[Illustration: FRONTISPIECE. Photo, H. KISCH Ladysmith. Engraved and Printed by Bale and Danielsson, Ltd. ] SURGICAL EXPERIENCES IN SOUTH AFRICA 1899-1900 BEING MAINLY A CLINICAL STUDY OF THE NATURE AND EFFECTS OF INJURIESPRODUCED BY BULLETS OF SMALL CALIBRE BY GEORGE HENRY MAKINS, F. R. C. S. SURGEON TO ST. THOMAS'S HOSPITAL, LONDONJOINT LECTURER ON SURGERY IN THE MEDICAL SCHOOL OF ST. THOMAS'S HOSPITALMEMBER OF THE COURT OF EXAMINERS OF THE ROYAL COLLEGE OFSURGEONS OF ENGLAND, AND LATE ONE OF THE CONSULTING SURGEONSTO THE SOUTH AFRICAN FIELD FORCE LONDONSMITH, ELDER, & CO. , 15 WATERLOO PLACE1901 TO SURGEON-GENERAL W. D. WILSON PRINCIPAL MEDICAL OFFICER TO THE SOUTH AFRICAN FIELD FORCE THE MEMBERS OF THE ROYAL ARMY MEDICAL CORPSEMPLOYED IN SOUTH AFRICA AND TO THE CIVIL SURGEONS TEMPORARILY ATTACHED TO THAT CORPS These Experiences are Dedicated AS AN EXPRESSION OF APPRECIATIONOF THE INVARIABLE KINDNESS AND SYMPATHY EXTENDEDTO THE AUTHORWITHOUT WHICH THE BOOK COULD NOTHAVE BEEN WRITTEN PREFACE A word of explanation is perhaps necessary as to the form in which theseexperiences have been put together. The matter was originally collectedwith the object of sending a series of articles to the _British MedicalJournal_. Various circumstances, however, of which the chief was thefeeling that extending experience altered in many cases the viewsadopted at first sight, prevented the original intention from beingcarried into execution, and the articles, considerably expanded, are nowpublished together. As to the illustrative cases introduced in support of various statementsmade in the text, only those have been chosen from my notes which wereunder my own observation for a considerable time, and many of these havebeen brought up to date since my return to England. I have, as a rule, avoided the inclusion of cases seen cursorily, and few simple ones havebeen quoted since their character is sufficiently indicated in the text. These remarks seem necessary since the mode of selection has resulted inthe inclusion of a number of cases of exceptional severity, and anyattempt to draw statistical conclusions from them would be mostmisleading. The first two chapters have been added with a view to affording someinformation, first, as to the conditions under which a great part of thesurgical work was done, and, secondly, as to the mechanism and causationof the injuries, which would not readily be at hand in the case of thegeneral surgical reader. For much of the information contained inChapter II. I must express my indebtedness to the work of MM. Nimier andLaval, so frequently quoted. The only other object of this Preface is to express my thanks to themany who have aided me in the task of amplifying the observations onwhich the articles are founded, and I think no writer ever received moresympathetic and kindly help in such particulars than the author. My first thanks, those due to the Members of the Royal Army MedicalCorps, I endeavour to express by the dedication of this volume. Anyattempt to make individual acknowledgment to either the Members of theService, or to the Civil Surgeons temporarily attached, would beimpossible. I have, however, tried to associate the names of many ofthose in charge of cases in the recital of histories and treatmentthroughout. My thanks are not less due to the Military Heads of Departments at theWar Office, who have helped me in the collection of details as to thesubsequent course of many of the cases described, and in the acquisitionof information regarding the weapons and ammunition treated of. I shouldparticularly express my gratitude to Colonel Robb, of theAdjutant-General's Department, and Colonel Montgomery, of the OrdnanceDepartment. I am greatly indebted to my former colleague Mr. Cheatle for two of theillustrations of wounds, and for permission to quote some of his otherexperience, and to Mr. Henry Catling, to whose skill I owe the majorityof the skiagrams of the fractures under my observation at Wynberg andelsewhere. I must also express my thanks to Mr. Danielsson and his artist, Mr. Ford, for the trouble they have taken in converting my rough sketchesinto the illustrations contained in the volume. Lastly, my warmest gratitude is due to my friends, Mr. Cuthbert Wallace, who has read some of my chapters, and to Mr. F. C. Abbott, who has readthe whole book for the press and suggested many improvements andmodifications. 47 CHARLES STREET, BERKELEY SQUARE, W. _February_ 1901. CONTENTS PAGECHAPTER I INTRODUCTORY Itinerary--Surgical outfit--Personal transport--General health of thetroops--Climate--Consideration of the number of men killed andwounded--Transport of the wounded--Vehicles--Trains--Ships--Hospitals 1 CHAPTER II MODERN MILITARY RIFLES AND THEIR ACTION General type--Calibre, length, and weight ofbullet--Velocity--Trajectory--Revolution--Varieties of rifle in commonuse by the Boers--Penetration--Comparison of bullets--Use ofwax--Comparative efficiency of different types 40 CHAPTER III GENERAL CHARACTERS OF WOUNDS INFLICTED BY BULLETS OF SMALL CALIBRE Type wounds--Nature of external apertures--Direct course of woundtrack--Multiple wounds--Small bore and sharp localisation oftracks--Clinical course--Mode of healing--Suppuration--Wounds of irregulartype--Ricochet--Mauser bullet--Lee-Metford bullet--Expanding bullets--Alteredbullets--Large sporting bullets--Symptoms--Psychical disturbance andshock--Local shock--Pain--Hæmorrhage--Diagnosis--Prognosis--Treatment 55 CHAPTER IV INJURIES TO THE BLOOD VESSELS Nature of lesions; contusion, laceration, perforation--Results ofinjuries--Primary hæmorrhage--Recurrent hæmorrhage--Secondaryhæmorrhage--Treatment of hæmorrhage--Traumatic aneurisms--Arterialhæmatoma--True traumatic aneurism--Aneurismal varix and varicoseaneurism--Conditions affecting development--Effects of aneurismal varixor varicose aneurism on the general circulation--Prognosis and treatmentof aneurismal varix--Prognosis and treatment of varicoseaneurism--Gangrene after ligation of arteries 112 CHAPTER V INJURIES TO THE BONES OF THE LIMBS Nature of wounds--Explosive wounds--Types of fracture of shaftsof long bones--Stellate, wedge, notch, oblique, transverse, perforating--Fractures by old types of bullet--Lesions of the short andflat bones--Special character of the symptoms in gunshot fracture, andof the course of healing--Prognosis--Treatment--Special fractures--Upperextremity--Pelvis--Lower extremity 154 CHAPTER VI INJURIES TO THE JOINTS General character--Vibration synovitis--Wounds ofjoints--Classification--Course and symptoms--General treatment--Specialjoints 225 CHAPTER VII INJURIES TO THE HEAD AND NECK Anatomical lesions--Scalp wounds--Fracture of the skull without evidenceof gross lesion of the brain--Fractures with concurrent braininjury--Classification--General injuries--Effect of ricochet--Verticalor coronal wounds in frontal region--Glancing or oblique wounds of anyregion--Gutter fractures--Superficial perforating fractures--Fracturesof the base--Symptoms of fracture of the skull, with concurrent injuryto the brain--Concussion--Compression--Irritation--Frontalinjuries--Fronto-parietal and parietal injuries--Occipitalinjuries--Forms of hemianopsia--Abscess of the brain--Generaldiagnosis--General prognosis--Traumatic epilepsy--Generaltreatment--Wounds of the head not involving the brain--Mastoidprocess--Orbit--Globe of the eye--Nose--Malar bone--Upperjaw--Mandible--Wounds of the neck--Wounds of the pharynx, larynx, andtrachea 241 CHAPTER VIII INJURIES TO THE VERTEBRAL COLUMN AND SPINAL CORD Fractures in their relation to nerve injury--Transverseprocesses--Spinous processes--Centra--Signs of fracture ofthe vertebra--Injuries to the spinal cord--Effects of highvelocity--Concussion, slight, severe--Contusion--Hæmorrhage, extra-medullary, hæmatomyelia--Symptoms of injury to the spinalcord--Concussion--Hæmorrhage--Total transverse lesion--Diagnosis of formof lesion--Prognosis--Treatment 314 CHAPTER IX INJURIES TO THE PERIPHERAL NERVES Anatomical lesions--Concussion--Contusion--Division orlaceration--Secondary implication of the nerve--Symptoms of nerveinjury--Traumatic neuritis--Scar implication--Ascendingneuritis--Traumatic neurosis--Injuries to special nerves--Cranialnerves--Cervical, brachial, lumbar, and sacral plexuses--Cases of nerveinjury--General prognosis and treatment 341 CHAPTER X INJURIES TO THE CHEST Non-penetrating wounds of the chest wall--Penetrating wounds, specialcharacters of entrance and exit apertures--Fracture of the ribs, symptoms, treatment--Wounds of the diaphragm--Wounds of theheart--Wounds of the lung, symptoms--Pneumothorax--Hæmothorax--Empyema--Diagnosis, prognosis, and treatment of hæmothorax--Casesof hæmothorax 374 CHAPTER XI INJURIES TO THE ABDOMEN Introductory remarks--Wounds of the abdominal wall--Penetration ofthe intestinal area without definite evidence of visceral injury--Woundsof explosive character--Anatomical characters of intestinal wounds--Woundsof the mesentery---Wounds of the omentum--Results of intestinalwounds, fæcal extravasation, peritoneal infection, septicæmia--Reasonsfor the escape of severe injury in wounds traversing theabdomen--Wounds of the stomach--Wounds of the small intestine--Woundsof the large intestine--Prognosis in intestinal injuries--Treatmentof intestinal injuries--Wounds of the urinary bladder--Woundsof the kidney--Wounds of the liver--Wounds of the spleen--Generalremarks on the prognosis in abdominal injuries--Wounds ofthe external genital organs--Wounds of the urethra 407 CHAPTER XII ON SHELL WOUNDS Varieties of shells employed--Large shells--Wounds produced by differentvarieties--Pom-Pom shells--Wounds produced by fragments andfuses--Shrapnel--Boer segment shells--Leaden shrapnel bullets--Treatmentof shell wounds 474 INDEX OF CONTENTS 487 ILLUSTRATIONS _PLATES_ VARIETIES OF AMMUNITION COLLECTED AT LADYSMITH _Frontispiece_ 1. SECTION OF MAUSER APERTURE OF ENTRY _To face p. _ 73 2. SECTION OF MAUSER APERTURE OF EXIT 76 3. PUNCTURED FRACTURE OF CLAVICLE 162 4. COMMINUTED FRACTURE OF SHAFT OF HUMERUS 180 5. COMMINUTED FRACTURE OF HUMERUS ACCOMPANIED BY AN EXPLOSIVE EXIT 182 6. COMMINUTED FRACTURE OF HUMERUS DUE TO OBLIQUE IMPACT 184 7. SAME FRACTURE HEALED 186 8. LOW VELOCITY FRACTURE OF HUMERUS WITH RETAINED BULLET 188 9. LOCALISED FRACTURE OF HUMERUS SHOWING FRAGMENTATION OF THE BULLET 190 10. WEDGE-SHAPED FRACTURE OF THE RADIUS 192 11. FRACTURE OF THE METACARPUS, SHOWING FRAGMENTATION OF THE BULLET 194 12. FINELY COMMINUTED FRACTURE OF THE FEMUR 196 13. THE SAME FRACTURE HEALED 198 14. STELLATE 'BUTTERFLY' FRACTURE OF THE FEMUR 200 15. LATERAL IMPACT OF BULLET, WITH COMMINUTION OF THE FEMUR 202 16. RECTANGULAR IMPACT OF BULLET, WITH HIGHLY OBLIQUE LINE OF FRACTURE OF THE FEMUR 204 17. PUNCTURED FRACTURE OF THE FEMUR WITH EXIT BONE-FLAP 206 18. FRACTURED PATELLA 208 19. OBLIQUE COMMINUTED FRACTURE OF THE TIBIA 210 20. TRANSVERSE FRACTURE OF THE TIBIA 212 21. PUNCTURE OF THE TIBIA, WITH AN OBLIQUE FISSURE 214 22. NOTCHED FRACTURE OF THE TIBIA 216 23. PUNCTURED FRACTURE OF THE FIBULA 218 24. THE SAME FRACTURE, LATERAL VIEW 220 25. VICKERS-MAXIM FRACTURE OF THE HUMERUS 482 _IN THE TEXT_ FIG. PAGE 1. LINEN HOLD-ALL WITH INSTRUMENTS 4 2. INSTRUMENT HOLD-ALL ROLLED FOR PACKING 5 3. TIN WATER-BOTTLE FOR EMERGENCY OPERATIONS 6 4. BUGGY ON THE VELDT 7 5. MCCORMACK-BROOK WHEELED STRETCHER CARRIAGE 19 6. INDIAN TONGA 20 7. SERVICE AMBULANCE WAGON 21 8. BUCK-WAGON LOADED WITH WOUNDED MEN 22 9. INTERIOR OF A WAGON OF NO. 2 HOSPITAL TRAIN 24 10. P. & O. HOSPITAL SHIP 'SIMLA' 25 11. TYPE OF GENERAL HOSPITAL 32 12. TYPE OF TORTOISE TENT HOSPITAL 33 13. SINGLE TORTOISE HOSPITAL TENT 35 14. FIVE TYPES OF CARTRIDGE IN COMMON USE DURING THE WAR 47 15. SECTIONS OF FOUR BULLETS TO SHOW RELATIVE THICKNESS OF MANTLES 51 16. ENTRY AND EXIT MAUSER WOUNDS 56 17. GUTTER WOUND OF SHOULDER 56 18. OBLIQUE GUTTER EXIT WOUND 57 19. OVAL ENTRY, STARRED EXIT WOUNDS 58 20. CIRCULAR ENTRY, SLIT EXIT WOUNDS 59 21. CIRCULAR ENTRY, STARRED EXIT WOUNDS 59 22. ENTRY AND EXIT WOUNDS IN SIX SUCCESSIVE SPOTS MADE BY SAME BULLET 61 23. FOUR SUCCESSIVE ENTRY AND EXIT WOUNDS OF SAME BULLET 62 24. SUPERFICIAL ABDOMINO-THORACIC TRACK 64 25. SUPERFICIAL LINEAR ECCHYMOSIS OF THIGH 65 25_a_. SECTIONS OF MAUSER ENTRY AND EXIT WOUNDS 74 25_b_. PROLAPSED OMENTUM 77 26. SECTIONS OF FOUR BULLETS 82 27. NORMAL MAUSER BULLET 83 28. FOUR MAUSER RICOCHETS 84 29. MAUSER RICOCHET, DISC FORM 85 30. FISSURED MAUSER MANTLE 86 31. MAUSERS DEFORMED BY IMPACT ON FEMUR 86 32. APICAL MAUSER RICOCHET 87 33. SPIRAL RICOCHET 88 34. NORMAL LEE-METFORD BULLET 89 35. APICAL LEE-METFORD RICOCHETS 90 36. " " " 91 37. FOUR TYPES OF SOFT-NOSED BULLETS 92 38. 'SET-UP' SOFT-NOSED LEE-METFORD BULLETS 92 39. FLATTENED, SOLID-BASED MANTLE FROM RICOCHET 93 40. MAUSER BULLET, JEFFREYS-TWEEDIE MODIFICATION 94 41. SECTION OF MARK IV. AND SOFT-NOSED MAUSER 94 42. TAMPERED BULLETS 95 43. LARGE LEADEN SPORTING BULLETS 98 44. EXPLOSIVE WOUND OF BACK 100 45. DEAD MEN ON FIELD OF BATTLE 102 46. FLATTENED LEADEN CORES FROM MANTLED BULLETS 105 47. EXPLOSIVE EXIT WOUND OVER FRACTURED ULNA 156 48. EXPLOSIVE EXIT WOUND OVER FRACTURED HUMERUS 158 49. EXPLOSIVE EXIT AND ENTRY WOUNDS OF LEGS 159 50. TYPES OF GUNSHOT FRACTURE 161 51. LOWER END OF FRACTURED FEMUR 164 52. OBLIQUE PERFORATION OF FEMUR, SEPARATION OF FRAGMENT AT EXIT APERTURE IN BONE 169 53. GUTTER FRACTURE OF HEAD OF HUMERUS 178 53_a. _ DIAGRAM OF 'BUTTERFLY' TYPE 180 54. WIRE GAUZE SPLINT 187 55. GUTTER FRACTURE OF PELVIS 191 55_a_. DIAGRAM OF 'BUTTERFLY' TYPE 200 56. CANE FIELD SPLINT FOR LOWER EXTREMITY 209 57. TUNNEL FRACTURE AT SURFACE OF TIBIA 219 58. CANE FIELD SPLINT FOR LEG 222 59. SKIAGRAM OF INJURY TO INTERPHALANGEAL JOINT 237 60. SKIAGRAM OF BULLET IN NASAL FOSSA 244 61. DIAGRAM OF APERTURE OF ENTRY INTO CRANIUM 245 62. APERTURE OF ENTRY INTO FRONTAL BONE 252 63. FRAGMENT OF INNER TABLE DISPLACED FROM OPENING SEEN IN FIG. 62 253 64. GUTTER FRACTURE OF FIRST DEGREE IN PARIETAL BONE 255 65. DIAGRAM OF GUTTER FRACTURES 256 66. GUTTER FRACTURE OF SECOND DEGREE IN PARIETAL BONE 257 67. DIAGRAMS OF GUTTER FRACTURES 258 68. SUPERFICIAL PERFORATING FRACTURE OF PARIETAL REGION 259 69. DIAGRAM OF SUPERFICIAL PERFORATING FRACTURE 260 70. FRAGMENT FORMING FLOOR OF TEMPORAL GUTTER FRACTURE 260 71. SCALE OF EXTERNAL TABLE IN LOW VELOCITY INJURY OF FRONTAL BONE 261 72. FRONTAL PERFORATION, APERTURE OF EXIT 261 73. VISUAL FIELD IN OCCIPITAL INJURY 279 74. " " " 279 75. " " " 281 76. " " " 281 77. " " " 283 78. " " " 283 79. CONTUSED SPINAL CORD 333 80. DIVIDED SPINAL CORD 334 81. SUPERFICIAL TRACK IN ANTERIOR BODY-WALL 377 82. SPIRALLY GROOVED BULLET 381 83. ECCHYMOSIS IN FRACTURED RIBS WITH HÆMOTHORAX 392 84. SUBCUTANEOUS DIVISION OF ABDOMINAL MUSCLES 409 85. LATERAL INCOMPLETE WOUND OF SMALL INTESTINE. SLIT FORM 416 86. LATERAL PERFORATION OF SMALL INTESTINE. GUTTER FORM 417 87. ENTRY AND EXIT WOUNDS IN A TRANSVERSE PERFORATION OF INTESTINE 418 88. INNER ASPECT OF PIECE OF INTESTINE SHOWN IN FIG. 87 419 89. IMPACTION OF OMENTUM IN EXIT WOUND OF ABDOMINAL WALL 421 90. FRAGMENTS OF LARGE SHELLS 475 91. FRAGMENTS OF PERCUSSION AND TIME FUSES 477 92. COMPLETE 1-LB. POM-POM SHELL 479 93. FRAGMENTS OF EXPLODED POM-POM SHELLS 480 94. PERCUSSION FUSE FROM 1-LB. POM-POM SHELL 481 95. FRAGMENTS OF BOER SEGMENT SHELLS 483 96. NORMAL AND DEFORMED LEADEN SHRAPNEL BULLETS 485 _TEMPERATURE CHARTS_ 1. CASE OF AXILLARY HÆMATOMA, BLOOD TEMPERATURE 119 2. CASE OF HÆMOTHORAX WITH RECURRENT HÆMORRHAGES 395 3. PRIMARY AND SECONDARY RISES OF TEMPERATURE IN HÆMOTHORAX, RECOVERING SPONTANEOUSLY 402 4. SECONDARY RISE OF TEMPERATURE IN HÆMOTHORAX 403 5. FALLS OF TEMPERATURE IN HÆMOTHORAX FOLLOWING PARACENTESIS 404 6. SECONDARY HÆMOTHORAX, SPONTANEOUS FALL OF TEMPERATURE 405 SURGICAL EXPERIENCES IN SOUTH AFRICA CHAPTER I INTRODUCTORY The following pages are intended to give an account of personalexperience of the gunshot wounds observed during the South Africancampaign in 1899 and 1900. For this reason few cases are quoted beyondthose coming under my own immediate observation, and in the fewinstances where others are made use of the source of quotation isindicated. It will be noted that my experience was almost entirelyconfined to bullet wounds, and in this respect it no doubt differs fromthat of surgeons employed in Natal, where shell injuries were morenumerous. This is, however, of the less moment for my purpose as thereis probably little to add regarding shell injuries to what is alreadyknown, while, on the other hand, the opportunity of observing largenumbers of injuries from rifle bullets of small calibre has notpreviously been afforded to British surgeons. I think the general trend of the observations goes to show that theemployment of bullets of small calibre is all to the advantage of themen wounded, except in so far as the increased possibilities of therange of fire may augment the number of individuals hit; also that suchvariations as exist between wounds inflicted by bullets of theMartini-Henry and Mauser types respectively, depend rather on the formand bulk of the projectile than on any inherent difference in the natureof the injuries. Thus in the chapter devoted to the general charactersof the wounds, it will be seen that most of the older types of entryand exit aperture are produced in miniature by the small modern bullet, and that the main peculiarity of the deeper injuries is the frequentstrict localisation of the direct damage to an area of no greater widththan that crossed by narrow structures of importance such as arteries ornerves. It is to be regretted that I am unable to furnish any importantstatistical details, but incomplete numbers, such as are at my disposal, would be of little value. In view, however, of the considerable intervalwhich must elapse before the Royal Army Medical Corps is able to arrangeand publish the large material which will have accumulated, it hasseemed unwise to defer publication until the completion of a reportwhich will deal with such matters thoroughly. It may be of interest to premise the opportunities which I enjoyed ofgaining experience during the campaign. I arrived in South Africa onNovember 19, 1899; two days later I proceeded to Orange River withSurgeon-General Wilson, and on the day three weeks after leaving homeperformed some operations in the field hospitals on patients from thebattle of Belmont. I remained at Orange River during the three nextengagements, Graspan, Enslin, and Modder River, and on the day ofMagersfontein I went forward to the Field hospitals at Modder River, arriving during the bringing in of the patients from the field ofbattle. I returned to Orange River with the patients and remained therea further period of three weeks, during which time the patients weregradually transferred to the Base hospitals at Wynberg. At Christmas Ifollowed the patients down to the base, and thus was able to observe thecourse of the cases from their commencement to convalescence. I remainedat Wynberg six weeks, during which time a number of cases from theneighbourhood of Rensburg and some from Natal were received. On February7, I left Wynberg, following Lord Roberts up to my old quarters atModder River, where I saw a few wounded men brought in from theengagements at Koodoosberg Drift. On Lord Roberts's departure forBloemfontein he requested me to return to Wynberg to await the woundedwho might be sent down from the fighting which might occur during hisadvance. I therefore had the disappointment of seeing the start of thearmy, and then returning to Wynberg, where I remained for another sixweeks in attendance at Nos. 1 and 2 General Hospitals. During this period a very large number of the wounded from PaardebergDrift and other battles were sent down and treated, after which surgicalwork began to flag. On April 14, I was recalled to the front and journeyed to Bloemfontein, where I stayed three weeks, making one journey out to the Bearer Companyof the IX. Division at the Waterworks. On May 4, I left Bloemfontein with Lord Roberts's army, and shortlyafter joined the IX. Division, with which I journeyed until thecommencement of June, seeing a good deal of scattered work in the fieldand Field hospitals, and in the small temporary improvised hospitals inthe towns of Winberg, Lindley, and Heilbron. Early in June I leftHeilbron with Lord Methuen's division, and spent the next four weekswith this division in the field. Thence I journeyed to Pretoria andJohannesburg, seeing a small number of wounded in each town, and on July10, with Lord Roberts's consent, I started for home, visiting a numberof the hospitals in the Orange River Colony and Natal on my way down toCape Town. During the movements briefly recorded above, which absorbed aperiod of nine months, my time was fairly evenly divided between Field, Stationary, and Base hospitals; hence I had opportunities of observingthe patients in every stage of their illnesses, and in all somethousands of men came under my notice. [Illustration: FIG. 1. --Linen Holdall with surgical instruments] My departure for the seat of war was rather hurried, hence my surgicalequipment was not of an extensive nature. It may be of interest, however, to shortly recount what it consisted in, since it proved anample one, and yet was carried in a small satchel. The plan of selectionadopted consisted in carefully going through the equipment of theBritish Field Hospital, and then adding such other instruments as seemedto me likely to be useful. With few exceptions, therefore, designed tomeet emergencies, my set of instruments formed a supplement to theactual necessities carried by the Service hospitals, and was asfollows:--4 trephines, Horsley's elevator, brain knife and seeker. 2pairs of Hoffman's and 1 pair of Lane's fulcrum gouge forceps, 3 bonegouges, 1 pair straight 1 curved necrosis forceps, 1 pair bone forceps. 1 Wood's 1 Horsley's skull saws, 18 Gigli's saws with an extra handle, and two Podrez' directors for the same. 1 set Lane's bone drills, broaches, screw-drivers, and counter-sink with eight ounces of screws:silver patella wire, and 1 pair Peter's bone forceps. 2 aneurismneedles, 1 bullet probe, 1 pair Egyptian Army pattern bullet forceps. 4Lane's and 3 pairs Makins's bowel clamps, Nos. 3 4 and 5 Laplace'sbowel forceps, 6 Murphy's buttons, 1 pair Morris's retractors, 6 dozenintestine needles, 2 Macphail's needle-holders, Nos. 4 5 6 Thomas'sslot-eyed needles, 1 mouth gag, 1 Durham's double raspatory, 3 strongplated raspatories, 1 pair tongue forceps, 1 tracheal dilator, 1 pairhernia needles, 1 hernia and 1 ordinary steel director, 1 transfusionset with metal funnel, and a stock of Messrs. Burroughes and Wellcome'scompound saline infusion soloids. 1 antitoxin syringe. 6 scalpels, 2blunt-pointed curved bistouries, 6 forcipressure forceps, 1 pair JordanLloyd's retractors, 1 pair ordinary retractors, 2 pairs of forceps, 3pairs of Scissors, 1 skin-grafting razor and roll of perforated tinfoil, 1 metal pocket case, and 1 hypodermic syringe with tabloids. Astock of silkworm gut, horsehair and silk ligatures, the latter preparedand sterilised for me by Miss Taylor, the Theatre Sister at St. Thomas'sHospital. Some pairs of McBurney's india-rubber, and cotton-threadoperating gloves. [Illustration: FIG. 2. --Instrument Holdall rolled] The instruments were packed in sets in small linen holdalls suggestedand made by Messrs. Down Bros. , who also devised my satchel. In thelight of the experience gained I should have preferred a tin case to thesatchel, as it never needed to be carried on horseback. For dressings I trusted entirely to the Royal Army Medical Corps, and atmy request Colonel Gubbins, R. A. M. C. , sent out to the Cape a quantityof sterilised sponges and pads made by Messrs. Robinson & Co. Ltd. OfChesterfield, which fully met all requirements in this direction. [Illustration: FIG. 3. --Tin Water-bottle for the march (MilitaryEquipment Company)] This equipment was superfluous at the Base hospitals, but when in thefield with the troops proved very useful. In the early part of thecampaign I was able to do all my travelling by train, but later Itravelled by road only. I received the greatest kindness and help inthis particular. General Sir William Nicholson, Chief Director ofTransport, provided me with a buggy, a pair of horses, and a driver, andPrince Francis of Teck, the Chief Remount Officer, selected a ponysuitable to my equestrian powers. The buggy proved a very great success;the box seat carried my instruments and dressings, the front a 4-gallontin water-bottle for emergency operations, and the rear shelf mypersonal belongings. The water-bottle was lent to me by the PortlandHospital. (Fig. 3. ) The cart was able to cross any drifts or dongas, and when an engagementwas in progress was able to accompany the Ambulance wagons, so that Ihad all my necessaries on the spot, even at the first dressing station. In point of fact when with the Highland Brigade, on some occasions, wedid all necessary operations on the spot during the progress offighting; a most useful performance, since fighting on several days didnot cease till dark, and the evenings were much too cold to allow ofoperations being done with safety to the patients. The great advantageof the buggy was its lightness and smallness. On one occasion itaccompanied me between 500 and 600 miles without a single accident, beyond the fact that one night I was relieved of both my horses by sometroopers whose own were worn out. [Illustration: FIG. 4. --My Buggy on the veldt at Bloemfontein. (Photo byMr. Bowlby)] With regard to the general health of the troops as subjects of surgicalwounds, I suppose a better class of patient could scarcely be found. Themen were young, sound, well set and nourished, and hard and fit fromexercise in the open air. Beyond this, in spite of the scarcity ofvegetables, a certain amount of fruit, rations of jam, and lime juicemade any sign of scurvy a rare occurrence--I never saw a case during thewhole of my wanderings. The meat was good, especially in the early partof the campaign, when it was for the most part brought from Australiaand New Zealand, and we enjoyed the two collateral advantages of gettingplenty of the ice which had been used for the preservation of the meat, in the camps, and the still greater one of having no butchers' offal toneed destruction or prove a source of danger. When bread was to be gotit was fairly good, and the biscuit was at all times excellent. Excepton the advance from Modder River to Bloemfontein, as far as I couldjudge, no large bodies of the men ever really suffered from shortness offood, and then only for a few days. Drink was a more serious problem: inthe early days beer was to be got at the canteens, but with the increaseof numbers and difficulties of transport this ceased to be the case, andwater was the sole fluid available. This was often muddy, and thesoldiers would take very little care what they drank unless underconstant supervision; hence a great quantity of very undesirable waterwas drunk. None the less I think the water was more often the cause ofsand diarrhoea than of enteric fever. A large quantity of fluid was byno means a necessity if the men would only have exercised someself-control. During the first week I spent at Orange River, I dranklime juice and water all day, but after that time, by a very slightamount of determination, I thoroughly broke myself of the habit, anddrank at meal-times only. Most of the men however emptied theirwater-bottles during the first hour of the march, and the rest of theday endured agony, seizing the first opportunity of drinking any filthywater they met with. When, for instance, we camped near a vlei, and theGeneral took the greatest care that the mules and horses should bewatered at one spot only, in order to preserve the cleanliness of therest of the pool, the men would often go and fill their water-bottlesamongst the animals' feet rather than take the trouble to walk the fewnecessary yards round. In such particulars they needed constantsupervision. The climate on the western side was a great element no doubt both in thegeneral healthiness of the men and in the general good results seen inthe healing of wounds. The days were often hot; thus even in November atOrange River the thermometer registered 115°F. In the single bell tents, but on the other hand the nights were cool and refreshing. The air wasvery pure and exceedingly dry, while the constant sunshine not only keptup the spirits, but also proved the most efficient disinfector of anyground fouled to less than a serious extent. Dust was our principalbugbear; and when a camp had been settled for a few days, flies; both ofthese evils increasing rapidly as the stay on any one spot wasprolonged. My personal experience of rain was small, but I was twice incamp, once at Orange River and once at Bloemfontein, when very heavyrain fell, and this was sufficient to make the camps terriblyuncomfortable for a few days. Under these conditions, as might be expected, until the outbreak ofenteric fever the health of the men was remarkably good, minor ailmentsalone prevailing. One of the most troublesome of these was diarrhoea, which gained the appellation of 'the Modders, ' already a classical nameas far as South Africa is concerned. This most frequently, I think, depended on errors of diet, combined with the swallowing of a largeamount of sand with the food as dust, and in the water drunk. Cases ofsevere dysentery, however, were also not very uncommon. Rheumatic painswere a common ailment, which, considering the dryness of the atmosphere, would hardly have been expected. Continued fever of a somewhat specialtype was not uncommon, and was sometimes spoken of under the name of thedistrict, sometimes as veldt fever--of this I will say nothing, asothers better fitted to point out its peculiarities will no doubt dealwith it. Enteric fever, our chief scourge, I will pass over for the samereason. I might, however, remark from the point of view of one not veryexperienced in this disease, that in a large number of the fatal cases Ihappened to see, the actual cause of death seemed to me to be septicæmiafrom absorption from the mouth. The mouths were unusually bad, evenallowing for the often insufficient cleansing that was able to becarried out, and I was inclined to attribute these in some degree to thedryness of the atmosphere, which very quickly and effectively dried upthe mucous membrane of the mouth in patients not breathing through thenose, and encouraged the formation of large cracks. Pneumonia was rare, and this was rendered the more striking from the comparatively largenumber of men who contracted the disease on board ship on the voyage outfrom England. As will be gathered from the above, medical disease seldom called forthe aid of the surgeon. Abdominal section was occasionally considered incases of perforation in enteric fever, and was, I believe, a few timesperformed, but as far as I know without success. It was also proposed totreat some of the severe dysentery cases by colotomy, but I never sawthe method tried. As far as I was concerned I never met with a case ofeither disease I thought suitable for the treatment. I saw one case inwhich an abscess of the liver had followed an attack of enteric, whichhad been successfully treated by incision, and a few cases of tropicalabscess which probably came into the country were also subjected tooperation. Some cases of appendicitis, as would be expected, also neededsurgical treatment. In a few instances empyema followed influenza, and afew cases of mastoid suppuration had to be dealt with. Of surgical diseases the one most special to the campaign, although notof great importance, was the veldt sore. This was a small localisedsuppuration most common on the hands and neck, but sometimes invadingthe whole trunk, more particularly the lower extremities however, whenthe covered parts of the body were attacked. The sores were no doubt theresult of local infections; they reminded me most of the sores seen onthe hands of plasterers, and I think there is no doubt the dust wasresponsible for them. I think piles were somewhat more prevalent thanthey should have been among the men, but this was probably dependent onthe strain involved in defæcation in the squatting position, since thesoldiers were for the most part regularly attentive to the calls ofnature. I saw a good many cases of lightning stroke, and some were fatal. Sunstroke was not common, and, considering the heat, it was veryremarkable how little the men suffered from this condition. This was nodoubt in part attributable to the absence of the possibility of gettingalcoholic drinks, but it is not common for any one in South Africa tosuffer in this way, probably as a result of the continuous nature of thesunshine. In spite of the labours of hospital surgeons at home, it was ratherinstructive to see the number of men who suffered with hernia, varicocele, and varicose veins to a sufficient degree to necessitategoing to the base. The experience quite sufficed to explain the troublewhich is taken to prevent men with these complaints entering theservice. GENERAL CONSIDERATION OF THE NUMBER OF MEN KILLED AND WOUNDED I will now pass to the question of the proportionate frequency withwhich the men were killed or wounded during the present campaign. Ipropose to take only one series of battles, with which I was personallyacquainted throughout, to illustrate this point. This seems the moresatisfactory course to follow, since the number of casualties is stillundergoing continuous gradual increase, and besides this the warfare hasassumed a peculiar and irregular form, statistics from which scarcelypossess general application. The battles included, those of the first Kimberley Relief Force, werefought under fair average conditions as to the nature of the ground. Inthe first two the defending enemy occupied heights, in the two followingthe ground advanced over by our men was comparatively even; thus atModder River there was only a gradual slope upwards, and atMagersfontein the advanced trenches of the Boers were only slightlyabove the level of the ground over which the advance was made. At thesame time, at the latter battle a great number of the Boers engaged wereon the sides of the hill well above the advanced trenches. In no casewere the Boers in such a position as to have to fire upwards, to them aconsiderable advantage. It must also be noted that throughout the Boerswere able to rest their rifles; hence the fire should have been at anyrate of an average degree of accuracy. In the advances of our own men, anthills and stones were practically the only cover to be obtained, andlittle or no help was given by variations in the general surface. Allthese points seem to favour a large proportional number of hits on thepart of the riflemen. I very much regret that I am unable to say whatwas the proportional number of shell wounds among the men hit, but I cansay with some confidence that among the wounded it was not as great asten per cent. I should be inclined to place it as low as five per cent. Again, I cannot fix the proportionate occurrence of wounds from bulletsof large calibre such as the Martini-Henry, but this was certainly notlarge. I think if ten per cent. Is deducted to represent the number ofhits from either of these forms of projectile, that we may fairly assumethe remaining 90 per cent. Of the wounds to have been produced bybullets of small calibre. The numbers of the opposing forces wereprobably fairly even. Taking all these circumstances together, and bearing in mind that ourarmy was always in the position of having to make frontal attacks on menwell protected in strong positions, I think it must be allowed that afair idea should be possible of the effectiveness of the modern weapons. Only one circumstance, one inseparable from any fighting with the Boers, seems to affect the numbers in an important manner. This consists in thefact that the Boer rarely fights to the bitter end, hence the greaterproportion of his hits are obtained at long distances. TABLE I +---------------------+--------+------+-------+-------+-----+-------------+| | Number | | | | |Percentage of|| | of | | | | | killed and || | troops |Killed|Wounded|Missing|Total| wounded to || | engaged| | | | |number of men|| | | | | | | engaged |+---------------------+--------+------+-------+-------+-----+-------------+|_Belmont:_ | | | | | | || Officers | 297 | 3 | 23 | 0 | 26 | 8. 75 || Non. -com. Officers | | | | | | || and men | 8, 396 | 55 | 206 | 4 | 265 | 3. 15 || +--------+------+-------+-------+-----+-------------+| Total | 8, 693 | 58 | 229 | 4 | 291 | 3. 34 || | | | | | | ||_Graspan:_ | | | | | | || Officers | 326 | 3 | 7 | 0 | 10 | 3. 06 || Non. -com. Officers | | | | | | || and men | 8, 213 | 18 | 163 | 7 | 188 | 2. 29 || +--------+------+-------+-------+-----+-------------+| Total | 8, 539 | 21 | 170 | 7 | 198 | 2. 31 || | | | | | | ||_Modder River:_ | | | | | | || Officers | 335 | 3 | 19 | 0 | 22 | 6. 56 || Non. -com. Officers | | | | | | || and men | 9, 856 | 67 | 377 | 18 | 462 | 4. 68 || +--------+------+-------+-------+-----+-------------+| Total | 10, 191 | 70 | 396 | 18 | 484 | 4. 74 || | | | | | | ||_Magersfontein:_ | | | | | | || Officers | 379 | 18 | 48 | 2 | 68 | 17. 94 || Non. -com. Officers | | | | | | || and men | 11, 068 | 148 | 669 | 101 | 918 | 8. 29 || +--------+------+-------+-------+-----+-------------+| Total[1] | 11, 447 | 166 | 717 | 103 | 986 | 8. 43 |+---------------------+--------+------+-------+-------+-----+-------------+ Table I. Gives the number of men engaged, and also that of the killedand wounded at each of four battles. Table III. Shows for comparison therelative number of killed and wounded in some former campaigns whileolder forms of weapon were in use. With regard to the numbers in Tables I. And II. It should be at oncesaid that they are only to be regarded as approximate, since they do notexactly tally with those officially reported in the 'Times' at a laterdate. Sources of error may, however, have crept into both, and as thereis little difference in the gross numbers, I have preferred to retainthe series compiled by Major Burtchaell, R. A. M. C. , as Table II. Containsinteresting information as to the proportionate number of men who diedduring the first 48 hours, after being wounded. TABLE II SHOWING PROPORTION OF MORTALITY AMONGST MEN HIT, (_a_) ON THE FIELD, (_b_) DURING THE FIRST FORTY-EIGHT HOURS ---------------------+-------+------+------+------+-------+---------------- |Number |Total | | Died | | Percentage | of |number| |within| | mortality -- |troops |of men|Killed|forty-| Total +-------+-------- |engaged| hit | |eight | |To men |To force | | | |hours | | hit |employed---------------------+-------+------+------+------+-------+-------+--------_Belmont_: | | | | | | | Officers | 297 | 26 | 3 | 3 | 6 | 23 | 2. 02 Non. -com. Officers | | | | | | | and men | 8, 396 | 265 | 55 | 8 | 63 | 23. 77 | 0. 75 +-------+------+------+------+-------+-------+-------- Total | 8, 693 | 291 | 58 | 11 | 69 | 23. 71 | 0. 79 | | | | | | |_Graspan_: | | | | | | | Officers | 326 | 10 | 3 | 1 | 4 | 40[2] | 1. 22 Non. -com. Officers | | | | | | | and men | 8, 213 | 188 | 18 | 3 | 21 | 11. 17 | 0. 25 +-------+------+------+------+-------+-------+-------- Total | 8, 539 | 198 | 21 | 4 | 25 | 12. 62 | 0. 29 | | | | | | |_Modder River_: | | | | | | | Officers | 335 | 22 | 3 | 1 | 4 | 18. 18 | 1. 19 Non. -com. Officers | | | | | | | and men | 9, 856 | 462 | 67 | 9 | 76 | 16. 45 | 0. 77 +-------+------+------+------+-------+-------+-------- Total |10, 191 | 484 | 70 | 10 | 80 | 16. 53 | 0. 78 | | | | | | |_Magersfontein_: | | | | | | | Officers | 379 | 68 | 18 | 4 | 22 | 32. 35 | 5. 80 Non. -com. Officers | | | | | | | and men |11, 068 | 918 | 148 | 20 | 168 | 18. 30 | 1. 51 +-------+------+------+------+-------+-------+-------- Total |11, 447 | 986 | 166 | 24 | 190 | 19. 26 | 1. 66---------------------+-------+------+------+------+-------+-------+-------- The high death rate among the officers will at once arrest attention, but this has been noticed in other campaigns, particularly in theFranco-German war. It is mainly attributable to the circumstance thatthe officers, as leading, are always in the front and most exposedposition. I much doubt whether at the end of the campaign the entireabandonment of distinctive badges will be found to have had any veryimportant result in decreasing the relative number of casualties asbetween officers and men. At close quarters distinctive uniform is nodoubt a danger, but at the common ranges of 1, 000 yards and upwards theenemy's fire is rather directed to cover a zone than to pick outindividuals. The especially high mortality among the officers at the battle ofGraspan was attributable to the casualties among the naval officers, andthe men of the brigade suffered most severely also. It will be noted that the most expensive battles were those of Belmontand Magersfontein. If the numbers of the men actually taking part in the fighting in thesebattles as given in Table I. Are massed, we get an approximate total of12, 420. [3] Of this number, 1, 959 or 15. 06 per cent. Were reported as killed, wounded, or missing. Thus: killed, 315 or 2. 53 per cent. ; wounded, 1, 512or 12. 17 per cent. ; missing, 132 or 1. 06 per cent. Reference to TableIII. Shows that these percentages almost exactly correspond with thoseobtaining in the entire Crimean campaign, and are greater than thoseobserved in the German army during the entire Franco-German campaign. The mortality statistics given in Table II. Are of great interest, since to those dying on the field are added all men dying within thefirst 48 hours in the Field hospitals. From the surgical point of viewthese men all received mortal injury, and are therefore properlyincluded among the fatalities. Their inclusion, moreover, makes anappreciable difference in the percentage proportion of mortal injuriesto wounds. Thus, if the numbers are massed (omitting the 'missing'), wefind that in the four battles 1, 827 men were hit, of whom 315, or 17. 24per cent. , were killed. Among the wounded carried off the field, however, 49 received mortal injuries, and if these are added to the 315, we find that the proportion of mortal injuries reaches 19. 92 per cent. TABLE III[4] +-----------------------+---------+---------+--------+---------+----------+| | | | 1871. | 1877. | 1899. || | 1815. | 1854. | Franco-| Russo- | Kimberley|| | Waterloo| Crimean | German | Turkish | Relief || | (English| War | War | War | Force || | troops) | (English| (German| (Russian| (English || | | troops) | troops)| troops) | troops) |+-----------------------+---------+---------+--------+---------+----------+| Number of troops | | | | | || engaged | 36, 240 | 97, 864 | 887, 876| 300, 000 | 15, 748 || | | | | | || Number of killed | 1, 759 | 2, 775 | 17, 570| 32, 780 | 315 || Percentage | 4. 85 | 2. 81 | 1. 97| 10. 92 | 2 || | | | | | || Number of wounded | 5, 892 | 12, 094 | 96, 189| 71, 268 | 1, 512 || Percentage | 16. 25 | 12. 35 | 10. 83| 23. 75 | 9. 60 || | | | | | || Number of missing | 807 | -- | 4, 009| -- | 132 || Percentage | 2. 19 | -- | 0. 45| -- | . 83 |+-----------------------+---------+---------+--------+---------+----------+| Total killed, | | | | | || wounded, and missing | 8, 458 | 14, 849 | 117, 768| 104, 050 | 1, 959 || Percentage | 23. 31 | 15. 17 | 13. 26| 34. 68 | 12. 43 |+-----------------------+---------+---------+--------+---------+----------+ The proportion of men killed to those wounded was as follows: killed315, wounded 1, 512, or 1 to 4. 8. If we add to the men killed on thefield of battle the 49 dying in the next 48 hours, the proportion offatalities is increased to 1 to 4. 15. The higher of these proportions iscertainly the surgically correct one. With regard to the general accuracy of the numbers given above, acomparison of those published for the campaign up to September 15, 1900, is of value, as the two series substantially tally. Thus, up to thatdate, 17, 072 men were hit, and of these 2, 998 were killed. Theproportion killed to wounded was therefore 1 to 4. 69. If it be borne in mind that of the wounded men included in Table I. , 1. 5per cent. Died later in the Base hospitals, the percentages are almostidentical. Table III. Is inserted with a view to instituting a comparison betweenthe number of casualties in the present and earlier campaigns. For the purposes of this table it is necessary to take the approximatenumber of men at Lord Methuen's disposal, irrespective of their activeparticipation in the fighting. The result of this addition to the total is to show that the percentageof men killed and wounded was slightly lower than in the Crimean war, and nearly corresponded with that observed in the Franco-Germancampaign. As it has been shown that our numbers correspond in general with thoseof the whole war up to September 15, 1900, there can be little doubtthat the same ratios will be maintained to the close of the campaign. On the face of the numbers, therefore, there is little ground forassuming that the change in the nature of the weapons has materiallyinfluenced the deadliness of warfare at all. This is capable ofexplanation on the ground that in the Crimea the battles were fought atmuch closer quarters, and hence the weapons of the time were aseffective, or more so, than the present ones. That this increaseddistance between the combatants will always counterbalance the increaseddeadliness of the weapons in the future is more than probable, since therange of effectiveness has been increased both in rifle and in artilleryfire. In the present campaign the effect of the latter was verynoticeable, since the Boers were, as a rule, quickly displaced by shellfire, unless they were in especially favourable positions, and thisalthough no great number of men was hit by the projectiles. Under thesecircumstances, except on some occasions, neither side derived all theadvantage from the increased shooting powers of their rifles which mighthave been expected. To a lesser degree this will probably always be thecase in the future. In connection with these remarks, however, I would point to column 4 ofTable III. , as showing how difficult it is to draw definite deductionsfrom any particular set of numbers alone. This column shows that in theRusso-Turkish War of 1877 all the percentages were practically doubledor more, and in the case of the number of men killed on the field ofbattle, the number was nearly five times as great as either in theCrimea or the present campaign. The explanation here depends on the raceof men and their tenacity in resistance alone. In the case of eithernation death in battle is little feared, and slight inclination to avoidit exists. When the theory of war held by the Boer--_i. E. _ going out toshoot an enemy without incurring risk of being yourself shot--is bornein mind, the special circumstances attending the present campaign aresufficiently obvious to need little further remark. A future campaign inwhich the combatants are as equally well armed, but each side stands tothe last, will probably give very different results. It is unfortunate that no details can be given as to the influence ofrange in altering the relative numbers of killed to wounded. It may bestated, however, that in no instance did the percentage of killed towounded reach 25 per cent. At the battle of Magersfontein it amounted to19. 26 per cent. , at Colenso to 17. 97 per cent. , and at both theseengagements there is little doubt that a considerable number of the menwere hit within a distance of 1, 000 yards. When the distances were veryshort the injuries were frequently multiple; and this character was amore common source of danger than increase of severity in the individualwounds received at a short range. A short consideration of the circumstances especially influencing theultimate mortality amongst the wounded subsequent to the reception ofthe injury is here necessary, although I shall be obliged to make myremarks as short as possible. The subject is best treated of under thetwo headings of Transport and Hospital Accommodation. _Transport. _--The importance of transport is felt from the moment of theinjury till the time of arrival of the patient in the mother country. Tothe surgeon it is of the same vital importance as the carrying of foodfor the troops is to the combatant general. (_a_) Removal of the wounded from the field of battle. My experience wasopposed to hurried action in this matter, although it is necessary togather up the wounded before nightfall if possible. As a rule woundedmen should not be removed from the field of battle under fire, at anyrate when the troops are in open order at a range of 1, 000 yards ormore. I saw several instances in which mortal wounds were incurred bypreviously wounded men or their bearers during the process of removal, while it was astonishing how many scattered wounded men could lie outunder a heavy fire and escape by the doctrine of chances. The erectposition and small group necessary to bear off a wounded man at oncedraws a concentrated fire, if fighting is still proceeding. As to the best and quickest method of removing the patients to the firstdressing station, there were few occasions when this was not moresatisfactorily done by bearers with stretchers than by wagons. Themovement was more easy to the wounded men, and, as a rule, time wassaved. Over rough ground the wagons travel slowly, and patients withonly provisional splints were shaken undesirably. A stretcher party inmy experience easily outstripped the wagon unless a road or very smoothveldt existed. A larger number of men is of course required, but I takeit that on the occasion of a great war men are both more easily obtainedand fed than are transport animals. From what I have been able to learn, both the Indian dhoolie-bearers and the hastily recruited Colonialbearer companies were most successful in the removal of the large numberof wounded men from the field of Colenso. I had several opportunities ofcomparing the two methods on a smaller scale during the fighting inOrange River Colony, and felt very strongly in favour of the stretcherparties. For removal of patients from one part of a hospital to another, orsometimes in loading trains, &c. , great economy of men, and increasedcomfort to the patients, may be attained by the use of some form ofambulance trolly. I append an illustration of what seemed to me the simplest and best Icame across among several in use in South Africa. The descriptionbeneath is by Major McCormack, R. A. M. C. , its inventor (fig. 5). When wagons were necessary or preferable, the Indian Tongas (fig. 6), presented by Mr. Dhanjibhoy, were most useful; they carried two menlying down, the same number as the big service wagon, and were drawn bytwo ponies only. Although somewhat highly springed, the vehicle is sowell arranged and padded, that the occupants are seldom hurt by strikingagainst the sides with rough jolting, unless quite helpless. Ioccasionally made long journeys in this vehicle with much comfort. [Illustration: FIG. 5. --The McCormack-Brook Wheeled Stretcher Carriage. It consists of an under-carriage built up of two light wheels with steelspokes and rims with rubber tyres and ball bearings; on the axle are twolight elliptic springs, to which is attached a transverse seat for thestretcher-carrier proper. This is securely bolted on to the seat, andconsists of two pieces of hard wood, suitably worked, and forming anangle frame. On the bottom side the stretcher poles rest, and the sidesof the L formed by the carrier proper prevent most effectually anyjerking or turning of the stretcher when once it has been laid in thecarrier. The carrier is about thirty inches long, but can be increasedto any length desired. It has been found that this length is admirablysuited for all purposes. To prevent the stretcher from any lateral orupward movement, two buttons with tightening screws are attached to thetop of the carrier on each side. When the stretcher is laid on thecarrier the screws are tightened and the stretcher is held rigid. Two iron supports are provided, one at each end and on opposite sides ofthe carrier. These are lowered when it is desired either to place thestretcher on the carriage or remove it therefrom, which can be effectedin a second. The carriage meanwhile remains perfectly still. When thecarriage is in motion the iron supports are turned up, and lie along therespective sides of the carrier, where each rests in a small clip. Thegreat object of this stretcher carriage has been to obtain mobility, strength, and lightness combined with efficiency and a ready and easymeans of transport for sick and wounded, no matter where a patient hasto be transported from. The loaded stretcher and wheeled carriage can bereadily handled by one man on good roads, and by two men in roughcountry. The springs prevent any jar being felt by the patient on thestretcher. ] (_b_) For the longer journeys to the Field or Stationary hospitals, theservice wagon and other transport vehicles came into use, particularlythe South African ox-wagon. [Illustration: FIG. 6--Indian Tonga on the march. (Photo by Mr. Bowlby)] The service wagon (fig. 7) is a heavy four-wheeled vehicle, drawn by tenmules. The good construction of the wagon was amply proved by the mannerin which it stood the hard wear and tear of the present campaign. It is, however, very heavy, and in comparison with its size affords very smallaccommodation. Two lying-down patients and six sitting is its entirecapacity. Some modified patterns were in use, notably those with theIrish and Imperial Yeomanry Field Hospitals, capable of carrying fourlying-down cases, the men being arranged in two tiers. Major Hale, R. A. M. C. , made a very successful trek from Rhenoster to Kroonstadt withsome of these, carrying twice the regulation number of lying-down casesin his wagons. Some modification in the mode of fixation is, however, necessary to increase the security of the stretchers of the upperseries. A really satisfactory wagon, combining both strength and comfort, stillremains to be devised. [Illustration: FIG. 7. --Service Ambulance Wagon, the six front mulesremoved. (Photo by Mr. C. S. Wallace)] During the later stages of the campaign, a very large number of patientswere transported by the South African ox- or mule- (buck) wagons. Although not of prepossessing appearance, and unprovided with any sortof springs, these vehicles were far from unsatisfactory. The ox-wagonconsists of a long simple platform, 19 ft. 2 in. In length, 4 ft. 6 in. In width, from the sides of which a slanting board rises over the wheelsfor the posterior two-thirds. These bulwarks increase the actual widthto 6 ft. 6 in. , which corresponds with the gross width occupied by thewheels. One third is covered by a small hood 5 ft. 6 in. In heighterected on wooden stave hoops. The latter was often absent in transportwagons. The two hind wheels are large, the fore somewhat smaller. Theyare attached to very heavy wooden cross-beams bearing the axles, and thetwo beams are connected by a longitudinal bar, continuous with thedüssel boom or pole. This latter bar is in two sections, the connectionof which allows considerable play in the long axis and serves to breakthe jolts occurring when either pair of wheels passes over uneven spotson the ground. When some sacks of oats or hay were spread over thefloor the wounded men travelled comparatively comfortably in thesewagons, the great distance between the fore and hind wheels tending tominimise the jolting. The principal objection to them was the slow paceof the oxen, and the fact that to obtain the greatest amount of workfrom these animals a major part of the journey must be performed duringthe night. The ox-wagon carries, with comfort, four lying-down cases onstretchers, or six without stretchers; or twenty sitting-up cases. [Illustration: FIG. 8. --South African Wagon, loaded with patients, andmule transport. (Photo by Mr. C. S. Wallace)] The mule- or buck-wagon, which is of the same class but smaller, canonly accommodate two stretchers, four lying-down men without stretchers, or 12-14 sitting-up cases. As a rule, the wagons were loaded withrecumbent cases in the centre, while more slightly wounded men sataround, and were able to give help to those lying down when needed. Thewagons can be covered with canvas throughout. The steady even pace of the oxen is a great advantage, and I was oftensurprised to see how well men bore transport in these wagons, who seemedutterly unfit to be moved had it not been an absolute necessity. A verylarge number of the wounded from Paardeberg Drift were transported toModder River in them. One other advantage of these wagons, the possibility of converting theminto an excellent laager, is not to be underrated. Any one who saw thecomfortable encampment which a naval contingent on the march made bymassing the wagons with intervals covered by macintosh sheets, could atonce appreciate their capabilities for a long trek. Traction engines were, as far as I know, never employed as a means oftransporting the sick. The tendency of these heavy machines to stick inthe mud and to break down bridges is so well known that it hardly needsmention. Putting these disadvantages on one side, with a supply of fuelensured, and such roads as are afforded by a civilised country, a greatfuture is probably before this means of transport for the wounded. Alarge number of patients might be carried at an even pace, and the campswould be saved all the trouble and worry of the transport animals. _Trains. _--In many cases in Natal, and in a few instances on the westernside, the wounded men were able to be transferred from the firstdressing station directly into the trains. Space will not allow me todescribe any of those in use, but the accompanying illustration showsthe general arrangement of the beds in Nos. 2 and 3 trains (fig. 9). Thecarriages were converted from ordinary bogie wagons of the CapeGovernment Railway stock under the supervision of Colonel Supple, R. A. M. C. , P. M. O. Of the Base at Cape Town. Each train was provided withaccommodation for two medical officers, two nursing Sisters, orderlies, a kitchen, and a dispensary, and each carried some 120 patients. Thetrains were under the charge of Major Russell, R. A. M. C. , and Dr. Boswell(and later other civilian medical officers) and of Captain Fleming, R. A. M. C. , D. S. O. , and Mr. Waters, and carried many thousand patientsfrom all parts of the country to the Base and Station hospitals. Theywere most admirably worked, and seemed to offer little scope forimprovement except in minor details. To them much of the success in thetreatment of the wounded who had to traverse the immense distancesincident to South Africa must be attributed. I made many pleasantjourneys in each of them. Later, two additional trains, Nos. 4 and 5, ofa similar nature, were added. Two trains, No. 1, and the PrincessChristian train, which I was not fortunate enough to see, performedsimilar duties for Natal. [Illustration: FIG. 9. --Interior of one of the Wagons of No. 2 HospitalTrain] _Hospital Ships. _--These were numerous and some especially wellarranged. Fig. 10 is of the 'Simla, ' a P. & O. Vessel which wasadmirably adapted to the requirements of a hospital ship. On her maindeck some 250 patients were accommodated in a series of wards all on thesame level, which much lightened the difficulties of service usuallyexperienced. During the present campaign the abundance of transportvessels rendered the transhipment of patients to England a matter ofcomparative ease, and good vessels were always available. Consideringthe constant transhipment of invalids from India and our other colonialpossessions, it would seem advisable that, in place of having tohurriedly improvise hospital ships, the Government should possess two orthree hospital ships of the 'Simla' type. It is true this would depriveour naval transport officers of a duty which in this war was performedwith extraordinary celerity and success; thus the 'Simla' was fitted inseven days, and sailed with a cargo of invalids ten days after herarrival at Durban; but on the other hand it would ensure that reallysuitable vessels were always provided. [Illustration: FIG. 10. --P. & O. Hospital Ship 'Simla' in DurbanHarbour] To give some idea of the amount of work contingent on the transport ofwounded men from an army of some 15, 000, fighting its way againstcontinued opposition, I will quote the approximate number of men movedduring Lord Methuen's advance from Orange River to Magersfontein. (Thenumber of men actually present at each battle is shown in Table I. , p. 12. ) Belmont, the first battle, was fought on November 23. _November 24. _--No. 2 hospital train removed 152 cases to the StationaryField hospitals at Orange River, then returned and loaded up with 130more. Some of the most severe cases in the latter were detrained atOrange River, and the remainder were taken direct to Wynberg (591-1/2miles). The division marched, and the battle of Graspan was fought during theday. _November 26. _--A train of specially constructed trucks brought 90 ofthe less severe cases, including 20 Boers, to Orange River. _November 27. _--The division marched, and in the morning No. 3 hospitaltrain removed 80 severe cases from the Field hospitals direct toWynberg. _November 28. _--Battle of Modder River. _November 29. _--339 patients, including a few sick, and some woundedBoers, were sent down to Orange River in open trucks with impromptushelters made with rifles and blankets. Later, 97 severe cases were sent down in ordinary carriages, of whichsome had doors sawn out to admit lying-down patients. _December 10. _--The division marched, and on the next day the battle ofMagersfontein was fought. _December 11. _--Nos. 2 and 3 trains were loaded up during the night andearly morning of the 12th, in part from the Field hospitals, in partdirectly from the Ambulance wagons. During the day of the 12th, No. 3train made three journeys to Orange River, and No. 2 was sent direct toWynberg. In all some 800 patients needed transport; they were picked up by 10ambulance wagons and 5 buck wagons for slighter cases and the two bearercompanies sent out from Modder River. On the 12th Lord Methuen sent outa number of bearers with stretchers, and at 12 noon all the wounded werecollected, but many had lain out through the night. The bearers had toretire under a shell fire kept up by the Boers as long as our army waswithin range of their position. Four Field hospitals were present, but only that of the IX. Brigade atModder River was so situated as to be of general use. This hospital, under the command of Major Harris, R. A. M. C. , did an immense amount ofwork most expeditiously and with great success. The nature of the advance on Kimberley necessitated the evacuation ofthe Field hospitals with extreme promptitude, as the troops were inconstant action, and the arrangements for this were carried out withgreat success by Colonel Townsend, the P. M. O. Of the First Division. The amount of fighting far exceeded anything that had been expected, andthe Stationary hospitals on the lines of communication at Orange Riverand De Aar were unable to cope with the number of severe cases thrown ontheir hands, with the constant possibility of new arrivals. Hence anumber of severe cases had to be sent direct to Wynberg. This experience strongly illustrated the necessity of possessingStationary hospitals of greater mobility and a higher degree ofequipment than the service at present possesses. In these a large numberof severe cases could have been retained, and only the slighter onesexposed to the fatigue and general disadvantage of transport. In SouthAfrica very special difficulties existed in the length of the line ofcommunication, the single line of rails, and the absence of any sourceof supply within 500 to 600 miles; but in any other country mobileStationary hospitals, although more easily equipped, would be equallyvaluable. The difficulties of transport experienced in the advance of theKimberley Relief Force were many times multiplied in that uponBloemfontein, since the whole of the severely wounded men had to be sentback thirty to forty miles to the railway. The ambulance accommodationon the occasion of this march, although, if untouched, proportionatelysmaller than that possessed by Lord Methuen, was reduced to one-fifth tomeet the exigencies of warfare. Beyond this the equipment transport ofthe Field hospitals was reduced from four ox-wagons to two, and theScotch cart was cut off, only two ox-wagons and the two water-cartsbeing allowed. This greatly hampered the Field hospitals on the march, and when they arrived at Bloemfontein and had to undertake the work ofStationary hospitals, their efficiency was seriously impaired. Again, onthe advance from Bloemfontein to Kroonstadt many of the Field hospitalswere unable to accompany their respective divisions, not alone onaccount of the number of patients remaining in them, but also becausethe mule transport had been otherwise employed for military purposes. The transport of the ambulances and hospitals stands in a very specialposition. As far as my experience went, neither ambulances nor hospitalswere ever taken or retained by the Boers, and consequently the transportanimals originally devoted to this purpose should have been held sacredto it. _Hospitals. _--Accommodation for the wounded was provided under canvas inthe Field hospitals, also in the large General hospitals. Beyond thisiron huts were erected in many of the Base and Station hospitals. AtCapetown, Maritzburg, and Ladysmith barrack huts were modified andequipped as hospitals, and in towns such as Bloemfontein, Kimberley, andJohannesburg large civil hospitals were at our disposal. Beyond thesesources of accommodation, churches, schools, public institutions, andprivate houses were made use of in the smaller towns. As to the broad question of canvas _v. _ buildings, experience amplyshowed that in a climate such as is possessed by South Africa, canvasaffords the greater advantages. The hospitals are more mobile, morereadily extended, and the more healthy. Except under unusual conditionsof rain and dust, the patients did excellently in the tents. Rain and dust were occasionally most troublesome, especially whencombined with wind. I once saw a whole hospital, fortunately unoccupied, levelled to the ground in the course of some twenty minutes. Under suchcircumstances iron huts present advantages, and were on many occasionsutilised with much success. They are readily erected, and it would havebeen a considerable improvement if a number of them had been ready foruse at the earliest part of the campaign. Except in the matter ofweight, they possess in a considerable degree the advantage of mobilitypossessed by canvas, and in addition they offer much more protectionfrom the weather. On the other hand, they are more liable to becomeunhealthy from prolonged use. Churches and public institutions were mainly troublesome from thenecessity of having to improvise sanitary arrangements, and sometimesthe disadvantage of the collection of a large number of men in onechamber could not be avoided. None the less I cannot look back withoutadmiration on the temporary hospitals established in the Raadzaal atBloemfontein, and the Irish hospital in the Palace of Justice inPretoria. The State schools in the smaller towns of the Orange River Colony alsoafforded excellent accommodation as small temporary hospitals. Private houses, possessing the disadvantages of ill-adapted constructionand the necessity of a considerably increased staff to work them, wereon the whole little used as hospitals. The scattered farmhousesoccasionally afforded shelter to very severely wounded men. In most ofthe country I traversed, however, the farms were so wide apart as to beof little use in this respect; and again, under the specialcircumstances, patients left in them might have to be abandoned to theenemy. The chief interest during the campaign centred in the working of theField and General hospitals. Two types of Field hospital were employed, one the Home, the other theIndian. The latter differs from the Home in that in it the bearercompany is attached and consists of Indian natives, and that thehospital is separable into four sections in place of two