Anatomical lesions.—The wound tracks, with regard to the injuries produced, may be well classified according to the direction they took; thus—vertical, transverse, and oblique.

Vertical wound tracks were on the whole the least serious, but this mainly from the fact of limitation of the injury to one orbital cavity. They were usually produced by bullets passing from above downwards through the frontal region of the cranium, and were received by the patients while in the prone position.

Transverse and oblique wounds owed their greater importance to the fact that both eyes were more likely to be implicated.

Besides these tracks, which actually crossed the cavities, a number involved the bony boundaries, producing almost as severe lesions in the globe of the eye, many of the patients being rendered permanently blind. The only difference in nature of such cases was the escape of orbital structures, and this was of minor importance in the presence of the graver lesion to vision. The following is an illustrative case:—

(74) Wounded at Colenso. Entry (Mauser), 1 inch below the centre of the margin of the right orbit; exit, behind the right angle of the mandible. Fracture of lower jaw, and development of a diffuse traumatic aneurism of the external carotid artery. The common carotid artery was tied for secondary haemorrhage (Mr. Jameson) some three weeks later.

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

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

Occasionally the margin of the cavity was merely notched.

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

(75) Entry (Mauser), 2 inches behind the right external canthus; the bullet pierced the external wall and traversed the floor of the right orbit beneath the globe, crossed the nasal cavity, and a part of the left orbit; exit, at the lower margin of the left orbit, beneath the centre of the globe of the eye.

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

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

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

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

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

Mr. J. H. Fisher reported as follows:

Ophthalmoscopic examination shows the left eye and fundus to be normal. The right disc is not atrophied, but the whole of the lower half of the fundus is coated with masses of black retinal pigment. There is atrophy in spots of the capillary layer of the choroid, and the larger vessels of the deeper layer are exposed between the interstices of the pigment masses. There is no definite choroidal rupture. The lesion encroaches upon and implicates the macular region.

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

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

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

Injury to the nerves was naturally of a very mixed character. In many instances the branches of the first two divisions of the fifth nerve were obviously implicated and regional anaesthesia was common. This was often transitory when the result of vibratory concussion, contusion, or pressure from haemorrhage. 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 haemorrhages from choroidal ruptures of a similar nature to those seen in the brain and spinal cord. The actual haemorrhagic areae varied in size; but, as far as my experience went, gross haemorrhages into the anterior chamber did not occur without severe direct contact of the bullet.

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

Cases were, however, seen occasionally in which the symptoms were less sudden, of which the following is an example. I did not think that the mode of progress seen here could be referred to simple orbital haemorrhage, although this existed, but rather to intravaginal haemorrhage 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 palpebrae superioris acted very slightly; the right, however, better than the left.

There were marked right proptosis, less left proptosis, and slight patchy subconjunctival haemorrhage 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, haemorrhage, 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. Anaesthesia 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 haemorrhage 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 palpebrae 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 haemorrhage, oedema and ecchymosis of lids.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(82) Wounded at Rooipoort. Entry (Mauser), through the lower lip; the bullet struck the base of the right lateral incisor and canine teeth, knocked out a wedge, and becoming slightly deflected, cut a vertical groove to the base of the mandible; exit, in left submaxillary triangle. The bullet subsequently re-entered the chest wall just below the clavicle, and escaped at the anterior axillary fold. The appearance of these second wounds suggested only slight setting up of the bullet; the original impact was no doubt of an oblique or lateral character.

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

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

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

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

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

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

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

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

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

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

(84) A Highlander was the unfortunate possessor of an entire set of upper teeth set in a gold plate. A small fragment of a shell perforated the upper lip by an irregular aperture, and struck the teeth in such a manner as to turn the posterior edge of the plate towards the tongue, which latter was cut into two halves transversely through to the base.

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

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

Tracheitis and septic pneumonia developed, and the man died of acute septicaemia thirty-six hours later. Death occurred just as the Division received marching orders, and no post-mortem examination was made. As a result of palpation at the time of the tracheotomy, the probabilities seemed against the presence of the tooth plate in the pharynx, but the absence of positive evidence scarcely allows the case to be certainly classed as one of cellulitis and septicaemia secondary to wound of the tongue.

WOUNDS OF THE NECK

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

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

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

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

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

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

In connection with the latter statement, the rarity of direct sagittal wounds in the hospitals should be mentioned. This is probably to be explained by the facts that wounds in the mid-line of the neck implicated the cervical spinal cord, and that sagittal wounds implicating the vessels were apt to lead more directly to the surface, and thus external haemorrhage 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 haemothorax. 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 haemorrhage.

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

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

(91) Entry (Mauser), through the mouth, knocking out the left upper canine and bicuspid teeth. Perforation of the soft palate just to the right of the base of the uvula and the posterior wall of the pharynx; exit, 1-1/2 inch internal to and 1/2 an inch below the tip of the right mastoid process. Haemorrhage 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 haemorrhage and signs of oedema were the only signs referable to the wound, but in addition the bullet contused the left vagus and gave rise to temporary laryngeal paralysis. The same course was observed in a second case of perforation of the larynx of which I was told.

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

(92) Entry (Mauser), on the outer side of the right arm, 3-1/2 inches below the acromion; exit, 3 inches below the tip of the left mastoid process, through the sterno-mastoid. Thirty six hours later there was very free haemorrhage into the right posterior triangle, emphysema at the episternal notch, dysphagia, and complete obliteration of the cardiac area of dulness. Respiration was rapid (40) and extremely noisy. Pulse 130, small and weak.

