Even when complete section of the nerve was a.s.sured by the absence of any power of reaction to stimulation by electricity from above on the part of the muscles, operation was better not undertaken until cicatrisation had reached a certain stage. If done earlier than at the end of three weeks, the sutured spot became implicated in a hard cicatrix, and any advantage to be obtained by early interference was lost. When partial division of a trunk was determined, the same date was the most favourable one for exploration, the gap in the nerve being freshened and closed by suture. There is little doubt, however, that in some cases such injuries were recovered from spontaneously.

In view of the uniformly bad results observed in the case of the seventh nerve, I am inclined to think that the above rules might be tentatively relaxed, and the nerve primarily explored by an operation resembling that for mastoid suppuration. It is of course doubtful whether the trouble does not generally result from the vibratory concussion alone; but as this is not certain, and the operation would only have to be performed on patients already permanently deaf, it might be worth while at any rate opening the Fallopian ca.n.a.l with the object of relieving tension. It is not probable that in any of the cases quoted much splintering of the bone had occurred, as the wounds appeared to be of the nature of pure perforations.

CHAPTER X

INJURIES TO THE CHEST

In regard to Prognosis wounds of the chest furnished the most hopeful cla.s.s of the whole series of trunk or visceral injuries. Cases of wound of the heart and great vessels afforded the only exceptions to an almost universally favourable course, both as regards life and the non-occurrence of serious after-effects.

This was mainly explicable on two grounds: first, the sharply localised character of the lesion produced by the bullet of small calibre; and, secondly, the fact that the lung, the most frequently injured organ, is not materially affected by the grade of velocity with which the bullet strikes. In point of fact, wounds of this organ probably afford an instance in which high grades of velocity are distinctly favourable to the nature of the injury, and this is possibly true in the case of wounds of the chest-wall also.

The significance of the calibre of the bullet in wounds of the chest is evident. The late Mr. Archibald Forbes, in one of his letters from the seat of the Franco-German war, remarked that in crossing a battlefield it was easy to recognise the patients who had suffered a wound of the lung from the fact that the whistle of the air entering and leaving the chest was plainly audible. This was, indeed, not uncommonly the case in wounds produced by the older bullets of large calibre, but with the employment of the smaller projectile it has become an experience of the past. Some evidence as to the comparative severity of wounds produced by the larger forms of bullet was, moreover, afforded by the present campaign, since Martini-Henry wounds were occasionally met with. Of some instances observed by myself, in one, external haemorrhage was a prominent symptom; in another, a piece of lung was prolapsed from a wound in the back, and twice I observed pneumothorax, an uncommon sequela to wounds from bullets of small calibre.

It may be remarked, however, that all these more serious injuries were recovered from, also that when we consider that the patients were comparatively young and healthy subjects, the favourable prognosis was what might have reasonably been expected. When, as occasionally happened, a patient of more mature years, with enlarged facial capillaries, received a wound of the lung, the course was in no way so favourable as that witnessed in the case of the younger men.

In support of this opinion I may add that wounds from shrapnel and fragments of sh.e.l.l also did remarkably well, although they sometimes gave rise to more troublesome symptoms than did wounds produced by bullets of the Mauser type. Again, these injuries as a whole were of nothing like so serious a nature as the lacerations of the lung produced by fractured ribs, which we commonly have to treat in civil practice, and are not accustomed to regard as especially dangerous.

It is also a striking fact that the most common and troublesome complication of wounds of the chest, haemothorax, was usually the result of the wound of the chest-wall and not of the lung. I preface these remarks to the detailed account of the thoracic injuries, because I think the favourable course usually taken by patients with wounds of the lung has been accorded somewhat greater prominence than the circ.u.mstances warranted.

_Non-penetrating wounds of the chest-wall._--Surface wounds were not very common, and were chiefly of interest in so far as they ill.u.s.trated the very superficial course that may be occasionally taken by a bullet without breach of the integument, and as sometimes affording opportunity for the exercise of diagnostic skill when the track traversed the axilla.

The most common situation for tracks taking a long course on the surface of the thoracic skeleton was the back. Such wounds were usually received while the patients were p.r.o.ne on the ground; thus I might instance a case in which the bullet entered the posterior aspect of the shoulder 3 inches above the spine of the scapula, pa.s.sed downwards, pierced that process, and emerged 2 inches below the inferior angle of the bone.

Wounds of a similar nature coursing in transverse and oblique directions, and not implicating bone, were also seen. Those implicating the vertebrae have been already dealt with. The scapular region was also a favourite one for the lodgment of retained bullets, some resting in the supra- and infra-spinatus muscles, others lying beneath the bone itself.