only. The amalgamation of the Field hospital and bearer company into one unitis much to be desired in the Home service, both for economy of workingand the more equal distribution of duties to the medical officersengaged. Again the divisibility of the hospital into four sections isalso an advantage. It allows of the advance or the leaving of sections, in the case of either small expeditions or the presence of a number ofseverely wounded men unfit to travel. As far as I could judge, itnecessitates very small addition to the present equipment, and is inevery way desirable. As to the working of the Field hospitals in the present campaign, itwas universally acknowledged to possess a very high degree ofexcellence. The equipment, with small exceptions, proved equal to thedemands made upon it. The mobility of the camps was proved again andagain, and the rules governing their administration evidenced by theireffectiveness the care and experience which have been bestowed on theorganisation of the hospitals. It is difficult for any one who has not had an opportunity of observingthe actual amount of work performed in the Field hospitals either toappreciate the storm and stress following an important engagement whenthe wounded men are first brought in, or the demands that are made onthe powers of the medical officers in charge. To a civilian the firstfeeling is one of impotence, followed by an attempt to see no furtherthan the case under immediate observation, and to nurture the convictionthat the work is to be got through if it is only stuck to. I gatheredthat this first impression was absent in the minds of the officers incharge of the Field hospitals, as work commenced at once, and wascarried on without intermission during the persistence of daylight, inthe winter often by the aid of lanterns, and eventually the huge taskwas accomplished. In early days at Orange River work commenced at 4A. M. , and was steadily continued until 6 P. M. Or later, and this stateof things persisted sometimes for many days together. The officers of the Field hospitals, the bearer companies, and thosedoing regimental duty carried out their duties with a calmness andefficiency which not only impressed observers like myself, but alsoexcited the admiration of our German colleagues sent by their governmentto observe the working of the British system. I saw on several occasions the German and Dutch ambulances, and was muchstruck by the excellence of their equipment. In some details there wasmuch to be learned from them, especially in the matter of appliances, dressings, and instruments. The Dutch ambulance I saw at Brandfort had acomplete installation of acetylene gas, which was carried, gasometer andall, in one Scotch cart. They were, however, really designed to fill thecombined position of our Field, Stationary, and General hospitals, andwhen it became necessary for them to move about frequently, the inferiormobility they possessed in comparison with our own Field hospitals wasat once demonstrated. The large General hospitals of 500 beds were a great feature in thecampaign. Although designed and organised some time since, the presentwas the first occasion on which they have come into general use, andthey may be said to have actually been on trial. The organisation ofthese hospitals proved itself excellent, and in the case of the best ofthem left little to be desired. In some cases the accommodation was temporarily strained enormously, andthe number of patients was extended beyond more than three times theregulation limit. The additional patients were then accommodated inmarquees and bell tents, according to the nature of their diseases. Under these circumstances the working of the hospitals was difficult, and the officers both of the R. A. M. C. And the civilian surgeons wereplaced at a great disadvantage. My space does not allow me to give any description of the generalarrangement of these hospitals, but I would suggest that a certainnumber of them should be so modified as to increase their mobility andallow of their being more readily utilised as Stationary hospitals. During the whole campaign it seemed to me that the Stationary hospitals(that is to say, the hospitals necessary to receive patients when theField hospitals were rapidly evacuated), were those in which someincreased uniformity of organisation was most needed. It scarcely needs to be pointed out that this is the most difficult linkof the whole hospital chain to be uniformly well organised and equipped. It is needed at short notice, and often for a short period, and it isdifficult to maintain a regular staff of officers ready for anyemergency without keeping a certain number of men idle. The conversion of Field hospitals to Stationary purposes is undesirable, as the troops move with only a regulation number of the former, whichunder ordinary circumstances is the minimum that may be necessary. Stationary hospitals as individual units are undesirable for the reasonsabove given. [Illustration: FIG. 11. --Type of a General Hospital (No. VIII. Bloemfontein) extended by use of bell tents in the distance. (Photo byMr. C. S. Wallace)] The difficulty might be met by increasing the mobility of a certainnumber of the General hospitals, by making them divisible into fivesections, each of which should be able to move independently, and to thelast of which should be attached the heavy part of the equipment, suchas the iron huts for operating and X-ray rooms, kitchens, store sheds, &c. The tents might also be lightened by the substitution of thetortoise tent for the service marquee. The tortoise tent is lighter (360as against 500 lbs. ), easily pitched and moved, and holds at least twomore patients with ease. The capabilities of this tent were amply provenduring its use by the Portland, Irish, and other civil hospitalsattached to the army. It withstood wind and weather, the former betterthan the service marquee. Figs. 11 and 12 show the appearance of campscomposed of the two varieties. I must admit a warm preference for theappearance of the service pattern, but I think it is indubitable thatthe other is the more useful. Given the possibility of division of a General hospital in this manner, single sections could readily be sent up the lines of communication toserve as Stationary hospitals at various points behind the advance ofthe troops, and on the cessation of active need, the sections could bereunited at any point to form an advanced Base hospital. The sectionscould be kept in touch throughout by visits from the officer of thelines of communication. This would appear a ready means of providingwell-organised Stationary hospitals at short notice, and would save thedisadvantage of a definitely separate series. [Illustration: FIG. 12. --Type of Tortoise Tent Hospital. PortlandHospital, Bloemfontein. (Photo by Mr. C. S. Wallace)] Such hospitals might have been used on many occasions when the transportof an entire General hospital was an impossibility. The service, moreover, has some experience in this direction, since at one time No. 3General Hospital was divided into two definite sections. Bearing in mind the extreme readiness and promptitude with which theofficers during the present campaign extended the accommodation ofeither Field or General hospitals, one of such sections as are proposedmight readily be made far more capacious than its regulation numberwould suggest. My duties being entirely in connection with the service hospitals, I didnot become intimately acquainted with any of the volunteer hospitalswhich did such excellent service, except the Portland, to the staff ofwhich I was indebted for much hospitality and kindness. This hospitalwas practically of about the capacity proposed for the above-mentionedsections, and the report of its work will no doubt furnish many pointsof detail as to equipment, &c. , which may be useful. The general results of the surgical work done during the campaign wereexcellent, and taken as a whole the occurrence of any severe form ofseptic disease was unusual. Pure septicæmia, especially in connection with abdominal injuries, severe head injuries and secondary to acute traumatic osteo-myelitis, was the form most commonly seen. Pyæmia with secondary deposits wasuncommon, and often of a somewhat subacute form; thus I saw severalpatients recover after secondary abscesses had been opened, or theprimary focus of infection removed. The only really acute case of jointpyæmia I heard of, developed in connection with a blistered toe followedby cellulitis of the foot. Cutaneous erysipelas I never happened to see, and really acutephlegmonous inflammation was rare. I may mention the occurrence of acute traumatic gangrene in two cases. This developed in each instance with gunshot fracture of the femur; inone amputation was performed, and the process extended upwards on to theabdomen. The cases occurred with the army in the field in theneighbourhood of Thaba-nchu and not in a stationary hospital. Acute traumatic tetanus occurred only in one instance to my knowledge. In this case the primary injury was a shell wound of the thigh, and thepatient developed the disease and died within ten days. To the civil surgeon the performance of operations, and the dressing ofsevere wounds at the front, proved on occasions a somewhat tryingordeal. When operations were necessary in the field, during the daytime, it wasoften possible to perform them in the open air, provided tolerableprotection could be obtained from the sun. A number of cases were sooperated upon during the march of the Highland Brigade from Wynberg toHeilbron, and gave excellent results, the patients deriving considerablebenefit from the early cleansing and closure of the wounds. [Illustration: FIG. 13. --Tortoise Hospital Tent. Portland Hospital. (Photo by Mr. C. S. Wallace)] In camp, in the Field, or Stationary hospitals, the difficulties wereoften much greater. The operations were necessarily performed undershelter for reasons of privacy. In the tents the draught carrying thedust from the camp was one of the commonest troubles. The exclusion ofdust was impossible, and it not only found its way into open wounds, butpermeated bandages with ease. Often when a bandage was removed, an evenlayer of dust moistened by perspiration covered the whole area includedwith a coating of mud. Again, in dust storms a similar layer of mudsometimes covered the whole of the exposed parts of the bodies ofpatients lying on the ground in the tents. It is of some interest to remark with regard to this dust, that Dr. L. L. Jenner lately kindly examined a specimen collected at Modder Riverafter the camp had been more than two months established, and discoveredno pathogenic organisms in it. As a period of seven months had elapsedsince this dust was collected, the fact is of no practical import, beyond showing that, if such organisms had existed, at any rate theywere not of a resistent nature. Insects, particularly common house-flies, were an intolerable pest attimes. In a fresh camp they were sometimes not abundant, but after twoor three days they multiplied enormously. Not only hospital tents, butliving and mess tents, swarmed with them, the canvas appearingpositively black at night. Even when dressing a wound, without unceasingpassage of the hand across the part, it was impossible to keep them fromsettling, and during operations the nuisance was much greater. Storms of rain were occasionally as troublesome as, though perhaps lessharmful than, those of dust. On one occasion a whole Field hospital wasflooded only a few hours after a number of important operations had beenperformed, and the patients were practically washed out of the tents. Itwas somewhat remarkable that none of the men suffered any serious ill asa result. At times the temperature was sufficiently high to make either dressingor operating a most exhausting process to the surgeon. The heat of theday was not on the whole so disadvantageous from the point of view ofthe operator, as the cold of the nights during the winter in OrangeRiver Colony. On one or two occasions serious operations had to be leftundone, as it was only possible to consider them in camp, where, as wearrived at night only, the temperature was too low to justify thenecessary exposure. Water for use at operations was often a great difficulty. Even at OrangeRiver, where, though muddy, the water was wholesome, it was impossibleto get water suitable for operations unless it had previously gonethrough the complicated processes of precipitation by alum, boiling, andfiltration. At Orange River a small room in the house of one of therailway servants was obtained and fitted as a rough operating room bythe Royal Engineers. The necessary utensils were provided by ColonelYoung, Commissioner of the Red Cross Societies. Here a stock of preparedwater was kept for emergencies. The remaining difficulties mainly consisted in those we are familiarwith in civil practice, such as the securing of suitable assistance inthe handling of instruments and dressing, when the rush of work was verygreat. At the Base hospitals accommodation for operating in properly equippedrooms obviated many of the difficulties above referred to. In concluding this introduction I should sum up in a few words myexperience of the general working of the hospital system during my stayin South Africa. The excellence of the Field hospitals for their purpose has been alreadyalluded to, and, as far as I could ascertain, won the confidence andapproval of patients, military commanders, and civilians such as myself. The Stationary hospitals (by which I intend to indicate those receivingthe patients directly from the Field hospitals before the establishmentof advanced Base hospitals), as already indicated, were not in myopinion so perfectly conceived or organised. The requirements of theseare, however, far greater than those of the Field hospitals, and they ofall others are dependent on the possession of facilities for rapidtransport. In South Africa the difficulties of supplying them wereenormous, and no doubt the conditions of the campaign in this, as somany other particulars, were novel and unusual. None the less theexperience gained will no doubt be utilised in the future. With regardto the extravagant criticisms levelled at the Field hospitals serving asStationary hospitals at the time of the early period of the occupationof Bloemfontein, it may be pointed out that the only proper ground forcomparison was not between the patients at Bloemfontein and those inhospital at the base, but between the men in hospital and those in thefield at that time, since the conditions were equally adverse to both. Besides, it must not be forgotten that a large proportion of thepatients, at that time, were really comfortably housed in the Raadzaaland other buildings, the preparation of which entailed a very greatamount of both labour and resource. The difficulties experienced at that time will, it is hoped, go fartowards securing greater facilities and rights of transport to the RoyalArmy Medical Corps in the future. As a civilian, one cannot butrecognise that the conditions of modern warfare are much altered fromthose of the past. Prisoners are well cared for and kindly treated, thesick and wounded are respected by both sides, and except in the actualhorrors of fighting the condition of the soldier is a happier one. Underthese circumstances the limitation of the transport facilities of adepartment so closely concerned with the well-being of all, and whichhas been organised on a most moderate scale, must soon become atradition of the past in civilised armies. As to the efficiency of the organisation of the General hospitals, either at the advanced or actual base, I have already testified. Naturally the working of these hospitals varied with the personalequation of the officer in charge of them, but as a whole the servicehas every reason to be proud of their success. As far as surgicalresults are concerned, and with these I had special acquaintance, thesuccess of the hospitals was amply demonstrated. Adverse criticism was not however wanting, and often expressed in thestrongest terms by persons totally unacquainted with hospital methods, and apparently unconscious that such excellence as is exhibited in aLondon hospital is the result of continuous work and development forsome centuries, and that such institutions are worked by committees andstaffs of permanent constitution. The proportion of female nurses employed in these hospitals underwentsteady increase from the commencement of the campaign, and the immensevalue of the nursing reserve was fully proved. There is no doubt that inBase hospitals the actual nursing should always be entrusted to women. The demands of the campaign necessitated the employment of a largenumber of civil surgeons in the various hospitals. These gentlemenaccommodated themselves with true British aptitude to the conditionsunder which they were placed, and in all positions their sterling workcontributed in no small degree to the success that was attained. One class of hospital still remains for mention. I refer to theimprovised hospitals prepared in the Boer towns prior to the Britishoccupation. They were met with in all the smaller towns, and also in thelarger ones such as Johannesburg and Pretoria. The Burke hospital in Pretoria, started by a private citizen and hisdaughter, and the Victoria hospital in Johannesburg, presided over byDr. And Mrs. Murray, were two of the largest, but each and all deservedue recognition. I am sure that many of our wounded officers and men who were cared forin these hospitals while prisoners in the hands of the Boers, will neverlose their sense of gratitude to those inhabitants who spared no effortto render their position as happy as possible under the circumstances;and the existence of these hospitals was no small boon to the servicewhen called upon to take charge of the sick and wounded thereincontained. I cannot close this chapter without recognition of the immensity of thetask which has fallen on the Royal Army Medical Corps in the treatmentof the sick and wounded during the course of the campaign and fullappreciation of the manner in which that task has been met. The strainthrown upon this department of the service, originally organised for theneeds of an army less than half the magnitude of that eventually takingthe field, was incalculably great, and the medical profession may wellbe proud of the efforts made by its military representatives to do thebest possible work under the circumstances. FOOTNOTES: [1] 3, 328 men of the IX. Brigade present are not included, as they nevercame into action. [2] The high mortality was due to deaths amongst the officers of theNaval Brigade. [3] To obtain this total the numbers of killed, wounded, and missing, after the three earlier battles, have been massed, and added to thetotal number of men known to have taken part in the battle ofMagersfontein. The inaccuracy dependent on the fact that some of the menreported as wounded or missing in the earlier battles had alreadyreturned to their regiments, and are included in the total of 11, 447, must be disregarded. [4] Numbers quoted from Fischer, _Handbuch der Kriegschirurgie_, vol. I. P. 22, 1882. CHAPTER II MODERN MILITARY RIFLES AND THEIR PROJECTILES IN RELATION TO INJURIESPRODUCED BY THEM ON THE HUMAN BODY Before proceeding to the actual description of the wounds inflicted bymodern military rifles, it is necessary to prefix a few remarks on themechanism and mode of production of these injuries. Recent tendency in the construction of military rifles has been in thedirection of reduction of bore, and a corresponding one in the calibreof the bullet, the resulting loss of weight in the latter as an elementin striking power being compensated for by the attainment of anaugmentation of velocity in the flight of the projectile, and acomparatively flat trajectory. Changes in this direction have endowed the weapons with increase both inrange and accuracy of fire; while the greater rapidity with whichmagazine rifles can be discharged and, in consequence of reduction inweight, the greater number of cartridges which can be carried by eachman, also form important factors in the possible deadliness of warfareat the present day. None the less the experience of the present campaignhas scarcely justified the early prognostications expressed as to agreat increase in the number and severity of wounds amongst thecombatants. [5] This comparative immunity is to be explained mainly ontwo grounds. The increased distance which for the most part separatedthe two bodies of men, a feature no doubt accentuated by the mode ofwarfare adopted by the Boer, and his strong sense of the folly of closecombat on equal terms, tended to efface one of the chief characters, velocity of flight, on the part of the projectile. The want ofeffectiveness of the small-calibre bullet as an instrument of seriousmischief also kept down the mortality. Since the year 1889 the calibre of the bullet in our own army has beenreduced from that of the Martini-Henry (. 450 in. ) to one of . 309 in. Inthe Lee-Metford, and a consequent reduction in weight from 480 to 215grains. To allow of the satisfactory assumption of the more complicatedrifling by the more rapidly projected bullet, the lead core has beenensheathed in a mantle of denser metal. The bullet itself is of anoriginal calibre (. 309 in. ) somewhat exceeding the bore of the riflebarrel (. 303 in. ), in which way a species of 'choke' is obtained anddeep rifling of the surface ensured. Beyond this the comparativetransverse and longitudinal measurements and shape have been altered inorder to maintain weight, preserve a proper balance during flight, andincrease the power of penetration. These alterations with slightdifferences in detail embody the general principles that underlie theconstruction of each of the weapons adopted by European nations. It willbe well here to consider the influence of each alteration from the pointof view of the surgeon. _Calibre. _--The effect of the diminution of calibre is (_a_) to reducethe area of impact of the bullet on the part impinged upon, and hence tolower the degree of resistance offered by the tissues; this to a certainextent tends to neutralise the augmented striking force resulting fromthe increased velocity of flight. (_b_) To limit considerably thedestructive powers of the bullet, as a smaller area of tissue is exposedto its action. (_c_) To allow of the production of very 'neat' injuriesand the frequent escape of important structures, also the production ofremarkably prolonged subcutaneous tracks in positions where such wouldbe regarded as scarcely possible, and in point of fact were impossiblewith the older and larger projectiles. _Length. _--The comparative increase in length of the bullet is, from thesurgical point of view, only of material importance in increasing theweight and therefore the striking power, and in so far as it is amechanical necessity for the flight of the projectile on an axisparallel to its long diameter, and so tends to ensure impact on thebody by the tip of the bullet. This latter is, however, surgicallyfavourable as ensuring a smaller wound. _Weight. _--The decrease in weight must be regarded on the whole asaltogether to the advantage of the wounded individual, since it cannotbe considered to be entirely compensated for by the resulting increasedvelocity of flight, unless the range of fire is moderately close. _Shape. _--The ogival tip and general wedge-like outline, whiledecreasing the aerial resistance to and increasing the power ofpenetration possessed by the bullet, at the same time allow the escapeof some structures by displacement, while others are saved from completedestruction by undergoing perforation. Beyond this the sharper the tip, the smaller is the area of the body primarily impinged upon, the lessthe resistance offered to perforation, and to some degree the less thedestruction of surrounding tissues. _Increased velocity of flight. _--This multiplies the striking force, andcompensates in part for decrease in volume and weight of the bullet. Itis customary to speak of the velocity as 'initial' and 'remaining. 'Initial velocity is the term employed to express the velocity at thetime of the escape of the bullet from the barrel; this is alsodesignated as 'muzzle velocity. ' 'Remaining velocity' expresses thatobtaining during any subsequent portion of the flight of the projectile. The greatest initial velocity is obtained with the use of bullets of thesmallest calibre, but this is not of the practical importance whichmight be assumed, since the remaining velocity of flight of suchprojectiles falls more rapidly than that of those of slightly greatermass. Thus, although there may be a difference of a hundred metres persecond in initial velocity between two rifles of calibres varying from6. 5 to 8 millimetres (. 303-. 314 in. ), at the end of 1, 000 metres thediscrepancy is greatly reduced, while at 2, 000 metres it hardly exists. Under such circumstances the projectile of greater weight and volume, aspossessing the greater striking force, is considerably the moreformidable of the two. This is the more important if it be allowed, as Ibelieve to be the case, that velocity _per se_ is of no practical importin the case of wounds of the soft parts of the body, which after allform the preponderating number of all gunshot injuries. The effect ofthe higher degrees of velocity differs, however, with the amount ofresistance met with on the part of the body; hence its serious import iswell exemplified when parts of the osseous skeleton are implicated, although even here considerable variations exist, dependent upon thestructure of that part of the bone actually involved. The most obviousill effect of injuries from bullets travelling at high rates is seen inthe case of the various parts of the nervous system, and here it isundeniable. High velocity and striking force are also responsible forthe prolonged course sometimes taken by bullets through the body. The actual degree of velocity, as judged by the range of fire at whichan injury is received and the resulting injury, is very hard to estimateon account of the many and varying factors which enter into itsdetermination. The mere recital of some of these will suffice to makethis evident. 1. Quality of the individual cartridge employed, as to loading, thematerials employed, and their condition. 2. The condition of the rifle as to cleanliness, heating, and the stateof the grooves of the barrel. 3. The angle of impact of the bullet with the part injured. 4. Resistance dependent on the weight of the whole body of the manstruck, or of an isolated limb. 5. Special peculiarities of build in the individual struck, such asthickness and density of the integument and fasciæ, strength andthickness of the bones, &c. 6. State of tension of the muscles, fasciæ, and ligaments at the momentof impact, and fixity or otherwise of the part of the body struck. 7. The degree of wind, temperature, and hygroscopic conditions of theatmosphere. These form some of the more important points which have to be taken intoconsideration, in addition to a mere calculation of the actual distancefrom which a wound has been received from a particular rifle, and takenwith the unsatisfactory nature of the evidence as to the latter, whichis usually alone obtainable, it is clear that definite assumptions arescarcely possible. In a great number of cases I came to the conclusionthat the only indisputable evidence of low velocity was the lodgment ofan undeformed bullet. There is little doubt, moreover, that the generaltendency of wounded men was to minimise the range of fire at which theywere struck, and again that in the majority of cases in this campaign itwas quite impossible to determine whence any particular bullet had come, since the enemy was seldom arranged in one line, but rather in several. Again, smokeless powder was generally employed. Beyond this, in somecases where there was no doubt of the short distance from which thebullet was fired, the wounds were due to 'ricochet' of portions ofbroken-up bullets. The following instance well illustrates this. Asentry fired five times at two men within a distance of six paces, knocking both down. One man received a severe direct fracture of theilium, the bullet entering between the anterior superior and inferioriliac spines and emerging at the upper part of the buttock. The entryand exit apertures were large but hardly 'explosive, ' as a subcutaneoustrack four to five inches long separated them. Besides this both men hadother lesser injuries; thus in the second two perforating wounds of thearm existed. The latter were not unlike type Lee-Metford wounds, andwere regarded as such until a few days afterwards when a hard body wasfelt in the distal portion of one track and removed. This proved to be apart of the leaden core only, and the similar wound had no doubt beenproduced by a like fragment, the bullet having broken up on striking thestony ground. _Trajectory. _--The comparative flatness of this depends on theconstruction of the rifle and the propulsive force employed, and variesas does velocity with the nature, excellence, and amount of theexplosive, the correctness of the principles upon which the bullet isdevised, and the mechanical perfection of its manufacture. Itsimportance naturally consists in the manner in which it affects thepossibility of covering objects on a wide area of ground and thuscreating a broad 'dangerous zone. ' A bullet fired on level ground fromany one of three of the rifles referred to later (Lee-Metford, Mauser, Krag-Jörgensen), sighted to 500 yards and fired from the shoulder inthe standing position, will cover some part of an erect man of averageheight during the whole extent of its flight. A body of men within thatdistance is therefore in a position of extreme peril in the face of agood shooting enemy. The importance of a flat trajectory is progressively lost, however, withany rifle, as the weapon is gradually sighted to greater distances. Thuswhen sighted to 2, 000 yards the bullet from the Lee-Metford rifle rises174 feet, and a whole army might comfortably be situated over aconsiderable area within that distance. The importance of flatness oftrajectory is also influenced by the nature of the ground occupied bythe combatants. Thus when the area to be covered consists in groundfirst rising then falling from the rifleman, the trajectory will becomemore or less parallel to the surface crossed, and the 'dangerous zone'will be correspondingly increased in extent. On the other hand, when theground slopes away from the rifleman the rise of the projectile isexaggerated, and reaches its most limited capacity of covering anintervening space when the flight crosses a hollow. _Revolution of the bullet. _--It only remains in this place to say a fewwords concerning the revolution imparted to the bullet by the rifling ofthe barrel. This ensures the flight of the projectile on a line parallelto its long axis, and notably increases its power of penetration. Both these properties of the flight are to the advantage of the wounded, since, as already mentioned, the more exactly the impact corresponds toa right angle with the skin, the more limited will be the area ofcontusion, even if it be of the most severe character, while to thetwist of the bullet must be ascribed a not inconsiderable part in theexplanation of the ready and neat perforations of narrow structureswhich are frequently produced. It has been pointed out that the Lee-Metford bullet turns on its ownaxis once in a distance of ten inches, while the Mauser revolves once ina distance of eight and eleven-sixteenths inches; hence not more than atmost two revolutions are made in tracks crossing the trunk, and not morethan half a full revolution in the perforation of a limb. None theless, no one can deny the influence of the one half turn of supinationin entering a perforating tool of any description, both as preventingsplintering, and in preserving the surrounding parts from damage. Beyond this, the spiral turn of the bullet, by diverting a part of thetransmitted vibrations into a second direction, must, in the case ofwounds of the body, help to throw off contiguous structures, and whilethose that are in actual contact are more severely contused, thesurrounding ones suffer somewhat less direct injury. It must be borne inmind, also, that rapidity of revolution does not fall _pari passu_ withthat of velocity of flight, but that the former undergoes acomparatively slighter diminution until the bullet is actually spent. Hence, the influence of revolution is felt, however low the velocity maybe, provided sufficient striking force is retained to enter the body. Aword must be added here as to the surface of a discharged bullet; this, in taking the rifling of the barrel, becomes permanently grooved. Thedepth of the groove differs with the variety of rifle. In theLee-Metford the grooves are deep (. 009), in the Mauser slightly less so(. 007), but the surface of both bullets is comparatively roughened whenrevolving in the body, and this circumstance, since the projectileexactly fits its track, may influence the degree of the surfacedestruction of tissue, and somewhat aid in the clean perforation ofbone, since a little bone dust is always found at the entrance apertureof a canal in cancellous bone. During the campaign many varieties of rifle projecting bullets of widelydiffering calibre were employed by the Boers, many of whom as sportsmenpreferred the rifle to which they were accustomed to a regulationweapon, and an illustration of a large variety of bullets fromcartridges which I collected from arsenals and camps is given below (p. 96). The great majority of the men, however, were armed withsmall-calibre weapons of some sort, and as the wounds produced by theseare of chief interest at the present day, I shall say little of anyothers, beyond an occasional reference to Martini-Henry rifle woundswhich may be considered to represent approximately those made by largeleaden sporting bullets. [Illustration: FIG. 14. --Type Cartridges in common use during the war. From left to right: Martini-Henry, Guedes, Lee-Metford, (Spanish)Mauser, Krag-Jörgensen] The most important, as the most frequently employed, rifles projectingsmall-calibre bullets were the Krag-Jörgensen, Mauser, Lee-Metford, andGuedes, given in the order of increase of calibre (from 6. 5 to 8millimetres, or . 254-. 314 in. ) in the bullets. As to the seriousness ofwounds produced by these there is little to choose, differences incharacter being only those of degree. Such differences depended on thearea of tissue implicated, corresponding with the calibre of theparticular bullet, the comparative weight of the bullet, and the degreeof velocity of flight maintained at the moment of impact. When, however, any of these bullets have been exposed in their flight to influencescapable of causing deformity of their outline and symmetry, peculiarities of construction and in the composition of the metalsemployed in their manufacture may materially alter the character of thewounds produced and revolutionise a classification founded purely on therelative weight, calibre, and degree of velocity with which each isendowed. TABLE I [Transcriber's note: table split to fit on page. ] +-------------------+----------------+------------------+----------------+| | Martini-Henry | Guedes | Lee-Metford |+-------------------+----------------+------------------+----------------+|Calibre of rifle | . 45 in. | . 314 in. | . 303 in. ||Number of grooves | 7 | 4 | 7 ||One twist in | 22 in. To right|9. 85 in. To right | 10 in. To left ||Muzzle velocity | 1, 300 f. S. | 1, 988 f. S. | 2, 000 f. S. ||Sighted to | 1, 450 yds. | 2, 600 paces | 2, 800 yds. ||Weight of cartridge| 758 grains |464. 05 grains[6] | 416-1/2 grains ||Weight of bullet | 480 grains | 244 grains | 215 grains ||Length of bullet | 1. 250 in. | 1. 250 in. | 1. 250 in. ||Calibre of bullet | . 450 in. | . 315 in. | . 309 in. ||Charge of powder | 85 grains | 20-23 grains | 31-1/2 grains || | (black powder) | (nitro- | (cordite) || | | smokeless) | ||Nature of alloy | -- | Mantle: Mild | Cupro-nickel || used for mantle | | steel, greased | || of bullet | | | ||Thickness of | -- | -- | Mark II. Bullet|| mantle | | | ||Tip | -- | . 031 | . 036 ||Sides . 984 from tip| -- | . 011 | . 015 |+-------------------+----------------+------------------+----------------+ +-------------------+---------------+--------------------+---------------+| | Lee-Enfield | Mauser | Krag- || | | | Jörgensen|+-------------------+---------------+--------------------+---------------+|Calibre of rifle | . 303 in. | . 276 in. | . 254 in. ||Number of grooves | 5 | 4 | 4 ||One twist in |10 in. To left |8-11/16 in. To right| 8 in. To left ||Muzzle velocity | 2, 000 f. S. | 2, 262 f. S. | 2, 309 f. S. ||Sighted to | 2, 800 yds. | 2, 187 yds. | 2, 406 yds. ||Weight of cartridge| 416-1/2 grains| 384. 5 grains | 372. 1 grains ||Weight of bullet | 215 grains | 173. 3 grains | 156. 4 grains ||Length of bullet | 1. 250 in. | 1 in. | 1. 250 in. ||Calibre of bullet | . 309 in. | . 280 in. | . 260 in. ||Charge of powder | 31-1/2 grains | 38. 0 grains | 36 grains || | (cordite) | (smokeless) |(nitro || | | | -smokeless) ||Nature of alloy | Cupro-nickel | Mantle: Steel |Mantle: Mild || used for mantle | | with alloy of | steel coated || of bullet | | copper on | with copper || | | surface | nickel, the || | | | composition of|| | | | the latter || | | | being that of || | | | the cupro- || | | | nickel of the || | | | Lee-Enfield || | | | bullet ||Thickness of |Mark II. Bullet| -- | -- || mantle | | | ||Tip | . 036 | . 031 | . 022 ||Sides . 984 from tip| . 015 | . 015 | . 015 |+-------------------+---------------+--------------------+---------------+ Some particulars of the four rifles and their projectiles are collatedin Table I. , to which is added the corresponding information regardingthe Martini-Henry for the purposes of comparison. TABLE II. --PENETRATION The penetration of the Martini-Henry and the Lee-Metford or Lee-Enfieldrifle with Mark II. Bullet is as follows: Martini-Henry 15-1/2 in. Of 1 in. Deal boards 19 in. Of sand 1 in. Apart containing 15 per cent. Of moisture Lee-Metford {Mark II. } 42 in. Of 1 in. Deal boards 60 in. Of sandLee-Enfield {bullet } 1 in. Apart containing 15 per cent. Of moisture The penetration of bullets of . 314 calibre differs little from thatpossessed by the Lee-Metford or Lee-Enfield, of which the muzzlevelocities are very little lower, with Mark II. Bullet. The BelgianMauser perforates 55 inches of fir-wood at 12 metres distance. Withregard to the penetration of bullets of smaller calibre that of theRoumanian Mannlicher (. 256) may be taken as typical. When fired into asand butt at 25 yards the bullet enters 9 inches and then breaks up. The comparative size of the different cartridges is shown in fig. 14. The general remarks already made as to the effect of weight, calibre, and velocity sufficiently explain the importance of the particularsgiven in this table, but it will be noted that the Lee-Metford rifle isinferior to both the Krag-Jörgensen and Mauser rifles in the initialvelocity transmitted to its bullet. The tendency to equalisation, inthis particular, when the remaining velocity is considered, has beenmentioned; but it may be of interest if I quote from Nimier and Laval[7]the scale on which the decrease in velocity takes place in the case ofthe three weapons. METRES PER SECOND +---------------------+-------------+--------+----------------+| | Lee-Metford | Mauser | Krag-Jörgensen |+---------------------+-------------+--------+----------------+| | | | || Initial velocity | 630 | 718 | 720 || Remaining velocity: | | | || At 100 metres | 574 | 699 | 718 || At 1, 000 metres | 249 | 264 | 269 || At 2, 000 metres | 159 | 165 | 165. 9 || | | | |+---------------------+-------------+--------+----------------+ Giving full importance to the effects of velocity as a factor in theseverity of the injuries produced, when the large proportion of woundsreceived at distances above 1, 000 yards is borne in mind, we see howrapidly the superiority of the smaller projectiles is lost. This loss, even in the early stages, is probably more than made up for in the caseof the Lee-Metford, when the superiority in weight, calibre, andbluntness of extremity as contributing to striking force is taken intoconsideration. The striking force (kinetic energy) of a bullet is indicated by thefollowing formula: F = 1/2 mv. ^{2}; that is to say, the striking forceis equal to half the weight of the bullet multiplied by the square ofthe velocity. In point of fact, with unaltered regulation bullets I was never able todetermine any very material difference between the wounds produced, further than that the wounds of entry and exit in the soft parts tendedto correspond with the calibre of the particular bullet concerned. Although the immense majority of the wounds which came under my noticewere caused by the Mauser bullet, yet I saw some hundreds of woundedBoers and a good many of our own men wounded by Lee-Metford bullets, inthe latter case no doubt by some of the sporting varieties. The onlycases that I can call to mind or have noted as exhibiting a superiorwounding power in the Lee-Metford bullet are some injuries to bone. ThusI saw a considerable number of clean perforations of the patellaproduced by Mauser bullets, while the only two Boers whom I saw withinjured patellæ had suffered transverse fractures. Again, I have alively recollection of an old Boer who had suffered a fracture of themiddle third of the femur, in the thigh of whom, with small apertures ofentry and exit, a cavity of destroyed tissue, five inches across, wasfound beneath the fascia lata at the distal side of the fracture. Icannot however say that I did not observe many equally severe injuriesto the femur produced by Mauser bullets in our own men, and as far asfractures of the skull went, a somewhat crucial test, among the menbrought off the battlefield alive, I never saw any difference inseverity whatever. [Illustration: FIG. 15. --Sections of four Bullets to show relative shapeand thickness of mantles. From left to right: 1. Guedes; regular dome-shaped tip; mild steelmantle; thickness at tip 0. 8 mm. ; at sides of body 0. 3 mm. 2. Lee-Metford; ogival tip; cupro-nickel mantle; thickness at tip 0. 8 mm. ;gradual decrease at sides to 0. 4 mm. 3. Mauser; pointed dome tip, steelmantle plated with copper alloy; thickness at tip 0. 8 mm. ; gradualdecrease at sides to 0. 4 mm. 4. Krag-Jörgensen; ogival tip as inLee-Metford; steel mantle plated with cupro-nickel; thickness at tip 0. 6mm. ; gradual decrease at sides to 0. 4 mm. The measurements of the sidesare taken 2. 5 cm. From the tip. Note the more gradual thinning in theLee-Metford mantle. ] These points of comparison having been made, it only remains to considerone other point, that of the relative stability of the bullets. This isa matter of the greatest importance as regards the regularity orotherwise of the wounding power of the projectile, and, as far as myexperience went, I believe the Mauser to far exceed the Lee-Metford ininstability of structure. The core of all four bullets is composed of lead hardened by a certainadmixture of tin or antimony, but the mantle differs in composition, thickness both general and in different parts of the bullet, mode offixation, and consequently in its power of resistance to violence. Fig. 15 gives an exact representation of the relative thickness of themantles, and shows the general tendency to a thickening of the mantle atits upper extremity, designed to increase both the stability andstriking power of the projectile. It will be noted that in generalstoutness the Lee-Metford stands first, as the case increases graduallyin thickness from base to apex. Beyond this it must be noted that the Lee-Metford is the only one of thefour that is ensheathed with a mantle composed of a definite alloy, thisconsisting of 80 parts of nickel and 20 of copper. Two of the remainingbullets, the Mauser and Krag-Jörgensen, are ensheathed with steelcovered with a thin coating of an alloy of copper or cupro-nickel, totake the rifling of the barrel, while the third has a plain steel mantlewhich is covered with a layer of wax to take the place of the nickelused in the manufacture of the two others. It is interesting to mentionhere that the Boers evidently found the copper alloy coatinginsufficient for its purpose, or at any rate not satisfactory inpreserving the weapon from the ill-effects consequent on the frictionbetween the steel case and the rifling of the barrel, as at about themiddle of the campaign they began to use their bullets waxed, as in thecase of the Austrian Mannlicher; hence the legend of the poisonedbullets which caused such a sensation for a short period amongst theuninitiated. It is possible also that the additional layer of wax wasnecessitated by the wearing of the barrel. The wax employed for the Mauser bullets was not originally green. Mr. Leslie B. Taylor informs me that it is probably paraffin wax, the greencolour depending on the formation of verdigris from the copper alloywith which the steel envelopes are plated. This completely correspondswith my own experience, since on the bullets in my possession the greencolour, originally pale, has steadily increased in depth. Many oldleaden bullets I found in the Boer arsenals were also waxed, but in thiscase no alteration in colour had taken place. The Guedes bullets, whichare cased in mild steel, become somewhat brown with exposure from asimilar oxidation or rusting of the surface. As far as my experience went, however, the steel casing has an importantsurgical bearing beyond the mere question of wear and tear on the riflebarrel. That it possesses elasticity and capability of bending isobvious, and in a later chapter, devoted to irregular wounds, severalillustrations of such deformities are given; but when it strikes stone Ibelieve it splits and tears with very much greater freedom than thecupro-nickel mantle of the Lee-Metford. At any rate, I never came acrossLee-Metford bullets deformed to the same degree as Mauser bullets, either when removed from the body, or as ricochet projectiles on thefield of battle. For this reason, therefore, provided the fighting takesplace on stony ground, I believe the Mauser bullet and others ensheathedin steel to be much more dangerous surgically than those encased incupro-nickel. I fancy this would be equally the case even if the mantleswere of exactly the same thickness. The layer of copper alloy on the steel mantles is also a physicalcharacteristic worthy of mention. This very readily chips off in amanner similar to that we are accustomed to see with nickel-platedinstruments. This may be due to the compression into the grooving of therifle, or as the result of passing impact of the bullet with an obstacleprevious to entering the body or contact with a bone within it. Smallscales of metal set free in one of these ways are seen in a very largeproportion of Mauser wounds, and although they are so small as usuallyto be of little importance, the presence of such in, for instance, thesubstance of one of the peripheral nerves which has been perforatedcannot be considered a desirable complication. To recapitulate, it would appear that at mean ranges, both in strikingforce and as regards the area of the tissues affected, the Lee-Metfordis a superior projectile to the Mauser, in spite of the greater initialvelocity possessed by the latter. On the other hand the comparative easewith which the Mauser bullet undergoes deformation either without orwithin the body, so ensuring more extensive injury and laceration, renders it the less desirable bullet to receive a wound from when not inits normal shape and condition. I can say little about the remaining two rifles. The Krag-Jörgensen waslittle used, and beyond pointing out its capacity to inflict very neatindividual injuries, in which it must surpass even the Mauser, I canonly add that I had no opportunity of forming an opinion as to thedanger dependent on the great initial velocity imparted to the bullet. The Guedes rifle has been included in the table because it approximatesin bore to the other three. Its bullet is of the same calibre as theAustrian Mannlicher, one of the most powerful military rifles in use, and it was used to a considerable extent during the war by the Boers. [8]As to its capabilities, it appeared an inferior weapon, since want ofvelocity and striking power of the bullets was indicated by the numberof these which were retained in the body, and by the fact that I neversaw one extracted that had undergone any more serious deformation thansome flattening on one side of the tip. On the other hand wounds of thesoft parts occasioned by it were only to be distinguished from Mauserwounds by their slightly greater size, and at a short range of fire theweight and volume of the bullet made it a dangerous projectile. The question of deformed bullets will be again referred to at length inthe section on wounds of irregular type, and a number of type specimensare there figured and described (p. 76). In the same chapter will befound illustrations of a number of sporting bullets of small calibre, aswell as of large calibres in lead, found in the Boer arsenals and camps. I have placed them in that position as mainly of interest in connectionwith the occurrence of large and irregular wounds (see figs. 42 and 43, pp. 95 and 98). The small sporting bullets were mostly of the Mauser (. 276), Lee-Metford(. 303), or Mannlicher (. 315) calibre. FOOTNOTES: [5] See tables, pp. 12, 13, 15, Chapter I. [6] The weights are from cartridges brought home. The charge of powderwas small and variable. [7] H. Nimier and E. Laval, _Les Projectiles des Armes de Guerre_, p. 20. F. Alcan. 1899. [8] Mr. Leslie B. Taylor informs me that this rifle is a discardedPortuguese regulation pattern, with which a copper-ensheathed soft-nosedbullet was originally employed. For the purposes of the present campaigna modified cartridge was constructed. Examination of some specimens inmy possession showed the charge of powder to be very small. (Table I. P. 48. ) CHAPTER III GENERAL CHARACTERS OF WOUNDS PRODUCED BY BULLETS OF SMALL CALIBRE The effects of injuries inflicted by bullets of small calibre may bedivided into two classes: 1. Direct or immediate destruction of tissue. 2. Remote changes induced by the transmission of vibratory force fromthe passing projectile to neighbouring tissues or organs. Those of the first class will be mainly considered in this chapter; theremote effects will be dealt with under the headings devoted to specialregions. In dealing with the wounds as a whole I shall first describe those ofuncomplicated character as type injuries, and deal with those possessingspecial or irregular characters separately. TYPE WOUNDS 1. _Nature of the external apertures. _--The apertures of entry and exitin uncomplicated cases are very insignificant, but the size naturallyvaries slightly with that of the special form of bullet concerned. Aswill be shown moreover, the difference in size is the only realdistinguishing characteristic in many cases between wounds produced bythe modern bullet of small calibre and those resulting from the use ofthe older and larger projectiles of conical form. I have been very muchstruck on looking over my diagrams of entry, and especially exit, woundsto find that they reproduce in miniature most of those figured in theHistory of the War of the Rebellion; some of these diagrams arereproduced in this chapter. _Aperture of entry. _--The typical wound of entry with a normalundeformed bullet varies in appearance according to whether theprojectile has impinged at a right angle or at increasing degrees ofobliquity, or again, to whether the skin is supported by soft tissuesalone, or on those of a more resistent nature such as bone or cartilage. [Illustration: FIG. 16. --Mauser Entry and Exit Wounds. A, entry inbuttock; circular opening filled with clot and crossed by a tag oftissue. B, exit in epigastrium near mid-line; irregular slit form, withwell-marked prominence. Specimens hardened in formalin immediately afterdeath; the resulting contraction has slightly exaggerated theirregularity of outline of the entry wound] [Illustration: FIG. 17. --Gutter Wound of outer aspect of shoulder, caused by a normal Mauser, which subsequently perforated a man's leg. Atthe central part the gutter was 3/4 in. Deep a few days after theinjury] When the bullet impinges at a right angle the wound is circular, withmore or less depressed margins, and of a diameter, corresponding to thesize of the bullet occasioning it, from a quarter to a third of an inch. The description 'punched out' has been sometimes applied to it, but itwould be more correct to reverse the term to 'punched in, ' since theappearance is really most nearly simulated by a hole resulting from thedriving of a solid punch into a soft structure enveloped in a densercovering. The loss of substance, moreover, in the primary stage is notactually so great as appears to be the case, fragments of contusedtissue from the margin being turned into the opening of the wound track. The true margin therefore is not sharp cut, and the nature of the linediffers somewhat according to the structure of the skin in the localityimpinged upon. Thus the granular scalp and the comparatively homogeneousskin of the anterior abdominal wall will furnish good examples of thenature of the slight difference in appearance. From the first the marginis also often somewhat discoloured by a metallic stain, similar to thatseen when a bullet is fired through a paper book. This ring is, however, narrow, and not likely to be noticeable when the bullet has passedthrough the clothing. In any case it is subsequently obscured by thedevelopment of a narrow ring of discoloration due to the contusion. Thislatter varies in width, and still later a halo of ecchymosis half aninch or more in diameter surrounds the original wound. [Illustration: FIG. 18. --Oblique Exit Gutter. Diagram enlarged to actualsize from case shown in fig. 24, p. 64. ] With increasing degrees of obliquity of impact more and more pronouncedoval openings of entry result, culminating in an actual gutter such asis seen in fig. 17. In all oval openings the loss of substance is more pronounced at theproximal margin, while the wound is liable to undergo secondaryenlargement at the distal margin, since in the former the epidermis ismainly affected, while in the latter the epidermis is spared as anill-nourished bridge, the deeper layers of the skin suffering the moreseverely. When the wound occurs in regions, such as the chest-wall orover the sacrum, where the skin is firmly supported, the oval openingsare often very considerable in size, reaching a diameter at least doublethat of the circular ones. In the case of the oval openings thedepression of the margins is not such a well-marked feature as in woundsresulting from rectangular impact of the bullet, since the distal marginis really lifted. [Illustration: FIG. 19. --Oval Entry Wound over third sacral vertebra. Exit wound, anterior abdominal wall. Slightly starred variety. Diagrammade on second day] _Aperture of exit. _--The wound of exit in normal cases offers far morevariation in appearance than that of entry, this variation depending onseveral circumstances: first, the want of support to the skin fromwithout, and such other factors as the degree of velocity retained bythe travelling bullet, the locality of the opening, and the density, tension, and resistance offered by the particular area of skinimplicated. When the range has been short and the velocity high, it is oftendifficult to discriminate between the two apertures. Both may becircular and of approximately the same size, and the only distinguishingcharacteristic, the slight depression of the margin of the wound ofentrance, may be absent if any time has elapsed between the inflictionof the injury and examination by the surgeon. One very strongcharacteristic if present is the general tendency of the margins, andeven the area surrounding the exit wound itself, to be somewhatprominent. Fig. 16 shows this point, although the wound from which itwas drawn had been produced thirty-six hours before death. The specimenwas then hardened in formalin and still preserves its original aspect. This character is, however, more frequently displayed in wounds receivedat mean, or longer, ranges. In wounds produced by bullets travelling atthe highest degrees of velocity it is often absent. [Illustration: FIG. 20. --Circular Entry back of arm; exit (bird-like) inanterior elbow crease] [Illustration: FIG. 21. --Circular Entry over patella. Starred exit ofelongated form in popliteal crease] When the range of fire has been greater and the velocity retained by thebullet lower, slit wounds are common, or some of the slighter degrees ofstarring. Actual starring I never saw, but reference to figs. 20 and 21will show a tendency in this direction, also a close resemblance to thestarred wounds resulting from perforations by large leaden bullets. Such wounds, I believe, are usually the result of a somewhat low degreeof velocity. Slit exit wounds may be vertical or transverse (fig. 20) in direction, and the production of these is dependent on the locality in which theyare situated, the thickness, density, and tension of the skin, and thenature of the connection of the latter with the subcutaneous fascia inthe locality. Thus in wounds of different parts of the hairy scalp, solittle variation exists in the relative density and structure of theskin, that, in spite of the want of external support at the aperture ofexit, it is often difficult to discriminate offhand the two apertures, if neither bone nor brain débris occupies that of exit. If, however, a wound crosses from side to side a region such as thethigh where well-marked differences exist in the subjacent support, thickness, and elasticity of the skin implicated in the apertures, thewound of entry, if in the thick skin of the outer aspect, was usuallycircular, while the exit in the thin elastic skin of the inner aspectwas either slit-like or starred. The difficulty in laying down anygeneral rule as to the occurrence of circular or slit apertures of exitin any definite region is, however, great, as may be seen by referenceto the accompanying diagrams taken from two patients wounded atPaardeberg (figs. 22 and 23). In fig. 22 the bullet entered the outer and posterior aspect of the leftbuttock, crossed the limb behind the femur, and emerged at the inneraspect by a vertical slit: the bullet then entered the scrotum by avertical slit, and emerged by a typical circular aperture; re-enteredthe right thigh by a transverse slit aperture, and, striking the femurin its further course, underwent deformation, and finally escaped by anirregular aperture 3/4 of an inch in diameter. The occurrence of exitslits in the adductor region is common, and to be explained by thetendency of the comparatively thin elastic skin to be carried before thebullet; the slit entry in this position must, I suppose, be explained bythe comparatively slight support afforded by the underlying structures, which are often in a condition of hollow tension. The scrotal wounds areperhaps more difficult to account for, but in this case the fact of thedistal aperture being directly supported by the right thigh is a readyexplanation of the circular exit, while the skin corresponding to theslit entry was no doubt carried before the bullet, and finally gave wayin the line of a normal crease. [Illustration: FIG. 22. --Entry and Exit Wounds in both thighs andscrotum. From right to left: 1. Circular entry in left buttock behindtrochanter. 2. Vertical slit exit in adductor region. 3. Slit entry inscrotum (probably inverted before bullet broke the surface, and then aslit occurred in a normal crease). 4. Circular exit in scrotum (heresupported by surface of right thigh). 5. Transverse slit entry in rightadductor region. 6. Irregular 'explosive' exit, the bullet having set upon contact with the front surface of the femur, but without havingcaused solution of continuity of the bone. ] In fig. 23 all the wounds are circular except the final exit, which wasirregular as a result of the bullet in this case also having struck thefemur in the second thigh. Considerable variation also exists in thesize of the circular apertures; this illustrates the secondaryenlargement often occurring in such wounds, and most marked at theapertures of entry, as the more contused. Both diagrams were made frompatients eight days after the reception of the wounds. [Illustration: FIG. 23. --Wound of both Thighs. First and second entrytypical circular wounds. First exit a small circular wound; the bullet'set up' on contact with the femur without causing solution ofcontinuity of the bone, and second exit is irregular and large. This diagram is of considerable interest when compared with fig. 22. Ibelieve the comparative regularity in the wounds to have been due to ahigher degree of velocity of flight on the part of the bullet] Lastly, vertical or transverse slits may be looked for with considerableconfidence in situations in which transverse oblique or vertical foldsor creases normally exist in the skin, and depend on the lines oftension maintained by the connection of the skin in these situations tothe underlying fascia. Thus I saw well-marked transverse and verticalslits in the forehead corresponding with the creases normally foundthere, and in this situation I noted some slit entries. Transverseslits were common in the folds of the neck, the flexures of the joints(fig. 20), and the anterior abdominal wall either in the mid line or increases like those stretching across from the anterior superior iliacspines. Again they were seen in the palms and soles, but here morereadily tended to assume the stellate forms. Vertical slits are lesscommon; they occurred with the greatest frequency in the posterioraxillary folds. Oval apertures of exit are far less common than those of entry, sincethe most common factor for the production of an oval opening, bonysupport, is never present. In long subcutaneous tracks, or verysuperficial wounds, they are however sometimes met with and mayterminate in a pointed gutter (see figs. 18 and 24). The greatest modifications in the appearance and nature of the aperturesof entry are dependent on previous deformation of the bullet, when allspecial characteristics are lost, and it becomes impossible to form anyopinion as to the type of bullet concerned. These modifications arenaturally far more common in the aperture of exit, since the bullet sooften acquires deformity in the body as the result of impact with thebones. Further remarks on this subject will be found with thedescription and comparison of the various bullets on p. 81. [Illustration: FIG. 24. Superficial Thoracico-abdominal Track. Smallentry: discoloration of surface over costal margin from deep injury toskin; well-marked 'flame' gutter exit (see fig. 18)] 2. _Direct course taken by the wound track. _--This character primarilydepends on the velocity with which bullets of small calibre are made totravel, and on the small area of the tissues upon which they operate. Inthis relation the degree of velocity retained by the bullet is often ofminor importance, provided it be sufficient to penetrate the body. Firedwithin a distance of 2, 500 yards there is little doubt that a bullet ofthe Lee-Metford, Mauser, or Krag-Jörgensen types, passes straightbetween the apertures of entry and exit when these are of the typeoutline, even when the bones are implicated. By reason of the small sizeof the projectiles, their shape, and the spin and velocity transmittedto them, there is no reason why at a sufficiently short range theyshould not traverse the body from the crown of the head to the sole ofthe foot. The necessary conditions of position and distance for such aninjury are obviously not often obtained, but it may be pointed out thatthe Belgian Mauser rifle at a distance of five yards is capable ofdriving a bullet 55 inches or nearly five feet into a log of pine-wood. Many examples of long tracks will be referred to later, but thefollowing instances may be of interest in this relation. A bulletentering at the occipital protuberance traversed the muscles of theneck, passed through the thoracic cavity, fractured the bodies of thethird and fourth and grooved the seventh and eighth dorsal vertebræ, grooved the seventh and eighth and fractured the ninth and tenth ribs, traversed the muscles of the back and finally lodged against the ilium;the whole length of this track measured some 25 inches. Again, at thebattle of Belmont a Mauser bullet entered the pelvis of a horse justbelow the anus, and traversed the entire trunk before emerging from thefront of the chest: it may be of interest to mention that this animalwas alive and moving about the next day, but I am sorry I can give nofurther information regarding his fate. [Illustration: FIG. 25. --Superficial Track on external surface of Thigh. Local discoloration of skin five weeks after reception of injury] The possibility of contour tracks travelling around the walls of thechest or abdomen has therefore rarely to be considered, except inoccasional instances where the bullet fired from a long range hasimpinged against a bone and is retained in the body. The small volume ofthe bullets, however, allows the production of very prolonged directsubcutaneous tracks in the body wall, in positions where they would bemanifestly impossible with projectiles of larger calibre. Figs. 24 and 25 illustrate wounds of this nature. In the case figured infig. 24 the bullet entered over the third rib in a vertical line abovethe right nipple; it then coursed obliquely down, crossing the seventhcostal cartilage, and finally emerged 3 inches above the umbilicus. Where the track crossed the prominence of the thoracic margin the skinwas so thinned as to undergo subsequent discoloration, while a distinctgroove was evident there on palpation. In some similar cases I have seenthe central part of the track secondarily laid open as a result of thethinning of the skin and consequent sloughing due to the interferencewith its vitality. Short of sloughing, the skin may show signs of alteration of vitalityfor a long period after the injury; thus fig. 25 depicts the conditionseen in a superficial wound of the thigh five weeks after the injury. The line of passage of the bullet between the two openings was stillclearly visible as a dark red coloured streak. Grooves in such cases aregenerally readily palpable in the early stages, while later the want ofresistance is replaced by the readily felt firm cord representing thecicatrix. These points are of much importance in discriminating betweenperforating and non-perforating wounds of the abdomen, and are againreferred to in that connection. The direction of the tracks obviously depends on the attitude assumed bythe patient at the moment of impact of the bullet and the directionwhence the firing has proceeded. The frequent assumption of the proneposition during the campaign led to the occurrence of a large proportionof longitudinal tracks in the trunk, or trunk and head, which will bereferred to later. Certain battles were in fact strongly characterisedby the nature of the wounds sustained by the men. Thus at Belmont andGraspan, where some rapid advances were made in the erect attitude, fractured thighs were proportionately numerous, while at Modder River, where many of the men lay for a great part of the day in the proneposition, glancing wounds of the uplifted head, of the occipital region, or longitudinal tracks in the trunk and limbs were particularlyfrequent. I very much regret that the material at my disposal does notallow me to add some remarks as to variation in the nature of thewounds according to whether they were received from an enemy firing froma height or from below, but it is possible that some information on thissubject may be forthcoming when the returns of the Service are made up, since it is naturally of great importance as to the effect of trajectoryin the proportionate occurrence of hits. 3. _Multiple character of the wounds. _--The same conditions responsiblefor the length and directness of the tracks, account for the frequentlymultiple character of the wounds implicating either the limbs orviscera--thus, lung, stomach, liver; neck, thorax, abdomen; abdomen, pelvis, thigh. Also for the frequent infliction of two or more separatetracks by the same bullet--thus, arm and forearm with the elbow in theflexed position; both lower extremities; both lower extremities, penisor scrotum; leg, thigh, and abdomen, with a flexed knee; upper extremityand trunk, and more rarely one upper and one lower extremity. Again, itwas remarkable how often the same bullet would inflict injuries on twoor more separate men, not unfrequently dealing lightly with the firstand inflicting a fatal injury on the second, or vice versâ. The smallcalibre of the bullet, moreover, allows of the neatest and most exactmultiple injuries. Thus in a patient who was crawling up a kopje on allfours, the flexed middle digit of the hand was struck. The bulletentered at the base of the nail, first emerged at the distalinterphalangeal flexor fold, re-entered the metacarpo-phalangeal fold, and finally emerged from the back of the hand between the third andfourth metacarpal bones. 