooth plate in the pharynx, but the absence of positive evidence scarcely allows the case to be certainly classed as one of cellulitis and septicæmia secondary to wound of the tongue.

The patient asserted that the plate had been driven down his throat, but nothing was palpable either in the fauces or on external examination of the neck. He spoke distinctly, but there was dysphagia as far as solids were concerned.

On the second day swelling of the neck due to early cellulitis developed, especially on the left side, and signs of laryngeal obstruction became prominent. Chloroform was administered, but on the introduction of the finger into the fauces, respiration failed and a hasty tracheotomy had to be performed. No foreign body was palpable with the finger in the pharynx.

Tracheitis and septic pneumonia developed, and the man died of acute septicæmia thirty-six hours later. Death occurred just as the Division received marching orders, and nopost-mortemexamination was made. As a result of palpation at the time of the tracheotomy, the probabilities seemed against the presence of the tooth plate in the pharynx, but the absence of positive evidence scarcely allows the case to be certainly classed as one of cellulitis and septicæmia secondary to wound of the tongue.

Wounds of the neck were not unfrequent and were of the gravest importance; there can be little doubt that they accounted for a considerable proportion of the deaths on the field. On the other hand, the neck as a region offeredsome of the most striking examples of hairbreadth escape of important structures. Consideration of a number of the vascular lesions (see cervical aneurisms, p. 135) also shows conclusively that in no region did the small size of the bullet more materially influence the result, since no doubt can exist that all these wounds would have proved immediately fatal if produced by projectiles of larger calibre.

In this place only a few general considerations will be entered into, as most of the important cases are dealt with under the general headings of vessels, nerves, and spine; but it is convenient to include here the few remarks that have to be made concerning the cervical viscera.

The wounds of the soft parts might course in any direction, but vertical tracks from above downwards were rare. In point of fact, these occurred only in connection with perforations of the head, and as vertical wounds of the latter were received in the prone position, usually when the head was raised, the necessary conditions for longitudinal tracks were seldom offered. One case of a complete vertical track in the muscles of the back of the neck has been already quoted (No. 69, p. 286).

Tracks coursing upwards from the trunk were somewhat more frequent in occurrence; thus a considerable number traversing the thorax were seen. In such instances the aperture of exit was generally situated in the posterior triangle, and some of the brachial nerves often suffered.

The commonest forms of wound were the transverse or the oblique. A large number of cases with such tracks will be found among the cases of injury to the cervical vessels and nerves. In some instances the course was restricted to the neck alone, in others the trunk or upper extremity was also implicated.

The favourable influence of the arrangement of the structures of the neck, which allows of the ordinary displacement excursions necessary for deglutition, respiration, and their cognate movements, was very strongly marked. Thus in several cases the bullet traversed the neck behind the pharynx and œsophagus without injuring either viscus, and the escape of the main vessels and nerves was equallystriking. In such wounds the wedge-like bullet without doubt separated and displaced all these structures, causing mere superficial contusion.

In connection with the latter statement, the rarity of direct sagittal wounds in the hospitals should be mentioned. This is probably to be explained by the facts that wounds in the mid-line of the neck implicated the cervical spinal cord, and that sagittal wounds implicating the vessels were apt to lead more directly to the surface, and thus external hæmorrhage was favoured. A few examples of cervical tracks will suffice to illustrate these remarks:—

(85)Entry(Lee-Metford), below angle of scapula;exit, centre of posterior triangle. Injury to the lung, and hæmothorax. No damage to neck structures.(86)Entry(Mauser), over Pomum Adami;exit, below right scapular spine. Median and musculo-spiral paralysis.(87)Entry, a large oval aperture through ninth right rib, 1/2 an inch external to scapular angle;exit, anterior border of sterno-mastoid opposite Pomum Adami. Second entry, opposite angle of mandible; exit, in centre of cheek.Wound of lung. Musculo-spiral paralysis still persisting at the end of nine months.(88)Entry(Mauser), 2 inches above left clavicle at margin of trapezius;exit, 1 inch from sternum in left first intercostal space. Contusion of brachial plexus, with mixed signs, which disappeared in two months. No signs of vascular injury.