On the anterior aspect of the chest, bullets coming from the front sometimes traversed and fractured the clavicle, and then took a short course downwards, emerging over the ribs or sternum. Figure 81 represents a particularly long track in this region. In other cases the precordial region was crossed, but I never witnessed any serious effect on the heart's action in any such injury at the time the patients came under my notice.

Wounds received with the arm outstretched and traversing the axilla sometimes gave considerable trouble in excluding with certainty a perforation of the thoracic cavity. Thus a bullet entered below the centre of the right clavicle and emerged 2-1/2 inches below, above the angle of the scapula, at its axillary margin. The arm was outstretched at the moment of the reception of the injury; but when the wound was viewed with the limb placed alongside the trunk, it seemed almost impossible that the chest cavity could have escaped. In some cases of this kind the difficulty was at once cleared up by noting evidence of injury to the axillary nerves.

A word will suffice as to the treatment of these wounds. The only special indication was to keep the scapula at rest for a sufficient period. I have dealt with the anatomy of them at such length only because in their extreme form they are so highly characteristic of the nature of the injuries which may be produced by bullets of small calibre.

_Penetrating wounds of the chest._--Tracks crossing the thoracic cavity in every direction were common. When the erect att.i.tude was maintained, frontal and sagittal wounds, pure or oblique, were received; when the p.r.o.ne position was a.s.sumed, longitudinal tracks, either purely or obliquely vertical, were the rule. Experience of wounds of the latter cla.s.s was extensive in the present campaign, from the fact that so many of the advances were made in p.r.o.ne or crawling att.i.tudes. The vertical and transverse tracks each possessed the special characteristic of frequently implicating both the thoracic and abdominal cavities, but the vertical were often prolonged into the neck, or even downwards through the pelvis. The vertical wounds in addition sometimes exhibited one very important feature, the fracture of several ribs from within, often at a very considerable distance from the aperture of either entry or exit.

[Ill.u.s.tration: FIG. 81.--Superficial Track in anterior Wall of Trunk]

_Characters of the apertures of entry and exit._--As has already been mentioned, the chest-wall was one of the situations in which the aperture of entry was often large, and the oval form due to obliquity of impact on the part of the bullet was particularly well marked. The exit wounds were often smaller than those of entry, especially if the bullet emerged by an intercostal s.p.a.ce; even when the ribs were comminuted, the fragments were, as a rule, too small to occasion more than a slightly enlarged and irregular aperture. Taken as a cla.s.s, however, and putting aside explosive exit wounds, wounds of the chest afforded more numerous examples of irregular outline and variation in size than were met with in any other region of the body.

When the tracks penetrated the broad upper intercostal s.p.a.ces, an interesting feature, due to the tense and rigid nature of the muscles closing the intervals, and their large admixture of fibrous tissue, was sometimes noticed. The bullet, especially if pa.s.sing obliquely, was apt to cut a slit in the muscles far exceeding in size the opening in the overlying integument, with the result of leaving a palpable subcutaneous defect. Under these circ.u.mstances the yielding spot was often noticed to rise and fall with the movements of respiration, external palpation met with an absence of normal resistance, and there was impulse on coughing.

_Fractures of the ribs._--These injuries were produced in either transverse or longitudinal coursing tracks, their special feature being a sharp localisation of the lesion of the bone.

In tracks crossing the chest transversely the injury to the ribs might consist in notching, perforation, or complete solution of continuity, sometimes with fine comminution. In the incomplete injuries some importance attached to the localisation of the lesion to the upper or lower border of the rib, in so far as the intercostal artery was concerned. Comminution at the wound of entry was, as a rule, not so extensive as at the aperture of exit, and in any case was less apparent, since the fragments were driven inward. The wider comminution at the exit aperture depends on the lesser degree of support afforded by the thoracic coverings to the convex outer surface of the rib, and on the fact that the velocity of the bullet has been lowered by its pa.s.sage through the opposite rib and the chest cavity.

The splinters of comminuted ribs are small, and wide-reaching fissures rare. These characters depend on the elastic nature of the resistance offered by the curved rib to the pa.s.sage of the bullet, which is calculated to preserve the bone from the full force of impact, except at the point actually impinged upon.

Fractures of the ribs, produced from within by bullets taking a longitudinal course through the thorax, were still more special in character. They were also more important, as giving rise to troublesome symptoms.

In these, again, the degree of injury to the bones varied considerably.

