Chapter Iii. P. 87, Illustrates the Capacity of the Hard Edge of the

bone to check the course of a bullet, and cause considerable deformity and fissuring of the mantle.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

WOUNDS OF THE NECK

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

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

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

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

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

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

In connection with the latter statement, the rarity of direct sagittal wounds in the hospitals should be mentioned. This is probably to be explained by the facts that wounds in the mid-line of the neck implicated the cervical spinal cord, and that sagittal wounds implicating the vessels were apt to lead more directly to the surface, and thus external haemorrhage was favoured. A few examples of cervical tracks will suffice to illustrate these remarks:--

(85) Entry (Lee-Metford), below angle of scapula; exit, centre of posterior triangle. Injury to the lung, and haemothorax. No damage to neck structures.

(86) Entry (Mauser), over Pomum Adami; exit, below right scapular spine. Median and musculo-spiral paralysis.

(87) Entry, a large oval aperture through ninth right rib, 1/2 an inch external to scapular angle; exit, anterior border of sterno-mastoid opposite Pomum Adami. Second entry, opposite angle of mandible; exit, in centre of cheek.

Wound of lung. Musculo-spiral paralysis still persisting at the end of nine months.

(88) Entry (Mauser), 2 inches above left clavicle at margin of trapezius; exit, 1 inch from sternum in left first intercostal space. Contusion of brachial plexus, with mixed signs, which disappeared in two months. No signs of vascular injury.

See also cases of cervical aneurism, &c.

Wounds of the pharynx.--I saw only three cases of wound of the pharynx; in each the injury was in the nasal or buccal segment of the cavity, and in each the soft palate was injured, in two instances the wound being a small perforation.

All three cases belong to the somewhat miraculous class. The first (89) was the only one in which the wound gave rise to subsequent trouble. The second was under the charge of Mr. Bowlby, and will no doubt be more fully recounted by him, as interesting signs of injury to the cervical cord were present. In the third the occipital neuralgia was the only troublesome symptom.

In both cases 90 and 91 the high position of the wound in the fixed portion of the pharynx no doubt accounted for the absence of any infective trouble.

(89) Wounds of the pharynx.--Entry (Lee-Metford), immediately below the tip of right mastoid process; the bullet traversed the neck, entering the pharynx close to the right tonsil, crossed the cavity of the pharynx and the mouth, emerging through the left cheek. Great swelling of the fauces and dysphagia persisted for some days after the injury, and there was considerable haemorrhage.

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

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

(91) Entry (Mauser), through the mouth, knocking out the left upper canine and bicuspid teeth. Perforation of the soft palate just to the right of the base of the uvula and the posterior wall of the pharynx; exit, 1-1/2 inch internal to and 1/2 an inch below the tip of the right mastoid process. Haemorrhage persisted for half an hour, and the patient could not swallow solids for a week. Great occipital neuralgia followed the wound.

Wounds of the larynx.--I saw only one wound of the larynx (see No. 10, p. 135). In this instance the thyroid cartilage was wounded on either side at the level of the Pomum Adami. Transitory haemorrhage and signs of oedema were the only signs referable to the wound, but in addition the bullet contused the left vagus and gave rise to temporary laryngeal paralysis. The same course was observed in a second case of perforation of the larynx of which I was told.

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

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

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

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