4. _Small 'bore' of the tracks, and tendency of the injury to belocalised to individual structures of importance. _--Here we meet withthe most striking characteristic of the injuries, and evidence thatreduction of calibre affects more strongly the nature of the lesion thandoes any other element in the structure of the modern rifle. Thediameter of the track slightly exceeds that of the external apertures, probably as a result of the more ready separability of the elements ofthe structures perforated than exists in the skin. The calibre, moreover, tends to be fairly even throughout when soft structures onlyare implicated, though local enlargements result wherever increasedresistance is met with. Thus a strong fascia may offer such resistanceas to increase locally the bore of the track, and in this particular thestate of tension of the fascia when struck will affect the degree of theenlargement. The most striking instances of local enlargement of thetrack are of course seen when a bone lies in the course of the bullet, but we must here bear in mind the introduction of a new element--thepropulsion of comminuted fragments together with the bullet itself. Incases of fracture the distal portion of the track is in consequence manytimes larger than the proximal. The most striking examples of small eventracks are seen, on the other hand, in punctures of the elastic andpractically homogeneous lung tissue, where the wounds are extremelysmall. On transverse section of the track the gross amount of actual tissuedestruction occupies a lesser area than that corresponding to thediameter of the bullet. The destructive action of the projectile is infact exerted mainly on the tissues directly lying in its course, thetrack being opened up during the rush of the passage of the bullet, partly as a result of its wedge-like shape and partly as a result of thethrowing off of the tissues forming the walls of the track by adiversion of a portion of the force in the form of spiral vibrationsdependent on the revolution of the bullet. Again, the opening out of thetissues may be aided by the direction taken by the first and strongestas well as the simplest series of vibrations transmitted, which wouldassume the shape of a cone of which the point of impact forms the apex. The escape from actual destruction by structures lying in the immediateneighbourhood of the track is indeed often surprising, but not perhapsso astonishing as the perforation of long narrow structures such as theperipheral nerves and vessels, without irreparable damage to the partsremaining, and this although the structures themselves may be of adiameter not exceeding that of the bullet itself. The capacity of theseprojectiles to split such structures as tendons was already well knownbefore our experience in this campaign, but the injuries to the nervesand vessels of the same character came as a surprise to most of us. Thelateral displacement of tissues seems to bear a strong resemblance towhat is seen on the passage of an express train, when solid bodies ofconsiderable weight are displaced by the draught created without evercoming into contact with the train itself. The tendency to lateraldisplacement is still more strongly exhibited when dense hard structuressuch as bone are implicated. Here the fragments at the actual points ofimpact on the proximal and distal surfaces of a shaft are drivenforwards, while the lateral walls of the track in the bone are simplycomminuted and pushed on one side without loss of continuity with theircovering periosteum. The extension of this form of displacement to a degree amounting to aso-called explosive character in the case of the soft tissues, even whenthe bullet passed at the highest degrees of velocity, was, however, never witnessed by me, and I very much doubt the existence of aso-called 'explosive zone' so far as wounds of the soft parts areconcerned. On the contrary, I am inclined to believe that the highestdegrees of velocity are favourable to clean-cut neat injuries of thesoft tissues. I saw a large number of type wounds of entry and exitinflicted at a range of under fifty yards. 5. _Clinical course of the wounds. _--The tendency of simple wounds suchas are above described to run an aseptic course was very marked, and, given satisfactory conditions, deep suppuration and cellulitis weredistinctly rare. It may also be confidently affirmed that whensuppuration did occur, with apertures of entry and exit of the normalsmall type, this was always the result of infection from the skin, orinfection subsequent to the actual infliction of the wound. Theinfrequency of suppuration depended on the aseptic nature of the injury, the smallness of the openings, the small tendency of the track to weepand furnish serous discharge in any abundance, the comparative rarity ofthe inclusion of fragments of clothing or other foreign bodies, andpossibly in some degree on the purity and dryness of the atmosphere, which favoured a firm dry clotting of the blood in the apertures ofentry and exit, and consequent safe 'sealing of the wound. ' As to the aseptic nature of the injury, it will be well to firstconsider the question of the sterility of the bullet. Putting laboratoryexperiments on one side, the large experience of this campaign seems toprove to absolute demonstration that, bearing in mind the very largeproportion of instances of primary union in simple tracks, the surgeonhas nothing to fear on the part of the bullet itself. This is the morestriking when we remember that these bullets shortly before theiremployment were carried in a dirty bandolier, and freely handled by menwhose opportunities of rendering either their hands or implementsaseptic were as bad as it is possible to conceive. Several explanations are to hand, but none of them conclusive. Two must, however, be shortly considered. First, the surface of the bullet, exceptits tip and base, is practically renewed by passage through the barrel. Secondly, there is the question of the heat to which it is subjected. Asfar as cauterisation of the tissues is concerned, this question has beenpractically settled in the negative, since actual determinations of theheat immediately after the moment of impact have been made, and again ithas been shown that butter is not melted, and that neither gunpowder nordynamite is exploded, by firing bullets through small quantities ofthose materials. Again, the absence of any sign of scorching of theclothes of the wounded is strong evidence against the possibility of anyconsiderable heat being applied to the tissues of the body; whileanother observation, although of less importance as affecting spentbullets only, that bullets, which have perforated the body but liebetween the skin and the clothing, leave no sign of cauterising actionon either, may be mentioned. None the less, the sources of heating whilethe bullet is passing from the barrel are many and obvious. Thus thereis the heat consequent on explosion of the powder, the warm state of thebarrel itself when the rifle has been fired a few times consecutively, and the heat resulting from the force and friction essential to thepropulsion of the bullet through the barrel. Again, bullets covered withwax before their introduction into the barrel retain no trace of thiswhen they have been fired, although at any rate the portion coveringthe tip is not exposed to friction on the part of the rifle, and lastlythe base of the bullet has no other explicable reason for itsinnocuousness than subjection to a certain degree of heat. While notclaiming any cauterising action on the tissues by the bullet, I shouldtherefore still be inclined to allow the probability of the heat towhich the surface of the bullet is exposed exerting a cleansing actionon the projectile. In regard to this point it is interesting to bear inmind that shots from an ordinary gun seldom or never give rise toinfection. Foreign bodies were rarely carried into the wounds with the bullet. Isaw several instances in which portions of the metal of cigarette casesand of cartridge cases when the bullet had perforated cartridges in thewounded man's bandolier, and in one instance small pieces of glass froma pocket mirror, must have been carried in without any obvious illeffect. Fragments of clothing, on the other hand, in every case causedsuppuration: clothing was not often carried in, the khaki linen wasperforated with a clean aperture, most commonly a slit; but the thickwoollen kilts of the Highlanders, and thick flannel shirts, occasionallyfurnished fragments. The introduction of large pieces of clothing is asure proof of irregularity of impact on the part of the bullet. Thefrequency with which portions of cloth were introduced from the kilt wasone of the strongest surgical objections to its retention as a part ofthe uniform on active service. Retained bullets themselves remained as foreign bodies in a certainnumber of cases. I cannot say that suppuration never followed theretention of a bullet, since in two of the instances where I saw suchremoved they lay in a small cavity containing at any rate a 'purulentfluid. ' In one of these the bullet was a Martini-Henry, and in both thebullet had been imbedded for some weeks, and had certainly notoccasioned a primary suppuration of the wound. The favourable influence of the pure and dry nature of the atmosphere inthis campaign must certainly not be underrated, and in support of thisinfluence I think I may say, from the experience of cases that I sawcoming from Natal where the climate and surroundings were not sofavourable as on the western side, that suppuration was more common andmore severe in the moister atmosphere. Putting aside all the above remarks, however, I am inclined to thinkthat a general tendency to primary union and the absence of suppurationwill always be a feature of wounds from bullets of small calibre, andthat this favourable tendency is attributable to certain inherentcharacters of the injuries. Of these the nature and small size of theopenings, the dry character of the lining of the track due tosuperficial destruction and condensation of the tissue forming its wall, the small disposition to prolonged primary hæmorrhage, and the absenceof any great amount of serous exudation during the early stages ofhealing are the most important. A mechanical factor of great importance also exists in the spontaneouscollapse and automatic apposition of the walls of the track. Thisclosure is rendered additionally effective in many cases by theinterruption of the continuous line in the wounded tissues consequent onalteration in the position of the parts traversed when an attitude ofrest is assumed by the injured part. The indisposition to suppurationand the apparent unsuitability of the tissue lining the track for thedevelopment and spread of infecting organisms are well illustrated byseveral observations. Thus, even if the bullet be thoroughly aseptic, the fragments of destroyed skin driven into the track by the bullet canscarcely be free from organisms; yet these seldom give rise to trouble. Again, if for any reason a deep portion of a track becomes infected andsuppurates, there is no tendency for the spread of infection along theline of wounded tissue, but rather for the development of a localabscess, pointing in the ordinary direction of least resistance, irrespective of the course originally taken by the bullet. [Illustration: PLATE I. Engraved and Printed by Bale and Danielsson, Ltd. G. L. CHEATLE. Mauser Wound of Entrance, a little more than 48 hours after infliction. About 12/1. Section of the entry segment of an aseptic Mauser wound removed a littleover forty-eight hours after its infliction. Magnified twelve diameters. The margins of the opening are still sloping and depressed, indicatingthe originally 'punched-in' nature of the aperture. A thin stratifiedlayer of epidermis completely closes it. No scab remains. The wound track is occluded by an effusion of lymph, commencingorganisation of which is shown under a higher magnifying power by thepresence of leucocytes near the margin of the bounding tissue, and somegiant cells. The effusion of lymph occupies a slightly wider areaimmediately beneath the papillary layer of the skin, then narrows, andbroadens again as the subcutaneous fascia is reached, indicating theeffect of resistance in widening the area of damage. The subcutaneous connective tissue bounding the track shows little signof alteration beyond a general slight tendency of the lines of structureto deviate in the direction of the passage of the bullet. No hæmorrhage is apparent beyond a small collection of blood situatedimmediately beneath the new layer of epidermis at the left-hand cornerof the opening. Range probably within 800 yards. Seat of wound, abdominal wall a highestpoint of iliac crest. ] Fig. 25 (_a_), A (plate I. ) represents a section carried across anaseptic aperture of entry. The specimen was removed by Mr. Cheatle froma patient who died forty-eight hours after reception of the injury. Itshows well the small amount of gross destruction suffered by thesubcutaneous tissue, and the rapid repair which follows, sincemacroscopically the track is scarcely discernible. Reference to plate I. Shows the remarkable fact that even at this early date considerableprogress towards definite healing has occurred, and a thin layer ofstratified epidermis covers the original opening. The question may beraised whether the origin of this epidermal layer is not in part afloating up of the margins of the main aperture. During the course of healing some variation takes place in theappearance of the apertures, especially that of entry. This, at firstcontracted, later becomes somewhat relaxed, while in many cases a smallhalo of ecchymosis develops around it. The blood-clot occupying itscentre now contracts, the margins rapidly become approximatedcentripetally, and a small circular dark spot only remains, which islater replaced by a small red cicatrix. The dark central spot underthese circumstances consists of the contused margin of the wound in theskin, and a small proportion of blood-clot which finally comes away as asmall dry scab. When slight local infection occurs in place of simplecontraction and dry scabbing, the process is prolonged, the contusedmargin separates by granulation, the clot in the opening breaks down, and a small ulcer of somewhat larger proportions than the original woundremains and takes some days to heal. [Illustration: FIG. 25 (_a_). --_A. _ Wound of entry 48 hours afterreception. _B. _ Wound of exit, 7-1/2 days after reception. 1. Skin. 2. Subcutaneous fat carried into the lips of the wound by the bullet. 3. Infected blood extravasation in subcutaneous tissue. Exact size. (Seeplates I. And II. )] The aperture of exit in simple wounds of the soft parts sometimes healseven more rapidly than that of entry, and if of the slit form may bealmost invisible at the end of ten days or a fortnight, actual primaryunion having taken place as after a simple small incision. Larger orirregular exit apertures, however, take a longer period to close thanentry wounds, and this is most often observed when the bullet hasundergone deformation within the body, or bone fragments have beendriven out with the bullet. Fig. 25 (_a_), B (plate II. ) represents a section of an infected exitaperture from a patient who died seven and a half days after itsinfliction. Two main points of interest are at once apparent: 1. Thecarrying forwards of the subcutaneous fat into the lips of the skinwound by the bullet. This illustrates the manner in which lightlysupported structures are carried forward by the bullet, and throws somelight on the mode by which vessels and nerves may escape by a process ofdisplacement. This figure may be compared with fig. 25 (_b_) which showsa tag of omentum similarly carried forward by a bullet crossing theabdominal cavity and plugging the exit wound. 2. The second feature ofinterest is the amount of hæmorrhage into the subcutaneous tissue. Inthis respect the contrast between the exit and entry apertures ismarked, since in the latter hæmorrhage is scarcely apparent. Thepresence of such hæmorrhages is explained by the same dragging action asthe extrusion of the fat, and is of course dependent on consequentrupture of small vessels. It is of importance as predisposing the exitwound to more easy infection, and it accounts for the persistingsubcutaneous induration more often detected beneath healed exit thanentry apertures. Again, it suggests that the presence of blood in thedeeper parts of the tracks may be the determining cause of the induratedcords often replacing them. [Illustration: PLATE II. Engraved and Printed by Bale and Danielsson, Ltd. G. L. CHEATLE. Mauser Wound of Exit, 7-1/2 days after infliction. Healing delayed byInfection. About 12/1. Section of the exit segment of a Mauser wound, removed seven and a halfdays after infliction. Magnified twelve diameters. The healing process has been delayed by infection. There is no attempt at closure by a layer of epidermis, and the marginsare not depressed. The wound track is narrower than that seen in the entry wound plate I. , and completely occluded by a plug of the subcutaneous fat which has beencarried forward by the bullet in its passage. A small wedge-shaped plugof lymph indicates the position of the actual track at its termination. Dragging on the surrounding tissue consequent on the extrusion of theplug of fat has ruptured some capillaries, and given rise toconsiderable extravasation of blood, which is seen as a darker layer inthe deepest portion of the wound. Comparison of this plate with the exit wound depicted in fig. 16, p. 56, explains the nature of the tags of tissue there seen to protrude fromthe convex opening. Range 800 yards. Seat of wound, abdominal wall below 9th costalcartilage. ] _Pari passu_ with the closure of the external openings, healing of thetrack takes place, but this is not always so rapid a process as isapparently the case. In many instances the closure, and even definitehealing, of the external wounds is complete long before the track hasactually healed, even though it be contracted up to complete closure asfar as any cavity is concerned. This is well seen in many cases in whichthe exit opening is large as a result of deformation of the bullet, orthe passage of bone splinters in conjunction with it; here, in spite ofabsence of all suppuration, the track may remain patent for many weeks. This may point to infection, but the tardiness in actual consolidationcorresponds with what we are well acquainted with in the case of allaseptic wounds when a slough has to separate or become absorbed, and itis therefore only what might be reasonably expected when we rememberthat every such bullet track is lined by a thin layer of damaged tissue. [Illustration: FIG. 25 (_b_). --Great Omentum carried by the bullet intoan exit track leading from the abdominal cavity. A. Outline of openingin the peritoneum] When fully healed, the points of entry and exit are so insignificant asto be less obvious than ordinary acne scars, and later are often hardlyvisible, but for a considerable period they are often more palpable thanapparent. This depends upon the induration of the line of cicatrixcorresponding to the course of the original track which is adherent tothe two points. The induration is indeed so marked as to occasionallygive rise to the suspicion that a foreign body such as a fragment oflead or of the mantle of the bullet has been enclosed during the healingof the wound. In the deeper portions of the tracks the extreme density of the cicatrixis a factor of great prognostic importance, since if it implicatesmuscles, tendons, vessels, or nerves, impairment of movement, circulatory disturbance, or signs of neuritis or nerve pressure areoften witnessed. Thus, for instance, a track traversing the calf, willmore or less tie the whole thickness of the structures perforated at onespot, and the apertures of entry and exit may be visibly retracted whenthe muscles are put in action with consequent pain and stiffness to thepatient. Such pain and stiffness form some of the most troublesomeafter-consequences of many simple wounds. It is remarkable for how longa period after the healing of the wound and resumption of active dutythe patients suffer from pain in and radiating from the locality of thewound, when fatigued or suffering from stiffness from the prolongedretention of one attitude or exposure to cold. The cords, however, eventually completely disappear, and the cicatrices become moveable. Theeffects of secondary pressure on the vessels and nerves are consideredunder the headings devoted to those structures. _Suppuration. _--While the occurrence of deep suppuration or septicphlegmon was rare, local suppuration of the apertures of entry and exitwas seen in a considerable proportion of the wounds. This was referableto infection from the skin itself, or to infection from withoutsubsequent to the infliction of the injury. Infection from the skin, difficult to obviate at all times, is especially likely to occur inwounds the first dressing of which is often delayed, and which happen tomen sweating freely into clothes the condition of which is at leastundesirable for contact with a recent wound. Beyond this, the firstdressing materials, removed from a soiled tunic by possibly a comrade ora stretcher-bearer, are scarcely above reproach of the probability ofcontaining septic organisms themselves. Again, once applied, theexigencies of the situation often necessitate an amount of movementfatal to the retention of the dressing over the wound, and a secondopportunity of infection arises before the patient comes into the handsof the surgeon in the Field hospital. The general tendency of such suppurations when they occurred inuncomplicated flesh wounds was to remain superficial, either involvingthe contused margin of the cutaneous opening and the plug of blood-clotoccupying it, and resulting in a slight enlargement of the wound only, or at most involving the subcutaneous tissue and not extending into thedeep planes of the trunk or limbs. In either case a slight delay inhealing was the most serious result, while constitutional signs ofinfection were either absent or of the slightest nature. The sameindisposition to spread by the track was equally noted when a deepportion became infected from, for instance, the intestine in a bellywound. Wounds of irregular type, however, such as those caused by ricochetbullets, or accompanying severe fractures, or those caused by fragmentsof larger projectiles, often suppurated freely in spite of exposure tono more unsatisfactory surrounding conditions than the wounds of smallbore. This appears to show conclusively that the first element in thegeneral slight consequences of small-bore wounds is their calibre, and, secondly, that increase of velocity on the part of the bullet, while itin some measure compensates for the loss of volume in the projectile, onthe other hand reacts in favour of the wounded in so far as the injuriesit effects on the soft tissues are ill suited to the development ofseptic organisms in the parts. _Retained bullets. _--These were met with more frequently than might havebeen expected, but I can give no idea as to their proportionaloccurrence, since so many of the slighter injuries never came under myobservation. Experience, however, showed that the bullets of largecalibre and low velocity employed during the campaign were far morecommonly lodged in proportion to the frequency of their use. Thus I sawa considerable number of Martini-Henry, Snider, large leaden sportingbullets, and shrapnel retained. Again, among the bullets of smallercalibre, the Guedes 8-mm. Bullet, which travels at a comparatively lowrate of velocity and with moderate spin, was far more frequently lodgedthan the Lee-Metford or Mauser in comparison with the number of Guedesrifles in use. Bullets of small calibre were, however, also retained with some degreeof frequency, either as the result of striking at a long range, or insuch a direction as to need to traverse a large segment of the bodybefore escaping, or as striking large or several bones, or making someirregular form of impact: the last was a not infrequent explanation oflodgment, especially when a bone lay in the course of the track. Ricochet bullets naturally were especially likely to be retained, bothon account of the low velocity with which they often travel and theirregularity of their surface with consequent loss of penetrating power. WOUNDS OF IRREGULAR TYPE Many of the wounds met with deviated so greatly in appearance andgeneral characters from what has been described above as to affordlittle or no evidence of having been inflicted by small-calibre bullets, and before describing these it is necessary to give a short account ofthe circumstances which are responsible for such departures from thecommon type. In the case of the wound of entry, the simplestexplanations are lateral impact on the part of the cylindro-conoidalprojectile, due to the position of the part struck or the direction inwhich the bullet has been fired, wobbling on the part of the bullet duesimply to loss of velocity and force in flight, or to turning of thebullet by impact with an obstacle to its course (ricochet) which mayamount to actual reversal of the striking end. As a rule, in such casesthe size of the aperture of entry exceeds that of exit, and in a largeproportion the bullet is retained within the body. Of these explanations that of the 'wobble' needs some passing notice. Inits simplest form it depends merely on loss of velocity of flight on thepart of the bullet, the centre of gravity of which lies behind itsmiddle; hence a tendency to turn over and over is acquired. As a resultof this, either the side of the tip, the side of the bullet, the side ofthe base, or the base itself may form the portion of the projectilewhich comes into contact with the body. The tendency to wobble isnaturally greatly increased in ricochet bullets, since the contact, iflateral, serves to check the spin on which the bullet depends for itsflight on an axis parallel to its long diameter. The first effect ofwobbling is to increase the size and interfere with the regularity ofoutline of the wound of entry; but it also acts in a more seriousmanner, since the increase of the area of impact augments the resistanceoffered by the body; therefore the degree of damage to the tissues isaccentuated and becomes greater than it would be from a bullettravelling at the same rate on its normal axis. Hence the wounds areboth large and severe, or if the velocity is very low, the projectile isespecially likely to be retained. Actual reversal of the bullet usually only slightly enlarges theaperture of entry, but injuries to cancellous bone are apt to be moresevere when the bullet enters in this manner, or again it is oftenretained. I saw several such cases during the campaign. Another form of wobble is suggested by Nimier and Laval, [9] of which Ican offer no experience. They suggest that, as rotation slows, thebullet may on impact wobble like a top before it ceases to spin. Probably the power of penetration possessed by a bullet wobbling in thismanner would not be very great, but its effect would mainly be alteredin the direction of an abnormal increase in the size of the aperture ofentry, or possibly in the degree of comminution in fractures. It is probable that some of the more serious wounds observed were merelythe result of unusual forms of impact with normal flight on the part ofthe bullet. The majority, however, depended, in the case of the wound ofexit, on deformation of the bullet within the body, or the propulsion ofbone fragments with it, and, when both apertures were affected, toprevious ricochet on the part of the projectile. It is here necessary to give a short account of the more commondeformities met with, and to refer to the special characters possessedby different types of bullet of small calibre which may affect the easewith which deformity is produced, and the degree to which it is commonlycarried. The effect of ricochet is to lower the velocity of flight, andat the same time to effect certain alterations of form in the bullet. These with rectangular impact in the case of bullets travelling at a lowdegree of velocity consist in a bending and deformation of the tip; inthe higher degrees, of bending, shortening, extensive destruction, orcomplete fragmentation. If the bullet makes lateral impact, onlywidening and flattening result, often with the escape of the lead corefrom the mantle. That a ricochet bullet may travel a considerabledistance is shown by the following observations quoted from Nimier andLaval. [10] [Illustration: FIG. 26. --Sections of four Bullets to show relative shapeand thickness of mantles. From left to right: 1. Guedes; regular dome-shaped tip; mild steelmantle; thickness at tip 0. 8 mm. ; at sides of body 0. 3 mm. 2. Lee-Metford; ogival tip; cupro-nickel mantle; thickness at tip 0. 8 mm. ;gradual decrease at sides to 0. 4 mm. 3. Mauser; pointed dome tip, steelmantle plated with copper alloy; thickness at tip 0. 8 mm. ; gradualdecrease at sides to 0. 4 mm. 4. Krag-Jörgensen; ogival tip as inLee-Metford; steel mantle plated with cupro-nickel; thickness at tip 0. 6mm. ; gradual decrease at sides to 0. 4 mm. The measurements of the sidesare taken 2. 5 cm. From the tip. Note the more gradual thinning in theLee-Metford mantle. ] Up to a distance of 1, 700 to 1, 800 metres the bullet may make severalricochet bounds. When the bullet strikes first at short distances (as600 metres), it may make several bounds of from 300 to 400 metres: atmoderate distances (as from 600 to 1, 200 metres), bounds of 200 to 300metres; and at distances above 1, 200 metres, bounds of 100 to 200metres. The length of the ricochet bounds depends on the angle of impactof the bullet with the ground, the nature of the slope of the latter, and the velocity of the bullet. Putting aside the question of calibre and volume of the bullets we areconcerned with, I believe the most important variations as seriouseffects of ricochet depend on the relative thickness and the compositionof the mantles. Fig. 26 illustrates the relative thickness of themantles in the Krag-Jörgensen, Mauser, Lee-Metford, and Guedes bullets. Given an equal degree of force and velocity on the part of the bullet atthe moment of impact, the assumption is justifiable that the thinnermantles would tear or burst more readily in direct ratio to theirrelative thinness. I believe this assumption to be borne out by my ownexperience of the common deformities that occurred; but the greatrelative frequency with which Mauser bullets came under my observation, and the difficulty of forming any estimate of the velocity and forceretained by any particular bullet at the moment of impact, make itimpossible for me to express myself with the confidence which I shouldwish. [Illustration: FIG. 27. --Normal Mauser Bullet] The second condition which influences the nature and degree of thedeformities depends on the relative tenacity or brittleness peculiar tothe metal employed in the manufacture of the mantles. In the case of theLee-Metford this consists of an alloy of 80 parts of nickel with 20 ofcopper. The Krag-Jörgensen and Mauser are ensheathed in steel platedwith cupro-nickel, and the Guedes has a plain steel envelope coated withwax. Both as a result of experience in the field gained from ricochetbullets, and in the hospitals from bullets which had undergonedeformation within the body, I am under the firm impression that thethin nickel-plated steel envelope of the Mauser bullet splits morereadily than the thicker and more tenacious cupro-nickel envelope of theLee-Metford, that the direction of the ruptures is more purelylongitudinal, and the fissuring itself more extensive and complete. I append below a series of deformities observed in Mauser bullets, someof which were collected on the field of battle, but all of which werefamiliar to me in bullets removed from the bodies of patients, exceptthe complete disc shape shown in fig. 29. They correspond with specimensof which I made sketches at the time of removal from the body, but whichI had not the heart to retain in view of the natural wish of thepatients to keep them as mementoes of their wounds. [Illustration: FIG. 28. --Four common types of lateral Mauser RicochetBullets. From left to right: 1. Slipper form; slight broadening and turning oftip. 2. More pronounced degree of form 1, with laceration of the mantleopposite the shoulder of the bullet. This is the weakest spot, for tworeasons: the alteration in curve at this position, and the junction ofthe thickened point of the mantle with the thinner sides. 3. Lateralricochet involving nearly whole length of bullet. Rupture of mantle frombroadening of core opposite shoulder. 4. Similar lateral ricochet withextensive longitudinal rupture of mantle, the latter being turned outand forming a cutting 'flange. '] Slight indentations and deviations from strict symmetry of form of suchdegree as not seriously to influence the outline and nature of theapertures were very common. Beyond these one of the most frequentprimary deformities was that we familiarly spoke of as the 'slipperform' (No. 1, fig. 28). This results from light glancing contact of thetip with a hard body: in it the mantle of the bullet is rarelyfractured, and the deformity itself is of slight importance, except inso far as it may influence the direction of the wound track, whichacquires a tendency to be curved. The tip of the bullet is slightlyflattened and turned up, down, or to one side, according to the pointstruck. I saw this deformity frequently, both with Lee-Metford andMauser bullets. Nos. 2, 3, and 4 are more pronounced degrees of the sametype of deformity, accompanied by more or less extensive fissuring ofthe mantle. No. 4 illustrates the turning out of the longitudinallyfissured mantle in such a way as to make a cutting flange. I have seensuch bullets removed, and the variety is of some importance asmaterially increasing the cutting capabilities of the bullet, andaugmenting its area of destructive action. No. 5, fig. 29, is the onlyform I have not seen removed, but such a bullet would account for someof the long irregular gutter wounds observed, if it retained sufficientvelocity to strike with any force. [Illustration: FIG. 29. --'Disc'-shaped Lateral Ricochet. This form is oflittle practical importance, as the velocity retained by the bullet islow, and no perforating power would be retained. It is insertedseparately in order to complete the series, shown in fig. 28. ] Fig. 30 illustrates complete longitudinal fissuring of the mantle. Suchmantles are common, and still more so are the opened-out sheets such asis shown still attached in fig. 29. Free mantles are often very numerouson stony ground, but are of little importance, since I never sawfragments of them removed or impacted. They probably travel a very shortdistance after their formation, and if they did strike would possesslittle power of penetration. The freed leaden cores do, however, sometimes enter the body, and some of the specimens removed have beenreferred to the use of expanding bullets. In all the Mauser specimensthe longitudinal direction of the fissuring of the mantle is striking. [Illustration: FIG. 30. --Ruptured Mauser Mantle, to illustrate thetendency to complete longitudinal fissuring] Fig. 31 represents bullets removed from the body and illustrates typesof deformity due to impact with the bones. The deformity resembles insome degree that of the mushroomed lead cores, and also indicates thatthe shoulder of the cased bullet is its weakest point. Each specimenexhibits shortening and widening without fracture of the mantle, thelatter being simply thrown into folds; both bullets were lodged in thethigh after fracturing the femur. The localisation of injury to the forepart of the bullet, and the fact of expansion, allow us to infer thatthe degree of velocity retained on impact with the bone wascomparatively low, and that neither bullet had been exposed to verysevere strain. [Illustration: FIG. 31. --Two retained Mauser Bullets which had producedcomminuted fractures of the femur of moderate severity. Each has givenway at the shoulder, but the mantle has developed creases withoutrupture, and the bullets are correspondingly bent. Both bullets weretravelling at a moderate if not low degree of velocity] Fig. 32 is also of a retained bullet in which the fore part of themantle is very extensively fissured and the core set free. In this themantle has suffered severely and the leaden core to a less extent. As anapical ricochet it corresponds with the Lee-Metford shown in fig. 36. [Illustration: FIG. 32. --Apical Ricochet Mauser Bullet (see text). The'mushrooming' of the core is moderate, but the destruction of theanterior part of the mantle very considerable] The deformity found in fig. 32 I met with both in retained bullets andalso in those which had been fired into sand or anthills. The particularspecimen figured was removed from the thigh of a patient wounded at thebattle of Belmont. An irregular entry wound was situated over theinternal tuberosity of the tibia, while a large fluctuating hæmatomaexisted in the lower third of the thigh, at the upper part of which ahard elongated body was palpable. As was so often the case with internalhæmorrhages, the patient's temperature rose high, and on the third daythe hæmatoma was incised by Major Coutts, R. A. M. C. The core of thebullet was then found in the blood cavity near the surface, but onintroduction of the finger a second body was discovered entangled in thequadriceps muscle, and this proved to be the tattered mantle. I sawsimilar deformity produced within the body by a bullet, which, enteringby a small type aperture in the left ala of the nose, struck the marginof the right malar bone, and lodged beneath the latter. The similarityof this bullet to that seen in the ricochet in fig. 32 was exact. Theform is of great importance both on account of the degree of lacerationit effects in the track, the presence of two foreign bodies in thewound, and from the fact that it can be produced by making the bullettravel through sand or antheaps, since both the former in the shape ofsandbags and the latter in their natural state so often formed the coverto men during the campaign. Bullets of 6. 5 mm. , such as theKrag-Jörgensen, with steel envelopes apparently break up with great easein sand. Fig. 33 shows a form not uncommon when the bullet comes into contactwith the ribs. It is produced in bullets travelling at a low rate ofvelocity and striking by their side. I several times met with it whenthe bullet was retained, and also without fracture of the rib. In somevariety it might occur after impact with any narrow margin of bone, andsome importance attaches to the form, since it affords evidence as tothe ease with which alterations in symmetry can be produced in Mauserbullets. Again its bent outline favours deviation in the further courseof the bullet subsequent to impact with the bone, a result which Iobserved on more than one occasion. [Illustration: FIG. 33. --Grooved Mauser removed from anterior abdominalwall after crossing the ribs. I saw several such removed from thethoracic wall, and am inclined to attribute the grooving to impact withthe margin of the ribs] Lastly, the question of actual spluttering or breaking up of the bulletsmust be considered. It is extraordinary into how many fragments either aLee-Metford or a Mauser bullet may break up if it strike a hard bodywhile travelling at a high rate of velocity. Fragmentation is exhibitedin the skiagram forming the subject of plate XI. P. 194. It is somewhatremarkable how often this occurred when the short hard bones of themetacarpus were struck. With regard to the casing, the separation ofsmall scales of the nickel plating has already been referred to;reference to the skiagrams, plates IX. And XVI. , shows how readily thewhole thickness of the mantle breaks up into small fragments, even whenthe bullet is travelling at moderately low degrees of velocity, andthis I believe to be a special characteristic of the thincupro-nickel-plated steel mantles. Any variety of cased bullet, however, when it strikes against a stone, hard ground, or a bone, may be broken into innumerable fragments. Theleaden fragments occasionally show a simple fractured surface, such asis illustrated on a larger scale by the broken shrapnel bullets shown infig. 96, p. 485. More commonly, however, the fragments, if of any size, appear torn, and if small, are mere spicules. These if of lancet shapeoften bury themselves in the skin only, while larger ones may penetratedeeply or even perforate. Thus, of a group of three officers standingnear a stone on which a bullet struck, all were spattered about theface; most of the fragments lodged in the skin, but one perforated theconcha of the ear and bruised the mastoid area, while others causedsmall jagged cuts. In another instance, both thighs of the patient werespattered after perforation of the clothes, and a large fragment lodgedbeneath the skin of the penis. A case in which larger fragmentsperforated and simulated type wounds has already been referred to on p. 44. [Illustration: FIG. 34. --Normal Lee-Metford Bullet] The above remarks apply, for the most part, to Mauser bullets only, because my experience of that projectile was far wider than of theLee-Metford. The only deformed Lee-Metford bullets that I saw removedfrom the body were of the 'slipper' variety, exactly corresponding tothe similarly altered Mausers, and with no fissuring of the mantle. Isaw none so freely deformed as the Mausers depicted in figs. 28, 29, 31, and 32. In spite of diligent search on several battlefields, I was unable tocollect many forms of Lee-Metford ricochet, although I found manyundeformed bullets. I insert here, therefore, some illustrations Iobtained through the kindness of Colonel Hopton, Director of the Schoolof Musketry at Hythe, which are of interest, and in some degreesubstantiate the impression I formed in South Africa as to the greaterstability of the Mark II. Lee-Metford bullet (fig. 34). I am aware that, as meeting a smooth target at right angles, some of these are notstrictly comparable to the Mauser bullets forming the subjects of thepreceding illustrations, which struck stones, and these mainly by theirsides (if we except figs. 31 and 32), but they sufficiently exhibit thecharacters on which I wish to insist. That they support my opinion isthe more probable as, with the exception of the type included above, Iam under the impression that the large majority, if not all, of theMauser bullets which struck stones fairly with their tips were broken topieces, otherwise I must have met with some among the immense numberwhich I saw. On the top of Tabanyama, for instance, the whole ground waslittered at the time of my visit with shattered mantles and leadencores, deformed almost past recognition. [Illustration: FIG. 35. --Apical Lee-Metford Ricochets. From Hythetargets. Tendency of cupro-nickel envelope to tear in transversedirection] The specimens depicted in figs. 35 and 36 indicate--(1) a greatermalleability on the part of the mantle; thus in fig. 35 the cupro-nickelis obviously hammered and flattened out, while the fissures are neithernumerous nor extensive. (2) Both bullets exhibit transverse tearing ofthe mantle, a common feature in Lee-Metford ricochets, of which I couldoffer other examples, but which I less often observed in Mauserbullets. (3) Tear is the term best expressing the nature of thefissures, while fracture more nearly expresses the nature of thefissures in the Mauser mantles. (4) Fig. 36 shows a mushroomed core andsplit mantle, which may be compared with the similarly deformed Mauserdepicted in fig. 31. I think the variation in appearance ischaracteristic, the fissuring of the mantle being much less extreme, while the leaden core is normal at its base in consequence of thesupport afforded by the more tenacious cupro-nickel mantle. With regardto complete splitting of the mantles, however, I must add that freeLee-Metford mantles are often found from bullets fired at the target orelsewhere, and Nimier and Laval figure numerous forms. [11] [Illustration: FIG. 36. --Apical Lee-Metford Target Ricochet. Well-marked'mushrooming' of core. 'Torn' nature of the fissures in the mantle andlimited extent. Compare with fig. 32] _Expanding bullets. _--The wounds resulting from perforation withdeformed regulation bullets, such as are described above, differ for themost part by deviation from the type appearances, and a tendency to takea less favourable course on account of their increased size and of thegreater degree of laceration of the tissues accompanying them. I mustnow pass on to the consideration of the forms of bullet especiallylikely to occasion those wounds spoken of as 'explosive' in character, and my remarks on these must be prefaced by a short description of thevarieties which were in use during the campaign. [Illustration: FIG. 37. --Four Soft-nosed Bullets from Boer trenches. From left to right: 1. Mauser (. 275); small amount of core exposed. 2. Lee-Metford (. 303). 3. Lee-Metford, with larger amount of exposed core, also cupped apex. This is probably the most effective of these forms. 4. Mannlicher (. 315)] These consisted in soft-nosed bullets of the Mauser and Lee-Metfordpatterns, Tweedie and Jeffreys modifications of the Lee-Metford andMauser, several soft-nosed bullets of a slightly larger calibre, mostlyold Mauser or Mannlicher types, and a large variety of sporting leadenbullets of larger calibre and volume. Figs. 37 and 43. With regard to the various soft-nosed bullets of small calibre, I willfirst advert to a feature common to all, which consists in a solid baseto the mantle. In the regulation whole-cased bullets the leaden core isinserted from the base, and the edge of the mantle is then so turnedover for fixation purposes as to leave the central portion of the leadexposed. The position of the exposed portion of the core is thereforereversed in the two varieties. The small experience I had theopportunity of obtaining was all to the effect that the solid baseconsiderably increases the stability of the mantle, and I never saw thelatter seriously torn in any specimen either collected on the field orremoved from the body. [Illustration: FIG. 38. --Two Soft-nosed Lee-Metford Bullets (see text). 1. Removed from forearm. 2. Removed from beneath skin of back after ithad perforated the scapula. In both the velocity retained was no doubtlow, and neither encountered great resistance] Fig. 38, 1, represents a soft-nosed Lee-Metford removed from just belowthe lesser sigmoid cavity of the ulna, after it had perforated theelbow-joint. The soft nose appears to have been torn, and separated byimpact with the bone, but the mantle is little altered. There can belittle doubt, however, that the bullet was travelling at a comparativelylow rate of velocity, since it was retained in the forearm, whence itsvarious parts were removed by Major Lougheed, R. A. M. C. I picked up anumber of similarly deformed bullets on the field. No. 2 represents asoft-nosed Lee-Metford which perforated the scapula from the front; thebullet was retained, hence again velocity cannot have been very high, and the comminution was slight. If it had passed out, a large exit woundwould, however, have resulted. [Illustration: FIG. 39. Soft-nosed Lee-Metford Mantle. Lateral ricochet. Illustrating effect of solid base in maintaining the stability of themantle] Fig. 39 represents a type of ricochet sometimes found on the field. Inspite of a considerable amount of violence which has caused the escapeof the core, the fissuring of the mantle is comparatively slight. Inpoint of fact, the casing is, as a rule, preserved from the severeviolence it suffers when complete, by the flattening and turning over ofthe soft nose. I am sorry I cannot append an illustration of a damagedsoft-nosed Mauser, but I am of opinion that those used during thecampaign were not of a very dangerous nature on account of the smallamount of lead exposed. To gain the full advantage of the soft nose atleast a third of the core should be exposed. No. 3, fig. 37, of aLee-Metford, probably represents the most effective form of suchbullets. I am inclined to think these bullets as a class, however, arenot more dangerous to the wounded man than the regulation Mauser firedat short range, if the latter either comes into contact with bone orsuffers ricochet. The Tweedie and Jeffreys bullets come under a somewhat differentcategory. In the Tweedie the top of the bullet is sawn off in such amanner as to flatten the tip and widen the surface of direct impact, andto expose the leaden core over a small area. The general principle ofthe flat tip resembles that of the French Lebel bullet. In the Jeffreysmodification the mantle is sawn down for about half the length of thewhole mantle, the slits neither reaching tip nor base. I seldom sawthese bullets removed, but they were used to a considerable extent. Fig. 40 illustrates one of Mauser calibre in the possession of Mr. CuthbertS. Wallace. It perforated the abdomen, producing fatal injuries, but theonly alteration in outline consists in slight bulging and shortening. This specimen, however, manifestly suffered but slight resistance. Asomewhat general impression existed that a number of severe injuries hadbeen produced by the Jeffreys bullets, but it was a matter ofconjecture, as few of them were removed. A weekly illustration appearsin the advertisement sheet of the 'Field, ' showing the deformity of someof them shot into animals, which bear a strong resemblance to the Mauserfigured earlier (fig. 31), and which we have seen can be produced in thehuman body by contact of a regulation fully cased bullet with a bonelike the malar. A tendency on the part of the longitudinal slits tobecome caught in the rifling of the barrel militates against the use ofthis bullet. [Illustration: FIG. 40. --Jeffreys modification of Mauser. The bullet isin the possession of Mr. C. S. Wallace. It perforated the abdomen andcaused death. The bullet is only slightly shortened by bulging at theshoulder] [Illustration: FIG. 41. --1. Section of Mark IV. Lee-Metford. Notethickness of mantle and exposed core at base. 2. Soft-nosed Mauser. Notesolid base. Short pattern] Fig. 41 represents sections of the soft-nosed Mauser, and the BritishMark IV. Bullet, and shows the different method of closure of the base. If the former remarks on the influence of the closed base in maintainingthe stability of the bullet be correct, Mark IV. Should be a verydestructive bullet. I have no experience of its use, but I am inclinedto think that here, as elsewhere, the thickness and resistance of thecupro-nickel mantle would endow it with considerable stability, unlessit met with very great resistance. [Illustration: FIG. 42. --Types of Bullets tampered with by the Boers inthe trenches. 1 and 3. Cross-cut tips, Martini-Henry and Lee-Metford. 2. Groove cut at base of exposed tip of Lee-Metford. Another modificationof the Martini-Henry consisted in boring it longitudinally and insertinga wooden plug] In connection with the subject of soft-nosed bullets, I should mentionthat the Boers occasionally extemporised various modifications of them, such as are shown in fig. 42, with intent to increase the wounding powerof the projectiles. I am unable, however, to give any information as tothe effects produced by these, and I do not think they were oftenemployed. The illustrations are from cartridges found in trenches whichhad been occupied for some time by the Boers, who had no doubt usedtheir spare time in exercising their ingenuity on the bullets. 'Explosive' bullets of small calibre were also said to have beenemployed; with regard to these I can only say that I never met with anyexample of a hollow bullet containing explosive material. One officer in a Colonial corps who spoke freely about them, told me hehad 'sawn' them in half and found the cavities, but the method ofinvestigation he had employed seemed against the presence of anyfulminant in the body of the bullets. Others based their statements onthe fact that they had frequently heard the bullets burst in the air;but this is probably to be explained by the breaking up of regulationbullets on impact with stones, which makes a smart crack like a smallexplosion. A clip of soft-nosed Mauser cartridges, in which a copper centre to thebullet suggested a percussion-cap, was sent home to the War Office. Colonel Montgomery has kindly furnished me with the following report onthe bullet: 'The bullet contains no explosive matter, it is fitted with a hollowcopper tube in the nose, similar to the ordinary "Express" bullet. Theenvelope is made with a solid base, which is possible in this bulletowing to the core being inserted from the front. ' One cannot help feeling some astonishment at the strong feeling that hasbeen exhibited regarding the use of expanding bullets of small calibre, both at the Hague Conference and during this campaign, when theMartini-Henry, a far more dangerous and destructive missile in itseffects at moderate ranges, is allowed to pass muster without notice. Lastly, we come to bullets of large calibre unprovided with a mantle. The Martini-Henry is practically representative of all these, but Iappend a photograph of some twenty out of thirty varieties which cameinto my possession during searches amongst captured ammunition. Some ofthese were provided with a copper core to facilitate 'setting up, 'others were cupped at the top, and others flattened, to increase theresistance on impact. I can say little about them except that I believesome of the forms were responsible for a considerable proportion of themost severe injuries we met with, in some of which a large and regularentry made their use certain, while a considerable proportion of themwere retained. In the case of the viscera their power of doing seriousdamage was very striking compared with that of the bullets of smallcalibre. As with the small sporting bullets I think their use was oftendue to the fact that the sporting Boer preferred to use the weapon hewas accustomed to rather than his military weapon. A considerable number of the Boers were armed with Martini-Henry rifles, and this was particularly the case with small bodies of men, rather thanwith the larger commandos fighting regular engagements. The TransvaalGovernment, moreover, had Martini-Henry rifles made as late as 1898. TheMartini-Henry bullet was responsible for some of the worst fracturesthat came under my notice, but it is of interest to remark that itscapability to do damage did not satisfy some of the Boers, who cut themas is shown in fig. 43. I cannot say what the effect of this manoeuvrewas, although it may have accounted for some of the wounds of the calfsuch as are mentioned below. Some odd missiles were met with during the campaign; thus, at Ladysmith, I was told ball bicycle bearings were at one time in use amongst theBoers. _Anatomical characters of wounds of irregular type. _--It will be seenfrom the above that in dealing with wounds of irregular type we have toconsider those due to irregular impact of normal regulation bullets, tobullets deformed by contact with bone, to ricochet bullets, and lastlyto bullets of the expanding type. No further mention of those due to irregular impact is needful beyondwhat has already been said under the heading of wobbling, except topoint out that, given a fair degree of velocity, these injuries mayassume an actual explosive character, especially in the case of skullfractures. The description of extensive wounds accompanying comminutedfractures finds its most appropriate place under the heading of injuriesto the bones, and will be there considered (Chapter V. P. 155). 'Explosive' exit apertures are, however, described as occasionallyoccurring in injuries involving the soft parts only. I saw no casessubstantiating this belief, but several were described to me as havingbeen met with in abdominal injuries, which terminated fatally at anearly date. [Illustration: FIG. 43. --Four Soft-nosed Bullets of small calibre shownin fig. 37. Twenty large-calibre leaden carbine and rifle bullets fromcartridges found in Boer arsenals. These were not very extensively used, but specimens of most varieties were at times removed from our woundedmen. It will be noted that some are of great weight, and a largeproportion either cupped or flattened at the apex to increase area ofimpact and consequent resistance. The 'express' bullet with a coppercore is included in this series. It is worth remarking that all thebullets of this nature in the Pretoria Arsenal were waxed, and that thewax retained its white colour on the lead. ] I still, however, incline to the opinion that the bullet in these caseshad come into contact with some bone, or was one of the larger varietiesof projectile. A few cases of wound of the calf did, however, come undermy observation which presented fairly typical 'explosive' characterswithout evidence of solution of continuity of the bones. I will shortlyrecount two of them. In the first the exit opening was very large and onthe outer aspect of the limb in the upper third. The bullet hadapparently passed between the bones. Secondary hæmorrhage from theanterior tibial artery necessitated exploration of the wound andligature of the vessel (Mr. Carré). When the wound was thus laid open noinjury to the bones could be detected, but I do not consider that itcould be actually excluded. In the second case a wound traversed thecalf transversely, just above the centre; the exit aperture was largeand ragged. Deep suppuration occurred, and the wound had to be laidopen, when a fracture of the tibia without solution of continuity wasdiscovered. I also saw one or two wounds of the buttock in which verylarge exit apertures were present with small entry openings; in theseagain it was impossible to exclude passing contact of the bullet with apart of the pelvic wall. Unfortunately in all these cases it isimpossible to obtain the bullet responsible for the injury. In thisrelation I append a diagrammatic illustration of a peculiar wound shownto me by Mr. Hanwell. In this case a typical small entry wound wassituated at the outer margin of the left erector spinæ muscle in theloin. The bullet had taken a subcutaneous course of not more thanthree-quarters of an inch, while the exit opening was a long shallowwound measuring 4-1/2 in. In length by 1-1/2 in. Width. (Fig. 44. ) The wound was stated to have been received at a distance of from fiftyto a hundred yards. I think we can scarcely assume that impact with themargin of the erector spinæ could have resulted in 'setting up' of thebullet, while an irregular tongue of skin at the point where the woundcrossed the spines of the lumbar vertebræ did suggest possible bonycontact. That the latter must have been of the slightest nature isevident, as no signs of concussion of the spinal cord were noted. Ishould rather be inclined to compare this case to one of gutter woundquoted on p. 56, and to assume that the bullet passed so closelybeneath the surface as either to entirely sever the skin, or at any rateto allow it to give way on flexion of the back on movement. [Illustration: FIG. 44. --Small Circular Entry, large 'explosive' skinwound of back. Track only an inch or less in length (see text)] On the ground of the observations made in the foregoing pages it will begathered that the opinion I formed was against either the very free useor the great wounding power of so-called expanding bullets of smallcalibre. I believe that a great number of the injuries which wereattributed to the employment of these missiles were produced either byricochet regulation bullets of small calibre, or by large leaden bulletsof the Martini-Henry type. _Symptoms. _--I very much doubt whether the general symptoms observed asthe result of wounds from bullets of small calibre differ in more thanslight degree from those described when larger bullets were regularlyemployed. Great variation was met with, but I do not think a diminutionin serious results in this direction corresponding to the comparativelylimited nature of the direct injury to the organs or tissues can beaffirmed. It is true that the immediate symptoms in many patients wereamazingly slight, but after all, this has always been a feature ofgunshot injuries on the field of battle and cannot be assigned aposition of distinctive importance. 