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 sh.e.l.l 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 sh.e.l.l 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 a.s.serted 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 cla.s.sed 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 p.r.o.ne 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 deglut.i.tion, 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 ill.u.s.trate 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 s.p.a.ce. 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 cla.s.s. 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 pa.s.sed 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 pa.s.sed 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 const.i.tuent vertebrae and the contents of the spinal ca.n.a.l 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 pa.s.sing 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 ca.n.a.l 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 pa.s.sed 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 r.e.c.t.u.m.

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 ca.n.a.l 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 a.s.sumed the p.r.o.ne 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 b.u.t.tock, 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 pa.s.sing across the intercostal s.p.a.ce. In one instance of a retained bullet lying beneath the skin of the back, its pa.s.sage between two contiguous dorsal spines without fracture of either was determined during an extraction operation.

When the p.r.o.ne position was a.s.sumed by the men, more or less longitudinal wounds in the course of the spine were naturally liable to occur. These tracks a.s.sumed 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.