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 ca.n.a.l, and destroyed the body of the vertebra, and pa.s.sing onwards had entered the left pleural cavity, into which air entered freely from the operation wound.

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

_Diagnosis._--The pure question of the fact of injury of the spinal cord needs no discussion; but it is necessary to make some remarks on the discrimination between concussion, contusion and 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 ca.n.a.l, 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 a.s.sumed 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 a.s.sume 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 pa.s.sed, 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 ca.n.a.l 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 cyst.i.tis, 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, cyst.i.tis, 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 a.s.sumption of the p.r.o.ne 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 ca.n.a.l 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 circ.u.mstances, 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 cla.s.s of case more strikingly ill.u.s.trates 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 att.i.tude 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 circ.u.mstances 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 pa.s.sage 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 a.s.sumed that the vibration transmitted to the nerve had occasioned such changes as to destroy its capacity as a conductor of impressions.

In some cases the presence of a certain amount of interst.i.tial blood extravasation was suggested clinically by early hyperaesthesia and signs of irritation; in others the paralysis was of such a degree as to lead to the inference that a complete regeneration of the existing nerve would be necessary prior to the rest.i.tution of functional capacity.

In a certain proportion of the injuries the development of a distinct fusiform swelling in the course of the nerve pointed to the existence of considerable tissue damage, while in others this was evidenced clinically by early signs of neuritis.

III. _Division or laceration._--The varying mechanical conditions affecting the last cla.s.s of injury play a similar role here. Thus the degree of laceration depends on the direction of the wound track, and as all lacerations are accompanied by contusion, the relative velocity retained by the travelling bullet a.s.sumes the same importance.