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

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



CHAPTER VIII

INJURIES TO THE VERTEBRAL COLUMN AND SPINAL CORD

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

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

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

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

For implication of the transverse processes sagittal wounds coursing in varying degrees of obliquity were mainly responsible. Such injuries might be unaccompanied by any nerve lesion. Thus a Boer received a Lee-Metford wound at Belmont which passed from just below the tip of the right mastoid process across the pharynx and through the opposite cheek. No bone damage was at first suspected; suppuration in the neck, however, followed infection from the pharynx, and when a sinus which persisted was opened up later, a number of small comminuted fragments were found detached from the transverse process of the axis. In other cases more or less severe symptoms of nerve lesion were observed, varying from transient hyperaesthesia, due to implication of the issuing nerves, to symptoms of spinal haemorrhage, 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 faeces, complete motor and sensory paralysis of the right lower extremity, and total absence of all reflexes. Anaesthesia existed over the whole area of skin supplied by the nerves of the sacral plexus, hyperaesthesia over that supplied by the lumbar nerves.

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

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

Cervical injuries, owing to the comparatively sheltered position of the more deeply sunk spines, and from the fact that the head was usually under cover of a stone or ant-heap, were less common; in one instance hyperaesthesia 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 laminae were frequently implicated. The relative importance of such injuries was dependent on the velocity of the bullet and the depth at which it travelled. As an instance of a more serious character the following may be given:—

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

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

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

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

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

The accompanying evidences of nerve injury varied from nil to those of pressure or irritation of the nerve roots, transient signs of spinal concussion, signs of contusion and haemorrhage, 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 vertebrae.—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 laminae differed merely in the degree to which the above signs were developed. Fractures of the transverse processes were generally only to be assumed from the position and direction of the wounds, the assumption being sometimes strengthened in probability by evidence of injury to the cord and nerves.

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

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

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

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

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

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

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

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

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

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

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

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

Haemorrhage.—This occurred as surface extravasation and in the form of parenchymatous haemorrhages. 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 haemorrhage 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 haemorrhage 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) haemorrhage are afforded by cases 99, 102, and 103; in none was it large in amount or widely distributed. The condition was probably also frequently associated in varying degree with that to be immediately described below.

Intra-medullary haemorrhage (haemato-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 haemorrhages of various sizes and extending for a longitudinal area of some three inches.

As to the frequency with which haemorrhage 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 haemorrhage.

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

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

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

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

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

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

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

(96) A private in the Yorkshire Light Infantry was wounded at Modder River; the bullet entered between the eleventh and twelfth ribs, just posterior to the left mid-axillary line, emerging in the posterior axillary fold, at its junction with the right side of the trunk. On the second day after the injury the lower extremities became drawn up, the knees and hips assuming a flexed position, and this was followed shortly by the advent of complete motor and sensory paraplegia, accompanied by retention of urine. Two days later, the patient again passed water normally, and gradual and rapid return of both sensation and motor power took place. At the end of fourteen days no trace of the condition remained, and the patient was shortly after sent home.

The symptoms, however, were rarely so simple as in this example; it was very much more common to meet with an admixture of signs of primary concussion, or at any rate symptoms of radiation. The following is an extreme but excellent example of more complicated and prolonged effects:

(97) A lance-corporal of the Black Watch was wounded at Magersfontein at a range of from 400 to 500 yards. The bullet entered over the left malar bone 2-1/2 inches from the outer canthus, while the aperture of exit was 2-1/4 inches above the inferior angle of the right scapula, 3/4 of an inch anterior to its axillary margin.

Very shortly after the injury complete motor and sensory paralysis developed in both upper extremities, followed by the development of a similar condition in the left lower limb, and retention of urine and faeces, but the latter unaccompanied by the marked abdominal intestinal distension so characteristic in cases of total transverse lesion. The right side of the chest continued to work well, but the intercostals of the left side were paralysed. No disturbance of the normal action or condition of the pupils was noted. After the first few days the condition began to improve.

Three weeks later, the chest was moving symmetrically and well, sensation and motor power had returned in considerable degree in the left lower extremity, with marked increase in both the plantar and patellar reflexes; sensation had returned in both upper extremities, a slight amount of motor power was regained in the right, but the left remained entirely flaccid and incapable of movement.

At the end of a month power was regained over both bladder and rectum, some slight movement of the left thumb was possible, and a certain degree of hyperaesthesia developed over the back of the forearm.

At the end of six weeks there was little further alteration, but that in the direction of improvement. There was some wasting of the muscles of the left upper extremity, and this was most marked in the muscles supplied by the ulnar nerve.

At the end of ten weeks the patient had been up some days; he could stand and walk, but was unable to rise from the sitting posture without help. The plantar and patellar reflexes were much exaggerated, and there was ankle clonus, most marked in the left limb. The right upper extremity was normal, but weak; there was wrist-drop on the left side and the deltoid was wasted and powerless; on the other hand the fingers could be flexed, and although the elbow could not be, there were signs of returning power in the biceps, and some movements of the shoulder could be performed by the capsular muscles. It was remarkable that common sensation was more acute in the left than the right lower extremity, but I attributed this to the remains of hyperaesthesia on the left side. The patient left for home shortly after the last note.