1. _Psychical disturbance and shock. _--Some remarkable instances ofpsychical disturbance were observed, and although perhaps in no wayinfluenced by the calibre of the projectile, they seem worthy of note inthis place. Thus a patient wounded over the cervical spine and whosuffered later with a slight degree of spinal concussion emitted aninvoluntary shriek like that of a wounded hare on being struck; another(Martini wound), after receiving a wound of the chest, lost all sense ofhis surroundings for a considerable period, and occupied himself inattempts to write on a white stone lying near him on the veldt; thensuddenly realising his position he was greatly bewildered in trying toaccount for his own action. A similar instance of preoccupation isprobably offered by the dead man in the accompanying photograph (fig. 45), whose arms, forearms, and hands had evidently been in play untilthe actual moment of death. Again the influence of the psychical stateon the actual occurrence of shock was often illustrated by the mentalcondition of the wounded after a battle; thus after the battles ofBelmont and Graspan the patients came into hospital in excellentspirits, and minimised their injuries in the wish of rapidly regainingthe front; while after the battle of Magersfontein the men weredepressed and miserable, shock was more pronounced, and their sufferingswere undoubtedly greater. On the whole, however, shock was by no means a prominent symptom in thesmall-bore injuries of soft parts, and was possibly less than whenlarger bullets were the rule, and again it was often remarkably slightafter the infliction of serious visceral injury. Still shock wasobserved in a considerable proportion of the patients, and itsoccurrence appeared to vary under very much the same conditions asobtain in civil practice. Grades of severity depended on individualidiosyncrasy, on the degree of excitement or preoccupation at the momentof injury, and to a certain degree on the range of fire at which theinjury was received. [Illustration: FIG. 45. --Note position of head, neck, and forearms inupper figure] The last is the only special factor, and as far as my observation wentit was one of considerable importance. When the soft parts only wereaffected, even high velocity did not produce much effect; but when to aflesh wound a severe bone fracture or injury to any part of the nervoussystem was added, shock might be severe or profound. The question ofshock dependent on visceral injury will be considered in succeedingchapters, but it may be well to state here that the most severe shockappeared to follow injuries to the central nervous system especially tothe spinal cord, fracture of the larger bones, and wounds of theabdominal and thoracic viscera, the latter especially when the cardiacneighbourhood was encroached upon: hence the severity depended almostsolely on the importance of the part injured and the degree of damageinflicted. I never observed instances of entire absence of shock invisceral injuries, unless the range of fire had been an especially longone. To these remarks on constitutional shock I should add a few on the'local shock' exhibited by the actual part of the body struck. Thephenomena were of a severity I was quite unacquainted with in civilpractice, and apparently were attributable to the local vibrationtransmitted to the whole structure of a limb or part of the trunk. Inmany fractures, and in some wounds of the soft parts alone, without thedirect implication of any large nerve trunk, the loss of functionalcapacity of the limb was complete, and this condition persisted forhours or even days. 2. _Pain. _--As an initial symptom the occurrence of pain varied greatlywith the idiosyncrasy of the patient, and according to the circumstancesunder which the wound was received. Some individuals are remarkablyinsensitive, and in these the fact of a wound being a gunshot injury inno way altered their habitual insensibility, but in persons of what maybe termed the normal type in this particular great differences wereobserved. When a wound was received in the full excitement of battle during arapid advance, pain was often slight, or so trifling in degree that itwas almost unnoticed; many patients did not realise that they had beenstruck until a second wound, possibly implicating a bone or somespecially sensitive structure, was superadded. In such instances thepain was often described as 'burning' in character, or even likened to a'sting from an insect. ' Occasionally the pain was referred to a distantpart; thus a man struck in the head first felt pain in the great toe, and another struck in the abdomen also felt pain in his foot only. Againin some multiple injuries, pain was only felt in the more sensitive ofthe regions implicated; thus a patient in whom a bullet (Martini)traversed the arm and chest emerging in the neck to again enter the chinand comminute the mandible, only felt pain in the chin and firstrealised that he had been wounded elsewhere when he undressed. Astriking instance of the entire absence of initial pain was afforded bya man shot through the buttock, the bullet then traversing the abdomen:this patient remained unaware that he had been hit until on undressinghe found blood in his trousers and exclaimed: 'Why I have got thisbloody dysentery!' None the less his internal injuries were sufficientlysevere to lead to death during the next thirty-six hours. Although initial pain might be slight or absent, practically all thepatients complained of some of varying severity at the end of an hourafter reception of the wound. In a large proportion of the wounded, however, pain was more or lesssevere from the first, and this was especially the case when the men hadbeen exposed to fire for some hours behind inadequate 'cover. ' The mostcommon descriptions under these circumstances were that they felt as ifthey had been struck by 'a brick, ' 'a ton of lead, ' or 'asledge-hammer. ' 3. _Hæmorrhage. _--This question is fully treated under the heading ofinjuries to the blood-vessels. It will suffice here to say thathæmorrhage was rarely of a dangerous nature so far as life wasconcerned, unless the large visceral vessels or those in the walls ofserous cavities were concerned, when death was often rapid. From limbwounds, even when the largest trunks were implicated, the generaltendency was to spontaneous cessation of the hæmorrhage. Consequently, except these patients were seen on the field, one seldom had to dealwith serious bleeding. None the less, the condition of the patients'clothes bore testimony to a free rush immediately after the injury, andpools of blood were occasionally found where patients had lain. Innearly all cases the rush of the bullet determined the initial flow ofthe blood from the exit wound, and this aperture usually furnished anyhæmorrhage of importance. _Diagnosis. _--The only diagnostic point which it is necessary toconsider in this chapter is the determination of the nature of thebullet which has caused the particular injury under observation, andthis is more a matter of interest than importance. The primary indication lies in the size of the aperture of entry, whichnaturally varies with the calibre of the bullet employed, and thedifference, except in the case of large projectiles, is not alwayseasily determined, unless we can be sure that the impact of the bulletwas at right angles. In the latter case it is possible to distinguisheven between, for instance, a Lee-Metford and a Mauser wound, if theresistance likely to be offered by the part struck is kept in mind. Aricochet bullet, on the other hand, may upset all our calculations, ifsize alone be taken as an indication; but here the irregularity of thewound often serves to exclude one of the larger varieties as the cause. The appearances of the exit wound are less useful in determining thenature of the bullet employed, as irregularities of outline are so muchmore common whatever projectile may have emerged; but examination ofthis wound often gives us useful information as to the existence of aninjury to the bones not involving loss of continuity. [Illustration: FIG. 46. --Two flattened Leaden Cores to illustrate meansof determination of nature of bullet. Note ring at base. The right-handbullet is probably a 'man-stopping' revolver bullet; it flattenedagainst bone] Other information beyond that furnished by the external wounds may begleaned from the presence of fragments of lead in the wound; these, ifunaccompanied by portions of casing, afford some presumptive evidence ofthe use of an unsheathen bullet, especially if found on the fracturedsurface of the bones; but it must be borne in mind that in the case ofricochet bullets the leaden core often perforates when entirely freedfrom its mantle. Pieces of the mantle again may give useful informationboth from examination of their thickness and composition. Lastly a nakedcore nearly always retains the marking on its base corresponding to theturning over of the mantle, this not being likely to suffer impactcalculated to efface the groove. When this groove existed the employmentof any of the soft-nosed bullets used in this campaign might be safelyexcluded (fig. 46). _Prognosis. _--The question of general mortality amongst the wounded hasalready been considered (Chapter I. P. 11), and it has been shown, putting aside those dying at once on the field, or during the firsttwenty-four hours, that the mortality was a low one. Some other pointsspecially dependent on the nature of the injury are, however, worthy ofmention in this place. First, it has been shown, with a slightreservation as to when a wound can be considered definitely sound, thatif suppuration did not occur, healing was rapid, and that many men withslight wounds were back with their regiments in the course of a very fewdays. Again, that suppuration when it did occur tended to be local incharacter; none the less, if it was at all extensive, it often provedvery prolonged and difficult of treatment, while residual abscessesafter apparent healing were not uncommon. In connection with thissubject I may quote from Colonel Stevenson[12] an observation that limbsthe subject of marked local shock are especially liable to furnishseptic discharges. Parts the subject of local shock when infected show alesser degree of vitality and power of resistance to the spread ofinfection than do normal ones, and if infected do badly. I think Iconvinced myself of this on many occasions, and also of the fact thatcases of fracture in which this condition was marked were slow inconsolidating. Again I am inclined to think that the bad results whichsometimes followed the tying of the limb arteries were also consequenton lowered vitality, and possibly vaso-motor disturbance due to theeffects of the exquisite vibratory force to which the nerves had beensubjected. On this account I was never anxious to hurry operations insuch cases, unless obviously necessary at the moment. The larger question of general nervous breakdown as the result ofinjuries from bullets of small calibre is at present hardly capable ofan answer, and is so complicated by the co-existence of concurrentmental anxiety, exposure, &c. , that a definite answer will always bedifficult. I think there is already sufficient evidence, however, tosuggest that the remote effects of many of these injuries may be farmore serious than we expected at the moment, especially in the directionof sclerotic changes in the nervous system. _Treatment_. --In view of the remarks on the treatment of specialinjuries contained in succeeding chapters, I shall confine myself hereto the question of the treatment of wounds of the soft parts alone. This consisted during the campaign in the primary application of theregulation first field dressing by one of the wounded man's comrades, anorderly, or less commonly an officer or a medical man. This dressing iscomposed of a piece of gauze, a pad of flax charpie between layers ofgauze, a gauze bandage 4-1/2 yards long, a piece of mackintoshwater-proof, and two safety pins, enclosed in an air-tight cover. Mr. Cheatle, [13] in insisting on the importance of an immediate antisepticdressing in the field, recommends the following. A paste contained in acollapsible tube, made up in the following proportions: Mercury and zinccyanide grs. 400, tragacanth in powder gr. 1, carbolic acid grs. 40, sterilised water grs. 800; sufficient bicyanide gauze and wool for thedressing of two wounds, a bandage, and four safety pins; the wholeenclosed in a mackintosh bag. The paste possesses the advantage over anyliquid or powder, that it can be applied in any position of the body tosevere wounds, and its application in the open air is not interferedwith by draughts of wind. Mr. Cheatle used a similar preparation withsuccess during the campaign. On arrival at the Field hospital, or in some cases at the station of thebearer company, the wounds were then commonly dressed as follows: Theparts around the wound were cleansed with an antiseptic lotion, eithersolution of perchloride of mercury 1 in 1, 000, or 2-1/2 per cent. Solution of carbolic acid. The wound itself was then cleansed, and adressing of double cyanide of mercury and zinc applied. This was coveredwith a pad of wool and secured with a bandage. The gauze was usuallywrung out in the lotion before application as a precaution againstprevious contamination, and the moistening was also useful as helping toensure the dressing from subsequent displacement. It was earlyrecognised that the drier the dressing the better, and hence anythinglike a mackintosh layer was carefully avoided. In some instances, antiseptic powders were employed, but they did not find much favour, andbecause they tended to favour slipping of the dressing, and to preventthe adhesion of the gauze dressing to the wound, they were certainly notdesirable when there was any necessity for the patient to travel. In theabsence of reliable water the use of antiseptic lotions was obligatory, and such is likely to be the case in most campaigns; in the present one, filtration of the thick muddy water was impossible, without aconsiderable expenditure of time, which could only be obtained when thehospitals were fairly stationary. I very much preferred carbolic acidlotions. The wound having been once cleansed, or rather the surroundings of thewound, the drier the surface was kept the better; hence a too heavy orimpervious dressing was not satisfactory; in point of fact, I think someof the slighter wounds in which all the dressings slipped off, and inwhich there was less consequent chance of the dressing being moistenedwith the sweat of the patient, did as well as any. I do not think the bicyanide gauze, absorbent wool, and common open-wovebandages, together with a good supply of nail brushes, soap, andcarbolic acid for the primary disinfection of the skin and the externalwound, are to be greatly bettered at the present day as materials forthe first permanent dressing of cases in the field. The wound itselfshould be carefully shielded during the preliminary cleansing of theskin by a firmly applied antiseptic pad, and then the dressing appliedas above described. The one desirable improvement is some mode ofensuring the dressing being kept in good position, and for this someform of adhesive covering for the gauze and wool should be devised. Whenthe atmosphere is such as to allow of rapid drying, thin moistenedbook-muslin bandages would be preferable to the plain open-wove ones. The one period of danger is that of transport, and when that is over, the dressing in Stationary or Base hospitals should give no trouble. As a rule the wounds themselves need no interference, but in someinstances either the exit or entrance wounds may be in undesirablepositions for purposes of asepsis, when a large opening may seem saferclosed and actually sealed. I saw this method tried in a few cases, butwithout much success. It is one which might be of much use in Basehospitals if the patients were brought directly into them, but in theField hospitals, in face of the rush with which the first dressings haveto be done, I think it is seldom applicable, and consider theinterference with the wound as rather likely to increase the danger ofinfection than to decrease it. Dressings should not be too frequent; two should suffice for simplewounds with type forms of entry and exit; there is little discharge andusually no bleeding: hence the more the dry scab form of healing can besimulated the better. When a dressing needs changing from fouling of itsouter parts, it is preferable to cut round the adherent part of the deeplayers and apply some fresh gauze over the central scab rather than toremove it. One point should be kept in mind: the first dressing in theField hospital seals the fate of the wound as to the chances of primaryunion, and hence too much care is impossible with it. Operations in the Field hospitals were proportionately not numerous, andthey should be kept down in number, as far as possible. At the same timesuch operations as are necessary are mostly of capital importance, suchas the treatment of fractures of the skull, abdominal section, theligature of arteries, and amputations. Of these only the first and lastclasses occur with any degree of frequency. In order to be prepared forthese a stock of filtered water which has been boiled, and some specialsterilised sponges, should be at hand if possible, also some smalltowels which can be wrung out in antiseptic lotion. If sterilisedsponges are not to be had, wool pads wrung out in carbolic lotion mustbe substituted. Primary amputations bore transport badly. I saw few sent down from thefront within a few days of their performance in which the flaps did notslough, or worse consequences ensue. On the other hand, if the firstfortnight could be tided over at the front, they did well enough. Thehead cases on the other hand bore movement fairly well, provided onlythat asepsis was ensured. Retained bullets are rarely suitable for removal in the rush of thefirst work of a Field hospital after an engagement. A short delay is ofno importance, and ensures their being removed safely if necessary. Withregard to the broad question of the advisability of removing them atall, it may be laid down that they should not be interfered with unlesssome obvious reason exists. Those most commonly calling for removal areas follows: 1. Bullets lying immediately beneath the skin or quitesuperficially in any region, or those which, although they have producedan exit opening, yet lie within the body. 2. Those which lie at thebottom of an infected track, or cause secondary suppuration. 3. Thosecausing pressure on important structures, particularly nerves. 4. Thosewhich interfere with the movements of joints when lodged in the bones orsoft tissues in close proximity, or those which lie within the articularcavity itself. Bullets sunk in the great body cavities or in positionsdifficult of access should never be interfered with. Retained bulletssometimes give rise to unexpected surprises; thus in a man with aretained bullet in the pelvis no steps for its removal were taken. During the man's voyage home on a transport he had an attack ofretention of urine. As a catheter would not pass, he was placed in awarm bath, and shortly after passed a Mauser bullet per urethram, andthus saved himself a cystotomy. One word may be added as to the treatment of shock when severe. Quiet inthe supine position, and the administration of a small amount ofstimulant, was usually all that was required. Hypodermic injections ofstrychnine sulph. Grs. 1/30 to 1/10 were useful, and in some severecases, especially where operations were needed, saline infusions with asmall amount of stimulant were made into the veins, either at the elbow, or in amputation cases into one of the large veins exposed. The treatment of hæmorrhage is dealt with in Chapter IV. The after treatment of simple wounds needs little comment, but bearingin mind what has been said as to the definite healing of the internalportion of the tracks, it will be obvious that in parts such as thethigh or calf, care was needed as to not commencing active work at tooearly a date. On the other hand, a too long period of absolute rest isalso to be deprecated. The best results were obtained by carefulmovement and massage, commenced after the first week or ten days, according to the appearance presented by the external wound, followed bya gradual resumption of active movement. It was a striking fact thatsome of the patients suffering from such wounds took longer to becomeapparently well than many of those who had suffered visceral injuries. FOOTNOTES: [9] _Loc. Cit. _ p. 31. [10] _Loc. Cit. _ p. 100. [11] _Loc. Cit. _ pp. 54, 55. [12] _Wounds in War_, p. 83. Longmans & Co. 1897. [13] A First Field Dressing, _Brit. Med. Jour. _ 1900, vol. Ii. P. 668. CHAPTER IV INJURIES TO THE BLOOD VESSELS The small calibre of the modern bullet, and its tendency to take adirect course, naturally favour the occurrence of more or lessuncomplicated wounds of the large vascular trunks, and both the natureof these wounds and the results which follow them are in some respectsmost characteristic. NATURE OF THE LESIONS 1. _Contusion or laceration without perforation. _--(_a_)The vessel maybe struck laterally, the injured portion then forming a part of thebounding wall of the wound track, or (_b_) one or more layers of thevessel wall may be destroyed over a limited area. Given primary union, these conditions are only of importance in so far as subsequentcontraction of the lumen of the vessel may result from implication inthe neighbouring cicatrix. One of the most striking features of thewounds as a whole was seen in the hair-breadth escapes of the large limbvessels with no subsequent ill effects, and such injuries were seen inevery situation. In a certain proportion of wounds in close proximity to large vessels, however, a diminution of the normal calibre of the arteries wasobserved, either shortly after the injury or later in the advancedstages of cicatrisation. As an example of early obstruction, thefollowing may be related. A Mauser bullet passed from the inner side ofthe thigh across the neck and great trochanter of the femur beneath thefemoral vessels, and probably struck and grooved the bone, since theaperture of exit was large and irregular, some 3/4 of an inch indiameter. One week later no pulse was palpable in either anterior orposterior tibial arteries at the ankle, and pulsation which was strongin the common femoral artery was very weak in the superficial femoral. Slight fulness existed in the hollow of Scarpa's triangle, but notsufficient to make any serious difference in the contour of the twolimbs. No thrill or abnormal murmur was discoverable. There was nooedema of the limb, which was also normal in temperature. The patientwas kept at rest in the supine position for three weeks, during whichtime the tibial pulses gradually returned. Three weeks later he wasinvalided home, the pulses, however, still remaining considerablysmaller than normal. In the advanced stages of cicatrisation narrowing of the lumen of thetrunk vessels was far from uncommon, especially in cases of wounds ofthe arm crossing the course of the brachial artery; in many of these theradial pulse was diminished almost to imperceptibility. How far thiscondition may prove permanent there has been little opportunity ofjudging; nor as to the possible ultimate weakening of the vessel walland the development of a secondary aneurism has time allowed theacquisition of experience. In the light of the observation of so manycases in which large vessels were wounded without the occurrence ofsevere hæmorrhage, either primary or secondary, it is impossible to becertain whether some of the cases of arterial obstruction were notsecondary to perforating lesions of the vessels. Pressure on, or minor lesion of the vessel was sometimes evidenced bythe development of a murmur, as in the following case. A Mauser bulletentered immediately within and below the left coracoid process, andemerged at the back of the arm at its inner margin, 2-1/2 inches abovethe junction of the right posterior axillary fold. During the first weekdysphagia and some pain and soreness in the episternal notch, with painand difficulty of respiration, were noticed. Eight weeks later notrouble with the pharynx or oesophagus remained, but a short sharpsystolic murmur was audible over the first part of the left axillaryartery, which could be extinguished by pressure on the subclavian; theradial pulse was normal. [14] When primary union failed or was prevented by infection andsuppuration, lesions, although incomplete, of the vessel coat naturallyfrequently gave rise to secondary hæmorrhage. 2. _Perforation of the vessels. _--(_a_) This may be oblique ortransverse to the long axis of a trunk; when the vessel is impinged uponlaterally, an oval or circular notch, as the case may be, is produced;or (_b_) the bullet may strike more or less in the centre of the vessel, perforating both in front and behind, while lateral continuity ismaintained; (_c_) beyond these degrees a vessel may, of course, becompletely divided. Cases of notching of the vessel will be referred tounder the heading of traumatic aneurism; those of perforation under thatof aneurismal varix and varicose aneurism, the perforations in thesecases affecting a parallel artery and vein. RESULTS OF INJURY TO THE VESSELS 1. _Hæmorrhage. _--The fact that hæmorrhage was not a prominent featurein the wounds received during this campaign can scarcely be regarded asan experience confined to injuries caused by bullets of small calibre. The same observation was often made in the case of larger bullets in olddays, and the absence of severe hæmorrhage has previously been regardedas a special characteristic of gunshot wounds. None the less, as high aproportion as 50 per cent. Of deaths occurring on the field in earlierdays has been ascribed to this cause. Unfortunately no new facts can be furnished on this point, although afew cases of rapid death from primary hæmorrhage will be found recountedunder the heading of visceral injuries. Beyond these the generalevidence offered by observations on men brought in from the field withvascular injuries, was opposed to the frequent occurrence of death fromhæmorrhage, at any rate of an external nature. This subject will bedealt with under the classical three headings of primary, recurrent, andsecondary hæmorrhage. _Primary hæmorrhage. _--A marked distinction needs to be drawn betweenexternal and internal hæmorrhage. External hæmorrhage from the greatvessels of the limbs, or even of the neck, proved responsible for aremarkably small proportion of the deaths on the battlefield. Thisstatement may be made with confidence, since it is not only my ownexperience, but coincides with what I was able to glean from manymedical officers with the Field bearer companies. It is, moreover, supported by the facts that cases in which primary ligature had beenresorted to were extremely rare at the Base hospitals, while, on theother hand, traumatic aneurisms and aneurismal varices of any one of thegreat trunks of the neck and limbs were comparatively common. Again, primary amputation for small-calibre bullet wounds, except whencomplicated by severe injury to the bones, was so rare as to render morethan doubtful the frequent occurrence of severe primary hæmorrhage onthe field. Only one case of rapid death due to bleeding from a limbartery was recounted to me. In this a wound of the first part of theaxillary artery proved fatal in the twenty minutes occupied by theremoval of the patient to the dressing station. The amount of hæmorrhagein many instances was no doubt checked by the application of pressure atthe time of the first field dressing; but it can scarcely be argued thatsuch dressings as were applied were of sufficient firmness to controlbleeding from such trunks as the brachial, femoral, or carotid arteries. The spontaneous cessation of hæmorrhage is rather to be ascribed to thespecial method of production and the consequent nature of the wound. Thelesions were the result of immense force strictly localised in itsapplication, which might well induce very complete and rapid contractionof the vessel wall; while the track in the soft parts was not onlynarrow, but also lined by a thin layer of tissue possibly so devitalisedsuperficially as to specially favour rapid coagulation of the blood. Beyond this the tracks were often sinuous when the position of the limbat the time of reception of the injury was replaced by one of rest. Theinfluence of mere narrowness of the track is illustrated by classicalexperience in the development of aneurismal varices after stabs byknives or bayonets; and in the injuries under consideration the frequentdevelopment of large interstitial hæmorrhages into the tissues of thelimbs indicated that blood does not readily travel along the woundtrack. It was noteworthy that when hæmorrhage did occur it was most freefrom, or often limited to, the wound of exit. This is due to thedirection of the active current set up by the rush of the bullet throughthe tissues. The mechanical factor is, no doubt, the most important. Control of primary hæmorrhage from a wounded vessel by the impaction ofa foreign body was of much less frequent occurrence than appears to havebeen the case with the older bullets. I saw a case in which, on removalof a fragment of shell (Mr. S. W. F. Richardson), very free hæmorrhageoccurred from a wound of one of the circumflex arteries of the thigh, but not a single one in which a similar result followed the extractionof a bullet of small calibre. The comparative infrequency of retentionof modern bullets is probably one of the main elements in this relation. A very curious instance of provisional plugging of a wound in the upperpart of the brachial artery by an inserted loop of the musculo-spiralnerve was related to me by Mr. Clinton Dent. This instance must, Ithink, be regarded as an accident definitely dependent on the size andoutline of the bullet and on the nature of the force transmitted by itto neighbouring structures. While, however, deaths from external primary hæmorrhage were rare, aconsiderable number resulted from primary internal hæmorrhage. In someof these, injury to the largest trunks in the thorax or abdomen led toan immediately fatal issue; in others wounds of the large visceralarteries, as of the lungs, liver, or mesentery, were scarcely less rapidin their results. In such cases the potential space offered by theperitoneal or pleural cavities favours the ready escape of blood fromthe wounded vessel, while the tendency of the blood effused into serouscavities to rapid coagulation is notably slight. Beyond this thecomparative deficiency in direct support afforded by surroundingstructures to vessels running in the large body cavities is also animportant element in their behaviour when wounded. These remarks receive support from the observation that few, if any, patients survived an injury to the external iliac vessels within theabdomen, while the remarkable instances of escape from fatal hæmorrhagefrom large vessels recorded below (cases 1-19) indicate that the meresize of a wounded vessel is not to be regarded as the sole factor inprognosis. _Recurrent hæmorrhage_ was occasionally met with both in the case of thelimb and trunk vessels. In the limbs it often necessitated ligature ofthe artery. I saw several cases in the lower extremity where recurrenthæmorrhage on the second or third day was treated by ligature of thefemoral or popliteal artery, and it also occurred during the course ofdevelopment of one of the carotid aneurisms recounted below. On twooccasions I saw rapid death follow recurrent abdominal hæmorrhage; inone I was standing in a tent when a man who had been wounded the daybefore suddenly exclaimed: 'Why, I am going to die after all. ' Theappearance of the man was ghastly, and on examining the abdomen it wasfound greatly distended, and with dulness in the flanks; the patientexpired a few minutes later. Another example of recurrent abdominalhæmorrhage is related in case 169, p. 432. _Secondary hæmorrhage. _--In simple wounds of the soft parts by_small-calibre bullets_ this was decidedly rare. In wounds complicatedby fractures of the bones, especially when they exhibited the so-called'explosive' character, secondary hæmorrhage was not uncommon, and thisnot necessarily in conjunction with infection and suppuration. In the chapter on fracture some remarks will be found on theprolongation of healing often observed in the exit portion of the woundtrack, which is explained by the well-known fact that, given an asepticcondition of the wound, sloughs of tissue separate very slowly. Secondary hæmorrhage in these cases is due to lesions of the vesselshort of perforation, but severe enough to so lower the vitality thatlocal gangrene of the wall occurs. In such instances hæmorrhage mostusually occurred on the tenth to the fourteenth day, but occasionallystill later. In one instance of ligature of the anterior tibial arteryfor such hæmorrhage three-quarters of the whole lumen of the vessel hadbeen devitalised. The resemblance of some cases of secondary hæmorrhageof this class to those occasionally observed after amputation, and dueto accidental non-perforative injury of the artery at the time ofoperation above the point of ligature, was very striking. In other cases secondary hæmorrhage was the result of perforation of thevessel by a sharp spicule of bone, but in the large majority sepsis andsuppuration were the cause. Naturally therefore the accident wascommoner in the more severe kinds of wound, and in those caused by_large_ bullets or fragments of shell. The symptoms in nearly all caseswere the classical ones of repeated small hæmorrhages followed by asudden copious gush. The forms of secondary hæmorrhage, however, which afforded most interestwere the interstitial and the internal, mainly on account of the scopethey allowed for diagnosis. Characteristic examples of internal secondary hæmorrhage are furnishedby cases of chest injury accompanied by hæmothorax and fully dealt withunder that heading (Chapter X. ). Cases of interstitial secondaryhæmorrhage are also described under the heading of traumatic aneurismand abdominal injuries (No. 194, p. 445). It therefore suffices heremerely to remark on the diagnostic difficulties the condition gave riseto. These mainly depended upon the elevation of general bodilytemperature by which the hæmorrhage was often accompanied. Furtherevidence of the condition was furnished by the development of localswellings, or physical signs indicative of the collection of fluid in aserous cavity. These signs developed rapidly, and the rise oftemperature was sudden and decided enough to suggest commencingsuppuration. In several cases incisions were made under the suppositionthat this had already occurred. The fever accompanying blood effusions was generally a somewhat specialfeature in the wounds of the campaign. At first bearing in mind that inevery case a track, even if closed, led from the surface to the effusedblood, one was disposed to suspect an infection of the clot of asomewhat innocuous nature. The absence of subsequent suppuration, however, was definitely opposed to this view, and suggested that thefever resulted from absorption of some element of the blood, possiblythe fibrin ferment, or some form of albumose. A pronounced illustrationwas in fact afforded of the evanescent rise of temperature usually theaccompaniment of simple fractures in the case of the limbs, and of themore marked rise not uncommon in cases of traumatic blood effusion intothe peritoneal cavity, or when the pleuræ or joints were the seats ofthe mischief. In the case of interstitial hæmorrhages I only remember tohave seen fever of such marked continued type in the subjects ofhæmophilia with recent effusions, although one is of course acquaintedwith it in a less pronounced form as a result of hæmorrhage intooperation wounds. In primary interstitial hæmorrhages a similar continued rise oftemperature was also common, and I cannot perhaps better illustrate itscharacter than by the brief relation of two instances. In a patient wounded at Kamelfontein the bullet entered four inchesbelow the acromion, pierced the deltoid, splintered the humerus, andcrossed the axilla. A large blood extravasation developed in the axilla, accompanied by cutaneous ecchymosis extending halfway down the arm. There was no perceptible pulsation in either the brachial or radialartery, but the limb was warm. There was partial paralysis of the partssupplied by the ulnar and musculo-spiral nerves and complete loss ofpower and sensation in the area of distribution of the median nerve. Sixmonths later the radial pulse was still absent in this patient, butthere was no sign of the development of an aneurism. [Illustration: TEMPERATURE CHART 1. --Axillary Hæmatoma. Shows range oftemperature during process of absorption and consolidation withoutsuppuration] The accompanying temperature chart is characteristic. The bloodeffusion gradually gained in consistency and underwent steady diminutionin size. No suppuration occurred. The median paralysis was found to be accompanied by the inclusion of thenerve in a sort of foramen of callus, when the patient was explored at alater date by Mr. Ballance. In a patient wounded at Paardeberg, a Mauser bullet entered by the leftbuttock, pierced the venter ilii, traversed the pelvis, and emerging atthe brim of the latter, crossed the back, fractured the spine of thefourth lumbar vertebra, and escaped below the twelfth right rib. Thetrack suppurated where it crossed the back, but the man did well untilthe twentieth day, when a swelling developed in the left iliac fossa andthe general temperature rose to 102°. An abscess was at once suspectedand the swelling incised by Major Lougheed, R. A. M. C. A largesubperitoneal hæmatoma only was discovered, and evacuated. Thetemperature at once fell and the after progress was uneventful, thewound healing by primary union. TREATMENT OF HÆMORRHAGE _Primary. _--No deviation from the ordinary rules of surgery should benecessary in the majority of cases, but in a certain number theconditions are so unusual that the special considerations must be takeninto account. The natural tendency to spontaneous cessation of primaryhæmorrhage in small-calibre wounds is the first of these. Experience hasshown that often mere dressing, or at any rate slight pressure, sufficesto efficiently stanch immediate bleeding. Although, however, immediatecontrol is to be obtained by such means, the cases of traumatic aneurismof every variety related in the next section show that the ultimateresult is in many such cases by no means satisfactory. Under these circumstances it may be said that the classical rule ofligation at the point of injury should never be disregarded. Againstthis, however, certain objections may be at once raised; thus in manycases both artery and vein need ligature, a consideration of muchimportance in the case of such vessels as the carotid and femoralarteries. Again in many of the injuries to the popliteal artery thewound directly communicated with the knee joint, a complication which, while it may be disregarded in civil practice, must take a much moreimportant place in the circumstances under which many operations inmilitary surgery are performed. On the whole, it seems clear that the military surgeon must be guided bycircumstances, since it may be far better to risk the chances ofrecurrent hæmorrhage, or the development of an aneurism or varix, all ofwhich are amenable to successful treatment later, than those of gangreneof a limb or softening of the brain. As a general rule, therefore, onthe field or in a Field hospital, primary ligature of the great vesselsis best reserved for those cases only in which hæmorrhage persists, while in those in which spontaneous cessation has occurred, or in whichbleeding is readily controlled by pressure, rest and an expectantattitude are to be preferred. A word must be added as to the objections to distant proximal ligaturefor primary or recurrent hæmorrhage. In some situations this may beunavoidable, and it is sometimes successful, but none the less it isopposed to all rules of good surgery and a most uncertain procedure. Itleaves the patient exposed to all the risks attendant on the employmentof simple pressure. In one case which I saw, the third part of thesubclavian artery had been ligatured for axillary bleeding; secondaryhæmorrhage, as might have been expected, occurred, and that as late asfive weeks after the operation. In another case ligature of the femoralartery for popliteal hæmorrhage was followed by the development of atraumatic aneurism in the ham. _Secondary. _--In secondary hæmorrhage the treatment to be adopteddepends upon the nature of the case. When the wound is aseptic, andbleeding the result of the separation of sloughs, local ligature is theproper treatment, and this was often successfully adopted, especially inthe case of such arteries as the tibials. In septic cases, on the otherhand, it is usually far better if possible to amputate, unless thegeneral state of the patient and the local conditions are especiallyfavourable. When neither amputation nor direct local ligature is practicable, proximal ligature may be of use. Sometimes this may be obligatory inconsequence of the difficulties attendant on direct local treatment. Isaw a few cases successfully treated in this manner: in one the commoncarotid was tied (Mr. Jameson) for hæmorrhage from an arterial hæmatomain connection with the internal maxillary artery. Although ligature ofthe external carotid would perhaps have been preferable, the result wasexcellent. When even this expedient is impracticable, local pressure isthe only resort. Lastly, as to the treatment of secondary interstitial blood effusions, Ibelieve the best initial treatment is the expectant. If interference isneeded, it is much more likely to be satisfactory the more chronic thecondition has become, since the source of the bleeding may be impossibleto discover. I never saw a patient's life endangered by the amount ofsuch hæmorrhage, but if this should seem to be likely, local treatmentis of course unavoidable. In several cases quoted below, incision andevacuation were followed by excellent results; in any such operation toomuch care to ensure asepsis is impossible. TRAUMATIC ANEURISMS The experience of the campaign fully bears out that of the past as tothe steady increase of the number of aneurisms from gunshot wounds indirect ratio to diminution in the size of the projectiles employed. Every variety of traumatic aneurism was met with, and most frequently ofall, perhaps, aneurismal varices and varicose aneurisms. While soexperienced a military surgeon as Pirogoff could say, in 1864, that hehad never seen a case of aneurismal varix, every young surgeon lately inSouth Africa has met with a series. Again, although the condition is awell-known one, it has been rather in connection with civil life; forthe great majority of recorded cases were the result of stabs orpunctured wounds such as are liable to be received in street brawls, oras a result of accidents with the tools of mechanics. Thus of ninetycases collected by K. Bardeleben in 1871, only 12 or 13. 33 per cent. Were the result of gunshot wound. _False traumatic aneurism or arterial hæmatoma. _--This condition was metwith comparatively frequently, and bears a very close relation to thatalready described under the heading of interstitial hæmorrhages. Thelatter might almost have been included here, since the differencebetween the two conditions depended merely on the size of the vesselsimplicated. The exact correspondence in the period of development ofsome of the arterial hæmatomata, and of the occurrence of the asepticform of secondary hæmorrhage, also explains the pathology of the twoconditions as identical; except that in the former the effused blood isretained in the tissues, while in the latter it escapes externally. Thehistory of these cases was uniform and characteristic. A wound of thesoft parts, or sometimes a fracture, was accompanied by a certain degreeof primary interstitial hæmorrhage, which might or might not have beenassociated with external bleeding. A hæmatoma resulted in connectionwith the wounded vessel, the general tendency in the effusion being tocoagulation at the margins and subsequent contraction. Meanwhile theopening in the artery became more or less securely closed by thedevelopment of thrombus, and possibly by retraction of the inner andmiddle coats of the vessel. With the return of full circulatory force asshock passed off, or with the resumption of activity and consequentfreer movement of the limb, the temporary thrombus became washed away. The newly formed wall of soft clot bounding the effusion provedinsufficient to withstand the full force of the blood pressure, andextension of the cavity resulted. In the more rapidly developinghæmatomata, temporary pressure by the effused blood on the bleedingvessels was also, no doubt, a common explanation of temporary cessationof increase in size. A diffuse soft fluctuating swelling, sometimes accompanied by pulsation, but oftener without, developed, and not uncommonly diffusion wasaccompanied by some discoloration of the surface and elevation of thegeneral temperature. Such arterial hæmatomata commonly developed fromten days to three weeks after the original wound. A few examples willsuffice. (1) A patient wounded at Elandslaagte was sent down to Wynberg. The antero-posterior wound in the upper third of the arm was healed, but a month after the injury a large fluctuating arterial hæmatoma developed in the axilla and upper third of the arm. This was incised (Colonel Stevenson) and a wound of the axillary artery in its third part discovered, and the vessel ligatured. The patient made an excellent recovery. (2) A patient received a wound at Doornkop which traversed the calf in an obliquely antero-posterior longitudinal direction. Three weeks later a soft fluctuating swelling developed at the inner margin of the tendo Achillis occupying the lower third of the leg. Neither pulsation nor murmur was detected. There was anæsthesia in the area of distribution of the posterior tibial nerve. No tendency to further increase was observed, and operation was postponed. The temperature was normal. (3) An Imperial Yeoman was struck at Zwartskopfontein at a range of one hundred yards. The man rode four miles on his horse after being hit, but the horse then fell and rolled over him twice. The man was treated successively in the Van Alen, Boshof, and Kimberley Hospitals, and from the last he was sent to Wynberg which place he reached on the twenty-third day. When admitted into No. 2 General Hospital the wounds of type form and size (_entry_, in posterior fold of axilla; _exit_, 1-1/2 inch below junction of anterior fold with arm) were healed. The whole upper arm was swollen and discoloured, while an indurated mass extended along the line of the vessels into the axilla. This was considered a blood effusion; it was not obviously distensile, and pulsation was very slight. The brachial radial and ulnar pulses were absent. A fluctuating swelling was present along the anterior border of the deltoid. There were some signs of nerve contusion, but no paralysis, beyond tactile anæsthesia in the area of distribution of the median nerve. Four days later little alteration had been noticed beyond a tendency to variation in firmness of the different parts of the swelling. On the thirty-first day considerable enlargement was observed. This enlargement, together with continued rise of temperature, aroused the suspicion of suppuration, and an exploratory puncture with a von Graefe's knife was made by Major Lougheed, R. A. M. C. , after consultation with Professor Chiene. Blood clot first escaped, followed by free arterial hæmorrhage. The incision was enlarged while compression of the third part of the subclavian was maintained; a large quantity of clot was turned out, and an obliquely oval wound half an inch in long diameter was found in the axillary artery. Ligatures were applied above and below the opening between the converging heads of the median nerve. The veins were not damaged. The wound healed by first intention. On the twelfth day a feeble radial pulse was perceptible, and shortly afterwards the man left for England, diminished median tactile sensation being the only remnant of the original symptoms. (4) A private of the 2nd Rifle Brigade was struck while doubling at Geluk, at a range of one hundred yards. The Mauser bullet entered four inches above the upper border of the left patella, internal to the mid line of the limb, and escaped in the centre of the popliteal space. The man lay in a farmhouse during the night and bled considerably from both wounds. He did not fall when struck, but could not walk. He was sent to No. 2 General Hospital in Pretoria. On arrival there the external wounds were scabbed over, and a large tumour existed beneath the entrance wound. There was much discoloration from ecchymosis, but no pulsation could be detected. The posterior tibial pulse was good. At the end of ten days pulsation became marked both in the front of the limb and in the popliteal space. There were no symptoms of nerve injury. On the thirteenth day an Esmarch's bandage was applied and Major Lougheed laid the tumour open opposite the opening in the adductor magnus. Much clot was removed, and both artery and vein, which were found divided in the adductor canal, were ligatured. The foot remained very cold for the first twenty-four hours, but otherwise progress was satisfactory, the wound healing by first intention. No pulsation was palpable in the tibials at the end of a month. For the last two cases I am very much indebted to Major Lougheed. I amglad to include them, as they illustrate one or two points of specialimportance. No. 3 shows the tendency to variation in the tension andfirmness of the tumours, the tendency to primary contraction of the sac, followed by diffusion, and the rise of temperature often accompanyingthe latter occurrence. This is of great interest in relation to thesimilar rise of temperature seen with the increase of hæmorrhage incases of hæmothorax. For purposes of comparison, the progress may wellbe considered alongside of that in the case related on p. 119, in whichthe wounded vessel was probably also the main trunk itself. No. 4 differs from any of the others in depending on a complete divisionof a large artery and vein. The development of the hæmatoma wasconsequently more rapid and continuous. Another point of interest wasthe maintenance of pulsation in the tibial vessels, in spite of completesolution of continuity in the parent trunk. That this was independent ofthe collateral circulation seems evident from its complete disappearanceand slowness of return after ligation of the wounded vessels. _Prognosis and treatment. _--The treatment in these cases is sufficientlyobvious, and consists in direct incision and ligature of the woundedvessels. The cases related show the success with which this procedurewas attended, since uniformly good results were obtained. When possible, an Esmarch's tourniquet should be applied in the case of the lower limb. In the upper, compression of the subclavian is necessary duringinterference with axillary hæmatomata, combined with direct pressure onthe bleeding spot after the clot has been removed. In the case of thearm, digital compression is always to be preferred, in view of thewell-known danger of damage to the brachial nerves from the tourniquet. Proximal ligature is always to be avoided. It is inadequate, and provedmore dangerous as far as the vitality of the limb was concerned, thelatter point probably depending on the interference with the collateralcirculation by pressure from the extravasated blood, which is unrelievedby the operation. I know of at least two cases of gangrene whichoccurred consecutively to proximal ligature of the femoral artery forthis condition. _True traumatic aneurisms. _--The cases met with differed so little fromthose seen in ordinary civil practice, that but slight notice of them isnecessary. They differed from the last variety mainly in the morelocalised nature of the tumour, the greater firmness of its walls, andthe more pronounced expansile pulsation. The development of this form ofaneurism was probably influenced by several circumstances, such as themore complete rest secured for the patient, the locality in the limb asaffecting movement of the spot in the vessel actually wounded, the sizeof the opening in the vessel, and the degree of support afforded bysurrounding structures. (Examples are furnished by cases 6-9. ) Under the influence of rest, all that I saw tended to contract andbecome firmer, and they so far resembled spontaneous aneurisms as to bereadily cured by proximal ligature of the artery. The ideal treatment nodoubt consists in local incision and ligature on either side of thewounded spot, with or without ablation of the sac. The choice of director proximal ligature in any case depends on the position of theaneurism, and the ease with which the former operation can be carriedout. In all these cases a very great advantage in the localisation anddiminution of the tumours was gained by postponing interference untilthey became stationary. I need scarcely add that any evidence ofdiffusion indicated immediate operation. The preference of direct orproximal ligation will probably, to a certain extent, always depend onthe personal predilection of the surgeon, but while proximal ligaturehas often given good immediate results during this campaign, it cannotbe with certainty decided whether the patients are definitely protectedfrom the dangers of recurrence. Reference to cases 7 and 9 as illustrating the possible spontaneous cureof traumatic aneurisms is of great interest. I saw a number of cases successfully treated by proximal ligature; alsoa number where continuous improvement followed rest, and which were senthome for further treatment. None of these demand any special mention. One case of a very special nature, which terminated fatally, is of greatinterest:-- (5) In a man wounded at Belmont the bullet entered the second left intercostal space and was retained in the thorax. He was sent directly to the Base and came under the care of Mr. Thornton at No. 1 General Hospital, Wynberg. Signs of wound of the lung developed in the form of hæmoptysis and left hæmothorax. The left radial pulse was almost imperceptible. The entry wound did not close by primary union, and three weeks later an incision was made into the chest in consequence of the presence of fever, progressive emaciation, and weakness. Breaking down blood clot was evacuated: general improvement followed, and the radial pulse increased considerably in volume. A fortnight later sudden severe hæmorrhage occurred from the external wound, and the man rapidly collapsed and died. At the post-mortem a traumatic aneurism the size of an orange was found in connection with an oval wound in the first portion of the left subclavian artery which admitted the tip of the forefinger. This case is noteworthy as an illustration of the magnitude of an arterywhich can be wounded without leading to rapid death from primaryhæmorrhage, even when in communication with a serous sac, and still moreas emphasising the importance of weakening of the radial pulse as a signin connection with a wound of the upper part of the chest on the leftside. It is somewhat surprising that this sign was not marked in twocases (Nos. 13 and 14, p. 140) recorded below, in which the innominateand right carotid arteries respectively were probably perforated. (6) _Traumatic popliteal aneurism. _--Wounded at Modder River. _Entry_ (Mauser), over centre of tibia 1 inch above the tubercle. _Exit_, about centre of popliteal space. No hæmorrhage of any importance occurred from the wound, but there was a typical hæmarthrosis, which subsided slowly. Twelve days after the injury a pulsating swelling the size of a hen's egg, to which attention was drawn on account of pain, was noted in popliteal space. The pulsation extended upwards in the line of the artery some 3 inches. The limb was placed on a splint and treated by rest, and a month later the aneurism had decreased to one half its former size, the wall having greatly increased in firmness. Pulsation was easily controlled by pressure above the tumour; there was no thrill present, but a high-pitched bellows murmur. The patient was sent home on February 1. When admitted at Netley the patient came under the care of Major Dick, R. A. M. C. , who ligatured the popliteal artery on the proximal side by anincision in the line of the tendon of the adductor magnus. The aneurismthen consolidated. (7) _Traumatic popliteal aneurism. _--Wounded at Magersfontein. _Entry_ (Mauser), centre of patella. _Exit_, centre of popliteal space; the knee was bent at the time it was struck. There was considerable primary external hæmorrhage, and so much blood collected in the knee-joint that it was aspirated. On the eighth day secondary hæmorrhage occurred from the exit wound and the femoral artery was tied in Hunter's canal. No further hæmorrhage occurred, but at the end of three weeks feeble pulsation was palpable in the popliteal space, suggesting an aneurism; the latter decreased and the patient was sent home apparently well. (8) _Traumatic axillary aneurism. _--Wounded at Karree. The bullet entered 2-1/2 inches below the acromial end of the right clavicle and emerged over the 9th rib in the posterior axillary line. The Mauser bullet was found in the patient's haversack. Both apertures were of the slit form, and healed per primam. Three weeks later at Wynberg a large arterial hæmatoma which pulsated was noted in the axilla. Signs of injury to the musculo-spiral nerve were also observed. The tumour altered little, but a fortnight later Major Burton, R. A. M. C. , cut down upon it through the pectorals. The aneurism was of the third part of the axillary artery, and a ligature was applied at the lower margin of the pectoralis minor. The wound healed by primary union and the aneurism rapidly shrank. The patient left for England a month later; the musculo-spiral paralysis was improving. I am indebted to Major Burton for the notes of this case. (9) _Traumatic popliteal aneurism. _--Wounded in Natal. _Entry_ (Mauser), immediately above head of fibula. _Exit_, immediately inside semi-tendinosus tendon at level of central popliteal crease. Fulness but no pulsation was noted at end of three weeks; seven days later pulsation was evident, and an aneurism the size of a pigeon's egg, with firm walls, became localised and palpable. It gave rise to no symptoms, and patient refused operation during the three weeks he remained in hospital. The aneurism continued to contract, and the patient was sent home. The aneurism has since spontaneously consolidated. _Aneurismal varix and varicose (arterio-venous)aneurism. _--Uncomplicated cases of aneurismal varix, as might beexpected, were less common than those in which the arterio-venouscommunication was accompanied by the formation of a traumatic sac. Theinitial lesion accountable for each condition was, however, probablyidentical, and dependent on the passage of a bullet of small calibreacross the line of large parallel arteries and veins. Thus, obliquelycoursing antero-posterior wounds of the neck produced carotid andjugular varices; vertically coursing tracks laid the subclavian vesselsin communication; antero-posterior tracks the brachial, popliteal, andlower part of the femoral; and transverse tracks, the vessels of thecalf and forearm. Given an arterial wound, the mode of development ofthe aneurismal sac in no way differs from that of the ordinarytraumatic variety; the main point of interest, therefore, is to seek anexplanation of the causes which may restrict the ultimate result to theformation of a pure aneurismal varix. The explanation is possibly to befound in some of the following circumstances. _Size, position, and symmetry of the vascular wound. _--It seems scarcelynecessary to insist on the calibre of the projectile, since this alonedetermined the frequency of these conditions, but it must be borne inmind that in the diameter of the bullets, classed as of small calibreduring this war, a range of from 6. 5-8 mm. Existed. In the case of boththe Krag-Jörgensen and Mauser, the shape of the bullet also was betteradapted to pure perforation of the vessels. I saw no case ofarterio-venous communication in which a larger bullet than one of thefour types chosen had been responsible for the primary injury, but adifference of 1-1/2 mm. In calibre in the small projectile might welldetermine the division, the pure and symmetrical perforation of the twovessels, or the giving way of one side, so that they were deeply notchedinstead of perforated. Such positive evidence as was afforded by operation as to the exactcondition of the vessels in two cases of femoral arterio-venous aneurismwas, that in either case a clean perforation existed. It is improbable that notching of the two vessels can primarily producea pure varix, although it may result in the formation of anarterio-venous aneurism, especially if the bullet should have passedbetween the two vessels in such a way as to notch the contiguous sides. It is impossible to say, in any given case, what the result of secondarycontraction of a sac produced in this manner may be in the determinationof the ultimate relation of the vessels. In many of the cases clinicallydesignated pure varix, the remains of such a sac may still actuallypersist. In the case also of pure perforation of the vessels, it isdifficult to believe that a localised blood cavity has not originallyexisted. Given complete division of the vessels, as far as my experiencewent, arterial hæmatoma was the uniform result. Under these circumstances I am inclined to believe that a symmetricalperforation of both vessels is the most common precursor of eithercondition; that the pure varix is the rarer and less likely result, andthat its formation is dependent mainly on certain anatomical conditions. The most important of these conditions are the proximity and degree ofcohesion of the two vessels, the comparative spaciousness or theopposite of the vascular cleft, and the degree of support afforded bysurrounding structures. Thus, the close proximity of the popliteal artery and vein, togetherwith the particularly firm adhesion which exists between the vessels, probably favours the formation of a varix; again, a varix more readilyforms if the femoral artery and vein are wounded in Hunter's canal thanif the injury is situated high in Scarpa's triangle, where the vesselslie in a large areolar space. The passage of a bullet between an arteryand vein may perhaps produce either condition, but wide separation ofthe two vessels, as for instance of the subclavian artery and vein, renders an aneurismal sac almost a certainty. These suggestions seemborne out by the cases recounted below, since the pure varices are onefemoral, one popliteal, and one axillary. I cannot include the calf andforearm cases, as the existence of a small sac could not be disproved. To these anatomical factors certain others must be added. In most casesa false sac exists at first, which tends to undergo contraction andspontaneous cure, as is observed in some of the ordinary traumatic sacs. This history of development is moreover supported by the observationthat proximal ligature of the artery usually converts an arterio-venousaneurism into an aneurismal varix. The process is no doubt favoured bycleanness and small size of the perforation, moderation in the amount ofprimary hæmorrhage, the tone and resistance of the surrounding tissues, special points in the circulatory force and condition of the blood, andthe possibility of maintaining the part at rest after the injury. Aneurismal varix, when pure, was evidenced by the presence of purringthrill and machinery murmur alone. In none of the cases I saw was painor swelling of the limb present. In one popliteal varix, slightvaricosity of the superficial veins of the leg was present, but it wasnot certain that the development of this was not antecedent to theinjury, as the patient did not notice it until his attention was drawnto its existence. In none of the cases under observation in South Africahad enough time elapsed for sufficient dilatation of the artery abovethe point of communication to give rise to any confusion from this causeas to the presence of a sac. When an arterio-venous sac has once formed, clinical observation showsthat the general tendency is towards extension in the direction of leastresistance. This direction of course varies with the situation of theaneurism, and also with the nature of the wound track. Speaking generally the direction of least resistance in a typically pureperforation is towards the vein. Initial flow of blood from the woundedartery is naturally favoured towards the potential space afforded by acanal occupied by blood flowing at a lower degree of pressure. Thepartial collapse of the vein dependent on the wound in its wall alsoprobably helps in determining the initial flow in its direction. Examples are afforded by the carotid aneurisms (cases 10, 11, and 14), and here it must be borne in mind that the outer limits of the cervicalvascular cleft are those least likely to offer resistance to extensionof the sac. In each the aneurisms mainly occupied the exit segment ofthe track; this is the general rule, as in the case of externalhæmorrhage, and is determined by the same cause. The latter rule however finds exceptions when the entry segment is sosituated as to cross a region of lesser resistance, and case 12illustrates this point with regard to the cervical vascular cleft. Examples of the tendency to spread in the anatomical direction of leastresistance are also offered by the cases of aneurism at the root of theneck, where extension was into the posterior triangle. The further clinical history and signs are as follows. A local swellingis found, usually at first diffuse, often commencing to develop withcessation of the external hæmorrhage. It increases, for the first fewdays maintaining its diffuse character. If near the surface, it may besuperficially ecchymosed. At the end of this time a tendency tolocalisation, as evidenced by increasing firmness and more definitemargination, takes place, and this is followed by general contractionand rounding off of the tumour. The latter process may be continuous, and eventually the sac may become small and stationary or ultimatelydisappear and a pure varix be the result. The latter is only likely tobe the case under the most satisfactory of the conditions enumeratedabove. Occasionally an opposite course may be followed, and freshextension take place, as evidenced by enlargement of the tumour, disappearance of sharp definition, softening, and pain. The naturaltermination of such cases in the absence of interference would no doubtbe rupture, and possibly death in some positions, loss of the limb inothers. The former I never saw. _Purring thrill. _--This, the pathognomonic sign of either condition, wasalways present in the fully developed stage, and is probably presentfrom the first unless a temporary thrombosis obstructs the vascularopenings. It was noted as early as the third day in case 13. In many ofthe other patients it was palpable only with the subsidence of theprimary swelling attendant on the injury. In some of the forearm andcalf aneurisms, and in some of the popliteal, it was only discovered byaccident some weeks even after the injury, but this often because noserious vascular lesion had been suspected. The thrill was widelyconducted, often apparently superficial on palpation, and much morepronounced with light than with forcible digital pressure. In case 10 the _visible_ vibration in consonance with the thrill whenthe vein was exposed during the operation of ligature of the carotid wasa novel experience to me. _Murmur. _--The typical 'bee in the bag, ' or 'machinery' murmur waspresent in every case, and was often very widely distributed, especiallyover the thorax. (Cases 13, 14, and 20. ) In all three carotid cases the murmur was troublesome, being audible tothe patient at night when the head was rested on the side correspondingto the aneurism. _Expansile pulsation. _--Pulsation in combination with the existence of atumour is the main feature in the diagnosis between the conditions ofpure varix and varicose aneurism. It was not always existent orprominent in the earliest stages, probably from temporary blocking ofthe artery, or from the diffuse and irregular nature of the cavityoffering conditions unsuitable to the satisfactory transmission of thewave. When localisation had occurred it was always present. EFFECTS OF ANEURISMAL VARIX OR VARICOSE ANEURISM ON THE CIRCULATION (_a_) _General. _--The most striking feature in these injuries is theremarkable effect of the disturbance to the even flow of the circulationon the heart. This first struck me in two of the cases of carotidarterio-venous aneurism recorded below (Nos. 10 and 11). In these I wasinclined at first to attribute the rapid and irritable character of thepulse solely to injury to the vagus, as in each laryngeal paralysispointed to concussion or contusion of the nerve. The pulse reached arate of 120-140 to the minute. This disturbance was not of a transitorynature, for in the two cases referred to the rapid pulse persists, inspite of entire recovery of the laryngeal muscles, and the fact that inone case the aneurismal sac has been absolutely cured, and in the secondonly a small sac remains, in each as a result of proximal ligature ofthe carotid artery. In the former a varix still exists, and at the endof seven months the pulse is still over 100. In the latter, in which asac is still present, the pulse rate varies from 110 to 130. In eachcase the condition has now existed twelve months. My attention oncedirected to this point, I noted a similar acceleration of the pulse inthe case of these aneurisms elsewhere; thus in a femoral aneurism therate was 120, and in an axillary varix of twenty years' standing whichcame under my observation the pulse rate varied from 110 to 120, according to the position of the patient. Unfortunately I had notdirected my attention to this point in the early series of cases whichcame under observation. It will be remarked in cases 13 and 14 that at the expiration of a yearthe pulse rate was still high, but these again are cervical aneurismseach in contact with or near the vagus. In a case of aneurismal varix of the femoral artery of three years'standing, which was under the charge of Mr. Mackellar, the pulse ratewas normal. In this instance great dilatation of the vessels hadoccurred. These observations raise the interesting question whether the irritablecirculation which has been classically considered one of thepredisposing causes of spontaneous aneurism should not rather beregarded as a result of the condition. (_b_) _Local. _--In none of the cases of varix was the period ofobservation long enough to allow me to determine the development ofdilatation of the arterial trunk above the point of obstruction. This, however, is the common sequence, and no doubt will occur in thosepatients who resume active occupation without operation. The effects of either condition on the distal circulation wereremarkably slight. The distal pulses were little, if at all, modified instrength or volume, and signs of venous obstruction, if present atfirst, disappeared with much rapidity. In one case (No. 15) of a largearterio-venous popliteal aneurism there was considerable swelling of theleg, but in this case the sac was large and situated at the apex of thespace, and no doubt exercised external pressure on the vein. In the case of the carotid aneurisms, especially that probably on theinternal carotid, transient faintness was a symptom in the early stagesof the case. All three of the cases recorded here, however, had been thesubjects of very free hæmorrhage, either primary or recurrent. (10) _Carotid arterio-venous aneurism. _--Wounded at Paardeberg. _Entry_ (Mauser) to the right side of the Pomum Adami, _exit_ at anterior margin of left trapezius, two inches below the angle of the jaw. There was some hæmorrhage at the time from the exit wound, but no hæmoptysis; about four hours later, however, in the Field hospital bleeding was so free that an incision was made with the object of tying the common carotid. During the preliminary stages of the operation bleeding ceased and the wound was closed without exposing the vessel. The patient remained a week in the Field hospital, and then made a three day and night's journey in a bullock waggon to Modder River (40 miles), and fourteen days later he was transferred to the Base hospital at Wynberg, when the condition was as follows. Operation and bullet wounds healed. Considerable extravasation of blood in the posterior triangle. Beneath the sterno-mastoid in the course of the bullet track, swelling, thrill and pulsation over an area 1-1/2 inch wide in diameter. Loud machinery murmur audible to the patient when the left side of the head is placed on the pillow, and widely distributed on auscultation. The left eye appears prominent, but the pupils are normal and equal in size. Voice weak and husky, and there is cough. Laryngoscopic examination showed the cords to be untouched, but some swelling still persisted. No headache, but giddiness is troublesome at times. Pulse 100, regular but somewhat irritable. The patient was kept quiet in the supine position for a month, and during this time the condition in many ways improved. The voice improved in strength, the pulse steadied, falling to 80, the prominence of the left eye disappeared, and all the blood effusion in the posterior triangle became absorbed. Meanwhile the aneurism contracted at first, until it became oval in outline, with a long axis of 2 inches by 1-1/2 broad extending in the line of the wound track, but mainly situated in the exit half. During the last fortnight, however, it remained quite stationary in size, and as it showed no further signs of diminution in spite of the favourable conditions under which the patient had been placed, it was considered best to try to ensure its consolidation by a proximal ligature. Thrill had become slightly less pronounced, and was less evident to the patient himself, but was otherwise unchanged. The probabilities in this case seemed rather in favour of wound of the internal carotid artery, and it was decided to bare the upper part of the common carotid, follow up the main trunk, and if possible apply the ligature to the internal branch. On April 12, 61 days after