These wounds are comparatively rare. During the War of Secession only 643 cases were seen, and in the war of 1870 only 289. Yet we have just come across a relatively large proportion of them in the ambulances and hospitals at Nancy.

The tracks of the bullets that strike the vertebral column or the spinal cord are antero-posterior, postero-anterior, transverse, or oblique.

The first affect simultaneously the important organs of the face, the neck, the chest, the abdomen, the pelvis. They are exceptional.

The second, less rare, endanger the posterior arches of the vertebrae.

When the axis of the track is median, we find in it notches and perforations of the bodies of the vertebrae or of the apophyses.

Lesions of the Bones.-Bullets notch the laminae, which are really flat bones, splinter, fissure, perforate them, the splinters being either sedentary or thrown forward, and finally separate them.

The laminae, either over or under those that have been directly hit, are sometimes obliquely or vertically fractured by the neighbouring laminae.

The spinous processes present the same lesions.

If these last are carried against the vertebral bodies, their laminae, or their apophyses, the strength of the vertebral column is not imperilled. This fact should be remembered.

Big shell fragments give rise to contusions, fractures, crushing and bony abrasions.

Bullets or splinters may penetrate the vertebral canal.

Meningo-Medullary Lesions - The meninges are generally perforated in a linear direction; sometimes they are torn. The spinal cord presents very diverse lesions, going from shock and compression to contusion and wounding.

Shock is characterized by small apoplectic foci. The distance action of armour-piercing shells lends to this shock a frequency and an importance unknown to our predecessors.

Compression is the result of an effusion of blood either inside or outside the dura mater. These compressive haematomata are exceptional in war surgery (Otis). Compression is also caused, but less rarely than by haematorrhachis, by the dislocation of a vertebral arch, by splinters, by a projectile, an abscess, a piece of callus (Laurent).

Haematic compression, after having revealed its presence by aggravation of the symptoms from the first hours or the first days, diminishes rapidly and spontaneously; this shows the uselessness of intervention. Compression due to foreign bodies ends in softening and sclerosis; this shows the utility of intervention.

Contusions have degrees of severity from slight suffusion of blood with superficial dissociation of medullary elements, to attrition, which is localized in situ, to the opposite points and to partial destruction.

Wounds are small punctures, grazes, furrows, grooves more or less deep, perforations, incomplete sections, very rarely complete, the result of projectiles or of splinters. Besides,big projectiles may give rise to elongations.

On the level of the cauda equina lesions are very limited.

The spinal roots are bruised, divided, or reduced to pulp.

Diagnosis of Medullo-Rhachidian Lesions.-The vertebral column undergoes no deformation, but movement is very painful, almost impossible. The patient holds himself stiffly.

Sometimes very slight pressure allows us to perceive an abnormal mobility and a localized crepitation.

Escape of cerebro-spinal fluid is exceptional.

The functional signs vary according to the seat of the lesion.

Lesions of the lumbar spinal cord, which commences at the first lumbar vertebra, may be disclosed by paralysis of the lower limbs, retention or incontinence of urine and of faeces.

Those of the dorsal spinal cord by paraplegia, paralysis of the abdominal, dorsal, and intercostal muscles, as far as the limits of the lesion, by recto-vesical paralysis, elevation of temperature, gastric crises, and vomiting.

Those of the cervical region by the preceding signs, to which must be added Cheyne-Stokes respiration, hiccough, dysphagia, contraction of the pupils, elevation of the temperature, rapid sacral decubitus.

We will now return to the signs that allow us to recognize generalized meningeal shock.

The meningo-medullary irritation produced by splinters gives rise to atrocious pain, epileptiform convulsions (Otis), contractions of a tetanic form. This fact should be remembered.

Destruction is known to have happened by signs of deficit.

If we refer to facts cited by Otis, we find that bullets which compress and depress the medullary coverings or become fixed in the medulla cause less acute irritating phenomena than splinters.

Extensive haemorrhage outside the dura mater, in cases of common fracture, causes similar pain, though it is less intense, and appears a little less rapidly and not immediately; but this haemorrhage is exceptional in the open lesions produced by bullets, so that differential diagnosis is not difficult in such cases.

Prognosis - Spinal traumatisms that have shown resistance to the first symptoms often end happily. The same cannot be said of rather deep medullary lesions. They carry a very unfavourable prognosis. They are nearly always fatal.

The deplorable results following surgical intervention in the Balkan War command ABSTENTION in medullary lesions. The focus of a lesion of the medulla is often absolutely impossible to find or to limit; haemorrhagic effusion and foci cannot be differentiated from damage to the medullary elements themselves; injury, nearly always limited, cannot indicate a suture; finally, a wound of the medulla by projectiles is, so to speak, invariably fatal (Laurent).