In both these cases the absence of marked hyperaesthesia or pain points to medullary haemorrhage (haemato-myelia) as the pathological condition produced by the injury. In this particular they contrast well with case 94 quoted on page 315, where the degree of both hyperaesthesia and pain indicated a combination of pressure and irritation of the nerve roots by surface haemorrhage on the affected side. In case 97 the persistence for four weeks of paralysis of the bladder and rectum suggested medullary haemorrhage in addition, while the return of patellar reflex in the paralysed limb negatived the occurrence of an extensive destructive lesion.

In view of the extreme interest of these cases I will shortly detail one other in which the cauda equina alone was affected.

I must confess my inability to place the case definitely in the category either of concussion or medullary haemorrhage. As so often happened, both conditions probably took part in the lesion. The immediate development of the primary symptoms is no doubt to be referred to concussion, while the patchy nature of the prolonged lesion and gradual recession of the symptoms point to the presence of haemorrhages. We find here the link most nearly connecting the spinal cord and the peripheral systemic nerves. Such a case goes far to show that the condition which I have in the next chapter often referred to as nerve contusion may in fact be produced by an injury far short of actual contact.

(98) A trooper in the Imperial Yeomanry, while advancing in the crouching attitude, was struck by a bullet from his left front, at an estimated distance of 300 yards. The bullet traversed the right arm anteriorly to the humerus, entered the trunk in the line of the posterior axillary fold, 1-1/2 inch below the level of the nipple, crossed the thoracic and abdominal cavities, deeply striking the lumbar spine, and finally lodged beneath the skin over the venter of the left ilium. The skin was broken, but the force of the bullet was not sufficient to cause it to pass through, and it was later expressed from the wound by the surgeon. The bullet was a Mauser, and not in any way deformed, although it must at any rate have struck the spine and perforated the ilium.

Immediate paraplegia resulted, both sensation and motor power were completely abolished, but there was no trouble either with the bladder or rectum. No symptoms of injury to either thoracic or abdominal viscera were noted.

Three days after the injury sensation and some return of motor power were observed in the left extremity, and some power of movement in the toes of the right foot.

During the next eight weeks steady but slow improvement took place; during the last three weeks of this period he made the voyage to England. Ever since the injury some elevation of temperature was noted, a rise at night to 100 deg. or at times to 102 deg.; for this no definite cause was discovered. In the tenth week the condition was as follows: The temperature has become normal. The patient has lost flesh to a considerable extent since the reception of the injury. The lower extremities are much wasted, especially the peroneal muscles. Patellar reflexes can be obtained, but the knee jerks are uncertain. Unevenly distributed paralysis exists in both lower extremities. Left—Sensation fairly good throughout. Quadriceps very weak; does not react to electrical stimulation. Calf muscles act fairly. Anterior tibial and musculo-cutaneous groups are paralysed. Right—Quadriceps acts better than on left, muscles below the knee paralysed, and in the same area there is complete absence of sensation. The patient complains of shooting pains in both legs, and there is some deep muscular tenderness.

Three weeks later an abundant crop of vesicles appeared over the front of the right thigh and leg, above and below the knee. Sensation in the limb at the same time returned to a considerable degree, anaesthesia persisting on the outer aspect of the thigh only.

At the end of four months very considerable improvement had taken place, but there was no return of motor power in the right leg, or the muscles supplied by the peroneal nerve in the left leg. There was some general oedema of the legs, especially of the right, possibly in connection with the herpetic eruption which was now disappearing. Muscular tenderness had disappeared. There was also definite improvement in the size and tone of the peroneal muscles, although no motor power was regained.

At the end of five months, slight gradual improvement was still taking place, but the loss of power was nearly as extensive as when the last note was taken. The skin of the right leg was glossy, that of the left apparently normal. At times some hyperaesthesia of the soles was noted, and the plantar reflex was very brisk.

The right anterior tibial and musculo-cutaneous groups of muscles reacted to the strongest faradic current, not to any galvanic current below 20-25 m.a., contraction very sluggish. The same muscles in the left leg also reacted to the strongest faradic current, but only locally, with no sort of effect on the tendons. Similar contractions could be induced in the right quadriceps, but none in the left (Dr. Turney).

Appreciation of heat and cold applied to the skin was fair, but, in the case of heat, distinctly slow in the right leg and foot.

At the end of seven months improvement was still taking place; the patient could now stand, walk a little with crutches, and even ascend and descend a staircase.

* * * * *

Severe concussion, contusion, or medullary haemorrhage producing signs of total transverse lesion, and complete transverse section.—The symptoms of these conditions will be taken together, because, with very slight variations, they may be considered as lesions of equal degree as to severity, bad prognosis, and unsuitability for active interference.

All were characterised by the exhibition of the same essential phenomena, symmetrical abolition of sensation and motor power on either side of the body, absence of any signs of irritation in the paralysed area, and loss of patellar reflex. In a small number of the cases of medullary haemorrhage some return of sensation was observed prior to death; in a still smaller, traces of motor power, and in one or two irritability of the muscles or feeble reflexes pointed to the fact that destruction of the cord was not absolute. As abstracts of a series of cases are appended on page 330, it is only necessary to add a few remarks as to any slight peculiarities which seemed directly dependent on the mode of causation.

It may be first stated that these severe injuries were accompanied by signs of a very high degree of shock. In fact, the shock observed in them was more severe than in any other small-calibre bullet injuries that I witnessed. The patients lay still with the eyes closed, great pallor of surface, sometimes moaning with pain, the sensorium much benumbed, or occasionally early delirium was noted. The pulse was small, often slow and irregular, and the respiration shallow. The originally quiet state was often changed to one of great restlessness of the unparalysed part of the body, with the appearance of reaction.