In some cases the bones were merely grooved internally, without any external deformity; in other cases a sort of green-stick fracture was produced, accompanied by the projection of a tender salient angle externally; in others complete solution of continuity was effected.

Another feature of importance was the occasional implication of several ribs. In this case the symptoms accompanying the injury were very much more like those observed in the corresponding injuries resulting from indirect violence seen in civil practice.

Injuries to the _costal cartilages_ closely resembled those to the ribs.

Perforation, bending from injury to the inner aspect, and comminution were observed. The latter condition differed from the similar one seen in the case of the ribs only in so far as the tougher consistence of the cartilage did not lend itself to such free comminution, and the splinters remained in great part attached. The nature of the fractures, in fact, somewhat resembled that seen on breaking a piece of cane.

I saw no fracture of the _sternum_ except of the nature of a pure perforation; these were not uncommon in the hospitals, either in the upper or the extreme lower portions of the bone. Fractures in other portions were no doubt usually a.s.sociated with fatal injuries to the heart. The openings were usually so small as to be difficult of palpation, and I never had the opportunity of examining one _post mortem_.

Perforations of the body of the _scapula_ were common, but they were of little importance in symptoms or prognosis.

_Symptoms of fracture of the ribs._--Fractures accompanying transverse wounds of the chest were characterised by the insignificance of the symptoms produced. Every common sign of fracture of the rib was in fact absent. Neither pain, st.i.tch on inspiration, nor crepitus, either audible or palpable, was, as a rule, present. This absence of signs was accounted for by the nature of the lesion: thus in perforations or notchings there was no loss of continuity, while in the freely comminuted fractures the loss of continuity was so absolute as to allow no possibility of the main fragments rubbing together. Again, part of the symptoms attending these injuries, as seen in civil practice, depends upon contusion and laceration of the surrounding structures--a condition precluded by the localised nature of the application of the violence by a bullet of small calibre. In order to establish a diagnosis, therefore, we were in many cases reduced to palpation, and occasionally to direct examination of the wound.

Fractures accompanying longitudinal tracks formed a cla.s.s rather apart in the matter of symptoms. In these mere groovings might also be accompanied by no signs, or at the most by slight local pain and tenderness. When, however, the grooving was sufficiently deep to be accompanied by deformity, or a complete solution of continuity was effected, the signs were often severe. The tender salient angle, or, in the absence of this, a highly tender localised spot, often pointed to the less severe injuries, and when the fractures were complete or multiple, pain was a very prominent symptom, both constant and in the form of inspiratory st.i.tch. The severity of the pain was probably to be in part ascribed to implication of the intercostal nerves, which in these injuries was direct and often multiple. Again, severe contusion or actual laceration of the nerves, with resulting anaesthesia, was less common than when the bullet directly implicated the nerves in transverse wounds. Free comminution and absolute solution of continuity were also less common than in the fractures accompanying transverse wounds; hence pain from rubbing of the fragments on inspiratory movement or palpation was more common, and crepitus, either on auscultation or palpation, was more often met with. Patients with this cla.s.s of fracture often suffered greatly from painful dyspnoea, and were unable to a.s.sume the supine position.

_External haemorrhage_ of severity was rare from these thoracic wounds; in many cases it did not amount to more than local staining of the shirt; altogether I saw only one or two cases where any serious bleeding occurred. Internal haemorrhage into the pleura, in consequence of the position of the intercostal arteries, was common, and often abundant; this will be treated of under the heading of haemothorax.

_Treatment of fractured ribs._--Transverse wounds of the thorax, with no symptoms of fractured ribs, needed to be dealt with as wounds of the soft parts alone.

In multiple fractures accompanying longitudinal tracks, bandaging or strapping for the purpose of fixation was necessary to relieve pain. A few fragments of bone sometimes needed primary removal, and occasionally small sequestra were removed at a later date; but necrosis was rare, unless some complication led to the development of a fistula.

Retained bullets were occasionally met with in the chest wall. In such cases the last remaining energy of the bullet often seemed to have been spent in diving under the margin of a rib and turning longitudinally up or down. Removal was sometimes necessary, either from the prominence produced, the presence of pain, or the continuance of suppuration. Some of the specimens removed offered interesting evidence of the capacity of the ribs to withstand considerable violence from a bullet. These were slightly bent, and marked by a half-spiral groove. I saw such bullets removed from the thoracic and the abdominal wall, and the evidence seemed rather against the groove having been produced prior to their entrance into the body.