(85)Entry(Lee-Metford), below angle of scapula;exit, centre of posterior triangle. Injury to the lung, and hæmothorax. No damage to neck structures.

(86)Entry(Mauser), over Pomum Adami;exit, below right scapular spine. Median and musculo-spiral paralysis.

(87)Entry, a large oval aperture through ninth right rib, 1/2 an inch external to scapular angle;exit, anterior border of sterno-mastoid opposite Pomum Adami. Second entry, opposite angle of mandible; exit, in centre of cheek.

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

(88)Entry(Mauser), 2 inches above left clavicle at margin of trapezius;exit, 1 inch from sternum in left first intercostal space. Contusion of brachial plexus, with mixed signs, which disappeared in two months. No signs of vascular injury.

See also cases of cervical aneurism, &c.

Wounds of the pharynx.—I saw only three cases of wound of the pharynx; in each the injury was in the nasal or buccal segment of the cavity, and in each the soft palate was injured, in two instances the wound being a small perforation.

All three cases belong to the somewhat miraculous class. The first (89) was the only one in which the wound gave rise to subsequent trouble. The second was under the charge of Mr. Bowlby, and will no doubt be more fully recounted by him, as interesting signs of injury to the cervical cord were present. In the third the occipital neuralgia was the only troublesome symptom.

In both cases 90 and 91 the high position of the wound in the fixed portion of the pharynx no doubt accounted for the absence of any infective trouble.

(89)Wounds of the pharynx.—Entry(Lee-Metford), immediately below the tip of right mastoid process; the bullet traversed the neck, entering the pharynx close to the right tonsil, crossed the cavity of the pharynx and the mouth, emerging through the left cheek. Great swelling of the fauces and dysphagia persisted for some days after the injury, and there was considerable hæmorrhage.Infection of the posterior portion of the track from the pharynx resulted, and suppuration continued for some weeks: a small sequestrum eventually needed to be removed from the tip of the transverse process of the atlas.(90)Entry(Mauser), through mouth; the bullet pierced the soft palate and the posterior wall of the pharynx, and passed out between the transverse process of atlas and the occiput. No serious pharyngeal symptoms.(91)Entry(Mauser), through the mouth, knocking out the left upper canine and bicuspid teeth. Perforation of the soft palate just to the right of the base of the uvula and the posterior wall of the pharynx;exit, 1½ inch internal to and 1/2 an inch below the tip of the right mastoid process. Hæmorrhage persisted for half an hour, and the patient could not swallow solids for a week. Great occipital neuralgia followed the wound.

Infection of the posterior portion of the track from the pharynx resulted, and suppuration continued for some weeks: a small sequestrum eventually needed to be removed from the tip of the transverse process of the atlas.

(90)Entry(Mauser), through mouth; the bullet pierced the soft palate and the posterior wall of the pharynx, and passed out between the transverse process of atlas and the occiput. No serious pharyngeal symptoms.

(91)Entry(Mauser), through the mouth, knocking out the left upper canine and bicuspid teeth. Perforation of the soft palate just to the right of the base of the uvula and the posterior wall of the pharynx;exit, 1½ inch internal to and 1/2 an inch below the tip of the right mastoid process. Hæmorrhage persisted for half an hour, and the patient could not swallow solids for a week. Great occipital neuralgia followed the wound.

Wounds of the larynx.—I saw only one wound of the larynx (see No. 10, p. 135). In this instance the thyroid cartilage was wounded on either side at the level of the Pomum Adami. Transitory hæmorrhage and signs of œdema were the only signs referable to the wound, but in addition the bullet contused the left vagus and gave rise to temporary laryngeal paralysis. The same course was observed in a second case of perforation of the larynx of which I was told.

Wounds of the trachea.—The two cases recounted below are the only tracheal injuries I met with; in one the œsophagus was also implicated. This patient died from mediastinal emphysema. In the second case the wide development of emphysema was prevented by the early introduction of a tracheotomy tube.