The degree of primary pain varied greatly, but as a rule it was considerable; in some cases it was excruciating in the parts above the level of the totally destructive lesion, and commonly of the zonal variety. A hyperaesthetic zone at the lower limit of sensation usually existed.

In the majority of the cases pain must have depended on meningeal haemorrhage. In one of the cases related, positive evidence was offered as to this particular by the autopsy, although this was made as long as six weeks after the original injury, since no other source of pressure or irritation was discovered. When I first saw this patient some twenty-four hours after the injury he was moaning with pain, although a strong and plucky man; I hastened to give him an injection of morphia, and assured him that it would relieve his suffering: as I left I heard him say to his neighbour: 'That is no use; they gave me three last night, and I was no better,' and his remark proved true.

In high dorsal and cervical injuries the temperature rose high, in one case to 108 deg. F.; I had no opportunity, however, of observing the temperature in any case immediately before and after death. During the hot weather the profuse sweating of the upper part of the body contrasted very strongly with the dry skin of the paralysed part.

The heart's action was often particularly irregular in the dorsal injuries, and the respiration slow and irregular; as these cases, however, were often complicated by severe concurrent injuries to internal organs, the irregularities could hardly be ascribed to the spinal-cord lesion alone. In cases of pure diaphragmatic respiration, the rate did not as a rule exceed the normal of 16 or 20 to the minute, and it was quite regular; this was noted soon after the injury and persisted throughout the course of the cases. As is usually the case, both respiration and the heart's action were most embarrassed in the cases in which abdominal distension was a prominent feature. In some of the neck cases the Cheyne-Stokes type of respiration was very strongly marked.

In cases of low dorsal injury intestinal distension was extreme, and I think more troublesome than the same condition as seen in civil practice. The distension was accompanied by most persistent vomiting, continuing for days, and in the cases that lived for some time severe gastric crises of the same type occurred in some instances.

Priapism was a common symptom; but, as is seen from the cases quoted, was rarely due to any gross direct laceration of the cord.

Trophic sores were both early to develop, and extensive; primary decubitus occurred in all the cases I saw, and steady extension followed. In one case a remarkable symmetrical serpiginous ulceration developed in the area of distribution of the cutaneous branches of the external popliteal nerve on the outer side of the leg.

The paralysis in nearly every case was of the utterly flaccid type, and wasting of the muscles was early and extreme. This was occasionally accentuated by the supervention of myelitis.

Opportunities for making observations on the quantity of urine secreted were not great, and I can offer no remark as to the occurrence of polyuria. In one rapidly fatal case, however, suppression of urine occurred.

(99) Lumbar region. Transverse lesion.—Range under 1,000 yards. Wound of entry (Mauser), over the seventh rib 1 inch from the left posterior axillary fold; exit, over the centre of the right iliac crest. Complete symmetrical motor and sensory paralysis of lower extremities, entire abolition of reflexes, retention of urine.

On the ninth day there was some return of sensation in the lower extremities, and a cremasteric reflex was to be obtained. A large bedsore had developed over the sacrum. No further change occurred in the lower extremities. The patient became progressively emaciated and exhausted, cystitis persisted, the bedsore deepened. The man eventually developed signs of a large basal abscess in the left lung, and died on the forty-second day.

At the post-mortem a fracture of the first lumbar lamina was discovered, with some splintering of the bone; the lumbar spinous process was attached and in its normal position. Opposite the centre of the cauda equina were the remains of a considerable haemorrhage, both extra- and intra-dural, the nerves appearing somewhat compressed, but of normal consistency. The muscles of the back were infiltrated with putrid pus on both sides. A pulmonary abscess cavity the size of a hen's egg occupied the upper part of the lower lobe of the left lung. The kidneys were congested, and the bladder thickened and chronically inflamed.

(100) Cervico-dorsal region. Total transverse lesion.—Wound of entry (Mauser), to the right of the sixth cervical vertebra: the bullet was removed on the field from the left of the seventh dorsal spinous process, which was somewhat prominent. Complete motor and sensory paralysis extended upwards to the third intercostal space; the breathing was almost entirely diaphragmatic. Retention of urine. Entire abolition of reflexes in lower limbs and trunk. Hyperaesthesia was present in both upper extremities, with a zone of hyperaesthesia around the chest. The patient suffered greatly for some weeks from pain in the hyperaesthetic area, he developed severe cystitis and later incontinence of urine. A large trophic sacral bed-sore steadily increased in depth and size.

About ten days before death, which occurred on the fifty-third day from exhaustion and septicaemia, the patient complained of pains in his legs; but there was no return of sensation, motion, or reflexes.

At the post-mortem, the seventh dorsal spinous process was found to be loose and the laminae of the fifth, sixth, and seventh vertebrae were separated from the pedicles, and somewhat depressed on the left side. These laminae were adherent to the dura, as were also a few small separated bony spiculae. There was no sign of old haemorrhage. The spinal cord was practically gone between the levels of the fourth and seventh dorsal vertebrae, and diffluent from myelitis up to the third cervical.

(101) Dorsal region; total transverse lesion.—Wound of entry (Mauser), in the left supra-spinous fossa of the scapula; exit, between the eleventh and twelfth ribs of the right side. Complete motor and sensory paralysis, with absence of reflexes from mid-dorsal region downwards. Upper intercostals working. Retention of urine, penis turgid. Sensation perfect to lower extremity of sternum. Early trophic sacral bed-sores developed and steadily increased in depth and extent, slighter ones developed on the heels. The paralysis was flaccid throughout. The patient gradually emaciated with fever, and died on the seventy-eighth day.