[Ill.u.s.tration: FIG. 82.--Spirally grooved Mauser Bullet]

_Wounds of the diaphragm._--Perforations of the diaphragm were very frequent, and as a rule of small significance. When, however, the course taken by the bullet was parallel with that of the slope of the diaphragm, a more or less extensive slit was the result. I saw such a wound still gaping, and 2 inches in length, in the body of a patient who died three weeks after the infliction of a fatal abdominal injury.

In several other obliquely transverse thoracic wounds there was reason to a.s.sume the existence of similar slits. Certain signs were more or less constant under these circ.u.mstances. These consisted in shallow respiration, often accompanied by a groan or the slightest degree of hiccough on inspiration, and considerable increase in respiratory frequency. In one patient the respirations were at first 48, only dropping to 36 some seventy hours after the reception of the injury. In some of the cases in which the abdominal cavity was implicated, wound to the diaphragm seemed a more likely explanation of early, frequent, and painful vomiting than did visceral injury. The possibility of the later development of diaphragmatic herniae in some of these patients will have to be borne in mind in the future.

_Visceral injuries._--The frequent escape of the thoracic viscera from injury, putting aside the lungs which fill so great a part of the cavity, was very remarkable. I never saw a case in which I could a.s.sume injury to any of the posterior mediastinal viscera, although such may have occurred on the field of battle. An injury to the oesophagus, for instance, would almost of necessity be accompanied by wound of either one of the large vessels, even the thoracic aorta, or the spinal column.

I was somewhat surprised, however, to learn on enquiry from surgeons who had seen a large number of the dead and dying on the field, that thoracic wounds, putting aside those that directly implicated the heart, were responsible for but a small proportion of the fatalities.

The escape of the posterior mediastinal viscera, the great vessels, and the heart, is, I believe, to be explained by the fact that all are supported and held in position by the loose meshed mediastinal tissue, which allows for their displacement after the manner observed in the case of the vessels and nerves lying in the loose tissue of the great vascular clefts.

_Wounds of the heart._--Perforating wounds of the heart were probably fatal in all instances, in spite of the fact that, in some patients who survived, the position of wound apertures on the surface of the body made it difficult to believe that the heart had not been penetrated.

(See cases below.)

In the case of this organ, we must bear in mind its constant variations in bulk, its elastic compressibility, and its variations in position in systole and diastole. The variations in bulk and position would be capable of explaining the escape of the organ from injury at some particular moment, when a second shot apparently through the same wound track might implicate it. Beyond this, reasoning from the case of a.n.a.logous hollow viscera, as the arteries or the intestine, a bullet might readily score the surface of the heart without perforating its cavity.

Such accidents were observed. Thus, in a case examined by Mr. Cheatle, the patient died of suppurative pericarditis, secondary to a wound of which the external apertures had closed. In this patient both auricle and ventricle were scored externally by the pa.s.sage of the bullet.

I am, however, disinclined to allow that many patients survived direct blows on the heart, since I believe that in the majority if not in all cardiac wounds the actual cause of death was not haemorrhage, but sudden stoppage of the heart's action. This is to be inferred from the fact that severe external haemorrhage did not occur; in some cases the shirt was hardly stained, and in all death occurred in the course of a very few minutes. Again, in none of the patients whom I saw who had received possible wounds of the heart-wall were there evident signs of haemo-pericardium. In view of the difficulty of detecting this condition from physical signs, this argument is naturally not of great weight, but must be allowed.

One or two death scenes from cardiac wound were described to me. In one the patient muttered 'They have got me this time,' and died quietly; in a second the patient's face became ghastly pale, he lay on his back with the knees flexed, clutching the ground, gasping for breath, and died only after some minutes of evident great agony. The absence of any _post-mortem_ details as to the condition of the heart in these injuries is much to be regretted.

(145) _Entry_, in the seventh left intercostal s.p.a.ce, in the posterior axillary line; _exit_, immediately below the ninth costal cartilage, close to the position of the gall bladder.

This track in all probability involved the diaphragm twice, both lungs and pleurae, and pa.s.sed immediately beneath the heart. The liver was also perforated, but the spleen and stomach probably escaped as far as could be judged from the symptoms. The patient afterwards developed a pneumo-haemo-thorax on the right side. The immediate symptoms were great distress in breathing and rapid irregular pulse. The difficulty in respiration was probably in part accounted for by the injuries to the lung and diaphragm. The pulse remained from 112 to 120 for three days, at first soft and hardly perceptible, later very irregular, and dropping one every fifth or sixth beat; and it seemed fair to attribute this to the shock to the nervous mechanism of the heart. The patient recovered from the chest injury.