(92)Entry(Mauser), on the outer side of the right arm, 3½ inches below the acromion;exit, 3 inches below the tip of the left mastoid process, through the sterno-mastoid. Thirty six hours later there was very free hæmorrhage into the right posterior triangle, emphysema at the episternal notch, dysphagia, and complete obliteration of the cardiac area of dulness. Respiration was rapid (40) and extremely noisy. Pulse 130, small and weak.A tracheotomy was performed (Mr. Stewart), but the patient died an hour later. When the operation was performed a considerable amount of mucus from the œsophagus was discovered in the wound. The bullet had passed obliquely between trachea and œsophagus, wounding both tubes.(93)Entry, at the centre of the margin of the left trapezius;exit, in mid line of the neck over the trachea. Dyspnœa was noted the next morning, which increased during a journey in a wagon. On the third day the dyspnœa was more troublesome and emphysema began to develop in the neck. A tracheotomy was performed (Mr. Hunter), and the tube was kept in for four days. No further trouble was experienced, and the wound shortly closed, and the patient, a surgeon, returned to his duties. Temporary signs of median nerve concussion and contusion were noted.

A tracheotomy was performed (Mr. Stewart), but the patient died an hour later. When the operation was performed a considerable amount of mucus from the œsophagus was discovered in the wound. The bullet had passed obliquely between trachea and œsophagus, wounding both tubes.

(93)Entry, at the centre of the margin of the left trapezius;exit, in mid line of the neck over the trachea. Dyspnœa was noted the next morning, which increased during a journey in a wagon. On the third day the dyspnœa was more troublesome and emphysema began to develop in the neck. A tracheotomy was performed (Mr. Hunter), and the tube was kept in for four days. No further trouble was experienced, and the wound shortly closed, and the patient, a surgeon, returned to his duties. Temporary signs of median nerve concussion and contusion were noted.

Every degree of local injury to the constituent vertebræ and the contents of the spinal canal was met with considerable frequency. Pure uncomplicated fractures of the bones were of minor importance, except in so far as they exemplified the general tendency to localised injury in small-calibre bullet wounds. Injuries implicating the spinal medulla, on the other hand, were proportionately the most fatal of any in the whole body to the wounded who left the field of battle or Field hospital alive, and these cases formed one of the most painful and distressing features of the surgery of the campaign.

The prognostic gravity of any spinal injury depended upon two factors: first, the obvious one of relative contiguity or direct implication of the cord or nerves in the wound track; secondly, the degree of velocity retained by the bullet at the moment of impact with the spine. Observation of the serious ill effects produced by bullets passing in the immediate proximity of large strongly ensheathed peripheral nerves surrounded by soft tissue, such as those of the arm or thigh, would lead one to expect that a comparatively thin-clad bundle of delicate nerve tissue like the spinal cord, enclosed in a bony canal so well disposed for the conveyance of vibrations, would suffer severely, and such proved to be the case.

Fractures in their relation to nerve injurywill be first dealt with, and secondly injuries to the cord itself.

Isolated fractures of the processes were not uncommon, the determination of the injury to anyone being naturally dependent on the position and direction taken by the wound track.

For implication of thetransverse processessagittal woundscoursing in varying degrees of obliquity were mainly responsible. Such injuries might be unaccompanied by any nerve lesion. Thus a Boer received a Lee-Metford wound at Belmont which passed from just below the tip of the right mastoid process across the pharynx and through the opposite cheek. No bone damage was at first suspected; suppuration in the neck, however, followed infection from the pharynx, and when a sinus which persisted was opened up later, a number of small comminuted fragments were found detached from the transverse process of the axis. In other cases more or less severe symptoms of nerve lesion were observed, varying from transient hyperæsthesia, due to implication of the issuing nerves, to symptoms of spinal hæmorrhage, such as are portrayed in the following:—