At the post-mortem the wound proved not to have penetrated the thorax, and both the vertebral spines and laminae were intact, no trace of bony injury being discoverable. Opposite the sixth dorsal vertebra, for a distance of 1-1/2 inch, the cord and dura were adherent, and over the same area the cord was represented by soft custard-like material. There was no sign of old haemorrhage.

(102) Dorsal region; total transverse lesion; slight extra-dural haemorrhage.—Wound of entry (Mauser), at the posterior aspect of the right shoulder; exit, 2 inches to the left of the spine below the ninth rib.

Complete motor and sensory paralysis below the site of the lesion, with absence of superficial and deep reflexes. Retention of urine. Great abdominal distension, pain, and vomiting. Bed-sores over the sacrum developed on the third day; meanwhile the vomiting continued on and off for a week, and very severe girdle pain persisted.

One month later when seen at the Base hospital considerable improvement had occurred. Sensation had returned in both lower limbs; but flaccid paralysis persisted and both were wasted, especially the left. There was no return of reflexes in the lower limbs, the urine was passed in gushes, and the patient was cognisant when these occurred. The sacral bed-sores were, however, very extensive and becoming larger and deeper.

At the end of the fifth week slight power was regained in the flexors and abductors of the right thigh, and the same muscles of the left limb could be made to contract feebly. Meanwhile the patient suffered with severe fever, accompanied by frequent rigors and profuse sweats; the bed-sore continued to extend, and the urine was foul and contained pus.

The patient continued in a similar condition, progressive emaciation and exhaustion taking place, and at the end of six weeks he died.

At the post-mortem the bullet was found to have tracked beneath the right scapula, entering the chest by the fifth intercostal space and lacerating the right lung; thence it entered the eighth dorsal centrum and tunnelled both this and the ninth diagonally, to escape beneath the ninth rib. On opening the spinal canal the tunnel was found to be separated only by the compact tissue of the centrum from the cavity, while a thin extra-dural haemorrhage separated the dura from the bones anteriorly. The spinal cord exhibited no sign of pressure and was firm and continuous, but up to the lower limit of the dorsal region there was septic myelitis and meningitis, the result of pus having tracked up the canal from the sacral bedsore. Suppurative cystitis and pyelitis were present. The patient was the subject of an old urethral stricture which had given rise to trouble during treatment.

(103) Dorsal region; total transverse lesion; slight intra-dural haemorrhage.—Wound of entry (Mauser), below spine of scapula, close to right axilla; exit, 2-1/2 inches to left of tenth dorsal spinous process.

Complete motor and sensory paralysis below ensiform cartilage, with well-marked hyperaesthetic zone around trunk. All reflexes absent. Retention of urine. Incontinence of faeces. Bed-sores in sacral region developed during the first two days, and seventeen days later well-developed serpiginous trophic sores developed on the outer side of each leg and continued to increase slowly until death. The paralysis remained of the absolutely flaccid variety. Great emaciation occurred, accompanied by hectic fever, the temperature ranging from normal to 102.5 deg.. During the third week double pleurisy developed.

At the post-mortem no bone injury could be detected. The cord and dura-mater were adherent over an area corresponding to the fifth to the eighth dorsal vertebrae, and opposite the seventh the cord was soft and of the consistence of butter. A small intra-dural haemorrhage was still evident below the main lesion, not extensive enough to give rise to serious compression. General adhesions in each pleura. Cystitis.



(104) Dorsal region; section of cord; retained bullet.—Wound of entry (Mauser), in seventh right intercostal space, 4-1/2 inches from the dorsal spinous processes, oval in outline; bullet retained.

Complete motor and sensory paralysis, with absence of reflexes below umbilicus. Retention of urine, incontinence of faeces. Large sacral bed-sore developed rapidly. Right haemothorax.

The patient emaciated rapidly, and for the last fourteen days the temperature ranged to 104 deg., the bed-sore steadily increasing in size. Death occurred on the forty-second day.

At the post-mortem a Mauser bullet was found embedded in the centrum of the twelfth dorsal vertebra. The bullet was slightly curved; its anterior extremity had passed across the spinal canal, and wounding the dura posteriorly rested against the left lamina. The plating of the mantle of the bullet was stripped from half the area of the tip. The dura was not adherent, and the cord was softened for half an inch above the point of section; above this it was normal, the vessels coursing normally to the softened spot. Below the point of section the cord was blanched, but offered no other macroscopic evidence of disease. No evidence of either intra- or extra-dural haemorrhage was detectible.



The right pleura contained a large quantity of dark cocoa-like fluid. Extensive adhesions were present in both pleural cavities. The spleen was much enlarged. At the base of the bladder a large submucous haemorrhage had occurred, the blood-clot had assumed a dark orange colour, and on first opening the viscus the appearance was that of a mass of faeces. The mucous lining elsewhere was slaty grey, with small haemorrhages. The kidneys were large, but no abscesses or pyelitis were present.

