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.

CHAPTER VIII

INJURIES TO THE VERTEBRAL COLUMN AND SPINAL CORD

Every degree of local injury to the constituent vertebrae 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