(94) A private in the Black Watch was wounded at Magersfontein from within a distance of 1,000 yards. Among other wounds, one track entered 1 inch to the right of the second lumbar spinous process, and emerged 1 inch internal to the right anterior superior iliac spine. There were signs of wound of the kidney, and in addition, retention of urine, incontinence of fæces, complete motor and sensory paralysis of the right lower extremity, and total absence of all reflexes. Anæsthesia existed over the whole area of skin supplied by the nerves of the sacral plexus, hyperæsthesia over that supplied by the lumbar nerves.On the tenth day subsequent to the injury, the hyperæsthesia in the area of lumbar supply was replaced by normal sensation, motor power began to be slowly regained in the muscles supplied by the anterior crural and obturator nerves, and the patellar reflex returned. At this time lowered sensation returned in the area supplied by the sacral plexus, but no improvement in motor power took place, and no control was regained over the bladder and rectum.During the succeeding week some sciatic hyperæsthesia developed, but on the twenty-eighth day the patient developed secondary peritonitis from other causes and died on the thirty-first. A fracture of the transverse process existed, but unfortunately the spinal canal was not opened for examination and no details can be given as to the condition of the cord. (See case 201, p. 463.)

On the tenth day subsequent to the injury, the hyperæsthesia in the area of lumbar supply was replaced by normal sensation, motor power began to be slowly regained in the muscles supplied by the anterior crural and obturator nerves, and the patellar reflex returned. At this time lowered sensation returned in the area supplied by the sacral plexus, but no improvement in motor power took place, and no control was regained over the bladder and rectum.

During the succeeding week some sciatic hyperæsthesia developed, but on the twenty-eighth day the patient developed secondary peritonitis from other causes and died on the thirty-first. A fracture of the transverse process existed, but unfortunately the spinal canal was not opened for examination and no details can be given as to the condition of the cord. (See case 201, p. 463.)

Fractures of thespinous processes, or those involving both the process and laminæ, were not uncommon. Isolatedseparation of the spinous process was usually the result of wounds crossing the back obliquely or transversely. Examples of this injury were numerous, especially in the dorsal region, as being the most prominent, particularly when the patients assumed the prone position when advancing on the enemy.

Cervical injuries, owing to the comparatively sheltered position of the more deeply sunk spines, and from the fact that the head was usually under cover of a stone or ant-heap, were less common; in one instance hyperæsthesia was noted in one upper extremity as the result of a crossing bullet having struck the fourth cervical spine. In a man wounded at Paardeberg Drift the bullet entered at the centre of the buttock, traversed the bones of the pelvis, and, leaving that cavity above the crest of the ilium, crossed the spine to emerge in the opposite loin. Suppuration occurred, and when the wound was laid open the third and fourth lumbar spinous processes were found to be loosened, but still connected to the surrounding soft parts. There were no nerve symptoms in this case; these would not have been expected, since by the time that the bullet had traversed the bones of the pelvis its velocity must have been considerably lessened, even if high at the moment of primary impact. In another case a dorsal spine, together with its lamina, was separated and moveable; the only nerve symptoms were slight pain and a crop of herpes on the line of distribution of the corresponding intercostal nerve, the bullet having probably struck the nerve in passing across the intercostal space. In one instance of a retained bullet lying beneath the skin of the back, its passage between two contiguous dorsal spines without fracture of either was determined during an extraction operation.

When the prone position was assumed by the men, more or less longitudinal wounds in the course of the spine were naturally liable to occur. These tracks assumed somewhat greater importance than the transverse ones, because the injury to bone was more often multiple, and the laminæ were frequently implicated. The relative importance of such injuries was dependent on the velocity of the bullet and thedepth at which it travelled. As an instance of a more serious character the following may be given:—

(95) In a Highlander wounded at Magersfontein, probably at a range within 1,000 yards, the bullet entered at the right side of the sixth cervical vertebra; tracking downwards, it loosened the laminæ of the fifth and sixth dorsal vertebræ from the pedicles, and separated the tip of the seventh spine. The bullet was extracted from beneath the skin at the latter spot, its force having been no doubt exhausted by the resistance of the firm neural arches supported by the weight of the man's body. Symptoms of total transverse lesion of the cord followed, and the patient died at the end of fifty-four days. The bone had not apparently been sufficiently depressed to exert continuous pressure, but the cord was diffluent and actually destroyed over an area corresponding with the fourth, fifth, sixth, and seventh dorsal segments.