Dent's mortality rate of 50 to 60 per cent. in the Transvaal has reference simultaneously to lesions of the vertebral column and of the spinal cord.

Treatment.-Laminectomy, that seemed more justifiable than more extensive, more radical intervention, has not given more brilliant results to those who have attempted it than other surgical measures. Nevertheless it is indicated, if not as a regular operation, at least as an atypical operation, in certain cases in which there seem no other means of replacing it with advantage. For instance, when sharp splinters forced against the meninges cause atrocious pain;

when it is practised in endeavours to remove an irritating projectile whose location has been duly discovered; finally, when it is to facilitate the emptying of an intrarhachidian abscess.

Excepting in these cases, the treatment must be expectant; this, however, does not mean that it should be inactive.

From the field of battle to the first-aid station or to the ambulance the wounded man, after having been gently raised, should be transported with the greatest care and the most extreme precaution, especially without being jerked.

A soldier hit in the back and unable to move his lower limbs is to be looked upon by the stretcher-bearers as having experienced a fracture of the vertebral column.

His greatcoat must be utilized as a hammock both in lifting him up and in setting him down.

He must not be transported any distance.

The application of Bonnet's hollowed out splint can be of no use, as there is no solution of continuity.

The usual aseptic dressing must be broad. Injections of morphine if necessary. Aseptic catheterism.

In cases of threatened sloughing or of sharp pain coming on at the slightest displacement, lay the patient on a stretcher, the canvas of which has been extensively cut away in a circular form on a level with the soldier's loins and gluteal region. The edges of this opening must be well padded with cotton-wool. The dressings will be kept in place by a large compress going round the patient's back like a hammock, and fixed to the canvas of the stretcher by safety-pins. By this means the dressing can be easily renewed without moving the wounded man.

As a general rule we must refrain from going primarily in search of loose or tolerated splinters, as they are insignificant, and may be useful in the process of repair.

When there is abundant effusion of cerebro-spinal fluid, we must put compression on the wound, and suture it if necessary.

The meningeal infection should be treated by lumbar puncture, in case of need by drainage, which must not reach the spinal cord.

In spite of all this necessary treatment, the evolution will nearly always be distressing ; after a few weeks of suffering these patients succumb, if the lesion is high up.

Cerebro-Medullary Shock. - Here we have, as it were, a fresh chapter, which the use of explosive projectiles has lately opened wide, and of which the elucidation was commenced by the surgeons in the Balkan War, particularly by Professor Laurent of Brussels. (The War in Bulgaria and in Turkey: A Campaign of Eleven Months, by Professor 0. Laurent. Maloine, 1914). We are desirous of drawing the attention of all surgeons in the present war to his work.

We have already seen several cases of this shock in the base hospitals. This shock may be slight and only manifested by torpor and tingling, specially in the lower limbs, by difficulty in walking, by hyperaesthesia with or without giddiness, by loss of consciousness.

It leaves behind, for a more or less lengthy period, a certain slowness of ideas, a kind of indifference, and retention of urine.

"When of a graver kind, it causes arrest of functions; the wounded man falls into torpor, becomes inert as if absolutely crushed, and all four limbs and the sphincters are paralyzed" (Laurent).

Recovery is rapid in many cases, and occurs in a few days; but paralysis and mental troubles may persist for some time.

These phenomena were observed in soldiers who were 2 to 10 or 15 metres distant from the point where an explosive percussion shell fell and burst, in that angular zone in which the shell fragments follow an ascending trajectory. In typical cases the men have not been struck by fragments of the shell, but they have sustained on the vertebral column, the spinal cord, and the brain, the effects of the excessive concussion - the shock of the column of air which has been intensely and violently displaced. The wind of the shell on other occasions, the contusion brought about by torn-up clods of earth, are the ordinary causes of these effects; but they may also be produced by the direct shock of a shell fragment or of a bullet hitting the vertebral column. Laurent reports a case in which the shock was the result of the grazing of the spine by an intact shrapnel, another in which it was produced by the shrapnel cylinder, and another in which the wounded man remained buried under masses of earth and of stones that had been upheaved by the shell. The cases in this last category are very different, in regard to their mechanism, from the first we have mentioned, which are altogether typical, and in which the shock seems to have been the result of a disturbance produced by the gases and the wind of the big projectile.

In the case of certain wounded men who, knocked over by the gas and wind of the shell, remain on the spot where they fall, it might be difficult to distinguish the psychical from the physical mischief. The symptoms that may be verified can only be attributed to the latter, in cases where these patients - and we have seen a few - have been helped up and taken some distance without again falling on their back.

Chapter 20

Wounds of the Upper Limb