the injury, the classical incision for securing the common carotid was made, and the sterno-mastoid slightly retracted. It was found that the sac of the aneurism extended over the bifurcation of the artery, reaching to the wall of the larynx. The omo-hyoid muscle was therefore divided, and the artery ligatured beneath, in order to ensure against any interference with the sac. Some difficulty was met with, for on opening the vascular cleft the vein was exposed and found to completely overlie the artery: although it was on the left side of the neck, the position of the vein was so completely superficial that there seemed no doubt that it had been displaced by the development of the aneurismal sac. A striking appearance was noted on exposure of the vein, the coats of which vibrated visibly, quivering in exact consonance with the palpable thrill. On tightening the silk ligature all pulsation ceased in the aneurism, and the vibratory thrill in the vein became much lessened. The patient made a good recovery, only disturbed by a slight attack of vomiting, and at the end of a week the wound had healed, and pulsation in the aneurism had completely ceased. The thrill persisted as before. Six months later, a small sac still exists beneath the sterno-mastoid. The pulse still reaches 110-120 in pace. The purring thrill is veryslight. The condition gives rise to little or no trouble. Pulsation isstrong in the external carotid artery, there is little in the commoncarotid. The voice is strong and good. This aneurism is either at thebifurcation of the common carotid, or on the immediate commencement ofthe internal carotid. Ligature of the external carotid will probablycure it. (11) _Arterio-venous aneurism, probably affecting both carotids. _ Wounded at Paardeberg. _Entry_ (Mauser), at dimple of chin immediately below mandibular symphysis. _Exit_, at margin of right trapezius, the track crossing the carotids about the level of normal bifurcation. The patient was lying on his back with the head down when struck. Some hæmorrhage from the exit wound occurred at the time, and later on the way to Jacobsdal this was so profuse as to be nearly fatal. A considerable hæmorrhage also occurred on the tenth day. The patient made the journey to Modder River safely, and was then under the charge of Mr. Cheatle. A large diffuse pulsating swelling developed on the right side of the neck, with well-marked thrill and machinery murmur. During the next three weeks the swelling steadily contracted, and the patient was sent down to the Base one month after receiving the wound, when the condition was as follows. There is no evidence of any fracture of the jaw. On the right side of the neck a large aneurism fills the carotid triangle, extending from the mid-line backwards to the margin of the trapezius, and from the level of the top of the larynx upwards to the margin of the mandible. The wall is fairly firm, pulsation is both visible and palpable, and a well-marked thrill and machinery murmur are present. The latter annoys him by its buzzing when the head rests on the right side. The pupils are equal. Pulse somewhat irritable, about 100. The voice is weak and husky, and there is difficulty in swallowing solids. The actual swelling is somewhat remarkable in outline, on the one hand following up the course of the external carotid and facial arteries, and on the other extending backwards in the line of the wound track towards the exit. The patient was kept on his back with sandbags around the head during the next fortnight. For the first eight days such change as occurred was in the direction of localisation and contraction, but during the last six, evident extension occurred both backwards and downwards; this extension was accompanied by severe pain in the cutaneous cervical nerve area of the neck. The larynx became pushed over 3/4 of an inch to the left of the median line, and the extension beneath the sterno-mastoid downwards raised a doubt as to whether the common carotid could be exposed without encroaching on the walls of the sac. Owing to indisposition I had not been able to see the patient for some days, but now, after consultation with Major Simpson and Mr. Watson, it was decided that the best plan would be to expose and tie the common carotid as high as could be safely done. The operation was performed six weeks after the injury, and somewhat to our surprise offered little difficulty. The carotid was exposed at the upper border of the omo-hyoid, only a small amount of infiltration having occurred in the vascular cleft. No dilatation of the jugular was noticeable, and when a silk ligature was applied to the artery all pulsation was controlled, and the thrill in the vein disappeared completely. The after progress was satisfactory, but four days later the wound was dressed, as the patient's temperature had risen above 100°. The tumour was consolidated: no pulsation could be felt, but there was little apparent diminution in its size. A loud blowing murmur was audible, especially at the posterior part of the swelling. On the morning of the fifth day the patient mentioned that he again heard the whirr during the night. There had been no sign of any cerebral disturbance and the pupils had remained equal throughout. A week after the operation the stitches were removed, there was evidence of some blood clot in the lower part of the wound, and this later liquefied and was let out on the eleventh day. At that time a slight bubbling thrill could be felt at the upper part of the tumour, also slight pulsation in the line of the external carotid and at the most posterior part of the sac. The latter was much contracted, diminished in size and apparently solid, so that it was hoped that such pulsation as existed was communicated. Ten months later, no trace of the aneurismal sac exists. Neck normal, except for purring thrill. Voice strong and good. Pulse 100. Following his usual work. (12) _Carotid arterio-venous aneurism_. --Wounded at Paardeberg. Aperture of _entry_ (Mauser), at the posterior border of the left sterno-mastoid, 1 inch above the clavicle; _exit_, near the posterior border of the right sterno-mastoid, 2 inches from the sterno-clavicular joint. The injury was followed by very free hæmorrhage, mainly from the wound of entry, some 'quarts' of blood escaping; at any rate his clothes were saturated. The voice was hoarse and weak, and there was much difficulty in swallowing; for the first twenty-four hours he could swallow nothing, but gradual improvement took place. The patient was carried two miles to the Field hospital, and three days later travelled 36-40 miles in a bullock waggon to Modder River. Thence he travelled to Orange River 55 miles by train on the next day. A swelling was first noted when the wound was dressed some seven days after the injury. No evidence was ever existent of gross damage to either trachea or oesophagus beyond the initial dysphagia. The hoarseness of voice due to left laryngeal paralysis slowly improved, and was probably the effect of concussion or contusion of the left recurrent laryngeal nerve. During the patient's stay at Orange River a large pulsating swelling with a strong thrill developed. This was at first diffuse, but under the influence of rest it steadily contracted and localised. During this period the patient was seen several times by Mr. Cheatle, who noted considerable temporary enlargement of the thyroid gland. At the end of eight weeks he had been allowed up some days, and travelled 570 miles to Wynberg. The aneurism was about 1-1/2 inch in diameter, smooth and rounded, extending just beneath the left clavicle and nearly the whole width of the sterno-mastoid, but well defined in all directions. There was well-marked expansile pulsation, purring thrill along the jugular vein and over the tumour, and loud machinery murmur widely diffused along the whole neck and into the thorax. The voice was still weak and husky, but there was no dysphagia or dyspnoea. The left pupil was larger than the right. The patient acquired enteric fever at Wynberg and when convalescent was sent to Netley, whence he returned home. The aneurism caused little discomfort. It may possibly have been of the inferior thyroid artery. (13) _Innominate arterio-venous varix_. --Wounded at Modder River. _Entry_ (Mauser) posterior margin of left sterno-mastoid, close above the clavicle. _Exit_ in anterior axillary line one inch below the right anterior axillary fold. Soon after the injury a considerable amount of blood was coughed up, and occasional hæmoptysis persisted for the next four days. The patient was moved from the Field hospital by train to Orange River, a journey of 55 miles and some four hours' duration, on the fourth day. When examined there was slight fulness over an area roughly circular and about 2-1/2 inches in extent, of which the sterno-clavicular joint lay just within the centre. Over this area there was faint pulsation with a strongly marked thrill and loud systolic bruit. The radial pulses were even, the right pupil larger than the left. No pain, and no dyspnoea. The right eye was partially closed, but could be opened by the levator palpebræ superioris. The patient was shortly afterwards sent to the Base, and when seen there twenty-five days after the injury, there was little change in the condition except that the fulness had disappeared, the thrill was more marked, and a typical machinery murmur transmitted along both carotid and subclavian arteries had developed. There was no headache and the man himself did not notice the bruit. Evidence of mediastinal hæmorrhage existed in the presence of subcutaneous discoloration of the abdominal wall, below the ensiform cartilage and extending slightly over the costal margin of the thorax. In the absence of an aneurismal swelling, or of the development of any further symptoms, the patient was sent home to Netley in January. I saw this patient in Glasgow a year later. He was employed as alamplighter, and was able to do his work well, only complaining ofattacks of shortness of breath on exertion. He said these were apt tocome on each evening about 6 P. M. The pulse was 100 when the erectposition was maintained, and 84 to 88 in the sitting posture. The rightpupil was still dilated, reacting for accommodation but little to light. The palpebral fissure was normal in size and there was little, if any, diminution in strength of the right radial pulse. On inspection no pulsation was visible; in fact, the pulsation of thenormal left subclavian was more apparent in the posterior triangle ofthat side. The sterno-mastoid was prominent, also the sternal third ofthe clavicle. On firm pressure some pulsation was palpable beneath thesterno-mastoid, but no definite evidence of the presence of a sac couldbe detected. Purring thrill and machinery murmur were still present, butthe former was slight, and palpable only with the lightest pressure. Themachinery murmur had ceased to be audible to himself, and was by nomeans loud or very widely distributed. The condition had, in fact, steadily improved, and become far lessobvious. The prominence of the sterno-mastoid and clavicle still presentwas difficult of explanation, except on the theory of an injury to thebone, or that an aneurismal sac had consolidated spontaneously. (14) _Arterio-venous aneurism, root of right carotid. _--Wounded at Magersfontein. _Entry_ (Mauser), centre of right infra-spinous fossa. _Exit_, 3/4 of an inch above clavicle, through point of junction of the heads of the right sterno-mastoid muscle. Range 200-300 yards. When wounded the man ran two hundred yards to seek cover. There was no serious external hæmorrhage, but the injury was followed by some difficulty in swallowing, and hæmoptysis, which lasted for the first two days. The right radial pulse was noted to be smaller than the left, and weakness in flexion of the fingers, with hyperæsthesia in the ulnar nerve distribution, was observed. The right pupil was also noted to be larger than the left. The patient was sent down to the Base, and on the twenty-fourth day the condition was as follows. A pulsating swelling existed extending 1-1/4 inch upwards beneath the right sterno-mastoid, from the mid line of the neck backwards to the centre of the posterior triangle, and downwards over 2 inches of the first intercostal space, which latter was dull on percussion. There was some evidence of a bounding wall, but it was thin and the tumour was soft and yielding. A loud machinery murmur was audible over the tumour, over nearly the whole extent of the thorax, and in the distal vessels as far as the temporal upwards, and the brachial as far down as the bend of the elbow. The murmur was audible to the patient with his ears closed. Over the swelling a strong thrill was palpable; this extended some little distance into the distal vessels and felt remarkably superficial. It was particularly evident in the line and course of the anterior jugular vein, and appeared to be extinguished by local pressure. Although readily felt in the posterior triangle, it was impalpable on deep pressure in the suprasternal notch, a fact which seemed in favour of localising the aneurismal varix to the subclavian artery and vein. The right pulse was good, although smaller than the left, and was said to have improved in volume. The right pupil was slightly larger than the left, but reacted normally. There was no pain or difficulty in swallowing. Weakness in power of flexion of the fingers persisted, and there was some impairment of sensation in the area of distribution of the ulnar nerve. Three weeks later no material change had occurred, except that the swelling was perhaps softer and the thrill more superficial, and at the end of two months the patient was sent to England. I saw this patient a year later in Glasgow, when the condition was asfollows. He was living at home, and out of employment. He complained ofshortness of breath on exertion, and said that when he mounted stairs hefelt 'as if his heart were going to leave him. ' The heart's apex beat inthe sixth interspace in the nipple line, and the precordial dulness wassomewhat increased. The pulse numbered 80 to 84. The muscles supplied bythe ulnar nerve were very weak, but not much wasted, and ulnar sensationwas imperfect. The aneurism had considerably altered in form and outline; its wallswere dense and firm; it extended 2-1/2 inches upwards in the line of thecarotid artery, beneath the sterno-mastoid, but projected beyond theposterior border of that muscle. The larynx was displaced 1/2 an inch tothe left of the median line; the voice was still husky, although muchstronger than it was; the anterior jugular vein was dilated. The purringthrill was very superficial, and chiefly palpable over the subclavianvessels. The machinery murmur was still loud, but much less widelydistributed than before; it was still audible to the patient when he layon his right side. This case was of much interest from the diagnostic point of view. When Ifirst saw the patient I considered the injury to have implicated theinnominate vessels. Later, from the facts that the thrill wasimperceptible in the episternal notch, and that the main part of thetumour was situated in the posterior triangle, that the wound was of theroot of the right subclavian vessels. It now appears that, at any rate, the root of the right carotid is theartery implicated. In spite of the continued existence of a large aneurism, thelocalisation of the sac, which had taken place, was very striking, considering that the man had been walking about freely, and living anordinary life, except that he had undertaken no work. (15) _Popliteal arterio-venous aneurism_. --Wounded at Paardeberg. _Entry_ (Mauser), at lower margin of patella. _Exit_, at centre of back of thigh. Perforation of lower end of femur. The patient was lying down with crossed knees when the injury was received. Much oedema of the foot and leg followed the injury, and on the third day a thrill was discovered. Three weeks later there was still some swelling of the calf, the posterior tibial pulse was imperceptible, the anterior very small. An aneurism was palpable at the inner part of the top of the popliteal space, about the size of a pigeon's egg; a strong thrill was to be felt, especially when the knee was flexed, and with this expansile pulsation and a loud machinery murmur. The entry wound was firmly healed; the exit still furnished blood-stained serous discharge. The synovial cavity of the knee was distended and doughy on palpation. During the next three weeks the aneurism contracted considerably and the patient was sent home. When admitted to the Herbert Hospital the patient complained chiefly of pains in the foot and leg. The aneurism was cured by ligation of the vein above and below the communication and proximal ligature of the popliteal artery. [15] (16) '_Femoral arterio-venous aneurism. _--A private of the West Yorkshire Regiment was hit on February 11, 1900, at Monte Christo by a bullet which passed through the inner border of his right thigh above its middle. On arrival at Woolwich the patient was found to have a varicose aneurism at the upper end of Hunter's canal. On May 31 the femoral artery was ligatured just above its communication with the vein, and as this stopped all pulsation in the vein, it was decided to postpone ligature of the latter to a subsequent occasion, if it should ever be necessary; such a procedure would, it was thought, interfere less with the circulation of the limb, and would therefore be less likely to be followed by gangrene, which is so frequent a result of high ligature of the femoral. But a few days after the operation the foot became cold and mummified, and there was no alternative but to amputate the limb through the condyles of the femur. From this operation the patient made a good recovery, and when discharged there was no sign of an aneurism of the vein. ' Case 16 is quoted from a paper in the _Lancet_ by Lieut. -Colonel Lewtas, I. M. S. It illustrates a result with which I became acquainted in threeother instances not under my own observation. ANEURISMAL VARICES (17) _Axillary. _--Wounded at Modder River. _Entry_ (Mauser), at inner margin of front of left arm, just below level of junction of axillary fold. _Exit_, at about centre of hollow of axilla. A month later when the wound was healed a typical thrill and machinery murmur were noticed. The latter was audible down to the elbow and upwards into the neck. The radial pulse appeared normal. No swelling or pulsation existed. At the end of three months the condition was unaltered; the patient said he noticed nothing abnormal in his arm, except that it was sometimes 'sort of numb' at night. (18) _Popliteal. _--Wounded at Magersfontein. _Entry_ (Mauser), in centre of popliteal space. _Exit_, about centre of patella, which latter was cleanly perforated. Three weeks later the typical thickening of the knee-joint following hæmarthrosis was present, also a well-marked thrill and machinery murmur in the popliteal vessels with no evidence of a tumour. The leg was normal except for slight enlargement of the internal saphenous vein and its branches, probably independent of the arterial lesion. (19) _Femoral. _--Wounded at Magersfontein. _Entry_ (Mauser), 7 inches below left anterior superior iliac spine. _Exit_, at inner aspect of thigh. One month later slight fulness without pulsation was discovered on the inner side of the femoral vessels just above the level of the wound track. Some blood-staining still remained in the fold between the scrotum and thigh. Machinery murmur and a well-marked thrill, most palpable to the inner side of the superficial femoral artery, were noted. No further symptoms developed and the patient was sent home. _Prognosis and treatment. _--No one can help being struck with thedisinclination shown by the older surgeons to interference in cases ofeither aneurismal varix or varicose aneurism, even after the time thatligation of the vessels had become a favourite and successful operation. The objections lay in the technical difficulties of local treatment, andthe danger of gangrene after proximal ligature. Modern surgery haslightened the difficulties under which our predecessors approached theseoperations, but none the less the experience in this campaign fullysupports the objections to indiscriminate and ill-timed surgicalinterference, as accidents have followed both direct local and proximalligature. In _pure varix_ no doubt can exist as to the advisability ofnon-interference in the early stage, in the absence of symptoms. This isthe more evident when we bear in mind that a stage in which ananeurismal sac exists can seldom be absent. In many cases an expectantattitude may lead to the conviction that no interference is necessary, especially in certain situations where the danger of gangrene has beenfully demonstrated. In connection with this subject I cannot helprecalling the first case of femoral varix that ever came under my ownobservation. I discovered the condition accidentally in a man admittedinto the hospital for other reasons. The patient remarked: 'For heaven'ssake, sir, do not say anything about that. I have had it many years, andit has never given any trouble. If it is known, I shall be worried todeath by people examining it. ' None the less it must be borne in mind that beyond enlargement of thevein dilatation of the artery above the seat of obstruction does occur, and gives trouble in some situations. Again the disturbance of thegeneral circulation already adverted to shows that the existence of thiscondition is sometimes of importance in its influence on the cardiacaction. Under these circumstances the treatment varies with regard to thevessels affected, and the degree of disturbance the condition gives riseto. With regard to locality, experience appears to have shown clearly thatcommunications between the carotid arteries and jugular veins usuallygive rise to so little serious trouble that, in view of the grave natureof the operation and its possible after consequences on the brain, interference is as a rule better avoided. I should, however, beinclined to draw a distinction between operations on the common andinternal carotid arteries in this particular, and should regard varix ofthe latter vessel and the internal jugular vein as especiallyundesirable for interference. The vessels at the root of the neck are probably to be regarded from thesame point of view, as to surgical interference. The arteries of the upper extremity are the most suitable for operation, and the axillary may perhaps be the vessel in which interference is mostlikely to be useful. In this relation it may be of interest to includehere a case of a man who took part in the campaign when already thesubject of an aneurismal varix of the axillary artery. (20) Twenty years previously the patient suffered a punctured wound of the left axilla from a pencil. A varix developed, but was only discovered by accident ten years later. The patient was seen by several surgeons, and treatment was discussed; the balance of opinion was, however, in favour of non-interference, and nothing was done beyond giving injunctions as to care in the use of the limb. Up to the time of discovery of the varix no inconvenience had been felt, although the patient was of athletic habits. Subsequently, the patient himself was positive that a swelling existed, but he pursued his usual work. In 1899-1900 he took part in the operations in South Africa as a combatant, and during this time was subjected to very hard manual work. During this he was seized with sudden pain in the left side of the head and neck, and in consequence invalided. No restriction in the movements of the upper extremity, and no subcutaneous ecchymosis developed, but the patient was positive as to the tumour having greatly enlarged. Four months later the condition was little altered. A pulsating swelling 1-1/2 inch broad existed along the line of the upper two-thirds of the axillary artery, and along the subclavian in the neck, rising some 1-1/2 inch into the posterior triangle. Pulsation was visible; the murmur was audible when sitting beside the patient, and widely distributed over the whole chest, the neck, and upper extremity on auscultation. The pulse rate varied with the mental condition of the patient, which was excitable, between 96 and 120. There was neuralgic pain in the neck and scalp, and down the distribution of the brachial plexus. The pupils were equal, but flushing of the face and profuse sweating followed any exertion. I concluded the tumour in this case to be mainly due to dilatation of the trunk above the point of obstruction on account of its outline, the absence of any restriction of movement in the upper extremity, and the non-occurrence of subcutaneous ecchymosis at the time of the attack of severe pain. Difficulties arose as to undertaking any active form of treatment for this patient, which, to be satisfactory, needed an antecedent period of absolute rest, and he passed from my observation. I think, however, operation by ligature above and below the communication would have been possible. The case affords a good example of the course the condition may sometimes take if precaution is neglected. The vessels of the arm or forearm may in almost all cases be interferedwith, but in many instances an absence of any serious symptom rendersoperation unnecessary. With regard to the femoral varices, I would refer to the remarks below, and those on the treatment of varicose aneurism as indicating that acertain amount of caution should be exercised in interfering with them. The same remarks in a lesser degree apply to the popliteal vessels. Inthe leg the tibials may readily and safely be attacked, but it may bementioned that the widespread and diffused nature of the thrill may insome cases give rise to considerable difficulty in sharp localisation ofthe varix to either of the vessels, or to any particular spot in theircourse. In one case in my experience the posterior tibial was cut downupon, when the varix was probably peroneal in situation. The operation most in favour consists in ligation of the artery aboveand below the varix, the vein remaining untouched. Even this operation, however, in two cases of femoral varix failed to effect more than atemporary cessation of the symptoms, although the ligatures were placedbut a short distance from the communication. Failure is due to thepresence of collateral branches, which are not easy of detection. Evenwhen the vessels lie exposed, the even distribution of the thrillrenders determination of the exact point of communication difficult, andthe difficulty is augmented by the temporary arrest of the thrillfollowing the application of a proximal ligature to the artery. Asuccessful case is reported by Deputy Inspector-General H. T. Cox, R. N. , in which the ligatures were placed 1/2 an inch from the point ofcommunication. [16] Single ligation, or proximal ligature, is useless. If the vein cannot be spared, excision of a limited part of both vesselsmay be preferable, particularly in those of the upper extremity. Proximal ligation of the artery combined with double ligature of thevein, as adopted in case 15 by Colonel Lewtas for a varicose aneurism, might offer advantages in some situations. Given suitable surroundings and certain diagnosis, the ideal treatmentof this condition, as of the next, is preventive--_i. E. _ primaryligation of the wounded artery. Many difficulties, however, lie in theway of this beyond mere unsatisfactory surroundings. It suffices tomention the two chief: uncertainty as to the vessel wounded, and thenecessity of always ligaturing the vein as well as the artery in a limboften more or less dissected up by extravasated blood, to show that thiswill never be resorted to as routine treatment. _Arterio-venous aneurism. _--Many of the remarks in the last section findequal application here, but in the presence of an aneurismal sacnon-intervention is rarely possible or advisable. In the early stagesthe proper treatment in any case consists in placing the patient in ascomplete a condition of rest as possible, and affording local support tothe limb by a splint, preferably a removable plaster-of-Paris case. Should no further extension, or, what is more likely, should contractionand diminution occur, it will be well to continue this treatment forsome weeks at least. When the aneurism has reached a quiescent stage the question of furthertreatment arises, and whether this should consist in local interferenceor proximal ligature. The answer to this mainly depends on the size andsituation of the vessels concerned. To take of the cases above describedthe five instances in which the cervical vessels were the seat of theaneurism. In No. 13 the symptoms appeared fairly conclusive of theinjury being to the innominate artery and vein, or possibly innominateartery and jugular vein. Fortunately the aneurismal sac in this case wassmall and showed a tendency to decrease, but in any case no interferencewould have been justifiable. I think a similar opinion was unavoidablein No. 14, probably affecting the root of the right carotid. Here underany circumstances interference would have been most hazardous. Theposition of large aneurism made the route of approach to the woundedspot necessarily through the sac, exposing the patient to the doubledanger of immediate hæmorrhage and of entrance of air into the greatveins. Nos. 10, 11, and 12 fall into the same category, except that inNo. 11 the immediate indication for interference was extension. In each, ligature of the artery above and below the point of communication wouldhave necessitated so near an approach to the sac which must remain incommunication with the vein as to have entailed injury to the latter, when both artery and vein must have been ligatured, probably riskingserious cerebral trouble. In No. 11 I believe both the external andinternal carotids were implicated; in No. 10 I believe the internalalone, close to its origin. The operation of proximal ligature ensuredprimary consolidation of the sac in both cases 10 and 11, but left thethrill unaltered, except in so far as it was temporarily weakened. It, in fact, converted these cases from arterio-venous aneurisms into pureaneurismal varices. In No. 10 a sac subsequently redeveloped. No. 12stood on a different basis. No operation was done for him in SouthAfrica, but the first portion of the carotid might have been ligaturedin the episternal notch, or by aid of removal of a part of the sternum, and a second ligature placed above the sac. Here a ligature above andbelow the communication would have been comparatively easy. As a general rule proximal ligature is to be reserved for those casesalone in which double ligature is either impracticable or inadvisable, and it can only be expected to convert a varicose aneurism into the lessdangerous condition of aneurismal varix. In the case of arterio-venous aneurisms in the limbs the possibilitiesof treatment are enlarged, and here the alternatives of (_a_) localinterference with the sac and direct ligature of the wounded point, (_b_) simple ligature above and below the sac, (_c_) proximal ligature(Hunterian operation), come into consideration. Direct incision of the sac is suitable, and the best method of treatmentfor aneurisms in the calf, forearm, and probably arm. Several cases inthe two former situations were successfully treated by this method. Onthe other hand, the only case I saw in which a proximal ligature hadbeen applied for an arterio-venous aneurism of the leg resulted mostunsatisfactorily. The sac in the calf suppurated at a later date, andfor many weeks the escape of small quantities of blood from theremaining sinus kept up the fear of a severe attack of secondaryhæmorrhage until the sinus closed. In the case of femoral and popliteal aneurisms the method of Antyllus isoften unsuitable. A case of arterio-venous aneurism of the femoralartery quoted in the _Lancet_[17] will illustrate the difficulty whichmay be met with in determining the actual bleeding point in theirregular cavity laid open. In any case the necessary ligature of bothartery and vein is a serious objection to the direct method either inthe thigh or ham, and more particularly if adopted before the damagedependent on the dissection of the limb by extravasated blood has beenrepaired. Proximal ligature (Hunterian) even, offers dangers under thesecircumstances. In one case with which I became acquainted, it wasfollowed by gangrene, necessitating amputation. The lesion in thisinstance was a perforating one of the femoral artery and vein. For either femoral or popliteal arterio-venous aneurisms ligature of theartery above and below the aneurism is the best and safest treatment. Inview of the healthy state of the vascular wall in most of these cases, the advantage of placing the ligatures as near to the wounded spot ascan be managed without interference with the sac is afforded. A numberof popliteal cases treated in this way did perfectly. In the femoralcases a considerable period of rest to allow of consolidation of thesac, and readjustment of the circulation, should always be allowed toelapse. In the case of popliteal arterio-venous aneurisms a number weresuccessfully treated by proximal (Hunterian) ligature, and by singleligature immediately above the sac. In a considerable proportion of thelatter both artery and vein were tied. This was apparently the result ofthe difficulty of isolating the vessels in the tangled mass of clot andcicatricial tissue surrounding them, and is a strong argument againsttoo early interference. The late Sir William Stokes expressed himself asin favour of ligature of the artery in Hunter's canal, combined withthat of the great anastomotic branch, and quoted some successful casesto me. I have grave doubts, however, whether the varix can often bepermanently cured by this operation. I can give no useful statistics on this subject, but with regard to thepopliteal aneurisms I may state that in three instances gangrene of theleg followed early operative interference in the popliteal space. My own opinion on this subject is strong, and to the effect that none ofthese operations should be undertaken before a period of from two tothree months after the injury, unless there is evidence of progressiveenlargement. In every case which came under my own observationprogressive contraction and consolidation took place up to a certainpoint under the influence of rest. When this process has becomestationary, and the surrounding tissues have regained to a great extenttheir normal condition, the operations are far easier, and beyond thismore likely to be followed by success. It appears to me that one argument only can be raised against the aboveopinion, viz. The possibility of healing of the recent wound in thevessels when the force of the circulation is lowered by proximalligature. Such experience as that quoted from Sir W. Stokes and two ofMr. Ker's cases, mentioned below, support this possibility, but in allthe reported results were recent. Against them I can only advance myknowledge of several mishaps following early operation. In concluding these observations on injuries to the arteries andaneurisms, a few general remarks as to the occurrence of gangrene afteroperation must be added. This was not uncommon, and in the main was nodoubt attributable--(1) to the lowering of the vitality of thesurrounding tissues by creeping blood extravasation, and sometimes toactual pressure by the extravasation on the vessels necessary for theestablishment of the collateral circulation. (2) To the frequency withwhich both artery and vein required to be ligatured. Beyond these common causes, however, others must be advanced, dependenton the general and local condition of the nervous system in these cases. In general mental state many of the patients were much shaken, and inothers the condition spoken of as local shock in a former chapter hadbeen marked. In a third series obvious individual nerve lesions wereco-existent with those to the vessels. Beyond this a fourth nervouselement of unknown quantity, the effect of the form of injury on thevaso-motor nerves accompanying the great vessels, must be taken intoconsideration. I believe all these factors were of importance, since it appeared to methat gangrene occurred more often than I should have expected. In onecase which I have heard of, gangrene followed a very slight injury tothe foot in a patient who had apparently made an excellent recoveryafter ligature of the femoral artery. The nervous factor seems another element in favour of reasonable delayin active interference with traumatic aneurisms of the above varietiesin the absence of threatening symptoms. It is worthy of remark that no case of gangrene due to aneurism cameunder my notice, except subsequently to operation. Since the above chapter was written, my friend, Mr. J. E. Ker, has sentme his experience in the treatment of four aneurisms, which is of suchinterest that I insert it as an addendum. _Arterial hæmatomata. _--(1) Popliteal, treated by local incision. Bothartery and vein completely divided. Ligature of the four ends. Cure. (2) Traumatic aneurism of upper third of forearm. Treated by rest andpressure by bandage. On the eighth day pulsation and bruit ceasedspontaneously, and the remains of the sac steadily consolidated untilthe man's discharge on the twenty-sixth day. _Arterio-venous aneurisms. _--(1) At junction of brachial and axillaryarteries. Proximal ligature. Cure. (2) Arterio-venous aneurism at thebend of the elbow. Ligature of the brachial at the junction of themiddle and lower thirds of the arm. Cure. FOOTNOTES: [14] The murmur is still present at the expiration of one year, but noother change. [15] Lieut. -Colonel Lewtas, I. M. S. See _Lancet_, 1900, vol. Ii. P. 1073. [16] _Lancet_, 1900, vol. Ii. P. 1074. [17] Sir W. MacCormac, _Lancet_, vol. I. 1900, p. 876. CHAPTER V INJURIES TO THE BONES OF THE LIMBS Injuries to the bones of the limbs formed a very large proportion of theaccidents we were called upon to treat, and afforded as much interest asany class, since they possessed many special features. I shall hope toshow, however, as in some of the other injuries, that these featuresdiffered only in degree from those exhibited by injuries from the oldleaden bullets of larger calibre, although with few exceptions they wereof a distinctly more favourable character. It is of considerable interest to note that, taking the fractures as awhole, there was a somewhat striking change in their nature during theearlier and later portions of the campaign. In the earlier stages Ithink there is no doubt that punctured fractures were proportionatelymore common than in the later, when comminuted fractures were much moreoften seen. There was, I believe, a source of error in this opinion, asfar as I myself was concerned, in that the first cases I saw were atCapetown and had come from Natal. There is no doubt that the puncturedfractures were earlier fit to travel, and hence a larger number of themfound their way to the Base hospitals at a period when the comminutedfractures were still in the Field or Stationary hospitals. I do not, however, rely on the cases seen at Capetown alone for my opinion, aswhile at the front I saw the same large proportion of clean punctures inthe early engagements of the Kimberley relief force. I am inclined to attribute the change to two reasons: first, I believethat the use of regulation weapons was more universal in the earlierpart of the war, while later, as more men were engaged, theMartini-Henry came more into evidence, and the Boers took more freelyto the use of sporting rifles and ammunition. Another element also inthe less clean punctures of the short and cancellous bones was probablythe less accurate and hard shooting of the Mauser rifles as they becameworn; the bullets seemed to evidence this by the comparative shallownessof their rifle grooves, which, I take it, would mean less velocity andaccuracy in flight. This would be of importance, since the cleanpuncture of cancellous bone was no doubt favoured by a high rate ofvelocity. The special features of the fractures caused by the small-calibrebullets were: (1) The nature of the exit wound, which in a certainproportion of the cases exhibited the so-called 'explosive' character. (2) The presence, in a marked degree in the severe cases, of thecondition spoken of in Chapter III. As 'local shock. ' (3) The strikingcontrast of clean perforation and extreme comminution in differentcases. (4) The occasional occurrence of fractures of a very high degreeof longitudinal obliquity. (5) The rarity of any that could be termedtransverse fractures. (6) The general tendency of longitudinal fissuringwhen it occurred to stop short of the articular extremities of thebones. It will perhaps be most convenient to consider first the explanation ofthe development of the so-called explosive apertures, and then to passon to a general consideration of the types of fracture commonly metwith, before proceeding to the description of the injuries to theseparate bones. _Explosive wounds in connection with fractures. _--The aperture of entryin these injuries presented little or no deviation from the normal, unless it was due to the passage of ricochet bullets, when it might bevery irregular, but usually not of great size. [Illustration: FIG. 47--(21) 'Explosive' Exit Wound of Forearm overmargin of ulna. Note creased tongue of skin originally covering wholewound. The entry wound was a small typical circular one] The aperture of exit offered special features beyond simple increase insize. First of all, as in the small type wounds, the actual extent ofdestruction of the skin was small, this having been projected outwardsby the passing bullet and then either burst or torn by the bullet andaccompanying bony fragments. Fig. 47 well illustrates this feature. Atriangular tongue of skin was lifted by the passing bullet and probablyby the lower end of the upper fragment of the fractured ulna; throughthe resulting opening a mass of soft tissues and bone fragments, boundtogether by an infiltration of coagulated blood, was extruded, separating the lateral lips of the aperture, while the original tonguehas shortened and retracted up to the top of the wound. The small extent of skin actually destroyed is an important element inthe rapid contraction often seen in these wounds when they progressfavourably. Thus the large wound portrayed in fig. 48 contracted toone-fourth its original size ten days after the diagram and measurementswere made. The large mass of protruded tissue was often most strikingwhen a muscle such as the biceps in fig. 48 had been divided; but theherniæ were more persistent when the mass projected in regions wheretendons formed a large integral constituent, as at the wrist or lowerthird of the forearm. The protruding tissues naturally consisted of manyvarieties, according to what lay in the track of any particular wound. It should be added that for 'explosive' features to reach theirstrongest development, it is necessary that the bone affected should lienear the surface of the body; hence the most characteristic explosivewounds were met with in the forearm or leg, over the metacarpus ormetatarsus, or in the arm. In the thigh, on the other hand, where thefemur in a great part of its course not only lies deeply, but is alsoprotected by particularly strong and resistent skin and fascia, anothertype of wound was met with. The explosive exit aperture, although large, was still only moderate in extent, sometimes, as in the front of thelower third, exposing a somewhat angular large track walled by thedivided quadriceps extensor cruris. In other cases, on introducing thefinger through a moderate exit opening on the inner aspect of the thigh, a large cavity, sometimes 4 or 5 inches in diameter, was discovered, full of clot and shreds of destroyed tissue and lined by a layer ofsimilar material. In either of these latter cases the fractured boneends were situated too deeply to take part in the actual laceration ofthe skin, while the force transmitted to the bone fragments, althoughsufficient to cause them to widely destroy the first soft tissues metwith, did not suffice to cause them to burst or lacerate the skinwidely. [Illustration: FIG. 48. --(22) 'Explosive' Exit Wound of front of Arm. Wound actual size eight days after its infliction. The prominences inthe upper and lower parts correspond with the lacerated biceps. The darkcrater led down to the fracture. In another week the wound hadcontracted to half the size. The entry aperture was a normal circularone. The arm a year later was used in the patient's employment as ahammer-man. ] With regard to the theories of the production of these phenomena, thatof the transmission of a part of the force of the bullet to thecomminuted fragments, which thus themselves acquire the characters ofsecondary projectiles, seems quite adequate. [18] Examination of any ofthe skiagrams in which considerable comminution has taken place, showsthat the fragments are carried forward and perforate the tissues distalto the fracture. [Illustration: FIG. 49. --'Explosive' Wounds of Legs. Large irregularentry (1 × 3/4 in. ). First exit (2 in. ) roughly circular. Second entrywound, produced by bone fragments driven out of left leg, very large andirregular (5 × 3-1/2 in. ). The measurements were taken eight days afterinfliction of the wounds. The right limb was amputated later forsecondary hæmorrhage] Fig. 49, although a poor delineation of the actual condition, shows wellthe possible action of projected fragments, even after they have beendriven from the wound. In this case either a large or a ricochet bulletentered on the outer aspect of the upper third of the left tibia; itproduced a severe comminuted fracture, the fragments from which, together with the deformed bullet, then struck and perforated the upperthird of the right tibia. A large irregular entry wound 5 inches intransverse diameter was produced in the second limb together with acomminuted fracture of the bone. The right limb had eventually to beamputated for secondary hæmorrhage, but I am unacquainted with the laterhistory of the patient. The mode of displacement of the lateral fragments when a wide shaft suchas that of the femur is struck, throws some light on that of thedisplacement of soft tissues such as the component parts of a perforatednerve or artery. The bullet, passing through, expends the chief part ofits energy in driving before it the fragments produced in its directcourse, while a minor part of the energy is expended on displacing thelateral fragments, which are pushed to either side without becomingseparated from their periosteal attachment. The appearance, in fact, somewhat suggests what might be expected were a small charge of dynamiteintroduced into the centre of a small tunnel made across the shaft ofthe bone. Examination of some of the skiagrams also illustrates anotherpoint of interest, viz. That a certain degree of recoil on the part ofthe bone results from the blow, since in many of them portions of themantle of the bullet and bone fragments are seen in that portion of thetrack proximal to the fractured bone. The importance of 'setting up' of the bullet is at once evident inrelation to the production of wounds of an explosive type in connectionwith fractures of the bones. There can be no doubt that a considerablenumber of the most severe injuries we saw were produced by the varioussoft-nosed or expanding forms of bullet, also that others of an equallyserious nature were produced by Martini-Henry or large leaden sportingbullets. Allowing for this, however, I think a considerable proportionwere the result of deformation from bony impact, or ricochet deformitiesexternal to the body acquired by regulation Mauser bullets, and I thinkthese bullets can be quite as formidable as any of the sportingvarieties met with. The soft-nose varieties of small calibre may not setup enough to cause severe injury, while the large leaden bullets oftenflatten out so completely as to lose all penetrating power. As far asmy impressions went, the small soft-nosed bullets needed to betravelling at a very considerable rate of velocity to be dangerous. Inthe form of soft-nose Mauser employed, the soft-nose was too short toallow of as successful a mushrooming of the bullet as often occurredwith the regulation projectile, because, as already explained, themantle acquires increased stability from its closed base. FRACTURES OF THE SHAFTS OF THE LONG BONES _Types of fracture. _--The common types of fracture of shafts of the longbones are illustrated diagrammatically in fig. 50. Of the whole seriescomminuted fractures were by far the most frequently met with, while thevarious wedge-shaped forms were the most strongly characteristic of thespecial form of injury in which we are interested. [Illustration: FIG. 50. --Five Types of Fracture: A. Primary lines ofstellate fracture; wedges driven out laterally and pointed extremitiesleft to main fragments. B. Development of same lines by a bullettravelling at a low degree of velocity; suppression of two left-handlimbs and substitution of a transverse line of fracture; a spurious formof perforation. See plate XXIII. C. Typical complete wedge. See plateVII. D. Incomplete wedge; impact of bullet, lateral or oblique, and twoleft-hand lines seen in A are suppressed. E. Oblique single line, oneright and one left hand line seen in A, suppressed. The influence ofleverage from weight of the body probably acts here. Compare plates XVI. And XXI. ] [Illustration: PLATE III. Skiagram by H. CATLING Engraved and Printed by Bale and Danielsson Ltd. (23) SPURIOUS PERFORATION OF CLAVICLE Range unknown, probably either mean or long. The bullet entered from the front, grooved the under surface of theacromial end of the clavicle with increasing depth, and eventuallyperforated the posterior margin of the bone, raising the compact tissuein an angular manner. The commencement of an incomplete groove extending from the anteriormargin is seen, resembling the groove of the humerus, fig. 58. ] 1. _Stellate comminuted fractures. _--A shows the primary nature of thelesion in all comminuted fractures of compact bone, consisting in theproduction of a number of radiating fissures, which assume a stellateform of which the point of impact corresponds to the centre. B shows anincomplete development of this form, the fragments being simplydisplaced laterally with slight loss of substance, so as to simulate areal punctured fracture. An illustration of this fracture produced by abullet travelling at a low degree of velocity is seen in plate XXIII. , which also shows the unaltered bullet lying in close proximity to theinjured fibula. The degree of comminution in these fractures depends first on the rangeof fire and consequent striking force retained by the bullet, a highdegree of velocity producing extreme comminution of compact bone. Theseverity of the latter again may be influenced by the measure ofresistance dependent on the density and brittleness of any individualbone, or on the possession of the same characters as a special propertyby the tissues of the man struck. Thus plate IV. Shows a fracture of thehumerus produced by a bullet shot from a short range, and the fragmentsare comparatively large and of even dimensions, while plate XIV. Showsextreme comminution of the portion of the femur exposed to directimpact, with elongated large fragments at the sides of the track. PlateXIX. Shows less extreme comminution and less separation of thefragments, and was probably produced by a bullet from a longer range offire. The separation of elongated lateral fragments is a special feature, andbest marked when the portion of bone struck is considerably wider thanthe bullet, as in the case of the shaft of the femur. These fragmentscorrespond in the method of their production to those seen in the wedgefractures described below, while their separation leaves a pointedextremity to either segment of the shaft. This fracture in its puresttype is, I believe, spoken of as the 'butterfly fracture. ' With regard to the spread of the fissures in the long axis of the boneinto neighbouring articulations I think fractures produced by bullets ofsmall calibre differ considerably from those produced by largerprojectiles, in that their general tendency is not to extend beyond thecommencement of the cancellous bone forming the joint end. This isperhaps capable of explanation on several grounds: first, the smallerarea of impact results in the assumption of a strongly marked stellatefigure, the radiating fissures of which rapidly reach the lateral limitsof the shaft, producing a solution of continuity in the bone whichinterrupts the continuance of the action of the wedge represented by thebullet. Secondly, the small size of the wedge itself is opposed to thewide separation of the parts directly implicated, which is necessary forthe continued progress of the process of fissuring, and again therapidity of passage minimises the period during which the force isexerted. It is in these points that I believe the chief differencesbetween the modern and old gunshot fractures find their explanation, since with the larger bullets fractures extending from some distanceinto the joints were a somewhat special feature. In addition it isprobable that the alteration in structure at the junction of the shaftswith the cancellous ends also tends to check the regular extension ofthe fissures, as a similar limitation is illustrated even in somefractures by Snider bullets. Fig. 51 of the lower end of the femurillustrates a not uncommon lower limit to a comminuted injury in thisregion. [Illustration: FIG. 51. --Lower end of Femur. From Case needingamputation. It shows the usual tendency of the fissures to stop short ofthe articular ends of the long bones] The degree and nature of the comminution also vary with the directnessof impact on the part of the bullet. The more nearly this approaches ata right angle, the more severe is the local comminution, but probably alesser area of the shaft is implicated. Plate V. Shows an example ofthis: all trace of continuity is lost, a wide gap separates the boneends, while the fragments themselves have been for the most part drivenaltogether out of the wound. Oblique impact, on the other hand, maywiden the comminuted area at the point of impact, while, if the bulletretains sufficient force and regularity of outline, it may then travel'cutting its way' through the remainder of the bone in an obliquedirection. It will be of course recognised that the exact impact of thebullet depends not alone on the direction of the projectile, but alsoon the nature of the slope offered by the surface of bone struck. 2. _Wedge fractures. _--This form (C and D, fig. 50) is equallycharacteristic of gunshot injury with pure perforation; it is met within two varieties. C illustrates the more strongly marked type; in it thebullet makes passing lateral impact with the shaft, and from the pointstruck radiating fissures extend to the opposite margin, so that awedge-shaped piece of bone often secondarily comminuted is separatedfrom the remainder of the shaft; see plate X. Of the radius. The second variety, D, is an incomplete development of the stellatefracture in which the fissures pass to one margin of the bone only. Theexplanation of this variation is probably to be sought in the directionof impact on the part of the bullet, since the main fissure is oftenaccompanied by secondary lines which run a somewhat parallel course tothe main one, and suggest the dispersion of the force in the form ofconcentric waves. Such fractures were most strongly marked in the tibia, the breadth of the surfaces of this bone presenting especiallyfavourable conditions for their production. 3. _Notched fractures. _--These may be a slight degree of the form ofwedge fracture last described; such a one is depicted in plate XXII. Where a portion of the spine of the tibia has been carried away by apassing bullet. Other notched fractures approximate themselves morenearly to perforations, the notch being a groove secondary to theopening up of such a track as is shown in the illustration of aperforation of the lower third of the shaft of the tibia (fig. 57 on p. 219). Notching or grooving is naturally much more common in thecancellous portions of bones. 4. _Oblique fractures. _--These also occur in two varieties: the firsthas been already alluded to; in it the bullet actually cuts an obliquetrack in the bone; the main line of fracture is often considerablycomminuted, usually at the proximal end of the track (see plates XV. AndXIX. ). The second variety (E, fig. 50) is less common; in it two of the mainlimbs of the simple stellate figure are suppressed, while the remainingtwo form a continuous line from one margin of the shaft to the other, the point of impact lying approximately in the centre of the line offracture. Such a fracture is illustrated by the skiagram of a femur inplate XVI. In which the bullet traversed the soft parts transversely atthe level of the centre of the fracture, which was 9 inches in length. In another case the line of fracture occupied the lower third of thefemur, passing from the inner border of the shaft, the lower end of theupper fragment was formed by the compact tissue forming the outer wallof the external condyle. This latter perforated the vastus externus andlay beneath the skin; as it could not be disentangled, an incision wasmade over it, and the fragments when reduced were screwed together byMr. S. W. F. Richardson. In neither fracture was there any comminution. Such fractures most nearly resemble the oblique or spiral ones met within civil practice as the results of falls. In all the instances Iobserved the patients were supported on the lower extremities at thetime of the accident, and one can only assume that a twist of the trunkconsequent on the fall of the body diverts the most forcible vibrationsresulting from the impact of the bullet into one line, and thus producesa solution of continuity of a simple oblique nature. In both the casesmentioned above the bullet was probably travelling at a low degree ofvelocity; in the first it was a ricochet and was retained. I never sawone of these fractures in the upper extremity. Plate XXI. Affords an excellent example of this mechanism. The patientwas standing when struck, and then fell backwards. An incomplete fissure7 inches in length is seen to extend from an otherwise pure perforationof the shaft of the tibia. 