I saw no instance of wound of theneural archfrom a direct shot in the back in any of our men, neither was I ever able to detect an injury to the articular processes as a localised lesion.

Injuries to thecentrawere very frequent, but differed extraordinarily in their importance. Perforation by bullets travelling at a relatively low grade of velocity, but still one sufficient to allow them to pass through the body, produced in many instances no symptoms whatever when the track did not lie in immediate contiguity to the spinal canal or perforate it.

In all the wounds which I had the opportunity of examining post mortem, the fracture was of the nature of a pure perforation of the cancellous tissue of the centrum, with no comminution beyond slight splintering of the compact tissue at the aperture of exit. In one instance the bullet passed in a coronal direction so close to the back of the centrum as to leave a septum of only the thickness of stout paper between the track and the spinal canal. In this case signs of total transverse lesion were present. I never happened to meet with a case in which the canal was encroached upon from the front by displaced bone. In some cases at the end of six weeks there was difficulty in determining the position of the openings, and section of the bone was necessary in order to assure oneself as to the direction of the track.

In some instances the centra were pierced in the coronal direction with varying degrees of obliquity; in others the direction was more sagittal; in two of the latter the bullet was retained in the spinal canal. The tracks were sometimes confined to one vertebra, but often implicated two. In others the bullet passed longitudinally through the thorax, grooving or perforating one or more centra.

The accompanying evidences of nerve injury varied from nil to those of pressure or irritation of the nerve roots, transient signs of spinal concussion, signs of contusion and hæmorrhage, or to evidence of total transverse lesion. Instances of all these conditions will be quoted under the heading of injuries to the cord or nerves.

Signs of injury to the vertebræ.—Separation of the spinous processes was often indicated by slight deformity, either evident or palpable, local pain, tenderness, mobility, and crepitus. In some cases these local signs were reinforced by evidence of cord injury. Fractures involving the laminæ differed merely in the degree to which the above signs were developed. Fractures of the transverse processes were generally only to be assumed from the position and direction of the wounds, the assumption being sometimes strengthened in probability by evidence of injury to the cord and nerves.

Fractures of the centra were also frequently only to be assumed from the direction of the wound tracks, and possibly from evidence of nerve injury. When no paralysis supervened, interference with the movements of the back, or pain, was so slight as to be inappreciable, especially in the presence of concurrent injury to other parts, which was seldom absent. I only once saw any angular deformity from this injury, and that slight, and not apparent before the end of three weeks. In this particular a very striking difference exists between injuries from small-calibre bullets and larger ones such as the Martini-Henry. In the only instance of Martini-Henry fracture of the spine that came under my notice, the centrum was severely comminuted and deformity was obvious. Still, as in so many particulars, the difference was only one of degree, since comminution of the centra in gunshot wounds has always been observed to be slight in naturecompared with what is met with in the compression fractures of civil life.

A few words will suffice to dismiss the questions of diagnosis, prognosis, and treatment of the above injuries. The diagnosis depended on attention to the signs above indicated, the prognosis almost entirely on the concurrent injury to the nervous system, which will be considered later, and the treatment consisted in enforcing rest alone.

Anatomical lesions.—In introducing the subject of the nature of the lesions of the spinal cord and membranes, I should again enforce the statement that their character and degree, in comparison with the slight accompanying bone damage, are pathognomonic of gunshot wounds, and that these characters find their completest exemplification in injuries produced by bullets of small calibre, endowed with a high grade of velocity. Again, that the varying degrees of damage depend comparatively slightly on the position of the bone lesion, apart from actual encroachment on the canal, while the degree of velocity retained by the bullet at the moment of impact is all-important. In no other way are the divergent results to be explained which follow an apparently identical injury, in so far as extent, position, and external evidence of damage to the spinal column are concerned.

