Chapter VIII: Injuries to the Vertebral Column and Spinal Cord

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

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

_Fractures in their relation to nerve 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 hyperæsthesia, due to implication of the issuing nerves, to symptoms of spinal hæmorrhage, such as are portrayed in the following:--

(94) A private in the Black Watch was wounded at Magersfontein
from within a distance of 1,000 yards. Among other wounds, one
track entered 1 inch to the right of the second lumbar spinous
process, and emerged 1 inch internal to the right anterior
superior iliac spine. There were signs of wound of the kidney,
and in addition, retention of urine, incontinence of fæces,
complete motor and sensory paralysis of the right lower
extremity, and total absence of all reflexes. Anæsthesia
existed over the whole area of skin supplied by the nerves of
the sacral plexus, hyperæsthesia over that supplied by the
lumbar nerves.

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

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

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

When the prone position was assumed by the men, more or less longitudinal wounds in the course of the spine were naturally liable to occur. These tracks assumed somewhat greater importance than the transverse ones, because the injury to bone was more often multiple, and the laminæ were frequently implicated. The relative importance of such injuries was dependent on the velocity of the bullet and 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 laminæ of the fifth and sixth dorsal vertebræ from the
pedicles, and separated the tip of the seventh spine. The
bullet was extracted from beneath the skin at the latter spot,
its force having been no doubt exhausted by the resistance of
the firm neural arches supported by the weight of the man's
body. Symptoms of total transverse lesion of the cord followed,
and the patient died at the end of fifty-four days. The bone
had not apparently been sufficiently depressed to exert
continuous pressure, but the cord was diffluent and actually
destroyed over an area corresponding with the fourth, fifth,
sixth, and seventh dorsal segments.

I saw no instance of wound of 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 hæmorrhage, or to evidence of total transverse lesion. Instances of all these conditions will be quoted under the heading of injuries to the cord or nerves.

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

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

_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 hæmorrhages into its substance. Either or both of these pathological conditions are produced by the impact of the bullet with the spine, given a sufficiently high degree of velocity, and it is difficult to separate clinically the resulting symptoms. This is a matter perhaps of less importance, since it stands to reason that a vibratory force, capable of rupturing the spinal capillaries, would at the same time damage the nervous tissue.

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

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

_Contusion._--This condition is very closely allied to the last. In cases 101 and 103 the spinal canal was as little encroached upon as in 102, but the bullet struck the 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 hæmorrhage sometimes still persisted.

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

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

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

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

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

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

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

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

I include below short abstracts of all the cases of lesion of the spinal cord which terminated fatally, in which I had the opportunity of witnessing the post-mortem conditions. In a considerable proportion of the cases at the end of six 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 hyperæsthesia or pain, pointing to a combination with the least extensive degrees of hæmorrhage; later, motor power was rapidly regained. The subjects of such symptoms often suffered from weakness and unsteadiness in movement for some days or weeks; a sharp line of discrimination between such cases and those described in the next paragraphs is manifestly impossible.

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

(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 fæces, 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 hyperæsthesia 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 hyperæsthesia on the left side. The patient left for
home shortly after the last note.

In both these cases the absence of marked hyperæsthesia or pain points to medullary hæmorrhage (hæmato-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 hyperæsthesia and pain indicated a combination of pressure and irritation of the nerve roots by surface hæmorrhage on the affected side. In case 97 the persistence for four weeks of paralysis of the bladder and rectum suggested medullary hæmorrhage 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 hæmorrhage. 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 hæmorrhages. 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° or at times to
102°; 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, anæsthesia 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
hyperæsthesia 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 hæmorrhage
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 hæmorrhage 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 hyperæsthetic zone at the lower limit
of sensation usually existed.

In the majority of the cases pain must have depended on
meningeal hæmorrhage. 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° 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 hæmorrhage, 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. Hyperæsthesia
was present in both upper extremities, with a zone of
hyperæsthesia around the chest. The patient suffered greatly
for some weeks from pain in the hyperæsthetic 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 septicæmia, 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 laminæ of the fifth, sixth, and
seventh vertebræ were separated from the pedicles, and somewhat
depressed on the left side. These laminæ were adherent to the
dura, as were also a few small separated bony spiculæ. There
was no sign of old hæmorrhage. The spinal cord was practically
gone between the levels of the fourth and seventh dorsal
vertebræ, 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 laminæ 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 hæmorrhage.

(102) _Dorsal region; total transverse lesion; slight
extra-dural hæmorrhage._--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 hæmorrhage 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 hæmorrhage._--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 hyperæsthetic zone around trunk. All reflexes
absent. Retention of urine. Incontinence of fæces. 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°. 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 vertebræ, and opposite the seventh
the cord was soft and of the consistence of butter. A small
intra-dural hæmorrhage 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 fæces.
Large sacral bed-sore developed rapidly. Right hæmothorax.

The patient emaciated rapidly, and for the last fourteen days
the temperature ranged to 104°, 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 hæmorrhage 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 hæmorrhage 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 fæces.
The mucous lining elsewhere was slaty grey, with small
hæmorrhages. 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°, 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 × 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 bullæ.

General hyperæsthesia 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°, 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 hæmorrhage, meningeal and medullary hæmorrhage, 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 hæmorrhage 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 hæmorrhage 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 hæmorrhage, 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 hyperæsthesia. I think its presence may also be assumed in cases of total transverse lesion due to medullary hæmorrhage or severe concussion, accompanied by well-marked pain and hyperæsthesia 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 hæmorrhage, and partial and total section of the cord.

First, with regard to compression of the cord, the possible sources are three; (i) extra-dural hæmorrhage, 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 anæsthetic 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 hæmorrhage. 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 hæmorrhage. 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 hæmorrhage. 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 hæmorrhage 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 hæmorrhage 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, septicæmia 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 hæmorrhage, 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 hæmorrhage 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 hæmorrhage.

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 hæmorrhage 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 hæmorrhage 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.