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.