Injuries to the nerve roots of the nature of concussion and contusion, are dealt with in Chapter IX.

Pure concussionof the spinal cord may, I believe, be studied from a better standpoint in the case of small-calibre bullet injuries than in any others, since in many instances it is, I think, possible to exclude any complications such as wrenches and strains of the vertebral column, and ascribe the symptoms to the pure effect of extreme vibratory force communicated to the cord by its enveloping bony canal. The condition must be considered under the two headings of slight and severe.

Inslight concussionthe usually transient effects of theinjury, and its happy tendency not to destroy life, place us in a state of uncertainty as to the occurrence of anatomical changes, since no opportunity of post-mortem examination occurred. The clinical condition included under this term corresponds with that implied in 'spinal concussion' in civil practice. One point of extreme interest, whether the subjects of small-calibre bullet spinal concussion will in the future suffer from the remote effects common to similar sufferers in civil life from other causes such as railway collisions, still remains for future determination. An ample field for such observations has at any rate been created by the present war.

Insevere concussiona far more highly destructive action is exerted. This condition may be followed by complete disorganisation of the cord, accompanied or not by multiple parenchymatous hæmorrhages into its substance. Either or both of these pathological conditions are produced by the impact of the bullet with the spine, given a sufficiently high degree of velocity, and it is difficult to separate clinically the resulting symptoms. This is a matter perhaps of less importance, since it stands to reason that a vibratory force, capable of rupturing the spinal capillaries, would at the same time damage the nervous tissue.

In speaking of concussion of this degree, it should be clearly recognised that a general condition, such as is indicated by the use of the term 'concussion of the brain,' is in no wise implied. The condition is really far more nearly allied to one of contusion, a strictly localised portion of the spinal cord undergoing the destructive process which affects the segments below only in so far as it interrupts the normal channels of communication with the higher centres.

Case 102 is an instance of such a lesion, the post-mortem examination showing clearly that the spinal canal was not encroached upon by the bullet. The cord in this instance appeared little changed macroscopically, and this fact was observed in other instances, both during operations and post mortem.

Contusion.—This condition is very closely allied to the last. In cases 101 and 103 the spinal canal was as little encroached upon as in 102, but the bullet struck the somewhatelastic neural arch in each case, and post mortem an adhesion between the cord and the enveloping dura opposite the point at which impact of the bullet was closest suggests that, in spite of the escape of the bone from fracture, it may have been momentarily depressed to a sufficient degree to contuse the cord, or the latter may have suffered acontre-coupinjury. For these reasons the inclusion of the cases as instances of pure concussion is not warranted. In both Nos. 99 and 100 the neural arch had actually suffered fracture, and although the bone was not depressed or exercising pressure at the time of the autopsies, it was no doubt driven in temporarily at the moment of impact of the bullet.

At the post-mortem examinations of injuries of this nature it was common to find one to four segments of the spinal cord completely disorganised. At the end of some five weeks, the common duration of life, the structure of the cord was represented by a semi-diffluent yellowish material, the consistence of which was so deficient in firmness as to allow the partial collapse of the membranes covering the affected portion, so as to exhibit a definite narrowing when the whole was held up (see fig. 79). In such cases traces of extra- or intra-dural hæmorrhage sometimes still persisted.

Hæmorrhage.—This occurred as surface extravasation and in the form of parenchymatous hæmorrhages. I saw the former both in the extra-dural and peri-pial forms, but never in sufficient quantity to exert a degree of pressure calculated to produce symptoms of total transverse lesion. Here again, however, it is difficult to speak with confidence since the conditions which regulate the tension within the normal spinal canal are so complicated and liable to variation, that it is very difficult to estimate the effect of any given hæmorrhage discovered.

My friend Mr. R. H. Mills-Roberts described to me one fatal case under his care in the Welsh Hospital in which extra-dural hæmorrhage was so abundant as, in his opinion, to have taken a prominent part in the production of the paralytic symptoms.

