In view of the uniformly bad results observed in the case of the seventh nerve, I am inclined to think that the above rules might be tentatively relaxed, and the nerve primarily explored by an operation resembling that for mastoid suppuration. It is of course doubtful whether the trouble does not generally result from the vibratory concussion alone; but as this is not certain, and the operation would only have to be performed on patients already permanently deaf, it might be worth while at any rate opening the Fallopian canal with the object of relieving tension. It is not probable that in any of the cases quoted much splintering of the bone had occurred, as the wounds appeared to be of the nature of pure perforations.
CHAPTER X
INJURIES TO THE CHEST
In regard to Prognosis wounds of the chest furnished the most hopeful class of the whole series of trunk or visceral injuries. Cases of wound of the heart and great vessels afforded the only exceptions to an almost universally favourable course, both as regards life and the non-occurrence of serious after-effects.
This was mainly explicable on two grounds: first, the sharply localised character of the lesion produced by the bullet of small calibre; and, secondly, the fact that the lung, the most frequently injured organ, is not materially affected by the grade of velocity with which the bullet strikes. In point of fact, wounds of this organ probably afford an instance in which high grades of velocity are distinctly favourable to the nature of the injury, and this is possibly true in the case of wounds of the chest-wall also.
The significance of the calibre of the bullet in wounds of the chest is evident. The late Mr. Archibald Forbes, in one of his letters from the seat of the Franco-German war, remarked that in crossing a battlefield it was easy to recognise the patients who had suffered a wound of the lung from the fact that the whistle of the air entering and leaving the chest was plainly audible. This was, indeed, not uncommonly the case in wounds produced by the older bullets of large calibre, but with the employment of the smaller projectile it has become an experience of the past. Some evidence as to the comparative severity of wounds produced by the larger forms of bullet was, moreover, afforded by the present campaign, since Martini-Henry wounds were occasionally met with. Of some instances observed by myself, in one, external hæmorrhage was a prominent symptom; in another, a piece of lung was prolapsed from a wound in the back, and twice I observed pneumothorax, an uncommon sequela to wounds from bullets of small calibre.
It may be remarked, however, that all these more serious injuries were recovered from, also that when we consider that the patients were comparatively young and healthy subjects, the favourable prognosis was what might have reasonably been expected. When, as occasionally happened, a patient of more mature years, with enlarged facial capillaries, received a wound of the lung, the course was in no way so favourable as that witnessed in the case of the younger men.
In support of this opinion I may add that wounds from shrapnel and fragments of shell also did remarkably well, although they sometimes gave rise to more troublesome symptoms than did wounds produced by bullets of the Mauser type. Again, these injuries as a whole were of nothing like so serious a nature as the lacerations of the lung produced by fractured ribs, which we commonly have to treat in civil practice, and are not accustomed to regard as especially dangerous.