(105) Cervico-dorsal region; total transverse lesion.—Wound of entry (Mauser), opposite right sixth cervical transverse process; exit, on left side of third dorsal spinous process. Slight grasping power was present in the hands, and the patient could hold his arms across his chest. Complete motor and sensory paralysis, with absence of all reflexes below. The pupils were moderately contracted. Retention of urine. On the second day blebs appeared on each buttock, and the patient complained of very severe pain in the neck: the temperature rose to 103 deg., and on the third day he died suddenly. No post-mortem examination was made.

I observed two similar cases in the Field Hospital at Orange River, the patients dying on the third day; pain and high temperature were prominent symptoms in both. In one patient early delirium was present.

(106) Dorsal region; Martini-Henry wound.—Wound of entry, oval, 1 inch x 3-1/4 inches; long axis obliquely crossing infra-spinous fossa of right scapula; bullet retained (Martini-Henry). Spine of third dorsal vertebra loose, and a distinct thickening to its right side. Complete symmetrical paralysis extending up to upper extremities. No sensation on surface of trunk below cervical area. Respiration entirely diaphragmatic. Retention of urine, penis turgid. Total absence of reflexes, superficial and deep. Reddening of buttocks, but no bullae.

General hyperaesthesia of upper extremities, with severe spasmodic attacks of pain.

On the third day an exploration was decided upon, in view of the local deformity, and the severe pain in the upper extremities. The third dorsal spine was found to be loose, as a result of bilateral fracture of the neural arch; the bullet had crossed the right limit of the spinal canal, and destroyed the body of the vertebra, and passing onwards had entered the left pleural cavity, into which air entered freely from the operation wound.

The patient was relieved from his pain by the exploration, and lived four days. On the second day after operation, however, the temperature rose to 107 deg., while on the last two days the temperature was normal in the mornings, rising to 105 deg. in the evenings. No alteration resulted in the trunk symptoms.

Diagnosis.—The pure question of the fact of injury of the spinal cord needs no discussion; but it is necessary to make some remarks on the discrimination between concussion, contusion and haemorrhage, meningeal and medullary haemorrhage, the latter condition and compression, and on partial and complete severance of the cord.

The sharp discrimination of cases of concussion from those of slight medullary haemorrhage was necessarily impossible. I think the only points of any importance in diagnosing pure concussion were the transitory nature of the symptoms, and the uniformity of recovery, without persistence of any signs of minor destructive lesion. In medullary haemorrhage the tendency for a certain period was towards increase in gravity in the signs. It goes almost without saying that the latter point was seldom accurately determined in patients struck on the field of battle; these perhaps lay out for hours before they were brought in, and when they were placed in the Field hospital the rush of work did not usually allow the careful observation necessary to clear up this difference in the development of the symptoms. Nevertheless it is preferable to consider the cases in which transitory symptoms persist for a period of hours, or even a couple of days, as instances of pure concussion, unless the existence of this condition can be disproved by actual observation.

Extra-medullary haemorrhage, accompanied by only slight encroachment on the spinal canal, certainly results with some frequency from small-calibre wounds. Some of the quoted cases show this decisively by post-mortem evidence, others by such clinical signs of irritation as pain and hyperaesthesia. I think its presence may also be assumed in cases of total transverse lesion due to medullary haemorrhage or severe concussion, accompanied by well-marked pain and hyperaesthesia above the level of paralysis. As affecting treatment, however, determination of its presence is of small importance.

The important conditions for discriminative diagnosis are those of local compression, actual destructive lesion, whether from concussion changes, contusion, or medullary haemorrhage, and partial and total section of the cord.

First, with regard to compression of the cord, the possible sources are three; (i) extra-dural haemorrhage, which may, I think, be dismissed with mention as rarely capable of producing severe symptoms. (ii) The displacement of bone fragments. This is of less importance than in civil practice, because an injury by a bullet of small calibre, capable of seriously displacing fragments, has probably at the same time produced grave changes in the cord. In the presence of severe immediate symptoms we may tentatively assume that a simultaneous destructive lesion has been produced. In such injuries pain, combined with a tendency to improvement in the paralytic symptoms and return of reflexes, is the only point in favour of bone pressure, unless considerable deformity of the spinal column can be detected by palpation or examination with the X-rays.

(iii) Pressure from the bullet. This is the most important form of compression, because the mere fact of retention of the bullet is evidence of a low degree of velocity, and therefore opposed to the existence of the most severe form of intramedullary lesion. In a case of apparent transverse lesion with retained bullet, shown to me at No. 3 General Hospital by Mr. J. E. Ker, the pain was very severe, and so greatly aggravated by movement that an anaesthetic had to be administered prior to the renewal of some necessary dressings. The general condition of this patient precluded a projected operation, and after death the bullet was found to be pressing laterally upon a cord not materially altered on macroscopic inspection. In the case of retained bullet recorded (No. 104), the slight degree to which the severed ends of the cord appeared altered has been already remarked upon.

Beyond this we are helped by the position of the aperture of entry, and its shape, as evidence of the direction in which the bullet passed, the presence of pain, and positive proof may be obtained by examination with the X-rays.

Lastly, we come to the discrimination of total or partial section, destruction by vibratory concussion or contusion, and severe intramedullary haemorrhage. Except in the case of partial section with localised symptoms, which must be rare, I believe this to be impossible from the primary symptoms, although some indication of possible encroachment on the canal may be obtained from careful consideration of the course of the wound, as evidenced by the position and shape of the openings, the position of the patient's body at the time of reception of the injury being taken into consideration. Later we may get some aid from the possible improvement in the symptoms in the case of haemorrhage. In cases with signs of total transverse lesion, however, the discrimination of the conditions is of little practical importance, since either is equally unfavourable and unsuitable for surgical treatment.