5. _Transverse fractures. _--Throughout these were of very rareoccurrence. Plate XX. Illustrates a pure transverse fracture produced bypassing contact of a bullet probably fired at a distance not exceeding400 yards, and which subsequently struck the fibula plumb and producedconsiderable comminution. No fissure extended into the ankle-joint. Comminutions such as that illustrated by plate V. More or less simulatedtransverse fractures, but I saw no examples of transverse trackscomparable to the oblique ones described above 'cut through' the shaftof a bone. 6. _Perforations. _--Although these were common in cancellous bone, theywere comparatively rare in the compact shafts. I saw, however, completepure perforations of the shafts of the tibia, femur, clavicle, and otherbones. These perforations were, I believe, always the result of lowdegrees of velocity, and they took the place of simple transversefractures of the 'cut' variety. The apertures of entry and exit in thebones resembled in character those seen in the soft parts, or in thebones of the skull in low-velocity injuries (see figs. 71 and 72, p. 261). The entry was more or less cleanly cut, while at the exit a plateof bone was raised, and either separated or turned back on a hinge bythe bullet (fig. 52), (plate XVII. ) Such a projecting hinged fragmentwas sometimes a source of some trouble; thus in a case ofpostero-anterior perforation of the lower third of the shaft of thefemur, the long exit fragment projected into the substance of thequadriceps extensor muscle, and interfered with flexion of theknee-joint. Fig. 57 of a superficial tunnel of the lower third of thetibia is especially interesting as bringing such injuries of the longbones into line with fractures of the flat bones of the skull, such asare illustrated in fig. 68, p. 259. Plate XXI. Affords an excellent example of perforation of the shaft ofthe tibia, although complicated by the secondary fissure. Plates XXIII. , VIII. , and III. , of the fibula, humerus, and clavicle, exhibit examples of what may be called spurious perforations of theshafts of bones, since comminution or loss of continuity accompanies allthree. Subsequently to writing the above paragraphs, I took the opportunity ofre-examining the magnificent series of gunshot fractures collectedduring the Franco-German campaign by Sir William MacCormac, andafterwards presented by him to the museum of St. Thomas's Hospital. The close approximation in type between the main features in these andthose in the fractures produced by the modern bullet is very striking. In the case of the shafts of the long bones, the same stellate, oblique, wedge-shaped, and even perforating injuries are illustrated on a coarserscale. In a specimen of a patella, a perforation of the lower half, implicating also the tendon of the quadriceps muscle is, though large, almost as pure as a Mauser perforation. The difference in the nature of the lesions of the bones is seen to be, firstly, one of pure magnitude, corresponding to the size of the largeSnider bullet by which they were produced. Thus the fragments generallyare larger, and occupy a wider area of the shafts, the first characterdepending on the lesser degree of velocity of the bullet, the latter onits volume and weight. Fine comminution, however, the most strikingfeature of the modern injury, is throughout absent. The effect of the larger size of the wedge provided by the bullet inincreasing the length of secondary longitudinal fissures is well marked, and for the same reason the perforations are usually accompanied byfissures of considerable extent. It is interesting to note, however, that even in the case of the large bullets, and the special tendencyshown by them to cause the extension of fissures into the joints, one ortwo specimens still show that these fissures incline to stop short whenthe point of junction between the portion of the shaft occupied by themedullary canal and that built on a foundation of cancellous tissue isreached. LESIONS OF THE SHORT AND FLAT BONES The above types of fracture are those common to the shafts of the longbones, but the difference in structure of the articular ends and theshort and flat bones endows lesions of these with somewhat differentcharacters, the nature of which varies between grooving, perforation, and great comminution. The most typical injury consists in the production of a cleanperforation of the cancellous bone; this was common both in thearticular ends and in the short bones. The tunnel differed little incharacter from those already described, a tendency always existing tothe lifting of a lid of compact tissue at the exit end of the track. For the production of the cleanest forms of injury I believe high ratesof velocity were distinctly favourable, although I am unable to maintainthis statement by proof in the case of injuries received at the shortestranges of fire. When the velocity was lower, yet with force stillsufficient to produce a perforating injury, the separation of anextensive scale of bone at the exit aperture was a marked feature notseen in perforations produced by higher degrees of velocity. Fig. 52, ofa perforation of the lower end of the femur, well exhibits this feature;but it must be borne in mind in this case that the illustration is not apure one, both shaft and epiphysis taking part in the walls of thetrack, and the exit opening is in the former, where a thicker layer ofcompact bone exists than would cover any epiphysis, and hence thefragment is larger. I use the example, however, because it so forciblyillustrates the effect of increased resistance on the part of the bonestruck in widening the area of the lesion. When the track was entirelylimited to the articular ends the small amount of damage at eitheraperture was shown by clinical evidence in the rarity of subsequentlimitation of joint movements due to bony deformity. [Illustration: FIG. 52. --Oblique perforation, implicating both epiphysisand diaphysis. Large fragment detached at exit aperture. Caused by abullet travelling at a low rate of velocity. Compare with figs. 71 and72 of a skull fracture. The dotted lines indicate the course of thetrack] Again, it was rare for fissuring to extend from these tunnels to thearticular surfaces; thus many instances could be given of perforation ofthe head of the humerus, the olecranon, or the femoral condyles, inwhich no evidence of joint fissure was discoverable. The slight amountof resistance offered by the cancellous ends was also clinicallyillustrated by the absence of severe synovial effusions when they werestruck. When the joint cavity was not crossed, slight effusion onlyresulted, while in the case of fractures of the femoral shaft greateffusion into the knee-joint, resulting from the forcible vibrationtransmitted to the limb, was a common feature, even when the pointfractured was situated above the centre of the bone. Again, when thejoint cavity was crossed a moderate degree only of hæmarthrosis was themost common result. With regard to the implication of joints, either primary or secondary, in connection with fractures of the articular ends, I am inclined toplace the lesions of the upper end of the tibia in a more importantposition than those of any other bone. Evidence of this implication wasin my experience more frequent here than in any other situation. Thismay in part be attributable to the complexity of structure of thisepiphysis, and perhaps more correctly to the influence of its irregularoutline in favouring lateral forms of impact on the part of the bulletand consequent increase in the area of damage. Next to tunnelling, grooving was the most common form of injury to theshort bones. In the case of superficial tracks the compact tissue mightbe considerably comminuted, but not, as a rule, over a width greatlyexceeding the calibre of the bullet. Comminution and crushing of a single or several bones were rare inproportion to the occurrence of similar injuries produced byMartini-Henry or large leaden bullets. When the condition was producedby bullets of small calibre, I believe it was in the majority of casesthe result of irregular impact on the part of the projectile. In supportof this view it may be added that such injuries were most common in thebones of the tarsus, bones especially liable to be struck by ricochetbullets. It was generally believed that bullets travelling at a very high degreeof velocity were liable to cause severe comminution of the short bones, but I never saw any cases supporting this opinion; in point of fact, allthe short-range lesions of this nature that I saw were of the cleanperforating variety. I believe that this is capable of satisfactoryexplanation on the ground of the thin character of the layer of compacttissue which for the most part ensheaths the short bones; this decreasesthe resistance offered to the bullet and so tends to localise thelesion. This statement may be supported by two observations with regardto the long and flat bones. First, if the shaft of a long bone be hitabove the junction of diaphysis and epiphysis, the cancellous tissue inand extending from the medullary cavity is pulverised, and examinationof fragments from such fractures gives the impression of the inneraspect having been scraped clean. Secondly, I saw one fracture of theilium produced by a bullet taking a course between its compact layersfor 3 inches from the notch between the anterior superior and anteriorinferior spines; the bone to the extent of 2-1/2 square inches waspulverised, the cancellous tissue blown away as dust, and the compacttissue only represented by scales still adhering by their periosteum tothe muscles attached to the two surfaces of the bone. This injury wasproduced from a rifle fired at five yards distance, and was an extremeexample; but, on the other hand, it illustrates only what we arethoroughly well acquainted with in the case of flat bones, such as thoseof the cranium, where the compact element is abundant in comparison withthe cancellous, and the resistance offered to the bullet is consequentlygreat. Some remarks on transverse fractures of the patella will be found underthe heading devoted to that bone. Lesions of the flat bones are considered at some length in Chapter VII. , which deals with injuries to the head, and their special features arethere described; some further remarks on these injuries will be foundunder the headings of the individual bones. _Special characters of the symptoms observed, and of the course ofhealing of the fractures. _--Peculiarities in the initial signs may berapidly passed over. The first depended on the large number of lesionsof the bone which were unaccompanied by loss of continuity. In the caseof perforations attention to the course of the track, externalpalpation, and possibly the detection of bone dust in the aperture ofexit, were usually sufficient to indicate injury to the bones. Whenthese did not suffice the introduction of a probe would usually set thequestion at rest; but this is always to be avoided if possible, asadding a fresh item of risk to the wound. The X rays were not always tohand, and are not always capable of giving reliable information in thematter of perforations, although very useful in detecting grooves ornotching. The latter injuries are those in which information as to thecondition of the bones is often of most interest in view of thecharacters of the external wounds. Fractures with solution of continuity were, as a rule, easy ofdetection, but the relative prominence of the classical signs variedsomewhat from what we are accustomed to see in civil practice. The first striking peculiarity noted in comminuted fractures of the longbones was the degree of local shock; the limbs were often quitepowerless, the muscles flaccid, and common sensation lowered. This wasof importance in two ways; firstly, shortening of the limb was oftenabsent as a sign, and, secondly, pain was sometimes not at allpronounced even when the patient was moved. The primary absence ofshortening, even persisting for the first two or three days, was aphenomenon always important to bear in mind, as it affected the degreeof extension needed in the treatment of the fracture, which, ifsufficient at the moment, often proved quite inadequate with the returnof tone in the muscles. Secondly, abnormal mobility was usually stronglymarked, and this sometimes without very definite crepitus, as a resultof the fine nature of the comminution and the displacement of the smallfragments. During the course of healing some other peculiarities are worthy ofmention. First of all, union was tardy and often not strong. On theother hand, an abundance of provisional callus was common, which formedlarge swellings apt to implicate neighbouring nerves, and sometimes tointerfere with the movements of joints. The slowness of healing wasparticularly noticeable in those cases where the degree of local shockhad been marked, and was probably to some extent dependent ondisturbance of the general nutrition of the tissues of the affectedlimb. Beyond this, however, it was in many cases a direct result of thedegree of comminution and displacement of the fragments, whichnecessitated the formation of a large amount of provisional callus, andtime for the proper consolidation and contraction of the same. In manycases a large ball-like mass of callus surrounding the fragments wasdeveloped, into which the actual ends of the broken bone only dipped, and hence union was weak and insecure. As to those cases in which thewounds closed by primary union, we must bear in mind in this relationthe tardy union often observed in civil practice, when the irritation ofsuppuration and consequent inflammation are absent. Another peculiarity of a similar nature was the occasional late necrosisof fragments; the wounds apparently healed well, only to break downweeks or months later for the discharge of a sequestrum. Such cases werequite distinct from those in which primary suppuration had occurred. Isaw one or two instances in fractures of the humerus, the troublearising with commencing use of the limb, and I suppose that fragmentswhich suffered death at the time of the injury had been enclosed, andonly caused irritation as foreign bodies when the muscles again cameinto action. In the absence both of evident necrosis and suppuration, however, in some cases the exit portion of the track in the soft partswas extremely slow in healing. Although no discharge beyond a smallquantity of blood-tinged serum escaped, the wounds remained open formany weeks, even when the fracture consolidated well. I ascribed this toslow separation of aseptic sloughs, a point which has already beenmentioned under the heading of wounds in general. Superabundance of callus, as far as I had an opportunity of judging, comparatively seldom gave rise to permanent mechanical trouble. This wasno doubt due to the infrequency of extension of the comminuted fracturesbeyond the junction of diaphysis and epiphysis. Lastly, with regard to suppuration, only a small proportion of thefractures, accompanied by the presence of large wounds, escapedinfection. When infection did occur, the results offered some specialfeatures dependent on the small relative amount of damage to the softtissues, compared with that suffered by the bone. In an ordinarycompound fracture, such as we meet with in civil practice, whether theresult of direct or indirect violence, a considerable amount ofcontusion or laceration, as the case may be, accompanies the injury tothe bone. The result of this is a widespread effusion of blood into thelimb, which tears and strips up the various layers of soft parts, andopens up the way to the spread of infection, often into the wholelength of the segment of the limb affected. In fractures produced bybullets of small calibre, even when the exit portion of the track islarge, the injury to the soft parts is far more localised, except inextreme cases, while the bone itself is the tissue which has sufferedthe most severe violence and contusion. When infection occurred, itsspread corresponded with this anatomical feature of the lesion, and thebone itself and its immediate neighbourhood suffered the most severely. At the present day one is naturally not very familiar with a largeseries of suppurating compound fractures, but during my whole experienceI have never seen so many cases of what might be regarded as fairly pureinstances of acute osteo-myelitis. The symptoms corresponded with themain seat of the suppuration; only moderate swelling of the limbsoccurred, this mainly consisting in soft superficial oedema; oftenthere was no redness, and fluctuation was difficult to determine. At thesame time symptoms of constitutional infection, such as continued fever, rapid pulse, restlessness, loss of strength, progressive anæmia, andemaciation, were marked. Pyæmia, as evidenced by secondary deposits, was, however, rare; I only saw two cases, both in fractures of thefemur; in both recovery followed secondary amputation. _Prognosis. _--This depended almost entirely on the nature of the injuryto the soft parts; given moderate injury to these, and the preservationof the wound from infection, scarcely any degree of injury of the bonesprecluded recovery, even if this were slow and prolonged. The existenceof perforations scarcely increased to an important extent the gravity ofa wound of the soft parts alone; in fact, this injury could not beregarded as more severe than an ordinary surgical osteotomy, putting therisks of infection of the wound under the special circumstances on oneside. With regard to the functional results, these depended on the degree ofcomminution; when this was extreme, union was slow and for a time weak, and shortening was often considerable, but a fair result was as a ruleobtained. Suppuration and osteo-myelitis were the dangerous features when theyoccurred; still, even in the presence of these, I never saw a fatalresult in an upper extremity fracture, although in the lower extremitya considerable mortality followed fractures both of the leg and thigh, the deaths being most commonly from septicæmia, or from a combination ofthis with secondary hæmorrhage. _Treatment. _--The general treatment was of a simple character. Theperforations may be at once dismissed, since nothing more was neededthan what has been already described under the heading of wounds of thesoft parts. Again, with regard to the co-existence of vascular injury, or injury to the soft parts generally, the ordinary rules guiding us incivil practice were followed. The first point of importance, and needing consideration in thetreatment of severely comminuted fractures, was as to whether in theseit was better simply to try to obtain union of the wound with as littledisturbance as possible, or to anæsthetise the patient and explore thewound, removing such fragments as were free or widely displaced. I thinkthe answer to this question depends entirely on the nature of theexternal wounds. If these be of the small type forms, or if the exitaperture is, at any rate, of only moderate size, a strictly conservativeattitude is the better when the risk of making an exploration under thecircumstances is borne in mind, the more so as an exploration, to besafe and useful, ought to be done at once. If the exit wound is of thelarge or explosive type, on the other hand, there is no doubt that thebest results are to be obtained by early exploration and the removal ofall loose fragments. I saw several excellent results obtained in thisway, even when the patients had to undergo the risk of transportshortly, in some cases the very next day, after the operation. The loosefragments are an immediate source of danger, and later may interferewith the healing of the fracture, even if suppuration does not occur. Inall the cases that I saw the exit wound was dressed, but left freelyopen, and I do not think any attempt to close it should ever be made. The question of operative fixation rarely needs consideration; itoccasionally happens, however, that oblique fractures, such as onementioned on p. 166, are met with, in which screwing or wiring of thebone ends is advisable. What has been said above as to fractures, accompanied by loss of continuity, applies equally to cases of severewedge-fracture, where many loose fragments exist. As to the disinfection of the limb, primary cleansing, mainly by soapand water, of course precedes the exploration, and when the latter hasbeen carried out a second cleansing and disinfection, preferably withspirit and carbolic acid lotion, are imperative. Immobilisation is a more difficult problem. In practised handsplaster-of-Paris splints answer most requirements except in the case ofthe thigh; but the splints take time to apply and also to set firmly, and, as sometimes needing frequent removal, are not altogether suitablefor Field hospital work. Of all the splints I saw in use, I think thebest were wire splints, and the Dutch cane folding splints for the thighand leg (figs. 56, 58); wire-gauze splints with steel at the margins(fig. 54), or strips of ordinary cardboard applied with some variety ofadhesive bandage for the arm and forearm; and plain wooden of variouslengths for any situation. A question of constant difficulty was that of frequency of dressing; ina Stationary or Base hospital this is not difficult, as the same surgeonhas the patient continuously under his charge, and can readily decide asto the proper moment for the renewal of the dressing. When the patientis, however, being moved from the Field to the Stationary hospital, andthence to the Base, a constant succession of surgeons has the case inhand for short periods, the movements during transport disturb thefixity of the dressing, and, in consequence, dressings are apt to be farmore frequent than is advisable. This question raises the larger one ofthe advisability of _any_ transport beyond what may be an actualnecessity. There is only one answer to this. No fractures of the thighor leg, and few of the arm, can be transported for any distance withoutmaterial disadvantage. The risks attendant on disturbance of thefracture and tissue injury, septic infection as a result of slipping ofthe dressing and the impracticability of efficiently renewing it, farmore than counterbalance any advantage to be gained from the superiorcomforts available at a Base hospital. For these reasons, if possible, all fractures of the arm, thigh, or leg should be kept at a Stationaryhospital for a period of three or more weeks, and, as far as splints andappliances are concerned, these should be as numerous and complete as ata Base hospital. I have had a useful set made of aluminium. A word willbe added later as to the splints suitable for different regions of thebody. The necessity for _primary amputation_ chiefly depends on the nature ofthe injury to the soft parts, less commonly on the extent of the injuryto the bones, and should be decided on exactly the same lines as incivil practice. So-called intermediate amputations are always to beavoided if possible; the results were consistently bad, and theoperation should only be undertaken in cases of severe sepsis wherelittle can be hoped from it, or for secondary hæmorrhage. When theoperation could be tided over until the septic process had settled downand localised itself, secondary amputation gave very fair results. Ineither intermediate or secondary amputation for suppurating fractures, it was necessary to bear in mind the special likelihood of the existenceof extensive osteo-myelitis. If this condition affected the upperfragment, an amputation was of little use unless the whole bone wasremoved, as septic infection continued and brought about a fatal issue, or a fresh amputation was required in order to obtain a stump that wouldheal. SPECIAL FRACTURES _Upper Extremity. _--Fractures of the _scapula_ were not uncommon, butwere mostly of the perforative variety; thus perforations both of thespine in longitudinal wounds of the back, and of the ala in perforatingwounds of the thorax, were tolerably frequent. They possessed littlepractical interest; as a rule, the openings were not large, and the mostunexpected feature was the small interference with the movements of thebone on the chest wall that resulted. It might be assumed thatcomminuted fragments would project into the muscles and cause both painand interference with movement; but neither was the case. I saw groovingof the crest of the spine, but never happened to meet with a fractureof the acromion process. Many axillary tracks passed in the closestproximity to the coracoid, but this again I never saw separated. Onepractical point of importance with regard to the scapula was thefrequency with which bullets lodged in the venter, or the firmlybound-down muscles of the supra- and infra-spinous fossæ. These retainedbullets often gave rise to remarkably little trouble in this situation;thus I have a skiagram of a shrapnel bullet lying in the deepest part ofthe subscapular fossa, which did not inconvenience its possessor. [Illustration: FIG. 53. Head of Humerus, showing broken perforation. Theroof forms a hinged covering to a groove. ] Every variety of _fracture of the clavicle_ was met with, evenperforation of the most compact portion of the shaft; comminuted, wedge, or notched fractures were, however, the more common, and wereaccompanied by the development of very large masses of provisionalcallus during the process of healing. An interesting skiagram isreproduced in plate III. , which shows a compound form of injury to theclavicle. The bullet has passed obliquely beneath the acromial end, rising to perforate the posterior compact margin, and producing one ofthe diamond-shaped openings sometimes occurring in compact bone with thepassage of bullets at a low rate of velocity. No case of perforation ofthe subclavian vein by comminuted fragments of the clavicle came undermy notice. _Fractures of the humerus_ of every variety were common, and I thinkwhen the statistics of the campaign are published, it will be shown thatthe humerus was the most frequently injured individual bone in the wholebody. I remember to have seen thirteen fractures of the shaft of thehumerus in one pavilion alone at Wynberg after the battle of Paardeberg. Perforations of the upper articular extremity were common, and as a rulegave rise to wonderfully little trouble in the shoulder-joint. The outeraspect of the head of the humerus is a common situation for theproduction of a special form of broken canal or groove (fig. 53). Theslope from the greater tuberosity to the shaft naturally favours theproduction of the injury in this position. I saw only one case in which a vertical fissure extended from a fractureof the shaft into the shoulder-joint; in this case the transversesolution of continuity was at the upper part of the middle third of thebone. Skiagram, plate IV. , illustrates a well-marked stellatecomminution of the shaft with large fragments. Plate V. Shows extremecomminution with fragments blown out of the wound. Two plates, Nos. VI. And VIII. , illustrate well the difference resulting from the obliquepassage of a bullet at high and low rates of velocity respectively. Inboth cases good results were obtained; in the more severe the resultantmass of ensheathing callus was very large, temporarily interfered withflexion of the elbow-joint, and consolidation was very slow (see plateVII. ). The patient was wounded at Belmont in November 1899, but he wasable to row at the end of the summer of 1900, although very prolongedsuppuration occurred, and the elbow movements became practically normal. Plate IX. Illustrates a transverse track, the bullet having undergoneconsiderable injury during its passage through the bone, as evidenced bythe presence of fragments both of mantle and lead in the limb. Thismight be called an example of transverse fracture, and illustrates thenearest approach to one seen when the bone is struck fairly plumb. [Illustration: PLATE IV. Skiagram by H. CATLING Engraved and Printed by Bale and Danielsson, Ltd. (24) COMMINUTED FRACTURE OF THE HUMERUS Range about '300 yards. ' The wound track took a directly antero-posterior course. Impactrectangular. The musculo-spiral nerve was completely divided. The plate affords a good example of the so-called 'butterfly' fracture. Two long doubly wedge-shaped lateral fragments, and pointed extremitiesto both main fragments, are shown. The fracture healed well, with the deposition of a large mass ofprovisional callus. The musculo-spiral nerve was united by suture somethree months later. ] Plate VIII. Exhibits an oblique fracture of the lower part of the shaftproduced by a bullet passing at a low rate of velocity. It does notwidely differ from a perforation, and the illustration possesses somefurther interest as showing the deviation of a bullet likely to occurwhen a bone lies in its course. Although the velocity with which thisbullet was travelling must have been very low, when the bone had beentraversed the deviation in its course was slight. A few bony fragmentsfrom the compact tissue of the posterior surface of the humerus havebeen carried into the distal portion of the track. Fractures of the various prominences of the lower articular extremitywere not uncommon, but deviated little from the types with which we arefamiliar in civil practice; the after results were good, both as tounion and movement of the elbow. Explosive wounds of the soft parts were not infrequent in the arm, andfig. 48, p. 158, exhibits an extreme example. The humerus in respect ofdepth of covering, however, comes between the femur and the bones of theleg and forearm; hence such injuries were not so easily produced as inthe latter segments of the limbs. In connection with the subject of fractures of this bone, one word mustbe added as to the occurrence of the most characteristic of itscomplications, musculo-spiral paralysis. This was frequent in everyposition of the fracture, and came on either immediately, or, at asubsequent period, as a result of callus irritation or pressure. Itsfrequency is only what would be expected when the nature of the fractureis considered, but the chief interest of the condition lay in thedifficulty of certainly detecting it in the initial stages of the cases;this depended on the fact that in many of them the local shock to thelimb was so severe that the function of the whole of the muscles waslowered, or in some cases, although the musculo-spiral was the nervechiefly affected, the other large trunks had also suffered concussion orcontusion. In consequence of this difficulty the actual localisedparalysis often only became evident at the end of a week, or even more, when there was difficulty in deciding as to whether the paralysis wasprimary or due to secondary trouble. In the fracture illustrated byskiagram, plate IV. , the nerve suffered complete division, and wasunited some three months later, improvement in the symptoms being veryslow. The latter was a common experience, and although not unusual incivil practice, I think it is more marked in these injuries as a resultof the more widespread character of the nerve lesion. [Illustration: PLATE V. Skiagram by H. CATLING. Engraved and Printed by Bale and Danielsson, Ltd. (25) COMMINUTED FRACTURE OF THE HUMERUS Range '50 yards. ' Velocity extreme. Impact somewhat oblique. The bullet entered anteriorly about 3 inchesabove the elbow crease. The wound of exit was on the inner aspect of thearm and explosive in character; it still measured 4 inches by 2 inchesthree weeks after the injury was received. The wounds suppurated locally, but at the end of six weeks fair union ofthe bone had taken place and the wound of exit had contracted to asinus. The musculo-spiral nerve was concussed, but not divided. The skiagram was taken three weeks after the reception of the injury. Comparison with plate IV. Demonstrates the effect of high velocity infree comminution of the bone, the sharper radiation of the stellatelines of fracture, and the propulsion of bone fragments. ] The _bones of the forearm_ were also often fractured. The principalpeculiarity of these fractures was the common localisation of the injuryto one bone, which is readily seen to be probable. Each bone offered some special features dependent on its structuralcharacter and anatomical position. In the case of the _ulna_, pureperforation of the olecranon process, without obvious evidence ofimplication of the elbow, was seen on several occasions. The otherimportant feature with regard to this bone depends on its subcutaneousposition, which accounted for the frequency with which highly developedexplosive exit wounds were met with. One is figured in the generalsection (fig. 47, p. 156). This, however, is a very slight instancecompared with what was often seen in the upper and middle thirds of thebone, where the lateral soft parts often protruded as a much largertumour, the particular illustration being mainly designed to show thenature of the injury to the skin. The _radius_, as more deeply placed inthe upper part of its course, was less often the seat of suchwell-marked explosive injuries; but when the lower end was struck thischaracter was sometimes very striking: thus in a track passingantero-posteriorly through this bone, the whole lower end appearedshattered, all the tendons at the back of the wrist being implicated inthe protruding mass, while the bone itself seemed shortened, so that thehand took up the position common in Colles's fracture. It was foundimpossible to place the bone in good position; nevertheless the patientretained his hand, which is still of use in writing. Plate X. Is a good example of a high-velocity injury in which lateralcontact with the radius has produced local comminution, some slightinjury to the casing of the bullet, and the separation of a large wedge. The case from which this was taken also illustrated well one of thechief troubles of such fractures of the forearm; the degree ofsplintering resulted in the formation of a large mass of callus, whichfor a time rendered any degree of pronation and supination impossible. [Illustration: PLATE VI. Skiagram by H. CATLING. Engraved and Printed by Bale and Danielsson, Ltd. (26) COMMINUTED FRACTURE OF THE HUMERUS Range '250 yards. ' Impact oblique. Wound of entry 1 inch below the insertion of thedeltoid; exit, on inner aspect of arm at a slightly lower level. Thebullet probably struck the bone laterally, and drove out the centralfragment. Prolonged suppuration resulted, but the humerus healed well, and goodmovement of the elbow was preserved. The effect of oblique impact together with high velocity is wellillustrated. Had the resistance been greater, as in the case of thefemur, a nearer resemblance to the effect seen in plate XV. Would havebeen the result. ] Of _fractures of the hand_ I have little to say. In the case of the_carpus_, the slight degree of resistance offered by the bones renderedinjuries of an explosive character rare. I never saw one. Fractures ofthe _metacarpus_, on the other hand, presented exactly the oppositefeatures. The density of these small bones was well illustrated by thefrequency with which the bullet suffered injury, even amounting tofragmentation, and the great comminution they themselves suffered. Thebreaking up of the bullet in these fractures was a curious feature, which may perhaps be explained by the tendency of the distal part of thelimb to be driven in the course of the bullet, with the result ofsomewhat lengthening the period of contact of the projectile, or moreprobably by somewhat frequently occurring irregular impact. Plate XI. Isa good example of an injury of this nature of moderate severity. Thesoft parts suffered much in these injuries, the tendons were torn andlacerated at the moment, and were very apt to acquire more or lesspermanent adhesion. This latter condition was sometimes to be improvedby the removal of bone fragments, and I have freed tendons from actualclefts in the bones where they had been carried in by the bullet. Insome cases very great deformity of the digits, due to shortening, developed, even when no fragments were removed beyond those blown awayby the bullet. One form of injury of some interest was multiple fracture of thephalanges produced by a bullet travelling in a course parallel to thelength of the rifle when pointed by the patient. Occasionally severaldigits were lost. _Treatment of fractures of the upper extremity. _--The general lines ofthis have already been foreshadowed in the general section, the remarksas to transport being applicable to all serious fractures of the shaftof the humerus, and this is the only one of the bones of the upperextremity on which anything special need be said, as the treatment ofall the other fractures exactly coincides with that of ordinary civilpractice. [Illustration: PLATE VII. Engraved and Printed by Bale and Danielsson, Ltd. (26_a_) CONDITION OF THE SAME FRACTURE SHOWN IN PLATE VI. , A YEAR AFTERITS PRODUCTION The ensheathing callus is still very abundant, but less so than at anearlier date. No trouble with the musculo-spiral nerve was noted, butresidual abscesses occurred from time to time in connection with thefracture. ] [Illustration: FIG. 54. --German Wire Gauze Splint on steel wirefoundation. (German Ambulance, Heilbron)] The treatment of wounds should be on the lines already laid down:thorough cleansing, and then an attempt to seal. In severely comminutedfractures, however, the exit wound may be of very large size, and thenfrequent dressings are necessary. Loose fragments, by which those freedfrom their periosteal connections are meant, need removal. The questionwhich most interested me was the best method of fixation. This needs tobe sufficient to effect immobility, but on the other hand in many casesthe weight of the arm as a means of extension is very valuable. Some ofthe most successfully treated cases that I saw were fixed by means ofsimple strips of pasteboard, applied moist, and fixed with an adhesivebandage. Ordinary book-muslin bandages are as good as anything for thispurpose, as they can be reinforced by a stronger form outside them. Where necessary, an angular piece of cardboard can be applied on theinner aspect, or a wooden angular splint may be substituted, if it is athand; but in this case most of the advantage of the weight of the arm asa means of extension is lost. The cardboard cases possess the greatadvantage of being readily cut off and reapplied much as is done withplaster of Paris. During the period in which dressing may be necessary Ibelieve this form of splint is as good as can be got for use in Fieldhospitals, the only point needing care being to ensure that thebandaging is not too tight. It is much more reliable than are ordinarysplints if transport is unavoidable, and is much lighter and lessirksome to the patient. With such strips of cardboard, a few of thegauze splints (fig. 54), and a few angular and wooden splints, I believea Field hospital is fully equipped for the treatment of any fractures ofthe upper extremity. [Illustration: PLATE VIII. Skiagram by H. CATLING. Engraved and Printed by Bale and Danielsson, Ltd. (27) OBLIQUE FRACTURE OF THE HUMERUS OF THE NATURE OF A PERFORATION Range more than '1, 000 yards. ' The distance was probably much greater, as the bullet was retained andundeformed, and the comminution of the bone was very slight. The woundof entry was just below the elbow. The bullet has cut its way through the inner half of the humerus, producing little comminution and mere solution of continuity of the bonewithout displacement] _Fractures of the pelvis. _--These, as a rule, were of so slight a natureas to form a very insignificant part of the entire injury with whichthey were associated, or when uncomplicated they were of little moreimportance than simple wounds of the soft parts. The very great majoritywere of the simple perforating type. I had the opportunity of examiningthree at the brim of the pelvis, these all passing in a downwarddirection. The openings were of about the same calibre as the bullet, and at their entrance was a small amount of bone dust such as would befound at the entry hole of a gimlet. It was these that made me considerthe possibility of the rifle grooves having some part in the ease withwhich certain perforations are made. Of a large number of cases in whichbullets traversed the ilium, the openings in the bone, as a rule, werewith difficulty palpated. I must say that I was astonished that I nevermet with an instance of an extensive stellate fracture in the case ofthe ilium. Such may have occurred in some of the cases fatal on thefield or shortly afterwards, but I never came across one in thehospital. It says much for the combined density and toughness of thehuman pelvis. Comminuted fractures were, however, occasionally met with when thebullet passed in a track parallel to the plane of the bone. One such ofan unusual character has already been mentioned on p. 171. A still moreinteresting form, and one highly characteristic of flat bone injuries, is shown in fig. 55. The patient, a man wounded at Modder River, wasstruck at a range of 300 to 400 yards. The bullet entered over about thecentre of the ilium and emerged in the anterior abdominal wall about 2inches above the anterior-superior spine. As there was some doubt as topenetration of the abdomen, and as the exit wound was of considerablesize, the wound was explored, an anæsthetic having been given. Aclean-cut track in the bone was discovered which allowed the middlefinger to be placed in it. There was little splintering of either inneror outer table of the bone beyond the width of the track, but plates ofeach table adhered on the one side to the origin of the gluteus medius, and on the other to the iliacus, the latter muscle being somewhat widelyseparated from the venter ilii by effused blood. There was noperforation of the abdominal cavity. [Illustration: PLATE IX. Skiagram by H. CATLING. Engraved and Printed by Bale and Danielsson, Ltd. (28) LOCALISED COMMINUTED FRACTURE OF THE HUMERUS Range '100 yards. ' The entry and exit wounds were on the front and back aspects of the arm, about 3 inches above the elbow. Fragmentation of the mantle of the bullet has occurred. It will be notedthat the fragments are lodged in both the proximal and distal segmentsof the track. This may indicate that the bullet was damaged prior toentry, or the recoil of fragments. I incline to the latter view. Theskiagram was taken a fortnight after the injury. The large median fragment carried forwards, and the small degree ofcomminution, suggest the decrease of resistance and prolongation ofimpact by carriage back of the arm when struck. The fracture is one of the nearest approaches to a transverse cleft thatI met with. The plate may well be compared with No. XII. , where the effect ofincreased resistance in augmenting the degree of comminution is seen. ] Lesser degrees of the same kind of injury amounting to grooving of thesurface or notching of the crest of the ilium were not uncommon, and theoccasional large character of exit openings in buttock wounds pointed tocontact of travelling bullets with other parts of the external pelvicwall. [Illustration: FIG. 55. --Clean Gutter Fracture of the Ilium (rangeplaced by patient at 300 yards. Highland Brigade, Magersfontein). Thegutter was clean cut, and admitted the forefinger. The inner and outertables of the bone were in part blown out of a large irregularlycircular exit opening about 1-1/2 in. Above the crest of the ilium. Thecancellous tissue was probably entirely blown out. Plates of the outerand inner tables still remained connected by their periosteum to thedeep aspects of the iliacus and gluteus medius muscles. The peritonealcavity was not opened. The patient did well. Compare with the gutterfractures of the skull shown in figs. 64, 66. ] Certain portions of the pelvis were subject to more severe comminution;thus in one case in which the bladder was wounded, a very muchcomminuted fracture of the horizontal ramus of the pubes was produced bya bullet which subsequently lodged in the thigh behind the femoralvessels. In this case the track was so oblique as to have necessitatedalmost pure lateral impact on the part of the bullet; hence the form ofinjury was nearly allied to the comminutions of the ilium alreadydescribed. [Illustration: PLATE X. Skiagram by H. CATLING Engraved and Printed by Bale and Danielsson, Ltd (29) Wedge-shaped Fracture of the Radius Range 'a few yards. ' The officer shot the man, his assailant, with a revolver. The entrywound was on the posterior aspect of the forearm at the junction of themiddle and lower thirds. The exit wound was on the anterior aspect ofthe forearm, 1 inch below the elbow crease, and of moderate size. Some fine fragmentation of the mantle of the bullet is indicated, andvery fine comminution of the bone. The fracture healed well, but theresulting mass of callus at the end of three months prevented anymovements of pronation or supination. ] I never observed a fracture of the floor of the acetabulum by a bulletwhich had entered from the back of the pelvis, although tracks enteringby the great sciatic notch were not infrequent. I saw one case in whicha bullet which traversed the upper part of the shoulder and emerged atthe axilla entered a second time an inch behind and above the anteriorsuperior spine, and split off a layer of the outer table of the ilium ofthe extent of two square inches, which involved the upper portion of therim of the acetabulum. No displacement upwards of the femur resulted;but external rotation was accompanied by crepitus. The wound suppurated, and some general infection resulted, but six weeks later there was noevidence of fluid in the hip-joint, the limb was adducted and slightlyrotated outwards, and some movement in each direction could be madewithout causing any great amount of pain. I can say nothing of thefurther course of this case, as I neglected to take the patient's name. I saw one or two instances of perforation of the sacrum. One ismentioned in the chapter on injuries to the abdomen, in which a centralpuncture at the level of the fourth vertebra was accompanied bytemporary incontinence of fæces. Fractures of the _femur_ were fairly numerous and formed one of the mostserious classes of case we had to treat, as well as one of the mostfertile sources of mortality in the Base hospitals. In spite of the lastobservation, however, it is probable that the results in this campaignwill be far better than in any previous war, both as to the smallerproportion in which amputation was needed and as to recovery. [Illustration: PLATE XI. Skiagram by H. CATLING. Engraved and Printed by Bale and Danielsson, Ltd. (30) COMMINUTED FRACTURE OF THE SECOND METACARPAL BONE Large fragments of the mantle of the bullet. Fragmentation of the bullet was comparatively common when the metacarpalbones were struck, also free comminution of a somewhat coarser varietythan that seen when bones offering greater resistance were struck. This may be a result of the more frequent lateral impact of the bulleton these small bones. ] In spite of a considerable experience, I never saw a case of perforationof either the head or neck of the thigh bone. I saw numerous tracksemerging at the side of the femoral vessels and entering at the buttockor vice versa, but never one accompanied either by effusion into thehip-joint or impairment of movement. Considering the regularity withwhich hæmarthrosis occurred when the other joints were crossed, and alsothe nature of the compact tissue of the neck of the femur, which musthave ensured some splintering, I do not think I can have overlooked aninjury of this nature. No doubt also the escape of the neck of the bonewas explained in some of the cases by the fact that the injuries werereceived while the hip-joint was in a position of flexion, the bulletpassing over the neck of the femur. In two cases of extensivecomminution of the upper third of the femur that I saw, the fissuresstopped short at the inter-trochanteric line anteriorly, but in one ofthem a large angular fragment was torn out of the posterior surface ofthe neck. Excepting transverse fracture every form was met with in the shaft, although I saw only two instances of perforation. One has been alreadyalluded to and was situated in the broadening portion of the lowerthird, the bullet taking an antero-posterior course. The second is seenin plate XVII. Plate XII. Shows an instance of extreme comminution of the upper thirdaccompanied by the presence of two typical elongated fragments. Thecourse taken by the bullet was almost directly antero-posterior, and thewounds were of moderate size even in the case of the exit one. Thisseems to preclude the possibility of the injury having been produced bya ricochet bullet, while the fact of perforation and escape of thebullet in spite of the serious damage suffered by the mantle points tothe injury having been produced at a short range of fire. The patienthimself owns to being quite unable to give any estimate of the distance. Although no suppuration occurred, this fracture was very slow inconsolidating, and the free comminution with consequent inaccurateapposition led to the development of four inches shortening of the limb. The skiagram was taken about six weeks after the occurrence of theinjury, a few days after I first saw the patient; I have, however, hadthe opportunity of seeing a second skiagram taken some four monthslater. This is of considerable interest, as throwing light on the modeof union of such fractures. The two elongated fragments in the laterskiagram are widened to three times their original breadth, and formbuttresses on either side of the point of union, while the irregularends of the shaft are rounded off, and the mass of fine fragments behindis consolidated. Beyond this the second skiagram shows that the upperfragment, apparently intact in the first, was really splitlongitudinally, and therefore was far less useful as a point of supportthan might have been assumed from the earlier skiagram, plate XIII. Thecase illustrates well the chief difficulty in the treatment of suchfractures: that of maintaining the fragments in line, since absolutelyno help is received from the apposition of the two ends, and artificialtraction alone must be relied upon. [Illustration: PLATE XII. Skiagram by H. CATLING. Engraved and Printed by Bale and Danielsson, Ltd. (31) HIGHLY COMMINUTED FRACTURE OF THE UPPER THIRD OF THE SHAFT OF THEFEMUR Range 'short. ' Impact fairly direct. The wounds were of moderate size and at nearly thesame level. The exit wound near the buttock fold was of moderate size, and presented no special features. Considerable fragmentation of the bullet occurred. The comminution ofthe bone is very fine, suggesting high velocity, and great resistance bythe bone. The skiagram was taken five weeks after the injury wasreceived, and at that time no union had occurred. Reference to plate XIII. Will explain more fully the difficultyexperienced in maintaining this fracture in position. The upper fragmentis seen to be split into fragments, beyond the separation of the longsplinter on the inner side; hence no aid was to be obtained from theapposition of the ends. About 2 inches of the shaft were actuallypulverised; the fine fragments seen in a mass to the inner side of thebone in the exit portion of the back, eventually formed a large mass ofcallus, and the fracture united, with considerable shortening. ] Plate XIV. Offers a good contrast; the fracture here presents a typicalstellate form, and a good result without shortening was readilyobtained. I assume that the difference in character of these twofractures depended mainly on the rate of velocity with which the bulletwas travelling, since it passed fairly directly across the limb in each. I think it is clear, however, that the bullet struck the femur rathernearer the centre of the width of the shaft and therefore more directly, in the more severe injury. This brings me to the question of explosive exit wounds in the thigh. Inspite of the great tendency to comminution of the shaft, these were rarein a severe form. This depended simply on the depth and thickness of thecoverings of the bone, and, as already mentioned, although the skinopenings were often comparatively small, a large cavity or area ofdestroyed soft tissues may be contained within the limb. I do not thinkI ever saw an exit wound in the thigh exceeding 1-1/2 inch in diameter. The oblique fracture illustrated by plate XVI. Has been already referredto, and the influence of the weight and movement of the trunk on itsproduction has been considered. Plate XV. Illustrates an obliquely comminuted fracture of anothercharacter. The bullet has here been stripped of its mantle, which hasundergone fragmentation, but the leaden core is little altered in shape. This is of much interest, since it shows that the bullet struck the boneby its side. The effect of such lateral impact on the part of theprojectile is well shown: there is great bone comminution of a lessregular character than usual, and the bullet is retained. Retention inthis case was probably not a result of low velocity of flight, but ofthe increased resistance offered by the broad area of bone struck, andthe check exerted on the axial rotation of the bullet by the lateralcontact. [Illustration: PLATE XIII. Engraved and Printed by Bale and Danielsson, Ltd. (31_a_) THE FRACTURE SHOWN IN PLATE XII. , SIX MONTHS AFTER RECEPTION OFTHE INJURY The amount of callus furnished around the loose fragments is verystriking. The upper end of the bone is shown to have been divided into at leasttwo fragments, hence one of the difficulties of maintaining the ends inapposition. The stoppage of the fissuring short of the epiphysis ischaracteristic. ] Slighter injuries to the femur in which the shaft was chipped or groovedwithout loss of continuity were not uncommon, and showed well thecapacity of the bone to withstand the lateral shock transmitted by smallbullets. Two figures inserted in the chapter on wounds in general (figs. 22, 23, pp. 61, 62) are of cases in which, from the appearance of thewound of exit, the bullet probably underwent deformation, or was sodeflected as to escape on a considerably altered axis. Beyond the natureof the exit wound in the case depicted in fig. 22, some thickeningbeneath the femoral vessels denoted bone injury, but unfortunately noskiagram was taken. I saw no case in which a transverse fracture of the shaft accompaniedsuch injuries, but am under the impression that, if they had beenproduced by bullets of greater volume and weight, transverse solution ofcontinuity would have been more common. In point of fact, no case ofpure transverse fracture of the femur ever came under my notice. The diagram depicted in fig. 51, p. 164, is from a sketch made of thelower end of a femur in which a severely comminuted fracture followed bysuppuration necessitated an amputation of the thigh, performed by MajorLougheed, R. A. M. C. It is inserted as an illustration of the tendency ofthe fissures to stop short above the actual articular extremities of thebones. In this case the comminution was extreme and accompanied by theusual long lateral fragments, one of which measured five inches inlength and might well have extended into the knee-joint had that been anordinary occurrence. Perforations of the lower extremity of the bone were very common. Thesewere sometimes transverse and limited to the articular extremity itself, or the same limitation occurred to the antero-posterior tracks. Thesewere the slightest forms of injury, putting on one side incompletetunnels and grooves on the surface of the bone. With regard to thelatter, however, when they invaded the joint cavity the injury wasliable to be more severe than a complete perforation, in consequence ofthe projection of comminuted fragments into the joint cavity near theline of reflection of the synovial capsule and ulterior interferencewith freedom of movement. [Illustration: FIG. 55_a_. --Diagram of 'Butterfly' type. ] [Illustration: PLATE XIV. Skiagram by H. CATLING. Engraved and Printed by Bale and Danielsson Ltd. (32) TYPICAL STELLATE (BUTTERFLY) COMMINUTED FRACTURE OF THE FEMUR Range 'short. ' Wounds small, impact direct, very little fine comminution. The boneunited without shortening of the limb. ] Other tracks took a direction of longitudinal obliquity, and thenimplicated both epiphysis and diaphysis. Fig. 52, p. 169, shows anexample, and also the peculiarity likely to be assumed by the exitaperture in the bone, especially if the bullet was travelling at a lowrate of velocity, a considerable plate of the compact bone being drivenout. In some cases these oblique tracks involved both femur and tibia. They will be referred to again under the heading of injuries to thejoints, and some remarks will also be found there regarding the synovialeffusion so often occurring into the knee-joint in cases of fracture ofthe shaft of the bone. It may be of interest to insert here a few remarks as to the clinicalcharacteristics of fractures of the femur. First with regard to theprimary signs and symptoms. A very considerable degree of general orconstitutional shock usually accompanied them, and this was perhaps moreconstant than in the case of any other injury in the body. This was, moreover, no doubt increased by the unfavourable conditions in whichpatients on the field of battle are situated in regard to transport. When the patients were brought into hospital some delay in the primarytreatment was often necessary until reaction took place. Local shock tothe part was also a prominent feature. Abnormal mobility was very freein the badly comminuted cases. Crepitus was often loose, and of 'the bagof bone' variety. The result of local shock and consequent flaccidity ofthe muscles was to reduce the development of primary shortening; in somecases of severe comminution this was practically nil during the firstday or two, when, with return of tone in the muscles, it sometimesbecame very considerable. Swelling of the limb was often very great, andvascular injury definitely far more common than in the fractures ofcivil practice, in consequence, no doubt, not only of the number andsharpness of the fragments, but also of the force with which they weredriven into the surrounding tissues. The exit segment of the track wasout of all proportion in size to the entry, as a result of thepropulsion of bone fragments through it. This often made the closure ofthe exit wound a very protracted event, the track continuing todischarge a small quantity of bloody serum and fragments of necrosedtissue for many weeks. [Illustration: PLATE XV. Skiagram by H. CATLING. Engraved and Printed by Bale and Danielsson, Ltd. (33) COMMINUTED FRACTURE OF THE FEMUR Range 'short. ' Normal entry wound of slightly oval form. Oblique lateral impact on the part of the bullet, the mantle of whichburst into numerous fragments. The bullet is seen to the inner side ofthe shaft, almost devoid of its mantle, and little deformed at the tip. The comminution of the upper portion of the fracture is very fine; thebullet has merely cut its way down the lower portion, and one or twolong fragments are separated. The skiagram shows well the result oflateral impact by the side of the bullet. Compare this plate with No. VI. As illustrating lesser resistance, andNo. VIII. As illustrating the effect of lower velocity. ] In a large proportion of the cases which were transported for anydistance suppuration occurred; this must have been the case in at least60 per cent. Of the fractures. Suppuration was of the character alreadydescribed in the general section, affecting particularly the boneitself, and accompanied by very marked signs of general infection. _Prognosis in fractures of the femur. _--As regards mortality fracturesin the upper third of the bone proved one of the most formidableinjuries which came under treatment. Suppuration was common, at least 60per cent. Of the wounds becoming infected. This depended on severalreasons, often inseparable from the injuries, or from their treatment inField hospitals: such as (1) the exit wound being situated in thedangerous region of the thigh; (2) ineffective dressing and fixation;(3) the impossibility of ensuring primary cleansing and removal ofdetached fragments of bone; (4) the necessity of the early transport ofpatients to the Stationary or Base hospitals, often for great distances;(5) the comparatively long period that often had to elapse before theopportunity of doing the first efficient dressing arrived. Fractures in the middle and lower thirds of the bone were more easy totreat successfully, but these also added to the list both of amputationsand fatalities. Punctured fractures of the lower articular extremity were usually oflittle importance, as they progressed without exception, as far as myexperience went, favourably. I can give no idea of the general results obtained during the wholecampaign, but I am able to state the results of the fractures of theshaft treated at No. 1 General Hospital during my stay in South Africa. Thirty-two cases of fracture of the shaft of the bone came undertreatment, and of these 6 or 18. 7 per cent. Needed amputation, and ofthe whole number 5 or 15. 6 per cent. Died. To emphasise the satisfactorynature of these figures I need only quote the results attained in theAmerican War of the Rebellion; mortality in upper third, 46 per cent. ;middle third, 40. 6 per cent. ; lower third, 38. 2 per cent. [Illustration: PLATE XVI. Engraved and Printed by Bale and Danielsson, Ltd. (34) OBLIQUE FRACTURE OF THE SHAFT OF THE FEMUR Range '300 to 400 yards. ' Aperture of entry just above the centre of the outer aspect of thethigh. Exit, about 2 inches lower, at the junction of the inner andposterior aspects. The bullet was retained just within the wound, andwhen removed the mantle fell off in two parts. The leaden core wasmushroomed. The bullet had passed through another soldier previous toentering the patient's thigh. Only two small fragments of the mantlewere retained, as seen in the skiagram. These were in the substance ofthe great sciatic nerve, and were subsequently removed by Sir ThomasSmith. It is difficult to determine how the bone was struck; reference to plateXXI. Would suggest that the shaft may have been perforated, but noevidence of this remains in the skiagram taken, which was five monthslater. The patient was standing at the moment of reception of the injury, andthe obliquity of the fracture no doubt depended on his fall and theresulting influence of the weight of the body. The length of thefracture cleft was 9 inches. ] I need hardly dwell upon the difference between the nature of theinjuries received in the American War of the Rebellion and in thepresent campaign, as in the former the old large bullets were employed, and shell injuries are possibly included; but I ought to add in thisrelation, that the numbers quoted from No. 1 General Hospital included, to my knowledge, at least three severe Martini-Henry wounds. The first element for a favourable prognosis is a small wound, andopportunity for an efficient primary treatment of the same; the secondthe absence of necessity for transport of the patient. With regard tothe second of these requirements, we were unfortunately situated inSouth Africa, and the majority of the cases which did badly were movedduring the first few days and for a distance of between five and sixhundred miles. On the other hand, as a rule, the external wounds weresmall. As to functional result, the fractures did well. I think an average ofan inch and a half would well cover the shortening, and in many thelength was little altered. Considering the serious nature of many ofthese fractures, this was good. _Treatment. _--In all punctured fractures of the lower extremity, dressing of the wounds like uncomplicated ones and a short period ofimmobilisation were all that was necessary. In oblique fractures, andthose with slight comminution, closure of the wound by dressings, afterit had been carefully cleansed, was all that was necessary prior toapplying the splints for immobilisation. [Illustration: PLATE XVII Skiagram by H. CATLING. Engraved and Printed by Bale and Danielsson, Ltd. (35) PERFORATION OFTHE SHAFT OF THE FEMUR. FLAP OF BONE RAISED AT THE APERTURE OF EXIT INTHE POPLITEAL SURFACE OF THE SHAFT. Range 'over 1, 000 yards. ' Compare with fig. 52, p. 169. ] In the highly comminuted fractures a more radical treatment wasindicated, especially if the exit wound was large. In these, aftercareful preliminary cleansing of the limb, the wounds, especially theexit aperture, needed exploration and, if necessary, enlargement, andall free splinters needed removal. If interference with the entry woundcould be avoided, this was always preferable, as it was rare for thisnot to heal by primary union unless free suppuration occurred. UnderField hospital conditions I think the exit wound should never besutured, whatever its situation; and in the present campaign, wherecarbolic acid lotion was freely used, this step was manifestlyinadvisable, in view of the abundant serous discharge always to beexpected when this disinfectant has been employed. Except in casesmanifestly infected at the time of exploration, the use of drainagetubes or plugs is not to be recommended. I would point out also that inthe majority of cases it is quite hopeless to attempt to make the entrywound the safety-valve for drainage, as its natural tendency, even ifenlarged, is to heal, while the condition of the tissues in the exitsegment of the track usually renders primary union an impossibility. The wound having been dealt with, the next indications were for thereduction of deformity, immobilisation of the limb, and the provision ofa proper degree of extension. As to the reduction of the fracture, thiswas always a matter of ease, needing only slight axis traction. Theprovision of efficient means of extension and immobilisation was a verydifferent matter. These questions had to be considered under two sets ofconditions: (1) when it was possible to keep the patient at rest in thehospital he was first deposited in; (2) when it was necessary for him tobe transported for a considerable distance, probably not less than 500miles. When transport is a necessity, the best method of immobilisation is theapplication of breeches of plaster of Paris, and a long outside splint. The latter we often had excellently made on emergency by the OrdnanceDepartment or the Royal Engineers. A perineal band is the only form ofextension possible under these circumstances. The Dutch ambulances wereprovided with a very excellent emergency splint for cases of fracturedthigh, which is illustrated in fig. 56. I think something of this kindshould be carried in one of the ambulances going on to every field ofbattle, as being far more suitable than a long outside splint for hastyand inaccurate application. This splint, fixed with some kind of firmbandage, is an excellent temporary one for use during transport. [Illustration: PLATE XVIII. Skiagram by H. CATLING. Engraved and Printed by Bale and Danielsson Ltd. (36) OBLIQUELY TRANSVERSE FRACTURE OF THE PATELLA Range 'short. ' The entry and exit wounds were small, and a distinct grooving from lossof substance of the bone was palpable superficial to the actual cleft ofthe fracture. ] [Illustration: FIG. 56. --Dutch Cane Field Emergency Splint for Thigh orLower Extremity. (Dutch Ambulance, Winberg)] In cases which can be treated at a Stationary hospital near at hand, along outside splint supplemented by plaster breeches, and a well-appliedAmerican extension, is a very good method of treatment, the only pointto bear in mind being frequent examination of the position of the limbto ensure the extension being efficient. As already mentioned, theshortening in the primary stages is often slight and easily combated, but in many of these cases if examined in a few days the limbs are foundto have shortened considerably, principally as a result of recovery oftone by the muscles, and the absence of any help from the resting of thetwo fragments end to end. The weight, therefore, has often to beprogressively increased and the fracture readjusted if necessary. Although this method of treatment is satisfactory in cases with a smallwound, it is very troublesome to carry out, even when a bracket isinserted opposite the wound, when frequent dressing is necessary, as isgenerally at first the case when the wounds are large. For this purposea much more satisfactory method is the use of Hodgen's splint. Thisallows of automatic adjustment of the degree of extension, and thedressing of the wound without interference with the position of thefracture. A continuous many-tailed bag is preferable to the stripsusually employed for the suspension of the limb, as more easilyadjustable and as offering a more even support to the limb. [Illustration: PLATE XIX. Skiagram by H. CATLING. Engraved and Printed by Bale and Danielsson Ltd. (37) OBLIQUE COMMINUTED FRACTURE OF THE TIBIA Range '600 yards. ' The entrance wound was large and the exit also. The fracture may havebeen caused by a Mannlicher (8 mm. ) soft-nosed bullet, or possibly aricochet. The fragmentation is somewhat coarse at the periphery, butvery fine in the track of the bullet. Several fragments of the mantleare visible. The fracture affords a good example of obliquity due to cutting by thebullet, and contrasts well with those due to rectangular impact such asare shown in plates IV. And XIV. ] While at Orange River, in conjunction with Major Knaggs, R. A. M. C. , andMr. Langmore, we treated several cases of fracture of the shaft of thefemur by this method. The splints were made for us by the OrdnanceDepartment, while the Royal Engineers erected a kind of gallows for usdown the centre of a commissariat marquee in order to avoid the risk ofusing the tent poles for suspension. The patients were then ranged oneach side of the tent in two rows so that the pull of the two sets oflimbs opposed each other on the gallows from which they were suspended. Although these patients had to lie on the ground, they were reallycomfortable compared with those treated with long outside splints, andthe results obtained were very good: in three cases which I had theopportunity of measuring later the bones were in good position and theshortening was less than one inch. I have no doubt whatever that Hodgen's splint is by far the best methodof treating all cases of fractured thigh in the Stationary fieldhospitals; and, more than this, I believe it is the only practicable andefficient one. It can be applied without the use of an anæstheticwithout causing undue suffering to the patient, it allows of readychange of the dressing, it is comfortable and permits considerable rangeof movement on the part of the patient, it is as efficient with patientslying on the ground as in a bed, it keeps the limb in good position andallows of constant inspection on this point, and it is the only methodwhich provides satisfactory extension without constant readjustment. [Illustration: PLATE XX. Skiagram by H. CATLING. Engraved and Printed by Bale and Danielsson Ltd. (38) TRANSVERSE FRACTURE OF THE TIBIA, COMMINUTED FRACTURE OF THE FIBULA Range '300 yards. ' Wound of soft parts nearly transverse, entry on tibial aspect. Thebullet crossed and grooved the posterior aspect of the tibia, but struckthe fibula full. This is the only instance of a transverse cleft whichcame under my notice. The wound suppurated, and a number of fragments of the fibula neededremoval; hence the amount of callus present. ] Cases in which operative fixation is indicated are rare, but a fewoblique fractures may be treated with advantage in this manner if theconditions surrounding the patient admit of it. Screwing is generallypreferable to wiring. Lastly, we come to the cases in which primary amputation is necessary. Imay say at once that I saw no case of wound from a bullet of smallcalibre in which this was indicated, and only one shell injury in whichit was performed. I believe with small bullets that injury to the mainblood-vessels is almost the only indication which is likely to be metwith, and this by no means always indicates an amputation. First of allthe question arises as to whether the wound in the vessel is caused by abone fragment or by the bullet itself; reference to the chapter onblood-vessels would seem to prove that a bullet wound is by no means anecessary indication for amputation. Given favourable conditions, itmight be treated locally by ligature at the time, while if hæmorrhage isnot proceeding, developments should be awaited before proceeding toamputation. In the case of bone fragment punctures, secondary hæmorrhageis a more likely indication for amputation than primary. Broadly, it may be laid down that very extensive injury to the softparts is the only indication for primary amputation beyond primaryhæmorrhage, and it may be added that the condition is rare with woundsfrom small-calibre bullets. If a primary amputation is necessary theobservations as to the transport of fractured thighs are equallyapplicable. I never saw a primary amputation do well that was movedduring the first week; sloughing of flaps or hæmorrhage followed as arule, and often death. Intermediate amputations were indicated in cases of septic infection andthose of hæmorrhage; they seldom did well, and should be avoided ifpossible. Secondary amputations for sepsis or hæmorrhage were attendedby fair results, but I can give no statistics. Unless extensiveosteo-myelitis is evident, or very widespread cellulitis of the limbexists, I am strongly of opinion that the amputations when the fracturesare above the middle of the thigh should be through the fracture, andnot at the hip-joint, even if a subsequent secondary operation isrisked. [Illustration: PLATE XXI. Skiagram by H. CATLING. Engraved and Printed by Bale and Danielsson, Ltd. (39) PERFORATION OF THE SHAFT OF THE TIBIA, AND INCOMPLETE OBLIQUEFISSURE EXTENDING FROM THE LOWER PART OF THE OPENING TO THE CREST OF THEBONE. Range medium. Entry and exit wounds at same level. The patient was standing when struck, and fell backwards, his riflefalling at the same time and striking the shin. The fibula is intact. The perforation indicated by the well-marked translucent spot is small. The forking of the lower extremity of the cleft suggests the starting ofthe fissure from above. The fissure comes to the surface at the seat ofelection, but its position may possibly have been determined by the blowfrom the falling rifle. The backward fall of the patient clearly explains the mechanism ofproduction of the fissure, and throws light on the production of anoblique fracture such as shown in plate XVI. ] _Fractures of the patella. _--Punctured fractures of the patella werecommon with direct impact of the bullet; these were often difficult topalpate, and were only to be certainly diagnosed by attention to thedirection of the track, and the development of hæmarthrosis. I saw atleast three or four in which the bullet, in addition to traversing theknee-joint, injured the popliteal vessels. I have notes of one case inwhich a bullet traversed the soft parts from above downwards and scoreda vertical groove on the surface of the patella; this was readilypalpable, but produced no solution of continuity. In several cases themargin of the patella was notched by a passing bullet. I never saw a case of stellate fracture, and by this my experience inthe case of the ilium was confirmed. On two occasions I saw pure transverse fractures of the bone; in eachthe wound was produced by a Lee-Metford bullet. This is of some interestas denoting that the greater volume and weight, in conjunction with theblunter tip, of the Lee-Metford may produce more severe injury to thebones than the Mauser. I believe this to be the case, given an equaldegree of velocity on the part of the bullet at the moment of impact;but it is probable that the position of the patella with regard to thecondyles of the femur when struck is of far greater importance inrelation to the production of transverse fractures. The skiagramrepresented in plate XVIII. Shows an obliquely transverse fracture, which in this instance resulted from a crossing bullet, which groovedthe surface of the bone. With regard to the two cases of transverse fracture above referred to, Imay add that one occurred in a youth under twenty, and a good result wasobtained by treatment with splints, and later by massage. In the secondthe patient was a man over fifty, who had received other injuries. Thewound over the patella healed and some union had occurred, when thepatient fell and burst both the bone union and the skin cicatrix. Secondary suppuration of the knee-joint, necessitating an amputation ofthe thigh, followed, but the patient made a good recovery. The thirdcase also did well. [Illustration: PLATE XXII. Skiagram by H. CATLING. Engraved and Printed by Bale and Danielsson, Ltd. (40) NOTCH FRACTURE OF THE CREST OF THE TIBIA Range 'short. ' The raising of the margins of the notch suggests a perforation. Comparewith figs. 51 and 57 in the text. ] The treatment of these injuries differed in no way from that adopted incivil practice, given satisfactory surroundings. Suture might beindicated in some cases of transverse fracture, but this would only benecessary if the fragments were widely separated. The puncturedfractures needed treatment as for simple wounds, combined with a shortperiod of rest and pressure for the condition of hæmarthrosis. It wasimportant not to prolong the period of rest beyond a week or ten days ifthe effusion was slight, in view of possible ulterior interference withrange of movement in the knee-joint. _Fractures of the tibia. _--Some remarks have already been made regardingfractures of the head of the tibia, and the importance of theoverhanging prominent margins in the production of somewhat irregularinjuries (p. 170). Putting these peculiarities on one side, thecancellous ends are subject to the type forms of injury; thusperforations either of the head of the bone or the malleolus were commoninjuries. The fractures