Examples of both extra- and intra-dural (peri-pial) hæmorrhage are afforded by cases 99, 102, and 103; in none was it large in amount or widely distributed. The condition wasprobably also frequently associated in varying degree with that to be immediately described below.

Intra-medullary hæmorrhage(hæmato-myelia).—The importance of this condition is lessened in small-calibre bullet injuries by the fact already alluded to, that it is almost invariably accompanied by concussion changes. In one instance in which death took place at the end of eight days, partly as the result of concurrent injury, in a man in whom signs of total transverse lesion of the cord were present, the substance of the cord was found to be closely scattered over with hæmorrhages of various sizes and extending for a longitudinal area of some three inches.

As to the frequency with which hæmorrhage into the substance of the cord occurred, I regret to be unable to give an opinion. In the late post-mortem examinations I witnessed, a yellow discoloration of the softened cord was the only macroscopic evidence of hæmorrhage.

Hæmorrhages of this nature may, however, account for the grave paralytic symptoms in some cases of partial or total transverse lesion not due to direct compression or laceration.

The conditions of concussion, contusion, or hæmatomyelia were, I believe, responsible for at least nine-tenths of the cases in which a total transverse lesion was indicated by the symptoms. The extreme importance of realising this fact and the rarity of the production of symptoms by continuing compression both from the prognostic and the therapeutic point of view is obvious.

The analogous injuries termed generally in Chapter IX. nerve contusion, although frequently accompanied by tissue destruction, may be followed by reparative change, and are capable of complete or almost complete spontaneous recovery; while the lesions in the spinal cord are permanent, and complete recovery is only witnessed in the parts affected by the remote pressure or irritation from blood extravasation, or in those influenced by concussion.

I include below short abstracts of all the cases of lesion of the spinal cord which terminated fatally, in which I had the opportunity of witnessing the post-mortem conditions. In a considerable proportion of the cases at the end of six weeksthe spinal cord was softened over an area of from two to four segments in such degree as to have practically lost all continuity. Although the autopsies were made on patients who had died slowly and in summer weather, often twelve to sixteen hours after death, I think it can be but fair to assume, when the consistency of the remaining portion of the spinal cord is considered, that the softening was only in slight degree if at all exaggerated by post-mortem change. Again symptoms of secondary myelitis and meningitis had been observed in some of the fatal cases prior to death.

I had but one opportunity of observing a case in which a retained bullet exercised compression, and none in which this was due to displaced bone fragments. I also only once came across a case of complete section, but no doubt both bone pressure and section may have occurred with greater frequency amongst patients dying on the field or shortly after. The case of section is illustrated in fig. 80. It will be noted that, although the section is complete, the bullet lies to one side of the canal, and hence the bullet, as fixed in its course by the bone of the centrum, directly struck but half of the whole width of the cord.

It was striking how little secondary change in the cord had occurred in the neighbourhood of the spot of division. This well illustrates the comparatively slight vibratory effect of a bullet travelling with a degree of velocity insufficient to completely perforate the vertebral column.

Symptoms of injury to the spinal cord.—Inslight spinal concussionthese exactly resembled those of the more severe lesions, except in their transitory nature. They consisted in loss of cutaneous sensibility, motor paralysis, and vesical and rectal incompetence. The phenomena persisted from periods of a few hours to two or three days, return of function being first noticeable in the sensory nerves, and often with modification in the way of lowered acuteness, or minor signs of irritation, such as formication, slight hyperæsthesia or pain, pointing to a combination with the least extensive degrees of hæmorrhage; later, motor power was rapidly regained. The subjects of such symptoms often suffered from weakness and unsteadiness in movement for some days or weeks; asharp line of discrimination between such cases and those described in the next paragraphs is manifestly impossible.

Spinal hæmorrhage.—The symptoms of this condition developed differently according to whether concurrent concussion existed. Occasionally very typical instances of pure hæmorrhage were observed with transient symptoms:—

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