In closing these remarks reference must be made to the occasional occurrence of paraplegic symptoms of an apparently purely functional nature. I saw these on one or two occasions, of which the following is a fair example. A man was wounded in the lower extremity and fell. When brought into the hospital he complained of loss of power in the legs and inability to straighten his back. No very definite evidence was present of serious impairment either of motor or sensory nerves, and the man was got up and walked with crutches. While moving about the hospital camp, another man pushed him down, and the patient then became completely paraplegic. He was placed in bed, and the next day moved his limbs without any difficulty, and gave rise to no further anxiety.

Prognosis.—In slight concussion the importance of prognosis is as to remote effects, and upon this no opinion can be given at the present time. The same may be said concerning cases in which transient symptoms followed the slighter degrees of surface and medullary haemorrhage. In the case of the latter, however, I think it would be rash to give a too confident opinion as to the future non-occurrence of secondary changes.

Severe concussion is probably irrecoverable.

Meningeal haemorrhage of either form is one of the slighter lesions, and less dangerous, both as an immediate condition and as to the probabilities of after trouble. None the less the possibilities of secondary chronic meningitis, or chronic trouble from adhesions, must be kept in mind.

Cases of medullary haemorrhage with incomplete signs are favourable in prognosis, as far as life is concerned; as to complete recovery, however, this is hardly possible; in many cases serious functional deficiency at any rate will remain, while in others the healing of the lacerated tissue and subsequent contraction can scarcely fail to influence unfavourably an already imperfect recovery.

I think it must be a rare occurrence for pressure from bone fragments to be able to be regarded as a favourable prognostic condition, since in the very large majority of cases the velocity of the bullet causing the injury will have been such as to inflict irreparable damage on the cord. Still, cases may occasionally be met with where the velocity has been sufficiently low, or contact with the bone slight enough, to allow of the comparative escape of the cord. In this relation cases in which the bullet is retained, especially if the symptoms of transverse lesion are incomplete, may be regarded as relatively favourable.

Cervical and high dorsal injuries, as in civil practice, offered the worst prognosis. In cases in which symptoms of total transverse lesion were present, as far as my experience went, it was, however, only a matter of importance as to the prolongation of a miserable existence. All the patients eventually died; those with higher lesions at the end of a few days; the lower ones, at the completion on an average of six weeks of suffering.

The actual causes of death resembled exactly those met with in civil practice, except in so far as it was more often influenced or determined by concurrent injuries, a complication so characteristic of modern gunshot wounds. Thus exhaustion, septicaemia from absorption from suppurating bed-sores or from severe cystitis, secondary myelitis, and pulmonary complications, carried off most of the patients.

Treatment.—The general treatment of the cases demanded nothing special to military surgery, except in so far as it was modified by the disadvantage to the patient of necessarily having to be transported, often for some distance. The ill effects of this, particularly in cases of haemorrhage, are obvious, but in so far as fracture was concerned the question of transport did not acquire the importance that it does in civil practice, since the nature of the fractures and their strict localisation did not render movement either painful or particularly hurtful. It was indeed striking how little pain movement, made for the purposes of examination, caused these patients. The treatment of bed-sores, cystitis, or other secondary complications possessed no special features.

The importance of insuring rest in the early stages of the cases of haemorrhage is self-evident; hence, if the possibility exists of not moving the patient, its advantage cannot be too strongly insisted upon. Again, if transport is inevitable, the shorter distance that can be arranged for the better. It should be borne in mind, also, that from the peculiar nature of causation of the injuries, stretcher or wagon transport for short distances is preferable to the vibratory movements of a long railway journey. Beyond this the administration of opium, and in some cases the assumption of the prone position, are both useful in the recent or possibly progressive stage of haemorrhage.

Lastly, as to active surgical treatment by operation. In no form of spinal injury is this less often indicated, or less likely to be useful. It is useless in the cases of severe concussion, contusion, or medullary haemorrhage which form such a very large proportion of those exhibiting total tranverse lesion, and equally unsuited to cases of partial lesion of the same character. Extra-medullary haemorrhage can rarely be extensive enough to produce signs calling for the mechanical relief of pressure; the section of the cord cannot be remedied. In one case with signs of total transverse lesion, in which a laminectomy was performed, no apparent lesion was discovered, and this would frequently be the case, since the damage is parenchymatous. The experience was indeed exactly comparable to that which followed early exposure of the peripheral nerves.

Only three indications for operation exist. 1. Excessive pain in the area of the body above the paralysed segment; operation is here of doubtful practical use, except in so far as it relieves the immediate sufferings of the patient.

2. An incomplete or recovering lesion, when such is accompanied by evidence furnished by the position of the wounds, pain, and signs of irritation of pressure from without, or possibly palpable displacement of parts of the vertebra, that the spinal canal is encroached upon by fragments of bone.

3. Retention of the bullet, accompanied by similar signs to those detailed under 2.

In both the latter cases the aid of the X-rays should be invoked before resorting to exploration.

Operation, if decided upon, in either of the two latter circumstances, may be performed at any date up to six weeks; but if pressure be the actual source of trouble, it is obvious that the more promptly operation is undertaken the better for early relief and ulterior prognostic chances.

In only one case of the whole series I observed did it seem possible to regret the omission of an exploration.