of the shaft also deviated from the type in sofar as the broad flat surfaces in the upper two thirds of the bonerendered it especially liable to the results of lateral impact, and tothe production of the extreme wedge-shaped types of fracture. PlateXXII. Illustrates the different result of a bullet striking the denseand strong spine at a low rate of velocity, a notch only resulting. If, on the other hand, the lateral surfaces were struck, a wedge with thebase corresponding to the posterior surface was the most common injury, the spine in many cases remaining intact and maintaining the continuityof the bone. Wedge-shaped fractures of this bone were apt to showmultiple secondary wave fissures concentric with the main line, andconsequently free comminution. I saw several examples, the loosefragments being remarkably numerous. Plate XIX. Is an example of anoblique fracture produced by a bullet which has ploughed across thebone, displacing large fragments anteriorly, but finely comminuting thebone in its course, and leaving small fragments of the mantle on itsway. Plate XX. Is an example of the rare condition of transversefracture. [Illustration: PLATE XXIII Skiagram by H. CATLING. Engraved and Printed by Bale and Danielsson, Ltd. (41) SPURIOUS PERFORATION OF THE FIBULA Moderate range, 'about 1, 000 yards. ' The injury was caused by an 8 mm. Bullet, which entered base foremostand lodged in the calf. The fracture is really an incomplete stellateform, two well-marked transverse fissures extending from the pointstruck. The position of the bullet suggests its entry into the limb baseforemost, and as it is retained low velocity may be assumed. ] This fracture was produced by a bullet travelling at a high rate ofvelocity, which struck the posterior surface of the tibia, and caused agrooving, accompanied by a horizontal fissure through the wholethickness of the bone; later it struck the fibula more directly, andproduced an ordinary comminuted fracture two inches above the malleolus. Perforations of the shaft were far more common than in the case of thefemur, and I saw them in every part of the length of the bone (plateXXI. ). Fig. 57 illustrates a form of peculiar interest as showing thegradual transition of the tunnel to the groove, and also as bringingfractures of the long bones into line with such fractures of the flatbones of the skull as are depicted in fig. 68. [Illustration: FIG. 57. --(42) Perforation of lower third of Tibia, showing lifting and fissuring of the compact roof of the tunnel. Comparewith fig. 68, p. 259, of a fracture of the cranial vault. ] _Fractures of the fibula_ offered no special features of importance. Anyform might occur. The plate No. XXIII. Is of interest as showing aspurious form of perforation, and also the primary form of displacementof the fragments in stellate fractures. It was produced by a reversedricochet, but undeformed, bullet, still seen in position in theskiagram; the bullet only possessed sufficient force to perforate thebone, and then appears to have turned on its transverse axis. Thefollowing plate, No. XXIV. , is inserted to show the depth at which thebullet lay, and its distance from the surface of the tibia, whichappears in the first plate to be nil. It is also of interest as showingthe ease with which a false impression may be obtained from a singlepicture, as, beyond a spot of transparency, no obvious injury to thefibula, and certainly no displacement, is discernible. [Illustration: PLATE XXIV. Skiagram by H. CATLING. Engraved and Printed by Bale and Danielsson, Ltd. (41_a_) This skiagram is inserted to show the depth at which the bulletlay from the surface. It is also interesting to note the insignificanceof the fracture of the fibula from this aspect. Without the secondskiagram the injury might have passed for a simple perforation or atransverse fracture. ] Fractures of the bones of the leg possessed an unenviable degree ofimportance. First, on account of the very severe injuries to the softparts that often accompanied them, without an apparently correspondinglyserious damage to the bone. Secondly, on account of the frequency withwhich the vessels were implicated in these injuries to the soft parts, either by the bullet or bone fragments. Beyond this, fracture of eitherarticular end of the tibia was certainly more frequently followed bytroublesome joint complications than occurred in the case of any otherbone. In the matter of 'explosive' injuries, I think more were seen in thecalf of the leg than in any other part of the body, and this oftenwithout solution of continuity of the bones, and sometimes withoutevidence even of contact of the bullet with either tibia or fibula. Someremarks on this subject have already been made in the chapter on woundsin general, and some sources of fallacy exposed. I believe that inpractically all these so-called explosive injuries the wound was eithercaused by a ricochet, or a bullet which deformed with great ease on bonycontact during its progress through the limb. A considerable number ofthe wounds which were referred by the men to the use of expandingbullets were probably the result of the use of Martini-Henry or largeleaden sporting bullets, and evidence of this was often forthcoming onexamination of the entry wounds. In other cases the irregularity of theopening plainly pointed to ricochet of a small bullet as the explanationof the character of the injury. The greater frequency of ricochetinjuries in the leg and foot when the men were standing is readilyunderstood. Concurrent injury to the vessels of the leg was common, but primaryhæmorrhage, as was the case generally, usually ceased spontaneously. Theimportance of injury to the vessels was rather in view of secondaryhæmorrhage, which occurred with some frequency, and I think morecommonly from the anterior than the posterior tibial vessels, usuallyoccurring at the end of a week or ten days, and naturally mostfrequently in cases which suppurated. _Prognosis and treatment in fractures of the leg. _--In fractures of theleg, except those of extreme severity, almost any form of splintsufficed to maintain the bones in position, but for field purposes theDutch cane splint (fig. 58, p. 222) was certainly very convenient. Forlater use in cases that needed frequent dressing, a wooden back splint, with a foot-piece, or, if obtainable, a Neville's splint with asuspension cradle, was the best. Where the wounds were small andfrequent dressing was not required, nothing was so good as plaster ofParis, especially when transport was a necessity. [Illustration: FIG. 58. --Dutch Cane Field Emergency Splint for Leg] In cases with large wounds suppuration was very frequent, and inconnection with this secondary hæmorrhage, or in the case of fracturesnear the articular ends, especially the upper, joint suppuration. Thetreatment of these cases varied: in many an amputation was the best oronly treatment advisable; but I several times saw good results followligation of the anterior tibial artery for secondary hæmorrhage, evenwhen suppuration existed, and occasional good results after incisionand drainage of joints if the infection was not of the most acute form. Primary amputation was rarely needed for any case of injury from abullet of small calibre, since it was only necessary either in the caseof injury to both main arteries, and this was rare, or in cases of veryextensive injury to the soft parts. I saw many of the latter make fairresults when treated conservatively, even though the condition seemedalmost hopeless at first sight. All the primary amputations that I sawwere either for shell or large bullet injuries. A word may be insertedhere as to the weight that ought to attach to nerve injuries in thisrelation. From the experience gained elsewhere it is clear that weshould attach little importance to these unless the divided nerves areactually in sight, as far as deciding on amputation is concerned. On theother hand, there is little doubt that the presence of concurrent nerveinjury, be it only concussion or contusion, exerts an important ulteriorinfluence on the healing of the wound, whether the part be amputated ornot. Amputation flaps in such cases possess a very considerably lowereddegree of vitality. Secondary amputations were often needed for sepsis, and on the whole didvery well; both for the same cause and for hæmorrhage intermediateamputations had occasionally to be performed; the results of these, aselsewhere, were bad. _Fractures of the tarsus. _--Wounds of these short bones were as a ruleof slight importance, given fairly direct impact on the part of thebullet. They then consisted of either simple perforations or surfacegrooving. A single bone might be implicated or several might betunnelled; in the latter case the implication of the joints veryconsiderably influenced the prognosis, since the addition of the jointinjury caused much more prolonged weakening of the foot. Wounds of the foot were common from the fact that when the men lay outin the prone position, the foot was often the part least protected bythe cover chosen, and particularly the heel. In these circumstances theos calcis was the bone most frequently implicated, and that by trackstaking an oblique course downwards from the leg to the sole. Again thefoot was often struck by ricochet bullets, as a result of its positionwhen the erect attitude was assumed. The latter fact was of muchimportance with regard to the nature of the injury sustained by thebones, as under these circumstances the mode of impact was irregular, and consequently comminution was often produced. The behaviour of the different bones of the tarsus varied somewhat. Onthe whole the prognosis in cases of injury to the os calcis was thebest, since the injury was more often individual and did not implicateany joint, and also because of the comparatively regular architecture ofthe bone. In the smaller bones concurrent injury to a joint was morefrequent. In the astragalus the central hard core extending upwards fromthe interosseous groove, as increasing resistance, I think accounted forthe fact that comminution was more marked in this bone than in anyother. The effect of wound of bones of the tarsus in producing a certaindegree of laxity in the mediotarsal joint resulting in a slightly flexedposition of the fore part of the foot and some projection of the head ofthe astragalus did not seem to me easy of explanation, but it occurredwith some regularity. The injuries to the _metatarsus_ corresponded so nearly to those alreadyspoken of in the case of the metacarpus that they need no furthermention. They were less common, however, and I am under the impressionthat fragmentation of the bullet was not such a marked feature, probablyon account of the lower degree of density of the bones, and theirgreater fixity of position. FOOTNOTES: [18] Col. W. F. Stevenson. _Loc. Cit. _ p. 69. CHAPTER VI INJURIES TO THE JOINTS Until recent times gunshot injuries of the joints formed a classentailing the gravest anxiety to the surgeon, both in regard to theselection of primary measures of treatment and in the conduct of theafter progress of the cases. The external wounds were severe, comminution of the bones was great, and retention of the bullet withinthe articulation was not uncommon. Operative surgery therefore found alarge field in the extraction of bullets, removal of bone fragments, excision of the joints, or even amputation of the limbs. The introduction of bullets of small calibre has robbed these injuriesof much of the importance they possessed in earlier days and during thepresent campaign direct clean wounds of the joints were little more tobe dreaded than uncomplicated wounds of the soft parts alone. No morestriking evidence of the aseptic nature of the wounds, and the harmlesscharacter of the projectile as a possible infecting agent, than thatoffered by the general course of these injuries in this campaign, is tobe found in the whole range of military surgery. The aseptic nature of the wounds, and the slight and localised characterof the bone lesions, have in fact justified the opinion previouslyexpressed by Von Coler, that these injuries in the future would be lessfeared than fractures of the diaphyses of the bones. Not less important than the localised character of the bone lesionitself is the fact that the accompanying wounds of the soft parts retainthe small or type forms. Thus I occasionally observed more troublesomeresults from minor shell wounds in the neighbourhood of joints, but notimplicating the synovial cavity, than in actual perforating injuriesproduced by bullets of small calibre. _Vibration synovitis. _--Before proceeding to the consideration of woundsof the joints, a short account is necessary of a condition of someimportance which is, I believe, more or less special to injuries frombullets of small calibre travelling at high rates of velocity. Thiscondition, if not novel, at any rate excited little comment in thedescriptions of the older forms of injury, although this may havedepended on the more serious nature of the primary local lesionsaccompanying wounds from the larger bullets, among which it formed acomparatively unimportant element. The condition referred to was the occurrence of considerable synovialeffusion into the joints of limbs in which the articulation itself wasprimarily untouched. These effusions sometimes occurred even when thesoft parts alone were perforated, especially when the wounds weresituated above or below the knee-joint. They were apparently the directresult of vibratory concussion of the entire limb dependent on the blowreceived from the bullet. The effusions were most strongly marked in cases of fractures of thediaphyses, although this was more noticeable in some situations thanothers. Thus with fractures of the shaft of the femur anywhere below thejunction of the upper and middle thirds of the bone, and in some caseseven higher, effusion into the knee-joint was very common, and sometimesextreme. On the other hand, similar effusions into the hip-joint wereless marked, since I failed to determine their existence in the majorityof cases. I am inclined to ascribe this to the different anatomicalarrangement of the two joints, particularly to the fact that the head ofthe femur is included in a bony cup, into the hollow of which it isaccurately fixed by the resilient cotyloid fibro-cartilage. The latterby its firm grasp of the head allows of little play in the joint; hencevibrations are conveyed directly to the acetabulum in continuous waves, and rocking of the articular surfaces is prevented. Beyond this no doubtthe difficulty of detecting small effusions in this joint is an elementwhich must be taken into consideration. I do not think that wrenches of the knee-joint in the act of fallingcan be suggested as an explanation of the frequency of effusions intothat articulation, since the fractures of the femur were not alwaysreceived while the erect position was maintained, and effusion was mostmarked when the diaphysis was the part affected, the latter pointillustrating the greater resistance offered by compact bone. Again, whenfracture had taken place, the solution of continuity rendered thedirectly injured point the most mobile, and tended to prevent lateralstrain from falling on the joints. Effusion into the knee or ankle, or sometimes both joints, was common infractures of the shaft of the tibia. In the articulations of the upper extremity the condition was alsocommon, but somewhat less marked than in the lower limb. Effusions intothe shoulder or elbow occurred. In the former these were less striking;again, perhaps, as a result of the difficulty of detecting smalleffusions in this situation. The elbow was to a certain extent protectedby the possession of a degree of fixity somewhat resembling that alreadymentioned in the case of the hip-joint, although here depending on theconformation of the bones alone. I think this explained the absence offree effusion in many cases of fracture of the humeral shaft, but whenthe latter affected the lower third effusion into the elbow was usuallyabundant. The lighter weight and greater mobility of the upper extremity as awhole, as decreasing the resistance to the bullet, were also probably anelement in the fact that these effusions were less severe than those inthe joints of the lower limb. The nature of the effusions was apparently simple, since they wererapidly reabsorbed, and little thickening of the synovial membraneremained to suggest either a marked degree of inflammation, or thedeposition of blood-clot on the inner aspect of the same. The only treatment indicated was a short period of rest, accompanied inthe early stages by pressure and slight fixation, followed later bymassage and movement if necessary. Before dismissing this subject, I should like to particularly emphasisethe fact, that in the cases described there was no reason to suspect theextension of fissures from the point of fracture in the shafts into thearticular ends of the bones. This was as far as possible excluded byclinical examination, and in the cases where wounds of the soft partsonly were present, the rapid return of the patients to active duty, withabsence of remaining joint trouble, negatived the possibility of suchfractures. I only saw one case in which a longitudinal fracture actually extendedfor any considerable distance into a neighbouring joint. In this acomminuted fracture occurred just above the centre of the shaft of thehumerus. At the time of examination and putting up of the fracture therewas considerable swelling of the whole arm, and nothing special wasnoticed about the shoulder-joint. Three weeks later, however, when thefracture was consolidating, difficulty in abduction of the shoulder wasnoted, and the arm could not be placed closely in contact with thetrunk. There was no evident displacement of the head of the humerusforwards. A skiagram, which I much regret I have not been able toinsert, showed that a longitudinal fissure extended from the seat offracture upwards in such a manner as to divide the upper fragment intotwo parts, of which the outer bore the greater tuberosity, the inner thearticular surface of the head. The latter fragment had become somewhatdisplaced downwards, and had united in such a manner that the headrested on the lower part of the glenoid cavity. Abduction of the limbtherefore brought the greater tuberosity into contact with the acromionprocess, and movement was checked. This case passed out of myobservation shortly afterwards, and I have no knowledge of the finalresult as to movement. Fractures of the bony processes surrounding the elbow-joint, and of themalleoli of the tibia and fibula, were not infrequent, but offered nospecial features. One other form of injury indirectly affecting the joints is perhapsworthy of mention, but I observed it only once, and that in the case ofthe shoulder, the only joint where it is likely to be marked. I refer tothe displacement of the head of the humerus by the force of gravity, when the circumflex nerve is injured. In the instance I refer to, afracture of the surgical neck of the humerus was accompanied bycomplete motor paralysis of the deltoid and very rapid wasting of themuscle. Circumflex sensation was impaired, but not absent at the timethe condition of the muscle was noted--a favourable prognostic sign ofmuch importance. At the end of five weeks, when the fracture of the bonewas consolidated, the head of the humerus had dropped vertically atleast an inch, but could be replaced with ease. Shortly afterwards animprovement in the condition of the muscle commenced, and with this thehead of the humerus was gradually raised. This patient later recoveredhis power in great part, but not completely. In a few cases bullets lodged in the neighbourhood of joints in suchpositions as to limit movement by mechanical impact with the bones. ThusI saw one case in which a bullet lay between the radius and ulna justbelow the lesser sigmoid cavity; in another the bullet lay in front ofthe ankle-joint, and limited the possibility of flexion; and in a caserelated to me by Mr. Bowlby, a bullet was removed by him from the wallof the acetabulum where it was tightly fixed in the substance of thebone. In two other cases I saw bullets lying deeply on the anteriorsurface of the hip capsule and so limiting flexion. In all such casesthe indication for removal of the bullet was sufficiently stronglymarked. WOUNDS OF THE JOINTS These may be divided into several classes, varying much in comparativeseverity, and in prognostic importance. 1. The comparatively rare instances in which a wound implicated a jointcavity, without accompanying lesion of any bone. 2. Perforating wounds in which the bullet was retained within thearticular cavity. These were also rare. 3. Wounds of the joints accompanied by grooving of the articularextremities of the bones. 4. Complete perforating tracks through the articular ends of the bones, crossing the joint cavity in various directions. 5. Comminuted fractures of the terminal parts of the diaphyses extendinginto joints. Of these several classes, the first was of the least prognosticimportance. In the absence of bone injury the wounds usually healedwithout any obvious ill effect beyond the transient effusion into thejoints of a mixture of blood and synovial fluid. When suppuration of thewound in the soft parts occurred, however, the remarks made as to theinjuries classed under the third heading also apply here in a lesserdegree. With regard to the retention of the bullet, in the case of bullets ofsmall calibre this was a distinctly rare occurrence. I never happened tosee an instance of retention of either a Mauser or Lee-Metford bullet inan articulation. It is only possible with bullets practically spent, ortravelling at a very low rate of velocity and making irregular impact. The influence of both volume and velocity of flight was well illustratedby my own small experience of retained bullets. In one case aMartini-Henry was found impacted between the femoral condyles, havingslipped in beneath the margin of the patella. It caused a semiflexedposition to be assumed by the joint, and was removed by Mr. Brown in No. 1 General Hospital at Wynberg. The second instance I saw in the PortlandHospital at Bloemfontein in a patient of Mr. Bowlby's. The bullet was aGuedes, a form which has been already described as possessing lowvelocity and deficient power of penetration; beyond this, in theparticular instance irregular impact was evidenced by the presence of alarge irregular contused wound of entry over the tuberosity of thetibia. The presence of the bullet in the knee-joint was later determined by theX-rays, and Mr. Bowlby removed it successfully. Seven months later therange of movement was nearly normal. I may add that I saw several instances of large leaden bullets lodgingin the popliteal space, and a comparatively insignificant number ofbullets of small calibre in the same situation. This was very striking, in view of the immense relative frequency of use of the latter forms. There is no doubt, moreover, that small bullets rarely lodge even in theneighbourhood of joints, unless at the distal end of a long track. Totake the extreme example of large bullets, those employed as shrapnel, in comparison with the frequency with which wounds were produced bythem, bullets lying at the bottom of short tracks in the neighbourhoodof joints were not uncommon. Thus I saw one lying over the hip-joint, and another in close proximity to the shoulder capsule. Wounds of the third class, where the bones had been superficiallygrooved, were in some respects the most serious. This was especially soin the knee and ankle joints, and some cases will be quoted later underthe heading of the special joints to illustrate this point. Danger onlyarose in the event of suppuration; and here the presence of the longoblique superficial track in a neighbourhood liable to comparativelyfree movement was the important element. Such tracks usually opened thesynovial sac more extensively than direct perforating wounds, and ifsuppuration occurred in any portion of the track, the pus was veryliable to be sucked into the joint on any free movement. The presence offine splinters of the bone displaced in the production of the groove wasalso a special character of wounds of this class. Another point worthyof mention is that in these cases it was not always easy to be quitecertain whether the joint cavity had been implicated or not, since casesoften occurred in which, although the bones had been grooved, the jointcavity escaped. The indication, however, was to consider any wound inthe immediate proximity of a joint as perforating until it was healed. This course was the more easy to take, since a large proportion of suchwounds were accompanied by some degree of synovial effusion, even whenthe neighbouring joint had escaped puncture. Wounds of the fourth class, although the most highly characteristic ofthe form of accident, were in many instances the most favourable inregard to their course. The tracks might course directly across thejoint in any direction, or they might course obliquely, traversingeither one or both the component bones. In the latter case the exitmight be in the diaphysis, and be accompanied by the separation of anexit fragment such as is illustrated in fig. 52, p. 169. Theparticularly favourable character of the direct transverse andantero-posterior wounds depended on the slight amount of splintering ofthe bones, the limited nature of the opening into the joint, and theshortness of the tracks in the soft parts, which ensured that, even ifinfection did occur, the resulting pus was near the surface, andgenerally spread in that direction and escaped. Wounds of the fifth class were the most dangerous, but the danger wasentirely a secondary one, dependent on the occurrence of infection. These injuries were liable to be accompanied by the presence ofextensive irregular wounds of the soft parts, in which suppuration wasfrequent, and the suppuration of the joint frequently meant subsequentamputation, if not a worse result. _Course and symptoms of wounds of the joints. _--The immediate result ofany perforation of a joint was the development of intra-articulareffusion. This consisted of synovial fluid admixed with a varyingproportion of blood. The degree of synovitis was apt to vary with theamount of force expended in the production of the injury; for thisreason both high velocity and irregular impact were of importance inthis relation. The constant feature, however, depended on the effusion of blood; thiswas not rapid, or, as a rule, very abundant, but tended to increaseduring the first twenty-four hours. It resulted in a swelling of thejoint, which possessed some peculiar features. At first elastic andresilient, it slowly decreased in volume with the assumption of a softdoughy character on palpation. In the case of the knee, where readilypalpated, it very much resembled a tubercular synovial membrane, exceptfor its extreme regularity of surface; still more closely the conditionnoted in a hæmophilic knee of some duration. Absorption took place withsome rapidity, and except for slight thickening, the joints might appearalmost normal, in a period of from two to four weeks. With thedevelopment of the effusion there was local rise in temperature of thesurface, and in a considerable number of the cases a general rise oftemperature. This latter was sometimes very marked, as in the case of all the othertraumatic blood effusions, but not quite so regular in occurrence. Itwas important, as I have seen it give rise to the suspicion ofsuppuration, when tapping resulted in nothing more than the evacuationof turbid synovia mixed with blood. Pain was rarely a prominent symptomin consequence of the generally moderate degree of distension. As a rule, these injuries were characterised by the small tendency tothe development of adhesions; but this in great part depended on thecare expended on their treatment. If kept too long quiet, either fromnecessity when the effusion was followed by much thickening, or when theexternal wound was large and so situated as to be harmfully influencedby movement, or in the ordinary course of treatment, troublesomestiffness, even amounting to firm anchylosis, sometimes followed. I sawseveral such cases, some of the most confirmed being wounds of theknee-joint complicated by injury to the popliteal vessels or nerves. Thelatter complication I saw altogether six times, but only once with athoroughly bad knee, and in this case the injury had affected both thevessels and the internal popliteal nerve. The joint in that case wasstraightened out by continuous extension by Major Lougheed, when it cameunder his charge some six weeks after the primary injury, but I hear hasagain relapsed, and the popliteal paralysis is not much improved. The small tendency to formation of adhesions in uncomplicated casesprobably depended on the coagulation of a layer of blood over the wholeinternal lining of the joint. This kept the synovial surfaces apart atthe lines of reflection of the membrane, and, given sufficiently activetreatment, mobility was restored before any firm union could take place. The primary escape of synovial fluid was rarely observed, as the woundsof the soft parts were too small and valvular to permit of it. Synoviain some abundance, mixed with pus, sometimes escaped in considerablequantity when infection had opened up the tracks. Primary suppuration in any joint as a result of small and direct woundswas very rare. I observed it only on one occasion. On the other hand, aconsiderable number of cases in which secondary suppuration occurredcame under my notice. In some of these the suppuration was secondary tocomminuted fractures of the shaft of the tibia, in which the articularextremity was implicated. These offered no special peculiarity. Inothers infection of the joint was secondary to infection and suppurationin the deep part of long oblique wound tracks, and these were ofsufficient interest to warrant the insertion of two illustrative cases. (43) In a man wounded at Paardeberg the bullet entered the leg to the inner side of the crest of the tibia, about 3 inches below the tubercle; thence it coursed upwards to emerge about 2 inches above the cleft of the knee-joint on the outer side. Regulation dressings were applied, and a week later the man arrived at the Base, with little apparent mischief in the knee-joint. He was placed in bed and warned against movement; on the second day, however, he got up and walked to the latrine. When bending his knee to sit down he was seized with agonising pain in the joint, and had to call out for help; he was then carried back to bed in a more or less collapsed condition. The knee commenced to swell; there was rise of temperature and great pain, together with extreme restlessness. I was asked to see him two days later, and after a consultation, Major Burton, R. A. M. C. , freely incised the knee-joint bi-laterally. One opening was closed, the second plugged for drainage, as there was a large quantity of pus. No improvement followed, and a week later Major Burton amputated through the thigh. An attack of secondary hæmorrhage a few days later, combined with the degree of septic infection, ended the man's life. On examination of the joint, a groove forming three-fourths of a tunnel was found in the external tuberosity of the tibia, leading into the knee-joint beneath the external semilunar cartilage. The bullet had then passed upwards over the outer border of the cartilage, bruised the margin of the external condyle of the femur in such a manner as to depress the outer compact layer, and finally escaped from the joint near the upper reflection of the synovial membrane. The synovial membrane was granular in appearance and reddened, but there was no suppuration outside the confines of the joint, except in a cavity corresponding to 2 inches of the track before it actually perforated the tibia. A localised abscess had evidently formed here and been diffused into the joint by the movement of flexion already described. (44) A man wounded during General Hamilton's advance on Heilbron was struck on the outer aspect of the heel. An oval opening of some size led down to a track in the os calcis; the bullet was retained. The foot was dressed, and put up later in a plaster-of-Paris splint. On the tenth day the splint was removed to see to the wound, which looked satisfactory and was re-dressed. A few hours later the man was seized with very severe pain in the ankle, and a day later I was asked to see him by Mr. Alexander. The man was anæsthetised, and I examined the wound with care, and also removed the retained bullet from the inner margin of the leg. The bullet was reversed, having no doubt suffered ricochet, hence the large aperture of entry, but it was in no way deformed. I could not certainly determine the presence of any fluid in the ankle-joint, and as the pain was apparently localised to the distribution of the musculo-cutaneous nerve, I decided not to freely open the joint. In this, however, I erred, and two days later, after consultation, the joint was freely incised by Mr. Alexander. It was then found that the bullet in its passage had just touched the posterior aspect of the tibia and wounded the ankle-joint. A localised collection of pus which had formed in the deep part of the wound had been diffused into the joint by the movements made when the splint was removed, in a similar manner to that described in the last case. This joint also did badly, and an amputation of the leg had to be performed by Mr. Alexander to save the man's life. These two cases are particularly instructive as showing, first, howquietly a small amount of deep suppuration may sometimes take place;and, secondly, the importance of keeping the joints quiet on a splintwhen there is any reason to suspect their implication by wounds of thischaracter. _The general treatment_ of the wounded joints was simple. The olddifficulties of deciding on partial as against full excision, oramputation, were never met with by us. We had merely to do our firstdressings with care, fix the joint for a short period, and be careful tocommence passive movement as soon as the wounds were properly healed, toobtain in the great majority of cases perfect results. Careful lightmassage, if available, was used to promote absorption of blood. If suppuration occurred, the choice between incision and amputation hadto be considered. In the early stages this choice depended entirely onthe nature of the injury to the bones. If this were slight, incision wasthe best plan to adopt. I saw several cases so treated which did well, although convalescence was often prolonged, and only a small amount ofmovement was regained. Amputation was sometimes indicated in cases ofsevere bone-splintering, when the shafts were implicated, but was as arule only performed after an ineffectual trial to cut short generalinfection of the septicæmic type by incision. I have dwelt at such length on the subject of suppuration on account ofits importance, but I should add that, on the whole, suppuration of thejoints was uncommon, except in the case of injuries far exceeding theaverage in primary severity. _Special joints. _--Such deviations from the general type of injury asabove described depended entirely on peculiarities of anatomicalarrangement, and peculiarities in the situation of the joint clefts inthe different parts of the body. A few words as to these are perhapsnecessary. _Shoulder-joint. _--Wounds of this articulation were by no means common. This depended, I think, on two points in the architecture of the joint:first, a bullet to enter the front of the cavity and traverse the jointneeded to come with great exactitude from the immediate front; secondly, wounds received from a purely lateral direction calculated to pierce thehead of the humerus and the glenoid cavity were naturally of very rareoccurrence. Wounds of the prominent tip of the shoulder received whilethe men were in the prone position were not uncommon, but it wasremarkable how rarely the shoulder-joint was implicated in these. Thequestion of the narrow nature of the cleft exposed also comes up in thisposition. As far as my experience went, injuries to the lower portion ofthe capsule accompanying wounds of the axilla were those most often metwith. The ease and neatness with which pure perforations of the head ofthe humerus can be produced was also an important element in thefrequent escape of this joint. No case of fracture of the glenoid cavityhappened to come under my notice. I saw few instances in which the joint needed incision, and cannotrecall or find in my notes any case in which serious trouble arose. _Elbow-joint. _--Injuries to this joint came second in frequency in myexperience to those of the knee. They were, in fact, comparativelycommon, especially in conjunction with fractures of the various bonyprominences surrounding the articulation. Fractures of the lower end ofthe humerus were of worse prognostic significance than those of theulna, on account of the greater tendency to splintering of the bone. Isaw several cases of pure perforation of the olecranon without any signsof implication of the elbow-joint. In a case which has been utilised forthe illustration of some of the types of aperture (fig. 20, p. 59), atthe end of a week there was no sign of any joint lesion, although thebullet had obviously perforated the articulation. Several cases of suppuration which came under my notice did well. I sawone of them a few days ago, six months after the injury, with perfectmovement. In another of which I took notes, the bullet entered over theouter aspect of the head of the radius, to emerge just above theinternal condyle anteriorly. A considerable amount of comminution of theolecranon resulted, and when the man came into hospital some ten dayslater the joint was suppurating. The joint was opened up from behind, and some fragments of bone removed by Mr. Hanwell. On the 26th day thisjoint was doing well, and considerable flexion and extension werepossible without pain. There was a somewhat abundant discharge of bloodysynovia during the first few days after the operation. [Illustration: FIG. 59. --Illustrates the very neat and limited injury tothe Phalanges over the dorsal aspect of the first inter-phalangeal jointof the Middle Finger, accompanying a gutter wound received by thepatient while holding a rifle. ] I never saw any troublesome results from perforations of the _carpus_. The joints of the _fingers_ also offered little special interest, except in so far as they afforded astonishing examples of the extremeneatness of the injuries which a small-calibre bullet can produce. Fig. 59 is a good example of such an injury. _Hip-joint. _--I can only repeat with regard to this joint what I havealready said as to the injuries to the head of the femur. I hadpractically no experience of small-calibre bullet injuries to thefemoral constituent, and beyond the single case of injury to theacetabular margin mentioned on p. 193 I saw no obvious wounds of thejoint at all. _The knee_, as usual, proved itself _par excellence_ the joint mostcommonly injured, no doubt as a result of its size, the extent of itscapsule anteriorly, and its exposed position. In spite, however, of thefrequency with which it suffered injury, and the opportunities itafforded for observation of the progress of the effusions towardsabsorption, the injuries to the joint gave less anxiety and attained amore favourable prognostic character than is the case in civil practice. This depended on the very favourable course observed in the frequentpure perforations following a direct line. These occurred in everydirection, the accompanying hæmarthrosis usually disappearing completelyin an average period of little over a month. The extremes can be fairlyplaced at a fortnight and six weeks. Limitation of movement was slightor non-existent in many cases; in others it was of a very moderatecharacter, and I only remember to have seen one case in which a reallyserious anchylosis developed. In this the man was struck from a distanceof 300 yards, and a considerable amount of bone dust from the femur wasfound in the lips of the exit aperture. The wounds healed _per primam_, but when I saw the man two months later anchylosis in the straightposition was apparently complete. The comparatively frequent association of popliteal aneurisms withwounds of the knee-joint has already been spoken of in relation toanchylosis. Wounds of the popliteal space from larger bullets sometimescaused more troublesome after-stiffness than wounds of the articulationitself. Again I remember a small pom-pom wound at the inner margin ofthe ligamentum patellæ without obvious wound of the joint, which wasaccompanied by synovitis from contusion, and was followed by veryconsiderable limitation of movement. This had only been partiallyimproved when the patient returned home, in spite of prolonged massageand passive movement. The general remarks on the joints cover all that need be said as tosuppuration of the knee-joint. _The ankle-joint_ maintained the undesirable character which it hasalways held as a subject for gunshot injuries. This is entirely aquestion of sepsis, and in great measure depends on the fact that thefoot, as enclosed in a boot, is invested with skin particularlydifficult to thoroughly cleanse; while the socks are an additionalsource of infection to the wounds before the patients come under propertreatment. Of seven cases of suppurating ankle-joint, of which I have notes, onlytwo retained the foot, and one of these after a very dangerous illness. This case was one of special interest as exemplifying the resultsdependent on variations in velocity on the part of the bullet. Thepatient was struck at a distance of twenty yards. The bullet entered thefront of the right ankle-joint and emerged through the internalmalleolus, just behind its centre, causing no comminution of the latter. It then entered the left foot by a type wound one inch behind and belowthe tip of the internal malleolus, traversed and comminuted theastragalus, and emerged one inch below the tip of the externalmalleolus. The first joint healed _per primam_. The second produced bythe bullet when passing at a lower rate of velocity was accompanied byconsiderable comminution of the bone. It suppurated, and gave rise togreat anxiety both for the fate of the foot and the life of the patient. It is probable that the more abundant hæmorrhage which took place fromthe second wound was in part responsible for the occurrence ofinfection. The second of the two cases is of some interest in relation to thedoctrine of chances as to the position in which a wound may be received. The man was wounded in one of the earlier engagements, a bullet passingtransversely through his leg immediately behind the bones and about halfan inch above the level of the ankle-joint. He recovered, and rejoinedhis regiment, only to receive at Paardeberg a second wound, about aninch lower, which traversed the ankle-joint. On his return to Wynberg hehappened to be sent to the same pavilion, and occupied the same bed hehad left on returning to the front. The subject of the result of wounds of the joints of the _foot_ hasreceived sufficient consideration under the heading of wounds of thetarsus. The repetition of the fact that, among the whole series of cases onwhich this chapter is founded, not a single instance of primary orsecondary excision of a joint, either partial or complete, is recorded, forms an apt conclusion to my remarks on this subject. CHAPTER VII INJURIES TO THE HEAD AND NECK Injuries to the head formed one of the most fruitful sources of death, both upon the battlefield and in the Field hospitals. It has beensuggested that the mere fact of wounds of the head being readily visibleensured all such being at once distinguished and correctly reported, while wounds hidden by the clothing often escaped detection. When theexternal insignificance of many of the fatal wounds of the trunk istaken into consideration this is possible; but, on the other hand, itmust be borne in mind that the head is in any attitude the mostadvanced, and often the most exposed, part of the body, and even whenthe soldier had taken 'cover, ' it was frequently raised for purposes ofobservation. For the latter reasons I believe injury to the head fullydeserved the comparative importance as a fatal accident with which itwas credited. A number of somewhat sensational immediate recoveries from seriouswounds of the head have been placed upon record. Observation, however, shows that these, with but few exceptions, belonged either to certaingroups of cases the relatively favourable prognosis in which is familiarto us in civil practice, or that the wounds were received from a verylong range of fire, and hence the injuries were strictly localised incharacter. ANATOMICAL LESIONS _Wounds of the scalp. _--Nothing very special is to be recorded withregard to these; they either formed the terminals of perforating wounds, or were the result of superficial glancing shots. The glancing woundswere of the nature of furrows, varying in depth from mere grazes towounds laying bare the bone. Their peculiarity was centred in the factthat a definite loss of substance accompanied them, the skin beingactually carried away by the bullet; hence gaping was the rule. Everygradation in depth was met with, but the only situations in which woundsof considerable length could occur were the frontal region in tranverseshots, or, when the bullet passed sagitally, the sides of the head, orthe flat area of the vertex. The danger of overlooking injuries to the bone was of special importancein the short subcutaneous tracks occasionally met with at the points atwhich the surface of the skull makes sharp bends. In all such wounds itwas a safe rule to assume a fracture of the skull until this wasexcluded by direct examination. In some of the gutter wounds andsubcutaneous tracks crossing the forehead and sides of the head, signsof intracranial disturbance were occasionally observed in the absence ofexternal fracture, such as transient muscular weakness, unsteadiness inmovements, giddiness, diplopia, or loss of memory and intellectualclearness. In connection with such symptoms the classical injury ofsplintering of the internal table of the skull, the external remainingintact, had to be borne in mind, but I observed no proven instance ofthis accident. I am of opinion, moreover, that its occurrence with smallbullets travelling at a high degree of velocity must be very rare, sincelittle deflection is probable unless the contact has been sufficientlydecided to fracture the external table; while in the cases of spentbullets the injury is unlikely, as requiring a considerable degree offorce. _Injuries to the cranial bones, without evidence of gross lesion to thebrain. _--It may be premised that these were of the rarest occurrence, and they may be most readily described by shortly recounting theconditions observed in a few cases I noted at the time. The injuriesresulted from blows with spent bullets, from bullets barely striking theskull directly, or those striking over the region of the frontalsinuses. Wounds of the mastoid process will not be considered in thisconnection as being of a special nature (see p. 299). I saw only one case of escape of the internal, with depressed fractureof the external, table of the skull. (45) In marching on Heilbron a man in the advance guard was struck by a bullet at right angles just within the margin of the hairy scalp. The regiment was at the time to all intents and purposes outside the range of rifle fire, and the patient was the only individual struck among its number. When brought into the Highland Brigade Field Hospital, a single typical entry wound was discovered; examination with the probe gave evidence of a slight depression in the external table of the frontal bone just above the temporal ridge. Although no perforation was detectible by the probe, and this was positively excluded on the raising of a flap (Major Murray, R. A. M. C. ), it was considered advisable to remove a 1/4-inch trephine crown, the pin of the instrument being applied to the margin of the depression. No depression or splintering of the internal table was discovered, nor any injury to the dura, nor blood upon the surface of that membrane. The man made an uninterrupted recovery. (46) A case of frontal injury was shown to me at Wynberg, in which a distinct furrow could be traced across the upper part of the frontal sinuses. There had been no symptoms beyond temporary diplopia, and the wound was healed; no surgical interference had been deemed necessary. (47) In a man wounded at Poplar Grove, a single typical wound of entry was found 3/4 of an inch above the right eyebrow and the same distance from the median line. No primary symptoms were observed, but on the evening of the second day the temperature rose above 100° F. , and the man seemed somewhat heavy and dull. The patient was examined by Major Fiaschi and Mr. Watson Cheyne, and it was decided to explore the wound. Mr. Cheyne removed fragments both of external and internal tables, one of the latter having made a punctiform opening, not admitting the finest probe, in the dura-mater. The bullet was traced into the nasal fossæ, where it was subsequently localised with the aid of the Roentgen rays when the patient came under my observation at Wynberg some days later (fig. 60). _Gunshot fracture of the skull with concurrent brain injury. _--This wasthe commonest form of head injury, and possessed two main peculiarities;firstly, the large amount of brain destruction compared with the extentof the bone lesion; secondly, the fact that any region of the skull wasequally open to damage. In consequence of the second peculiarity, theposition and direction of secondary fissures are not so dependent onanatomical structure as in the corresponding injuries of civil practice. Thus, fractures of the base, for instance, were less constant in theircourse and position. The cases as a whole are best divided into fourclasses. [Illustration: FIG. 60. --Mauser Bullet in Nasal Fossa. (Skiagram by H. Catling. ) Case No. 47] 1. Extensive sagittal tracks passing _deeply_ through the brain, andvertical wounds passing from base to vertex or _vice versa_, in theposterior two thirds of the skull. These will be referred to as generalinjuries. 2. Vertical or coronal wounds in the frontal region. 3. Glancing or obliquely perforating wounds of varying depth in any partof the head. 4. Fractures of the base. Of these classes the first was nearly uniformly fatal; the secondrelatively favourable, and with low degrees of velocity oftenaccompanied by surprisingly slight immediate effects; while the thirdhad perhaps the best prognosis of all, but this varied as to the defectsthat might be left, and with the region of the head affected. 1. _General injuries. _--Fractures of this class may be treated of almostapart. For their production the retention of a considerable degree ofvelocity on the part of the bullet was always necessary, and the resultswere consequently both extensive and severe. The aperture of entry was comparatively small, since to take so directand lengthy a course through the skull the impact of the bullet neededto be at nearly an exact right angle to the surface of the bone. Anydisposition to assume the oval form, therefore, depended mainly upon thedegree of slope of the actual area of the skull implicated. In size theaperture of entry did not greatly exceed the calibre of the bullet; inoutline it was seldom exactly circular, but rather roughly four-sided, with rounded angles, slightly oval, or pear-shaped. The margin of theopening consisted of outer table alone, the inner being alwaysconsiderably comminuted. Fragments of the latter, together with themajority of those corresponding to the loss of substance of the outertable, were driven through the dura mater and embedded in the brain. These bony fragments were more or less widely distributed over an areaof a square inch or more, and not confined to a narrow track. [Illustration: FIG. 61. --Diagram of Aperture of Entry in Occipital Bone, showing radiating fissures exact length. The exit in the frontal regionwas of typical explosive character. Range '100 yards'. ] The amount of fissuring at the aperture of entry was often not soextensive as I had been led to expect. Fig. 61 is a diagram illustratinga fairly typical instance; in some cases no fissuring existed. As a rulethe nearer to the base, the greater was the amount of fissuringobserved. The fissures were sometimes very extensive in this position, probably as a result of the lesser degree of elasticity in this regionof the skull. Again, when the aperture of entry was near the parts ofthe vertex where sudden bends take place, considerable fissuring of thesame nature as that seen in the superficial tracks (fig. 68) wasproduced in the flat portion of the skull above the point of entrance. Radial fissuring around the aperture of entry in the skull scarcelycorresponds in degree with that seen when the shafts of the long bonesare struck, and is far less marked and regular than when one of thesesmall bullets strikes a thick sheet of glass set in a frame. I sawseveral apertures in the thick glass of the windows of the waterworksbuilding at Bloemfontein produced by Mauser bullets. They differedlittle from the opening seen in an ordinary plate-glass window resultingfrom a blow from a stone, except perhaps in the regularity andmultiplicity of the radial fissures. As in the skull, the opening was alittle larger than the calibre of the bullet, and the loss of substanceon the inner aspect considerably exceeded that on the outer. The degree of fissuring is probably affected by the resistance offeredby the particular skull, or the special region struck, but as a rule theelasticity and capacity for alteration in shape possessed by the bonycapsule, is opposed to the production of the extreme radial starringobserved in the long bones or a fixed sheet of glass. Corroborativeevidence of the influence of elasticity in the prevention of starring isseen in the limited nature of the comminution of the ribs in cases ofperforating wounds of the thorax. In the most severe cases we can only speak of the 'aperture' of exit ina limited sense in so far as the opening in the scalp is concerned; thiswas often comparatively small, not exceeding 3/4 of an inch in diameter. Beneath this limited opening in the soft parts, the bone of the skullwas smashed in a most extensive manner. The portion exactlycorresponding to the point of exit of the bullet was carried altogetheraway, but around this point a number of large irregularly shapedfragments of bone, from 3/4 to 1 inch in diameter, were found loose, andoften so displaced as to expose a considerable area of the dura-mater. Beyond the area of these loose fragments, fissures extended into thebase and vertex, in the latter case often being limited in their extentby the nearest suture. Over extensive fractures of this nature general oedema andinfiltration of the scalp, due to extravasation of blood, were present. When the exit was situated in the frontal region ecchymosis oftenextended to the eyelids and down the face, while in the occipital regionsimilar ecchymosis was often seen at the back of the neck. The opening in the dura mater at the aperture of entry was eitherslitlike, or more often irregular from laceration by the fragments ofbone driven in by the bullet. At the point of exit a similar limitedopening corresponded with the spot at which the bullet had passed, whileseparate rents of larger size were often seen at some little distance. The latter were the result of laceration of the outer surface of themembrane by the margins of the large loose fragments of bone abovedescribed. Injury to the brain more than corresponded in extent to the fractures ofthe bone. Pulping of its tissue existed over a wide area both at thepoints of entrance and of exit. In the former position the amount ofdamage was the less, the gross changes roughly corresponding with thetissue directly implicated by the bullet itself, and the fragments ofbone carried forward by it. The degree of splintering of the skulltherefore in great part determined the severity of the lesion. At theexit aperture much more widespread destruction existed, while masses ofbrain tissue, small shreds of the membranes, fragments of bone, and_débris_ from the scalp were found occasionally bound together bycoagulated blood and protruding from an exit opening of some size. Thelargest masses of such _débris_ were most often seen in instances inwhich the bullet had entered by the base to escape at the vertex of theskull. The brain in the line of injury suffered comparatively slightly, butsmall parenchymatous hæmorrhages into its tissue indicated in lesserdegree the same type of injury undergone by the mass of brain pulp andsmall blood-clots found at the external limits of the wound. Beyond thisextensive hæmorrhages at the base of the skull were common. With regard to the extensive character of the brain destruction in theregion of the aperture of exit, it must be borne in mind that thislesion corresponds in position with one which would exist even if theinjury were of a non-penetrating degree. A large proportion of thecontusion and destruction is therefore explained by violent impact ofthe projected brain with the skull prior to the passage of the bullet, and not to the direct action of the bullet on the tissues. These cases of 'general injury' afford a marked example of the lesionsto which the term 'explosive' has been applied, and as such have animportant bearing on the theories held as to the mode of production ofexplosive effect. The increased area of tissue damage at the aperture ofexit favours the theory of direct transmission of a part of the forcewith which the bullet is endowed, to the molecules of tissue boundingthe track made by the projectile. Thus the area of destructioncorresponds with the cone-like figure which one would expect to be builtup by the vibrations spreading from the primary point of impact. Theexit region of the skull is subjected not alone to the force of thetravelling bullet, but also to that exerted over a much wider area bythe tissue to which secondary vibrations have been communicated. Thebrain itself is, in fact, dashed with such violence against the bone asto cause a great part of the injury. No doubt the brain in its reaction to the bullet forms as near anapproach to a fluid as any solid tissue in the human body, andexperimental observation has shown how greatly its presence or absencein the skull affects the degree of comminution on the exit side; hencethe fondness for the so-called hydraulic theory that has been alwaysexhibited in the case of these injuries. The localisation of the injuryin its highest degree to the neighbourhood of the exit aperture, however, shows that in any case the main wave takes a definite directionin a course corresponding to that of the bullet. The real importance of the presence of the brain within the skull inincreasing the amount of damage at the exit end of the track, is as amedium for the ready transmission of forcible vibrations. That thelatter are to some extent conveyed as by a fluid is evidenced by theoccasional presence of brain matter and fragments of bone in theaperture of entry, which suggests recoil or splash such as would beexpected from a fluid wave. Experience of the character of the lesions observed after severeconcussion by the ordinarily somewhat coarser forms of violence commonto civil life, fully explains the severity of the damage to the braintissue met with in injuries due to bullets of small calibre. Viewing theelaborate arrangements which exist for the preservation of the centralnervous system from the moderate vibration incidental to ordinaryexistence, it is easy to appreciate the harmfulness of such exquisitevibratory force as that transmitted by a bullet of small calibretravelling at a high rate of velocity. _Effect of ricochet in the production of severe forms of injury. _--Inconnection with the lesions above described mention must be made ofcases in which the aperture of entry reaches a large size, or a portionof the skull is actually blown away. Examples of the former class were not uncommon; I will briefly relateone. (48) A Highlander while lying in the prone position at Rooipoort, was struck by a bullet probably at a distance of about 1, 000 yards. A large entry wound in the scalp was produced, while the defect in the skull was coarsely comminuted and was capable of admitting three fingers into a mass of pulped brain. Both brain matter and fragments of bone were found in the external wound, which was situated just anterior to the right parietal eminence. The bullet passed onwards through the base of the skull, crossing the external auditory meatus, fracturing the zygoma and probably the condyle of the mandible, and eventually lodged beneath the masseter muscle. Blood and brain matter escaped from the external auditory meatus. The patient was brought off the field in a semi-conscious condition, the pupils moderately contracted but equal, the pulse 66, very small and irregular in beat, the respiration quiet and easy, and with paralysis of the left side of the body. The fæces had been passed involuntarily. The wound was cleansed and bone fragments removed. The patient had to travel in a wagon for the next three days until the column halted. The progress of the case was unsatisfactory, as the wound became infected, and the man eventually died on the 14th day of general septicæmia, but with little evidence of local extension of septic inflammation. In this instance the head was no doubt struck by a bullet which had previously made ricochet contact with the ground. I saw several such cases. Closely connected with such injuries are those in which large portionsof the skull and scalp were actually blown away. I never witnessed oneof these myself, but I recall two instances described to me by officerswho lay near the wounded men on the field. In one the frontal region wascarried away so extensively that, to repeat the familiar descriptiongiven by the officer, 'he could see down into the man's stomach throughhis head. ' In a second case the greater part of the occipital region wasblown away in a similar manner, and this was of especial interest as thewounded man was seen to sit up on the buttocks and turn rapidly roundthree or four times before falling apparently dead. The observationoffers interesting evidence of the result of an extensive gross lesionof the cerebellum. In the absence of exact information, it may well be that such injuriesas the two latter were produced by some special form of bullet, but asboth were produced while the patients were lying on the ground, andtherefore especially liable to blows from ricochet bullets, I aminclined to attribute both to this cause. In considering injuries of the above nature, one cannot help speculatingon the possible influence of a head-over-heels ricochet turn on the partof the bullet while traversing the long sagittal axis of the skull. Itis not uncommon for apical target ricochets to present evidence ofdamage to the apex and base of the mantle alone. This must depend on arapid turn on impact, which might well be imitated in the case of theskull, and would then go far to explain the production of some of themost severe forms of explosive exit wounds met with. See cases 48, 54, 68. Short of ricochet, the influence of simple wobbling must also beconsidered in shots from a long range. The entry wound may be large as aresult of this condition, but as the velocity possessed by the bullet islow, the injuries would probably not be of a very severe nature. In connection with the subject of wobbling, reference should be made tothe form suggested by Nimier and Laval, in which the wobble, as theresult of resistance to the apex of the revolving bullet, assumes theform of movement seen when the spin of a top is failing. This wouldexplain a peculiarity in some wounds of entry over the skull firstpointed out to me by Mr. J. J. Day. When such wounds were explored, aswell as the presence of brain in the entry aperture, a number offragments of the external table of the skull were found everted andfixed in the tissues of the scalp. As already suggested, this may bemere evidence of splash, but it may be equally well explained by aprocess of wobble around the axis of revolution of the bullet. Thismight, no doubt, also be invoked to explain the displacement of some ofthe fragments in fractures of the long bones, where considerableresistance to the passage of the bullet is offered. II. _Vertical or coronal wounds in the frontal region. _--These injurieswere common, and offered some of the most interesting illustrations ofthe variations in symptoms and effects following apparently exactlyidentical lesions, judging from the condition of the external soft partsalone; since the latter sometimes gave little indication of the force(dependent on the rate of velocity) which had been applied. With the lower degrees of velocity simple punctured fractures of theskull resulted, without extensive lesion of the frontal lobes asevidenced by immediate symptoms. The nature of the fractures differed inno way from the punctured fractures we are familiar with in civilpractice. The openings of entry in the bone were irregularly rounded, corresponding in size to the particular calibre of the bullet concerned. The margin consisted of outer table alone, while the inner table waseither considerably comminuted, or a large piece was depressed, woundingthe dura-mater and projecting into the brain substance (see fig. 63). The aperture of exit presented exactly the opposite characters, thesplintering comminution or separation of a large fragment affecting theouter table, while the inner presented a simple perforation. The lattercondition is represented in figs. 71 and 72, and I will here give shortnotes of four illustrative cases, as being the shortest and mostsatisfactory method of conveying a correct idea of the nature of suchinjuries. [Illustration: FIG. 62--Aperture of Entry in Frontal Bone. Case No. 50. 