CHAPTER IX

INJURIES TO THE PERIPHERAL NERVE TRUNKS

The occurrence of these injuries has undoubtedly increased in frequency with the employment of bullets of small calibre, and no other class of case more strikingly illustrates the localised nature of the lesions produced by small projectiles of high velocity. Again, no other series of injuries affords such obvious indications of the firm and resistent nature of the cicatricial tissue formed in the process of repair of small-calibre wounds, and in none is the advantage of a conservative and expectant attitude so forcibly impressed upon the surgeon. Implication of the nerves may be primary, or secondary to an injury which left them originally unscathed.

Nature of the anatomical lesions.—In degree these vary in mathematical progression, but the extent of the lesion is not always readily differentiated by the early clinical manifestations, and again the actual damage is not to be estimated by the gross apparent anatomical lesion alone; but, in addition, consists in part in changes of a less easily demonstrable nature, varying with the velocity with which the bullet was travelling and the consequent comparative degree of vibratory force to which the nerve has been subjected. In these injuries, as in those of every part of the nervous system, the degree of velocity appears to gain especial importance both in regard to the general symptoms and the local effect on the functional capacity of the nerve.

This is perhaps a fitting place for the introduction of a few further remarks as to the significance of the term 'concussion' in connection with the injuries produced by bullets of small calibre, since the most striking exemplification of the results following the transmission of the vibratory force of the projectile is afforded by the behaviour of the comparatively densely ensheathed and supported peripheral nerves.

As already pointed out in Chapters VII. and VIII. the chief concussion effects on the nervous tissue of the brain and spinal cord are of a destructive nature, far exceeding those accompanying the injuries designated by the same term seen in the ordinary accidents met with in civil practice, and this damage is comparatively localised in extent.

In the case of the peripheral nerves I have still employed the terms 'concussion' and 'contusion' to designate certain groups of symptoms and clinical phenomena, but any sharp distinction between the two conditions on a morbid anatomical basis is impossible. The results of severe vibratory concussion may, in fact, be more generally destructive than those of contusion, and the subsequent effects more prolonged. A certain length of the affected nerve is apparently completely destroyed as a conductor of impulses, the connective-tissue element alone remaining intact. Under these circumstances a nerve, the subject of the most serious degree of vibratory concussion, which, if cut down upon, may exhibit no macroscopic change, may take a longer period to recover than one in which the presence of considerable local thickening points to direct contact with the bullet, with resulting haemorrhage into the nerve sheath and perhaps partial gross rupture of nerve fibres.

The therapeutic and prognostic importance of the above remarks, if correct, is obvious. The course of the nerve is preserved by its intact connective-tissue framework, and ultimate recovery by a regeneration of the nerve fibres is more likely to be complete, and will be just as rapid, if nature be relied on and the nerve be left untouched by the hand of the surgeon.

It is, I think, undeniable that nerve trunks may escape severe or irrecoverable injury by lateral displacement. The mere fact that the trunk itself may be perforated by a slit in its long axis would suggest the possibility of displacement of the whole structure, and this no doubt occurred with some frequency. Displacement would naturally be most frequent in the case of nerves, such as those of the arm, which run long courses in comparatively loose tissue. In a remarkable case already narrated, an exploratory operation showed the musculo-spiral nerve in the upper part of the arm to have been driven into a loop which projected into, and provisionally closed, an opening in the brachial artery.

I. Simple concussion.—Anatomically, or histologically, no information exists as to the changes which give rise to the often transitory symptoms dependent on this condition. We are reduced to the same theories of molecular disturbance and change which have been invoked to account for similar affections of the central nervous system. The causation of concussion is, however, materially influenced in its degree by the velocity of flight of the bullet and consequent severity of the vibratory force exerted. Hence actual contact of the bullet with the nerves is not necessary for its production, as is seen in the temporary complete loss of functional capacity in the limbs in many cases of fracture, where the vibrations are rendered still more far-reaching and effective as the result of their wider distribution from the larger solid resistance afforded by the bone. The relative density and resistance offered by the different parts of the bone acquire great significance in this relation, since local shock due to nerve concussion is far more profound when the shafts are struck than when the cancellous ends furnish the point of impact.

The form of concussion which most nearly interests us in this chapter is that affecting single nerve trunks in wounds of the soft parts alone, and here the passage of the bullet is, as a rule, so contiguous to the nerve that there is difficulty in drawing a strict line of demarcation between such cases and those dealt with in the next paragraph.

II. Contusion.—Clinically this was the form of nerve injury both of greatest comparative frequency and of interest from the points of view both of diagnosis and prognosis.

The seriousness of a contusion depends on two factors: first, the relative degree of violence exerted upon the nerve, which is dependent on the force still retained by the travelling bullet; and, secondly, on the extent of tissue actually implicated. The range of fire at which the injury was received determines the importance of the first factor; the second varies with the degree of exactness with which the nerve is struck, and on the direction taken by the bullet. Naturally transverse wounds affect a small area; while an oblique or longitudinal direction of the track may indefinitely increase the extent of injury to the nerve trunk, and hence acquire prognostic significance in direct ratio to the amount of tissue which needs to be regenerated.

As to the actual anatomical lesion resulting in the cases which we designated clinically as contusion I can give no information. On many occasions when the symptoms were considered of such a nature as to render an exploration advisable, no macroscopic evidence of gross injury was obtained. It was therefore impossible to draw a definite line of demarcation between such cases and those which we considered merely concussion. It could only be assumed that the vibration transmitted to the nerve had occasioned such changes as to destroy its capacity as a conductor of impressions.