1/2] (49) _Vertical perforation of frontal bone. _--Wounded at Belmont, while in the prone position. Aperture of _entry_ (Mauser), at the anterior margin of the hairy scalp on the left side; course, through the anterior part of the left frontal lobe, roof of the left orbit, cutting the optic nerve and injuring the back of the eyeball, floor of the orbit, the antrum, the hard palate, and tongue. _Exit_, in mid line of the submaxillary region. No cerebral symptoms were noted, and on the fifth day the man was sent to the Base hospital without operation; the pulse was then 70 and the temperature normal. The movements of the eyeball were perfect, but blindness was absolute. At the Base hospital the eye suppurated and was removed. The patient was then sent home apparently well. He has since been discharged from the service, and is now employed as a painter in Portsmouth Dockyard. (50) _Vertical perforation of frontal bone. _--Wounded at Paardeberg while in the prone position. Range, 600-700 yards. Aperture of _entry_ (Mauser), at the fore margin of the hairy scalp above the centre of the right eyebrow; course, through the anterior third of the right frontal lobe, roof of orbit, front of eyeball, margin of floor of orbit making a distinct palpable notch, and cheek; _exit_ through the red margin of the upper lip, 1/2 an inch from the right angle of mouth. The bullet slightly grooved the lower lip. The patient rose almost immediately after being struck, and walked about a mile, although feeling dizzy and tired. The wounds, which both bled considerably, were then dressed. After three days' stay in a Field hospital, the patient was sent in a bullock wagon three days and nights' journey to Modder River and thence to the Base. There was anæsthesia over the area supplied by the outer branch of the supra-orbital nerve, extending from the supra-orbital notch backwards into the parietal region, but none over the area supplied by the second division of the fifth nerve. On the tenth day there were no signs of cerebral disturbance except a pulse of 48. The eyeball was suppurating, and the temperature rose to 99° at night. The lids were still swollen and closed. A few days later the eyeball was removed and at the same time a flap was raised and the fracture explored (Major Burton, R. A. M. C. ). An opening somewhat angular, 1/3 of an inch in diameter, was found with a thin margin in the outer table of the skull (fig. 62); when this was enlarged with a Hoffman's forceps, an opening in the dura was discovered, and cerebro-spinal fluid escaped. A piece of the inner table of the skull (fig. 63), 3/4 by 1/3 an inch in size, was discovered projecting downwards vertically into the brain. This latter was removed and the wound closed. Healing by primary union followed, and no further symptoms were observed. [Illustration: FIG. 63. --Fragment of Inner Table depending vertically from lower margin of puncture shown in fig. 62. The centre was perforated. Exact size] (51) _Transverse frontal wound. _--Wounded at Paardeberg. The man was sitting down at the time he was struck, in the belief that he was out of the range of fire. The _entry_ and _exit_ wounds were almost symmetrical, placed on the two sides of the forehead at the margin of the hairy scalp, 2-1/4 inches above the level of the external angular processes of the frontal bone. The patient lost consciousness for about half an hour, then rose and walked half a mile to the Field hospital. The wounds were dressed, and after a stay of three days in hospital, the man was sent the three days' journey to Modder River; during the journey he got in and out of the wagon when he wished. After two days' stay at Modder, a journey was again made by rail to De Aar (122-1/2 miles). The wounds were healed. The man stayed at De Aar nearly a month, and then, rejoining his regiment, made a two days' march of some 22 miles on hot days. He had to fall out twice on the way by reason of headache, feeling dizzy, and 'things looking black. ' He did not own to any loss of memory or intellectual trouble, but was invalided to England. This patient returned to South Africa later, and is now on active service. (52) _Transverse frontal wound. _--Within a few days an almost identical symmetrical wound in the frontal region occurred in the same district, from a near range. The patient became immediately unconscious, and remained so until his death some four days later, his symptoms being in no way alleviated by operation and the removal of a quantity of bone fragments and cerebral _débris_. At the _post-mortem_ examination, extensive destruction of both hemispheres of the brain was revealed, and large fissures extended into the base of the skull. III. _Glancing or oblique perforating wounds of varying depth in anyportion of the cranium. _--These injuries were the most common, the mosthighly characteristic of small-calibre bullet wounds, the mostinteresting from the point of view of diagnosis, prognosis, andtreatment, and beyond this they formed the variety most unlike any thatwe meet with in civil practice. They were met with in every region of the cranium, and in every degreeof depth and severity. The lesser are best designated as gutterfractures, the deeper are perforating and gradually approximatethemselves to the type of injury described as class 1. When the bullet struck a prominent or angular spot on the skull aconsiderable oval-shaped fragment was occasionally carried away, leavingan exposed surface of the diploë (case 60, p. 274). Under thesecircumstances the apparent lesion on raising a flap was slight, butexploration often showed extensive intra-cranial mischief. Thus in thecase referred to both dura and brain were wounded, and continuinghæmorrhage led to the development of progressive paralysis, relievedonly by operation. From the more deeply passing bullets a more or less oval openingresulted, in which both tables were freely comminuted and displaced. These cases differed from the typical gutter fracture only in length andoutline, and the nature of the accompanying intra-cranial lesion wasidentical, while in the latter particular they differed much fromfractures in which the impact of the bullet was direct, in spite of anear resemblance in the appearances in the osseous defect. I saw one instance in which a circular fissure about 1-1/2 inch fromthe actual opening of entry surrounded the latter, the area of bonewithin the circle being somewhat depressed, though radial fissures wereabsent. In several of these cases fragments of lead were either found on thefractured surface of the bone or within the cranial cavity, showing thatthe bullets had undergone fissuring of the mantle, or had actuallybroken up on impact. _Gutter fractures. _--The nature of the injury to the bones in these isbest illustrated by a series of diagrams of sections such as are shownbelow. [Illustration: FIG. 64. --Gutter Fracture of first degree. The drawingdoes not show well the small fragments of bone usually carried from themargins of the depression by the bullet. ] In the most superficial injuries the outer table was grooved anddepressed, usually with loss of substance from small fragments directlyshot away: these latter had either been driven through the wound in thesoft parts, or remained embedded on the deep aspect of the envelopingscalp (fig. 64). In the less common variety the scalp was slit to alength corresponding with the injury to the bone, but more often ovalopenings in the skin existed at either end of the track. The inner tablewas practically never intact, but the amount of comminution naturallyvaried with the depth to which the outer table was implicated (fig. 65_A_, and _B_). The following is an illustrative example of this degree, and alsoemphasises the consequences which may follow primary non-interference. [Illustration: FIG. 65. --Diagrammatic transverse sections of varyingcondition of bones in Gutter Fractures of the first degree. _A. _ With noloss of substance. _B. _ With comminution. ] (53) _Superficial gutter fracture in parietal region. Convulsive twitchings. Secondary paralysis. _--Wounded at Modder River. Range, 400 yards. A scalp wound 3 inches in length ran vertically downwards, commencing 1 inch from the median line, and situated immediately over the upper third of the right fissure of Rolando. The patient was unconscious for several hours after the injury, and later suffered with severe headache, and twitchings in the left shoulder and arm. The wound healed, but a well-marked groove was palpable in the bone beneath, and the twitchings persisted. The latter came on about every twenty minutes, and loss of power in the left upper extremity, and to a less degree in the lower, developed. The memory was defective, and the patient suffered at times with headache. The pupils were equal but sluggish in action. No changes were discovered in the fundus beyond a well-developed myopic crescent at the lower and outer part of the left disc (Mr. Hanwell). The twitchings became more frequent and latterly were accompanied by somewhat severe muscular contractions in the upper extremity, while the loss of power in the lower extremity became more marked. Headache was also more troublesome. The patient throughout refused any operation, saying he would rather go home first, and at the end of a month he left for England. In the deeper injuries more and more of the outer table was cut away, and the inner became gradually more depressed, fractured, or comminuted(fig 66). [Illustration: FIG. 66. --Gutter Fracture of the second degree. Perforating the skull in the centre of its course. External table alonecarried away at either end. ] Bevelling at the expense of the outer table at both entry and exit endsof the course existed, but in either case a portion of the inner tablewas also detached and depressed. Sometimes the depressed portion of theinner table was mainly composed of one elongated fragment; this waseither when the bullet had not implicated a great thickness of the outertable, or had passed with great obliquity through especially dense bone(see fig. 70). When the bullet had passed more deeply the inner tablewas comminuted into numberless fragments. I have frequently seen 50 or60 removed. Where such tracks crossed convex surfaces of the skull, thetwo conditions were often combined; thus at one portion of the track, usually the centre, the comminution was extreme, while at either end aconsiderable elongated fragment of inner table was often found, thelatter perhaps more commonly at the distal or exit extremity (fig. 67). [Illustration: FIG. 67. --Diagrammatic transverse sections of completeGutter Fracture. _A. _ External table destroyed, large fragment ofinternal table depressed. (Low velocity or dense bone. ) _B. _ Comminutionand pulverisation of both tables centre of track. _C. _ Depression ofinner table (low velocity)] The nature of the injury to the bone when the flight of the bulletactually involved the whole thickness of the calvarium was comparable tothat seen in the case of the long bones when struck by a bullettravelling at a moderate rate (see plate XIX. Of the tibia, or what isillustrated in the case of the pelvis in fig. 55). In point of fact, aclean longitudinal track appeared to have been cut out. The length ofthese tracks naturally depended upon the region of the skull struck. When a point corresponding to a sharp convexity, or a sudden bend inthe surface, was implicated, an oval opening of varying length in itslong axis was the result; when a flat area, as exists in the frontal orlateral portions of the skull, was the seat of injury, a long track wascut. _Superficial perforating fractures. _--These formed the next degree; thechief peculiarity in them was the lifting of nearly the whole thicknessof the skull at the distal margin of the entry, and the proximal edge ofthe exit, openings; the flatter the area of skull under which the bullettravelled the more extensive was the comminution. In some cases nearlythe whole length of the bone superficial to the track would be raised;in fact, the bullet having once entered, the force is applied fromwithin in exactly the same way that it operates on the inner table inthe gutter fractures. A corresponding injury is met with in the case ofthe bones of the extremities (see fig. 57 of the tibia), and again theresemblance between these injuries of the skull and such perforations ofthe long bones as are illustrated by skiagrams Nos. III. And XXIII. Ofthe clavicle and fibula is a close one. [Illustration: FIG. 68. --Superficial Perforating Fracture. Illustratinglifting of roof at both entry and exit openings] I will add here a case of coexistent gutter fracture and perforatingwound of the skull, the conditions of the bone in which will illustratethe behaviour of the outer and inner tables respectively, when struckwith moderate force. [Illustration: FIG. 69. --Diagrammatic longitudinal section of Fractureshown in fig. 68] [Illustration: FIG. 70. --Fragment forming the main part of the floor ofGutter Fracture in the squamous portion of the temporal bone. (Lowvelocity, hard bone)] (54) Wounded at Thaba-nchu. Guedes bullet. _Entry_ behind left ear, just above posterior root of zygoma; gutter fracture; bullet retained within skull. Above and corresponding to right frontal eminence there was a hæmatoma, beneath which a loose fragment of bone was readily palpable. When brought into the Field hospital, twenty-four hours after the injury, the man appeared to understand when spoken to, but made no answers to questions. The urine was passed unconsciously, the bowels were confined. He was drowsy, the pupils widely dilated, the pulse 68, of good strength, and the temperature 104°. He slept well the following night and midday there was little change, except that the pupils acted to light, and the pulse had risen to 88, becoming dicrotic and small. The temperature was 103°, the tongue furred and dry, but he was lying with the mouth wide open. At 2 P. M. The wound was explored. The entry led down to a typical gutter fracture in the squamous portion of the temporal bone, at the point of junction of the vertical with the horizontal part; the floor of the gutter had been displaced inwards as a single fragment (fig. 70). A flap was raised in the frontal region, where a scale of outer table (fig. 71), clothed with diploic tissue, was found loose. Beneath this a puncture on the frontal bone, about corresponding in size to the bullet, was discovered. This opening was enlarged, and a bullet detected and removed. The bullet was a Guedes, with no marks of rifling, and was in no way deformed. At least a square inch of the right frontal lobe was pulped, so that the bullet lay in a cavity. The patient improved somewhat during the next two days, and on the third took a 16 hours' journey to Bloemfontein, where Mr. Bowlby (who was present at the operation) kindly took him into the Portland Hospital. The pulse gradually rose to 112, the temperature remained on an average from 102° to 103°, the respiration rose to 36, the face became somewhat livid, and on the sixth day death occurred rather suddenly, apparently from respiratory failure. For two days before his death the patient sometimes asked for food, &c. ; there was occasional twitching of the left angle of the mouth, and, when the posterior wound was manipulated, some twitching of the fingers of the left hand. When the wound was dressed on the fourth day, there were breaking-down blood-clot and signs of incipient suppuration. Mr. Bowlby made a _post-mortem_ examination, and found considerable pulping of the tip of the right frontal and left temporo-sphenoidal lobes, and a thick layer of hæmorrhage extending over the whole base of the brain. [Illustration: FIG. 71. --Scale of outer table of Frontal Bone andDiploë. Exact size, from fracture shown in fig. 72] [Illustration: FIG. 72. --Perforating Fracture of Frontal Bone fromwithin Separation of plate outer table. (Low velocity. ) 1/2] The injury to the _cranial contents_ varied with the degree of boneinjury. Hæmorrhage on the surface of the dura may in rare instances havebeen the sole gross lesion; I never met with such a condition, however. In all the cases in which comminution had occurred, some laceration ofthe dura, even if not more than surface damage or a punctiform opening, had resulted. In the more serious gutter fractures an elongated rent ofsome extent usually existed. In the perforating fractures two more orless irregular openings were the rule. The amount of hæmorrhage, even ifthe venous sinuses were implicated, was on the whole surprisingly small, when the cases were such as to survive the injury long enough to bebrought to the Field hospital. I never saw a typical case of middlemeningeal hæmorrhage, although many fractures crossing the line ofdistribution of the large branches came under observation. Case 60, p. 274, illustrated the fact that the osseous lesions of lesser apparentdegree are sometimes the more to be feared in the matter of hæmorrhage, as compression is more readily developed. The degree of injury to the brain depended on the depth of the track, the resistance offered by the bones of any individual skull, the weightof the patient, but chiefly on the degree of velocity retained by thebullet. It was sometimes slight and local as far as symptoms would guideus; but in the majority of cases out of all proportion to the apparentbone lesion, if the range was at all a short one. Cases illustrative ofthese injuries are included under the heading of symptoms. It will be, of course, appreciated that the coarse brain lesions underthe third heading differed in localisation and in extent alone, and inno wise in nature, from those observed in the two preceding classes. Thedamage consisted in direct superficial laceration and contusion, andbeyond the limits of the area of actual destruction, abundantparenchymatous hæmorrhages more or less broke up the structure of thebrain, such hæmorrhages decreasing both in size and number asmacroscopically uninjured tissue was reached. No opportunity was everafforded of examining a simple wound track in a case in which no obviouscerebral symptoms had been present. IV. _Fractures of the base. _--In addition to the above classes, a fewwords ought to be added regarding the gunshot fractures of the base ofthe skull. These possessed some striking peculiarities; first in thefact that they might occur in any position, and hence differed from thetypically coursing 'bursting' fractures we are accustomed to in civillife as the consequence of blows and falls, and consequently were oftenpresent without any of the classical symptoms by which we are accustomedto locate such fissures. Secondly, the peculiar form was not uncommon inwhich extensive mischief was produced from within by direct contact of apassing bullet. As far as could be judged from clinical symptoms, indirect fractures ofthe base such as we are accustomed to meet in civil practice inconnection with fractures of the vault were decidedly rare, and, as hasalready been mentioned, ocular evidence of extensive fissures extendingfrom perforating wounds of the vertex was wanting, except in the extremecases classed under heading I. For these reasons I am inclined to regardthem as uncommon. Direct fractures of the base, on the other hand, were of commonoccurrence, especially in the anterior fossa of the skull. These mightbe produced either from within, the most characteristic form of gunshotinjury, or from without. The fractures from within were often simplepunctures of the roof of the orbit or nose. Punctured fractures of the roof of the orbit caused little trouble asfar as the cranium was concerned, but the orbital structures oftensuffered severely. I saw one or two very severe comminutions of the roofof the orbit caused by bullets which had crossed the interior of theskull; in one case the whole roof was in small fragments, while thedamage in others was not greater than chipping off some portion of thelesser wing of the sphenoid. The roof of the orbit again was sometimesvery severely damaged by bullets which first traversed that cavityitself; thus in one case which recovered, the bullet passedtransversely, smashing both globes, and fracturing the roof of bothorbits and the cribriform plate so severely as to lacerate bothdura-mater and brain, portions of the latter being found in the orbit onremoval of the damaged eyes. Fractures of the middle and posterior fossæ were met with far lessfrequently, partly I think because vertical wounds passing from thevertex to the base in these regions were with few exceptions rapidlyfatal, and partly from the fact that the occipital region, beingordinarily sheltered from the line of fire, was rarely exposed to thedanger of direct fracture from without. As an odd coincidence I maymention that in my whole experience during the war I only once sawbleeding from the ear as a sign of fracture of the base, apart fromdirect injuries to the tympanum or external auditory meatus. _Symptoms of fracture of the skull, with concurrent injury to thebrain. _--These consisted in various combinations of the groups of signsindicative of the conditions of concussion, compression, cerebralirritation, or destruction. Although the symptoms possessed no inherentpeculiarities, yet certain characteristics exhibited served toillustrate the fact that, as a result of the special mechanism ofcausation of the injuries, the type deviated in many ways from thataccompanying the corresponding injuries of civil practice. The characters of the external wounds will be first considered, followedby some remarks concerning the symptoms attendant on the differentdegrees and types of lesion, the symptoms special to injuries todifferent regions of the head, and on the subsequent complicationsobserved. In the simplest injuries the type forms of entry and exit wound werefound, and it has already been observed that in these, if symmetrical, considerable difficulty existed in discriminating between the twoapertures. This is to be explained by the fact that the arrangement andstructure of the scalp are identical in corresponding regions; hence theonly difference in the conditions of production of the entry and exitwounds exists in the absence of support to the skin in the latter. Thegranular structure of the hairy scalp is opposed to the occurrence ofthe slit forms of exit, hence the openings were usually irregularlyrounded. Any increase of size in the exit wound in the soft parts due tothe passage of bone fragments with the bullet, was equalised in that ofentry by the fact that the latter, as supported by a hard substratum, was usually larger than those met with in situations where the skincovers soft parts alone. In some cases of gutter fracture the wounds of entry were large andirregular, as a result of upward splintering of the bone at the distalmargin of the aperture of entry in the skull, and consequent lacerationof the scalp. Again, on the forehead very pure types of slit exit woundwere often met with in the position of the vertical or horizontalcreases. With higher degrees of velocity on the part of the bullet andconsequent comminution at the aperture of exit in the bone, the scalpwas more extensively lacerated, and large irregular openings in the softparts, often occupied by fragments of bone and brain pulp, were metwith. It is well to repeat here, however, that the presence of brainpulp in a wound by no means necessarily indicated the aperture of exit, for it was sometimes found in the entry opening also. In the most severe cases, such as are included in class I. , the exitwound often possessed in the highest degree the so-called 'explosive'character. From an opening in the skin with everted margins two or moreinches in diameter a mass of brain débris, bone fragments and particlesof dura-mater, skin, and hair, bound together by coagulated blood, protruded as a primary hernia cerebri if the patient survived the firstfew hours after the injury. In other cases of the same class the actualopening was smaller, but the whole scalp was swollen and oedematous, sometimes crackling when touched from the presence of extravasated bloodin the cellular tissue, while firm palpation often gave the impressionthat the head consisted of a bag of bones over a considerable area. Gutter fractures of the scalp were sometimes situated beneath an openfurrow, gaping from loss of substance, or beneath a bridge of skin; inthe latter case they were usually palpable. Simple punctures were alsousually palpable, but the smallness of the openings sometimes renderedtheir detection more difficult than might be assumed. I never saw a case in which the skull escaped injury when the bulletstruck the scalp at right angles, but the frequency with which Mauserbullets were found within the helmets of men would suggest that thismust have sometimes occurred. A case of injury to the external tablealone has been described (p. 243). An illustration of the next degree ofinjury is afforded by the following:--A bullet lodged in the centre ofthe forehead, the point lying within the cranial cavity, while the baseprojected from the surface: this patient suffered but slight immediatetrouble, so little, indeed, that he merely asked his officer to removethe bullet for him, as it was inconvenient. The bullet was subsequentlyremoved in the Field hospital. In a few cases the bullet entered the skull and was retained, when onlya single wound was found. Such cases are described in Nos. 54 and 68, where the position of the bullet was determined by palpable fracturesbeneath the skin. With regard to the retention of bullets, however, insmall-calibre wounds, it was always necessary to examine the other partsof the body with great care, and to ascertain, if possible, thedirection from which the wound was received, as an exit was often foundsome distance down the neck or trunk. Again the possibility of theopening having been produced by glancing contact had to be considered. In cases which survived the injury on the field, free hæmorrhage, as inwounds of other regions, was rare, and although general evidence of lossof blood was often noted in patients brought in, progressive bleedingwas seldom observed. Again, when the wounds were explored, the amount ofblood, although considerable, was usually not more than sufficed to fillup the space consequent on the loss of brain tissue. This was especiallystriking when large venous sinuses, as the superior longitudinal, wereinvolved in the injury. None the less, hæmorrhage at the base of thebrain was, I believe, responsible for early death in many of the severecases, especially when the wounds were near the lower regions of theskull. Escape of cerebro-spinal fluid was not so prominent a feature as mighthave been expected, considering how freely the arachnoid space wasopened up in many cases. I think this was usually checked by earlycoagulation of the blood, and later by adhesions. It must be rememberedalso that extensive wounds were most common on the vertex, or at anyrate over the convex surface of the brain, while fractures of the middlefossa were usually rapidly fatal. _Concussion. _--Cases exhibiting symptoms of pure uncomplicatedconcussion were distinctly rare, as would be expected from themechanism of the injuries. On the other hand, symptoms of concussionformed the dominant feature of all severe cases. The symptoms in many instances consisted in great part in transitorysigns of the so-called 'radiation' type, such as are seen in destructivelesions where the signs of nervous damage rapidly tend to diminish andlocalise themselves. As to the causation of the 'radiation' symptoms, it is difficult todiscriminate the effects of neighbouring parenchymatous hæmorrhages fromthose of local vibratory concussion of the nervous tissue. The localcharacter of the signs seems, however, to point to causation bymolecular disturbance, resulting from the conduction of forciblemechanical vibration to the brain tissue rather than to upset in theintra-cranial pressure. Again the limited nature of the paralysisobserved, sharply defines it from the general loss of power accompanyingordinary cases of concussion of the brain. The similarity of thephenomena to those described in other parts of the body under theheading of 'local shock' is sufficiently obvious. The following instance well exemplifies the condition in question: (55) Wounded at Spion Kop. A scalp wound 3 inches in length crossed the left parietal bone nearly transversely, starting 1-1/2 and ending 2 inches from the median line: the centre of the wound corresponded with the position of the fissure of Rolando. The patient was struck at a distance of fifty yards while kneeling; he fell and remained unconscious an hour and a half. Right hemiplegia without aphasia followed. The wound was cleansed and sutured, and in three days both arm and leg could be moved, after which time the man improved rapidly. Three weeks later when I saw him at Wynberg there was still comparative weakness of the right side, but beyond some neuralgia of the scalp, the man considered himself well. No groove could be detected on the bone on palpation. (This case offers a good example of the ease with which bone injury may be overlooked. The man came over to England 'well;' but while on furlough, two pieces of bone came away spontaneously. He is now again on active service. ) _Compression. _--Equally rare was it for pure symptoms of compression tobe exhibited. This depended on two circumstances: first, the rarity ofinjuries giving rise to meningeal hæmorrhage; secondly, the fact that innearly every case a more or less extensive destructive lesion waspresent, at the margins of which less completely destroyed tissueremained, capable of giving rise to symptoms of irritation. Again, as wehave seen, free hæmorrhage into, or from the walls of, the cavitiesproduced in the brain was not a marked feature, and beyond this thelarge defect in the cranial parietes was calculated to render a highdegree of compression impossible. As the most serious head injuries presented a remarkable similarity intheir symptoms, I will shortly summarise their common features. Every degree of mental stupor up to complete unconsciousness was metwith, but in some instances where the pulse, respiration, and generalbodily condition pointed to speedy dissolution, the patients answeredrationally often between moans or cries indicative of pain. Widespread paralysis often existed, but this was seldom completelygeneral; more commonly it was combined with extreme restlessness of theunparalysed parts, or sometimes, even when the whole of one hemispherewas tunnelled, and in all probability widely destroyed, restlessness wasthe only symptom. In some cases twitching of the features or the limbsor severe convulsions were superadded. The pupils were rarely unequal, and at the stage in which these patientswere first seen were usually moderately contracted. Wide dilatation wasuncommon throughout. The pulse was with very few exceptions slow, sometimes irregular. Insome instances, when the wounds had been thought suitable forexploration, the slow pulse was altered after operation to a rapid one, and death usually quickly supervened. Respiration was irregular, sometimes sighing; in the late stage often ofthe Cheyne-Stokes type; actual stertor was exceptional, but therespiration was often noisy. The temperature was often raised from an early stage to 99° or 100°, andif the patient survived a day or two, it often rose to 103° or 104°. Howfar the secondary rise depended on sepsis it was not always easy todetermine. The urine was usually retained. Cases presenting the above characters were usually those suffering fromlesions such as are described in class I. , and mostly died intwenty-four to forty-eight hours. The correspondence of the train ofsymptoms with those due to combined brain destruction and severeconcussion is at once apparent. To illustrate the nature of the symptoms in patients suffering from theless extensive forms of injury, such as those included in classes II. And III. Under the heading of anatomical lesion, the relation of a shortseries of histories will be advisable. I may first premise, however, that the special characteristics of these were in some instances thealmost entire absence of primary symptoms of gravity; in others generalsymptoms of a severity out of apparent proportion to the externallesion; while in all destructive lesions, very widely distributedradiation symptoms developed, often disappearing with great rapidity. The symptoms consisted in those of concussion, irritation, localpressure, and actual destruction. The symptoms of concussion were either general, and then usuallytransient, or local paralysis of the radiation variety, which alsorapidly improved. Signs of irritation consisted in irritability of temper, drowsiness, closure of the eyes and objection to light, contracted pupils sometimesunequal, a tendency to the assumption of the flexed position at all thejoints, twitchings, and sometimes convulsions. Sometimes these appearedearly as a direct result of mechanical irritation from bone fragments orblood-clot; sometimes only in the course of a few days, as a result ofirritation of parts recovering from the radiation effects which hadprevented earlier nervous reaction. Possibly in some cases the symptomsof irritation depended upon an increase in the amount of hæmorrhage, andin others upon the development of local inflammatory changes. Local pressure, or actual destruction of brain tissue, was evidenced bytemporary paralysis in the former, permanent loss of function in thelatter, condition. Fractures of the anterior fossa of the skull were attended by verymarked evidence of orbital hæmorrhage, as subconjunctival ecchymosis(rarely pure), increased tension, and proptosis. Injuries to the cranial nerves at the base, with the single exception oflesion of the optic nerves, which was not rare, were in my experienceuncommon in the hospitals--a fact pointing to the very fatal nature ofdirect basal injuries, except in the anterior fossa of the skull. Signsindicative of injury to the olfactory lobe were occasionally observed. I should, perhaps, again insist here on the rarity with which acutediffuse septic infection occurred in cases of these degrees of severity, also on the fact that interference with the wounds in the way ofsecondary exploration, even when they were manifestly the seat of localinfection, was followed almost without exception by good immediateresults; and, lastly, that when suppuration did occur, it was usuallystrictly local in character. The influence of the climate of SouthAfrica and our surroundings has already been discussed, but whetherclimate, condition of the patients, or peculiarity in the nature ofcausation of the wounds was responsible, in no series of cases was theabsence of acute inflammatory troubles more striking than in this one ofbrain injuries. Frontal injuries were those most frequently unaccompanied by primarysymptoms of severity; slowing of the pulse--this often fell to 40--andoccasional irregularity, were almost the only constant signs of cerebraldamage. Some patients temporarily lost consciousness, others rose atonce and walked to the dressing station, and in few cases was anypsychical disturbance noted in the early stages. I think, however, it may be affirmed that frontal injuries, accompaniedby trivial signs, resulted without exception from the passage of bulletstravelling at a low rate of velocity. Thus in several of the instanceshere related the patients at the time of reception of the wound wereunder the impression that they were entirely beyond the range of fire, and in one, in which well-marked signs of concussion followed, thebullet, which had traversed the head, retained only sufficient force toperforate the skin of the neck and bury itself in the posteriortriangle without even fracturing the clavicle, against which itimpinged. In men struck at a shorter range, signs of concussion, oftenfollowed by transient radiation signs of injury to the parietal lobe, were common. These signs were, I think, not as a rule due to surfacehæmorrhage, since they were of a purely paralytic nature and notirritative. Several cases with partial or complete hemiplegia, hemiplegia and aphasia, or facial paralysis are recorded below. (56) _Frontal injury_. --Wounded at Magersfontein. In prone position when struck, distance 700 to 800 yards. _Entry_ (Mauser), at the margin of the hairy scalp above and to the left of the frontal eminence; course, through anterior third of left frontal lobe, roof of orbit, obliquely across line of optic nerve, inner wall of orbit, nose, right superior maxilla piercing alveolar process, and passing superficial to inferior maxilla: _exit_, one inch anterior to angle of jaw. The bullet again entered the posterior triangle of the neck, struck the right clavicle, and turned a somersault, so that its base lay deepest in the wound. The patient was unconscious for a short time, suffered with general headache and giddiness, and was somewhat irritable. On the third day the pulse was 70, temperature normal, and he was sent to the Base. There was considerable proptosis, oedema and discoloration of the eyelid, and subconjunctival ecchymosis, but the movements of the eyeball could be made and light could be distinguished. The sense of smell was apparently absent. A week later the headache was gone, the pulse numbered 80 to 90, the temperature was normal, he slept well, sat up in bed and smoked, took his food well, and exhibited no cerebral symptoms. He could detect the smell of tobacco, but not as a definite odour. No further symptoms were noted, the sense of smell returned, the swelling of the eyelid and proptosis decreased, but the upper lid could not be raised. When the lid was drawn up, there appeared to be vision at the margins of the field with a large central blind spot. The patient left for England at the end of a month apparently well. (57) _Gutter fracture of frontal bone. _--Wounded at Paardeberg. _Entry_ (Mauser), 3/4 of an inch within the margin of hairy scalp above outer extremity of right eyebrow; gutter fracture; _exit_, 2 inches nearer middle line, at the same distance from the margin of the hairy scalp. The patient was knocked head over heels, his main feeling being a sense of dulness in the right great toe. He sat up and got a first field dressing applied, then lay down, but as he was still under fire, he retired 1, 000 yards to the collecting station; here he dressed some patients, and later mounted an ambulance wagon and was driven to the Field hospital. The next day he helped with the work of the hospital, amongst other things controlling the artery during an amputation of the arm. He then took a three days' and nights' journey to Modder River in a bullock wagon, during which journey he had a fit, which was general, the thumbs being turned in and a wedge being necessary between the teeth to prevent him biting his tongue. On the sixth day the wound was examined, and between this and the tenth day he had several fits of the same nature as the first, accompanied by stertorous breathing and profuse sweating. On the tenth day Mr. Cheatle opened up the wound and removed numerous fragments of bone, leaving a clean gutter 2 inches by 3/4 of an inch. After the operation no further fits occurred, and eight days later he was conscious, but was excitable and talked at random. On the twentieth day he arrived at the Base after 30 hours' railway journey (623 miles). He was then quite rational, but unable to make any demands on his memory and very sensitive to noise; at times he wandered in the evenings and his temperature rose as high as 100°. The wound was open and granulating, the floor pulsating freely. Three weeks later the wound was still open, and the skin dipped in at the lower margin. The mental condition was much improved, although attempts at giving a history of his case were obviously tiresome. The wounds in the leather headband of this patient's helmet were interesting, the round aperture of entry in the exterior of the helmet being followed by a starred exit aperture in the leather band, the second entry opening in the leather band being again circular, and the external opening in the puggaree a transverse slit. (58) _Transverse superficial perforating frontal injury. _--Wounded at Graspan. Aperture of _entry_ (Lee-Metford), at upper and outer part of left frontal eminence; _exit_, at margin of hairy scalp over outer third of right eyebrow. On the second day the patient complained of giddiness and headache; the pulse was 60. He was then walking about. The wounds were explored and typical entry and exit apertures discovered in the frontal bone from which cerebral matter was protruding. Both openings were enlarged (Mr. S. W. F. Richardson) with Hoffman's forceps, and a considerable number of splinters of the inner table were removed from the aperture of entry. The headache gradually passed off, but there was throbbing about the scar, and pulsation was visible for some three weeks, after which no further symptoms were observed. (59) _Oblique frontal gutter fracture. _--Wounded at Magersfontein. _Entry_ (Mauser), 1/2 an inch to right of median line of forehead, 3/4 of an inch from the margin of the hairy scalp; _exit_, about 3/4 of an inch anterior to the lower extremity of the right fissure of Rolando. Weakness of left facial muscles, especially of angle of mouth. No further motor symptoms. Wounds explored (Mr. Stewart); numerous fragments of bone and some pulped cerebral matter were removed. Patient developed no further signs; the paralysis, although improved, did not completely disappear. The man a year later was still on active duty, the paralysis almost well, and no further ill effects of the injury remained. In the fronto-parietal or parietal regions, signs of damage to thecortical motor area were seldom absent, sometimes evanescent, at othersprolonged. In some cases the signs were permanent and followed byevidence of local sclerosis. The motor area on both sides of the brain was sometimes implicated; thusin a child shot at Kimberley the bullet entered in the right frontalregion, and emerged to the left of the line connecting bregma and iniona little behind its centre. Paralysis of both lower extremitiesresulted, power rapidly returning in the right, while incompleteparalysis persisted in the left. In only one instance (see case 73, p. 292) was any permanent sensorydefect observed, and the mental condition of this patient would havecertainly suggested a functional explanation for its presence, had itnot been for the accompanying inequality in the axillary surfacetemperatures. In a second case (No. 67) blunting of sensation followed a definitelesion of the inferior parietal lobule. In this instance an occipitallesion was associated with the parietal. (60) _Parietal gutter fracture. _--Wounded at Magersfontein. A scalp wound 3 inches in length ran transversely across the right parietal bone at the level of the lower third of the fissure of Rolando. A second wound of entry was found crossing the third dorsal spine; the bullet was retained and was palpable over the right scapula. There was left facial paralysis, weakness and numbness of both upper extremities, especially of the left, and some difficulty in swallowing. The man was sent to the Base, where he arrived on the fourth day. The symptoms had then become much more marked, consciousness was incomplete, and articulation slow and imperfect. There was complete left hemiplegia, and deviation of the tongue to the right. The pulse was 40. An exploration (Mr. J. J. Day) showed that an oval plate of the outer table of the parietal bone had been struck off. A trephine was applied to the exposed diploë and a crown of bone removed; considerable comminution of the inner table had occurred, several large fragments having perforated the dura-mater. The latter did not pulsate; it was therefore freely incised, and many more fragments of bone and a large quantity of blood-clot removed. The first effect of the operation was slight, but ten days later rapid improvement commenced, the first sign being acceleration of the pulse, which rose to 70. On the eighteenth day the original symptoms still remained to a diminished extent, but a fortnight later there remained traces of the facial weakness only, and there was little difference in the grip of the two hands. The patient was shortly afterwards sent home. Ten months later he returned to South Africa on active service. (61) _Fronto-parietal gutter fracture. _--Wounded at Graspan. _Entry_ (Mauser), 1 inch within the margin of the hairy scalp, 1/2 an inch to the left of the median line; _exit_, 3-1/2 inches posterior in same line. Complete right-sided hemiplegia. The wounds were explored on the fourth day (Major Moffatt, R. A. M. C. ) and a gutter fracture involving the frontal and parietal bones exposed. The dura-mater was lacerated and brain matter from the frontal lobe escaped freely. A large number of bone fragments were removed. On the fourth day after the operation, the patient became unconscious with right-sided twitchings, but rapidly improved, and at the end of three weeks, except for slight headache, he was well, the power of the right side being good. Ten months later he rejoined his regiment in South Africa, no apparent ill effects remaining. (62) _Fronto-parietal perforating fracture. _--Wounded at Magersfontein. _Entry_, within the margin of the hairy scalp; _exit_, behind and below the left parietal eminence, the track crossing about the centre of the fissure of Rolando. Right hemiplegia, the lower half of the face only being involved. The wounds were explored and a large number of fragments of bone and a quantity of pulped cerebral matter removed. Six days later the hemiplegia persisted, speech was slow, headache was troublesome and the pulse not above 45. After this, gradual improvement took place, and a month later the lower extremity and face had regained good power. The upper extremity remained flaccid and paralysed, except for some slight power of movement of the shoulder. (63) _Fronto-parietal perforating fracture. _--Wounded at Magersfontein. _Entry_ (Mauser), 2-1/2 inches from the median line, 3-1/2 inches from the occipital protuberance; _exit_, 3/4 of an inch from the median line, 4-1/2 inches from the glabella; sanious fluid escaped from both ears. There was left facial paralysis, complete paralysis of the left upper extremity, and partial paralysis of the left lower extremity. The patient was deaf, drowsy, and the pulse 45. Exploration showed the entry wound to be in the parietal, the exit to involve both parietal and frontal bones. The openings were enlarged, and a number of fragments of bone, together with pulped cerebral matter and blood-clot, were removed. The wound healed, except at the front part, where a small prominence suggested a hernia cerebri. The patient improved slowly; fourteen days after the operation he could hear well, and the flow from the ears had ceased. The facial weakness was slight, the upper extremity was still powerless, but he could move the lower and draw it up in bed. At the end of six weeks the wound had healed, and he was got up and dressed. At the end of two months he was well enough to be sent home; there was only a trace of facial weakness; the right upper extremity, however, was powerless and slightly rigid, occasional twitchings occurring in it. Considerable power had been regained in the lower extremity, so that the patient could walk with help, but foot-drop persisted; the gait was spastic in character, the reflexes were much exaggerated, and there was marked clonus. The patient was sensible, but his manner suggested some mental weakness. Both the openings in the skull were closed by very firm material, apparently bony. This patient became a Commissionaire some ten months later. His mental condition is normal, and loss of memory seems confined to the events immediately following the injury. The lower extremity has improved, but the upper is useless. (64) _Parietal injury: retained bullet. _--Wounded at Paardeberg. Aperture of _entry_ (Mauser), 1 inch diagonally below and anterior to left parietal eminence. No exit. The patient was trephined by the surgeons of the German ambulance at Jacobsdal. Sixteen days later he arrived at the Base. A circular pulsating trephine opening was then to be felt beneath the flap, but no information was forthcoming as to the bullet. The patient could speak, but lost words and the gist of sentences; he could remember nothing as to himself since the day of the injury. There was right facial weakness; he could not close the right eye or whistle, but there was little apparent want of symmetry; there was weakness in the grip of both hands, more marked on the right side; both lower extremities could be moved. The reflexes were normal, although the left limb was slightly rigid. The pupils were equal, reflex normal; slight nystagmus. Pulse 72, small and regular. Temperature normal. Rapid improvement followed. During the fourth week the temperature rose to 103°, and remained elevated for six days, but no local or general signs appeared; at the end of five weeks there was little evidence of the paralysis remaining. The patient was discharged from the service on his return home. In the upper part of the occipital region glancing or superficialinjuries were comparatively favourable; those near the base, especiallyif perforating, were very dangerous. Two such cases are referred toelsewhere. Case 69 is included as the only example of cerebellar injuryI happened to see who lived any appreciable time after the accident. The main interest in these cases centres in the defects produced in thearea of the visual field. I am extremely indebted to my colleague, Mr. J. H. Fisher, who has kindly determined this for me in three of thefollowing cases. It will be noted that in two instances the injury wasto the left occipital lobe. In these the resulting hemianopsia was ofthe pure lateral homonymous character, and in both the visual symptomswere accompanied by a certain degree of amnesic aphasia (65 and 68). In 65 the injury was definitely unilateral, and at the time of theoperation I decided that at least an inch and a half of the posteriorextremity of the left occipital lobe was totally destroyed. In 68 the lesion was probably confined to the left lobe, but it isimpossible to exclude slight injury to the right lobe also. In thisinstance amnesic aphasia was a far more marked symptom than in 65, andthe position of the lesion suggested damage both to the visual andauditory word centres. Cases 66 and 67 are instances of damage to both occipital lobes. In 66, although the wound was a glancing one, and did not perforate, it was sonear the median line, and accompanied by such severe damage to the bone, that a symmetrical lesion of the cuneate and precuneate lobules of bothright and left sides is to be inferred. In 67 the great longitudinalfissure was traversed by the bullet obliquely. It is of great interestto observe that in each of these cases the lesion of the visual fieldwas a horizontal one and affected the lower half in place of assuming alateral distribution. In all four cases the primary effect of the occipital injury was thesame--viz. Absolute blindness--while the return of vision in each was ofthe nature of the dawning of light. I regret that I am unable to furnishany detail as to increase of the field of vision in the progress of thecases, but circumstances rendered continuous observation of the patientsimpossible. In each case deafness was apparently the direct result of concussion ofthe ear on the side corresponding to the wound. Deafness of the oppositeear was never noted. In case 67 some general blunting of sensation was noted in the paralysedupper extremity, and in this patient, no doubt, injury to the inferiorparietal lobule accompanied the occipital lesion. (65) _Injury to left occipital lobe. _--Wounded at Belmont. A single transverse wound, 2 inches in length, extended across the occipital bone, 2 inches above the level of the external protuberance. When seen on the third day the wound was gaping and pulped cerebral matter was found in it. The patient was very drowsy, lying with closed eyes, and complaining of great coronal and frontal headache. He could distinguish light and darkness, but not persons. Total blindness immediately followed the injury, persisting some three days, and the patient spoke of return of sight as of the appearance of dawn. The pupils were equal, moderately dilated and acted to light, which was unpleasant to him. He was somewhat irritable and silent, but apparently rational. Temperature 99°. Pulse 56 full. Tongue clean. No sickness, no difficulty in micturition. Fifty-six hours after the injury the wound was opened up and cleaned, and an oval fractured opening about 3/4 by 1/2 inch was exposed 3/4 inch to the left, and 2 inches above the occipital protuberance. The margins of the opening showed several small fragments of lead attached to the bone. A 3/4-inch trephine was applied at the left extremity of the opening, and it was found that about a square inch of the internal table was comminuted and driven into the brain, together with several small fragments of lead. On introducing the finger, about 1-1/2 square inches of the occipital lobe were found to be pulped, and the finger could be swept across the tentorium. There was no sinus hæmorrhage (nor did the history suggest that hæmorrhage had ever been severe). The cavity was carefully sponged out, and the wound closed with a drainage aperture. Little change followed in the patient's condition, and on the sixth day he was sent to the Base hospital. Three weeks later the wound was firmly healed. The patient still complained of frontal headache, and wore a shade, as the light hurt his eyes and made them water freely. The pupils acted, but were wide; objects could be distinguished, and also persons. Otherwise, the man's condition was good: he began to get up, and at the end of six weeks returned to England. A year later the man was earning his living as a Commissionaire porter. He complains of giddiness when he stoops, or when he looks upwards, and at times he suffers much with headache both in the region of the injury and across the temples. There is a bony defect and slight pulsation at the site of the injury, but no prominence. When attempts are made to read the lines run together, and a dark shadow comes before his eyes. He speaks of the latter as still terribly weak. Speech is slow and somewhat simple, but he makes no mistakes as to words. Memory is bad for recent events. Mr. Fisher makes the following report as to the eyes: Pupils and movement of eyes normal in every respect. No changes in fundi. Vision, R. 5/12 with--0. 5 5/6 L. 5/9 with--0. 5 5/5 [Illustration: FIG. 73. --Right Visual Field, in case 65. Injury to leftoccipital lobe. Field for white. Test spot 10 mm. Good daylight. Righthomonymous hemianopsia] [Illustration: FIG. 74. --Left Visual Field, case 65] There is therefore practically full direct vision. Though the man chooses a concave glass he is not really myopic. There is typical right homonymous hemianopsia; the answers, when tested with the perimeter, are quite certain, and the fields absolutely reliable. The man's statements confirm the condition; he is aware of his inability to see objects to his right-hand side, and is apt to collide with persons or objects on that side. The lesion is one of the left occipital cortex in the cuneate lobe and the neighbourhood of the calcarine fissure. The speech suggests a slight degree of aphasia. (66) _Injury to occipital lobes. _--Wounded at Magersfontein while in prone position. Distance, 500 yards. He says he was never unconscious, but for two days was absolutely blind. His eyesight gradually improved, but headache was very severe, and sleeplessness nearly absolute. On the eighth day the wound, which was situated over the right posterior superior angle of the parietal bone, was opened up, and a number of fragments of bone and a quantity of pulped brain removed from a depressed punctured fracture, surrounded by an annular fissure, completely encircling it, 1-1/2 inch from the opening. The portion of brain destroyed was probably a considerable portion of the cuneate and precuneate lobules of both sides, as well as a portion of the first occipital convolution, and the superior parietal lobule of the right side. There was no evidence of injury to the superior longitudinal sinus in the way of hæmorrhage. After the operation the patient slept better, but still complained of headache, and when he arrived at the Base, the flap became oedematous, and the stitch holes and also the central part of the wound suppurated. The temperature rose to 101°. The wound was therefore re-opened, and a number of additional fragments of bone, some as deeply situated as 2 inches from the surface, were removed. Steady improvement followed, and at the end of a further three weeks the wound was healed, the headache had ceased, and there were no abnormal symptoms, except that light was unpleasant to the right eye, and the field of vision was manifestly contracted (Mr. Pooley). A year later the man was employed as a letter-carrier. He complains of headache at times, and on six occasions has had 'fainting fits. ' He says that the latter commence with tremor, that his legs then give way and he falls. In a quarter of an hour he gets up, and feels no further inconvenience. Speech is perfect, there is no deafness. The bone defect is very nearly completely closed. Mr. Fisher reports as follows as to the vision. There is a high degree of hypermetropia in each eye, the R. Has nearly 6. 0 D and the L. About 5. 0 D. With correction he gets practically full direct vision with each. [Illustration: FIG. 75. --Right Visual Field, in case 66. Injury to bothoccipital lobes. Field for white. Test spot 10 mm. Good artificiallight. Defect in field complicated by functional symptoms] [Illustration: FIG. 76. --Left Visual Field, in case 66. Defect in lowerhalf of field] The patient has been examined before, and has been informed that his vision quite incapacitates him from further service. He began by stating that he could not see on either side of him, but only straight in front; that he is apt to collide with people in walking, was nearly knocked down by a horse, and that his acquaintances accuse him of passing them unnoticed. The fields of vision are very small, but the loss is not typically in the temporal half of either. That of the right eye which we know as the spiral field, becoming more and more contracted as the perimeter test is continued, is what is found in functional cases; that of the left, however, shows a characteristic loss of the lower part of the field of vision, and agrees with the statement of the man that he can see the upper part of my face but not the lower when he looks at me. Such a loss agrees with a lesion involving the upper part of the cuneate lobe above the calcarine fissure. I feel satisfied that there is considerable loss in the right field also, but the functional element obscures its exact nature. The fundi, pupils, and ocular movements are all normal. (67) _Injury to occipital lobes and left motor and sensory areas. _--Wounded outside Lindley (Spitzkop). Range within 1, 000 yards. _Entry_, one inch within the right lateral angle of the occipital bone, external wound more than 1/2 an inch in diameter; _exit_, 2 inches from the median line, over the upper half of the left fissure of Rolando. Behind the wound of exit comminution of the parietal bone, extending back to the lambdoid suture, existed. I attributed this to oblique lateral impact by the bullet on the inner surface of the skull. The patient could afterwards remember being struck, but became rapidly unconscious. When brought into the Field hospital some five hours later the condition was as follows: Semi-conscious, can speak, apparently blind, pupils equal, of moderate size, do not react to light. Right hemiplegia. No sickness. Moans with pain in head. Passes water normally. Considerable hæmorrhage had occurred from each wound, the scalp was puffy, and the bones yielded on pressure over the left parietal bone, indicating considerable comminution. The night was so cold that no operation could be considered, so the head was partly shaved, the wounds cleansed, and a dressing applied. The next morning the Division marched at 5 A. M. , and it was considered wise to leave the man at Lindley in the local hospital. [Illustration: FIG. 77. --Right Visual Field, in case 67. Injury to bothoccipital lobes. Field for white. Test spot 10 mm. Good artificiallight. Defect in lower half of field] [Illustration: FIG. 78. --Left Visual Field, in case 67] No operation was performed there, but I heard later that the man recovered full consciousness at the end of five days, and at the end of a fortnight he commenced to see again. Six weeks later he travelled to Kroonstadt, thence to Bloemfontein, and thence to Cape Town and home to Netley. The paralytic symptoms meanwhile steadily improved. Seven months later his condition is as follows: Scarcely a trace of facial paralysis. Slight power of movement of arm, forearm, and fingers, but grip is very weak. Little power of abduction of the shoulder or of straightening the elbow. The latter movement is made with effort and in jerks. Sensation over the back of the arm is somewhat lowered, and is 'furry' at the finger tips. There is very little wasting of the muscles noticeable. Walks well, but with some foot-drop. Slight increase of patellar reflex. He says that he does not walk in the street with confidence, as he often feels as if omnibuses &c. Were coming too near him. He is absolutely deaf in the right ear. The openings in the skull are closed, the occipital lies about halfway between the external auditory meatus and the external occipital protuberance, while the parietal still affords evidence of the earlier comminution, one fissure passing backwards as far as the lambda, and the whole surface is lumpy and uneven. The track through the brain no doubt involved a considerable extent of the outer aspect of the right occipital lobe and the cuneate lobule. It must also have crossed the great longitudinal fissure, and penetrated the left Rolandic region, just above its centre, probably involving the precuneate lobule, and a portion of the internal capsular fibres as well as the cortex on the left side. The deafness was probably due to concussion of the internal ear. Mr. Fisher has kindly furnished the following note regarding the vision. The pupils, movements, and fundi are quite healthy. There is good direct vision R. Or L. 5/5 fairly, and together 5/5. The man complains he has lost his side sight, also the lower; he demonstrates the latter quite obviously with his hand, and says he has to repeatedly look down when walking. He thinks no improvement has taken place during the last month. The accompanying fields of vision show the loss quite characteristically. (68) _Injury to left occipital lobe. _--Wounded at Paardeberg. _Entry_ (Mauser), through the lambdoid suture on the right side of the mid line. Bullet retained, but a palpable prominence behind the left ear suggested its localisation. The patient became at once unconscious and remained so for several days. He was completely blind; vision returned later, but only to a limited degree. There was complete loss of memory as to the events of the day. When admitted at Rondebosch into No. 3 General Hospital the condition was as follows: The field of vision is limited, and examination shows right homonymous hemianopsia. When any one comes into the tent the patient sees a shadow only until his bed is reached. When spoken to the patient 'thinks and thinks, ' and then apologises for not answering, saying he will remember at some future time. He is absolutely unable to remember times, names, or localities, but places his hand to his head and appears to think deeply in the effort to recall them. Occasionally when you go into his tent he suddenly remembers something he has been trying to think of for some days, and will tell you. A fortnight later after an attack of influenza the patient was not so well, and vision was apparently becoming more impaired. An incision was made (Mr. J. E. Ker) so as to raise a flap the centre of the convexity of which was 2-1/2 inches behind the left external auditory meatus. A slight prominence and a fissure was discovered in the temporal bone, and over this a trephine was applied. On removal of the crown of bone the bullet was discovered with the point turned backwards (having evidently undergone a partial ricochet turn) on the upper surface of the petrous bone, just above the lateral sinus. The dura-mater was healed but thickened, and some clot upon its surface was removed. The wound healed per primam, and a rapid recovery was made. Ten days later a running water-tap was able to be detected 120 yards from the tent door. The hemianopsia however persisted. The following letter, dictated by the patient to his wife, and sent tome, gives a clear account of his condition ten months later:-- I am pleased to say my memory is better than it was some time ago, though at times I am entirely lost and really forget all that I was speaking about. I also find that I often call things and places by their wrong names. I sometimes try to read a paper or book which I have to read letter by letter, sometimes calling out the wrong letter, such as B for D &c. , and by the time I have read almost halfway through, I have forgotten the commencement. My sight is about the same. There is no improvement in the right eye, and the doctor at Stoke said that the left eye was not as it ought to be and might get worse. I ofttimes go to take up a thing, but find I am not near to it, though it appears to me so. I have no pain to speak of in the head, though at times a shooting pain. I have a continual noise in the left ear as if of a locomotive blowing off steam, and a deafness in the left ear which I had not before being wounded. I am extremely indebted to my friend Mr. J. Errington Ker for the notesof the above case, so successfully treated by him. (69) _Injury to occipital lobe. _--Wounded at Modder River. Scalp wound in occipital region. Two days later on arrival at the Base the patient was extremely restless and in a condition of noisy delirium. The wound was explored (Mr. J. J. Day) and a vertical gutter fracture discovered 1/2 an inch above and to the left of the occipital protuberance. The gutter was 1-1/2 inch in length and finely comminuted, the dura wounded, and the left occipital lobe pulped. A number of fragments of bone (one lodged in the wall of, but not penetrating, the lateral sinus) and pulped brain were removed. No improvement took place in the general condition, but the patient lived twenty-two days, during which time he coughed up a large quantity of gangrenous lung tissue and foul pus. At the _post-mortem_ examination a wound track was found extending to the crest of the left ilium, where the bullet was lodged. The patient was no doubt lying with his head dipped into a hole scooped out in the sand (a common custom) when struck; the bullet then traversed the muscles of the neck, entered the upper opening of the thorax, where it struck the bodies of the second and third dorsal vertebræ, one third of the bodies of each of which were driven into an extensive laceration of the lung; it then grooved the inner surfaces of the eighth and ninth ribs, fractured the tenth and eleventh, and passing the twelfth traversed the deep muscles of the back to the pelvis. Beyond the injury to the occipital lobe, the cerebellum was found to be lacerated and extensively bruised and ecchymosed. _Complications. _--_Hernia cerebri_ as a primary feature has already beenmentioned as one of the peculiarities of some explosive wounds. In thelater stages of the cases in which primary union did not take place thedevelopment of granulation tumours was often seen, sometimes inconnection with slight local suppuration, sometimes over a cerebralabscess. In some cases a wound which had once closed reopened and ahernia developed. This sequence was chiefly of prognostic significanceas an indication of intra-cranial inflammation, usually of a chroniccharacter, and affecting rather the lowly organised granulation tissueformed in the cavity than the brain itself. When primary union of theskin flap and wound failed, the process of definitive closure of thesubjacent cavity was always a very prolonged one, and it was in suchcases that a great proportion of the so-called herniæ developed. _Abscess of the brain. _--Local abscesses formed in a considerableproportion of the cases where serious damage to the brain had occurred, in whatever region this happened to be. I never saw one develop in caseswhere primary union had taken place, even when bone fragments had notbeen removed; neither did I ever see an abscess situated at a distancefrom the original injury. I take it that the latter is to be explainedby the early date of the suppuration, and the fact that in the greatmajority of small-calibre wounds the exit opening exists in thesituation of the contre-coup damages of civil practice. The main feature in the symptoms when abscesses developed was theinsidious mode of their appearance, usually at the end of fourteen totwenty-one days, and their comparative mildness. Very slight evidences of compression were observed; thus, varyingdegrees of headache, drowsiness, irritability of temper or depression, twitchings, or in some cases Jacksonian seizures, combined with slowpulse and slight rises of temperature. I never happened to see completeunconsciousness. The slight evidence of compression was perhapsexplained in most cases by the large bony defect in the skull, whichacted as a kind of safety-valve. Again the firm nature of thecicatricial tissue which formed at the periphery of the injury andextended up to the skull and there formed a more or less firmattachment, also preserved the actual brain tissue to some degree fromeither pressure or direct irritation. After evacuation of the pus, theusual difficulty was experienced in ensuring free drainage, anddefinitive healing and closure of the cavities was very slow. Thefollowing two cases will illustrate the character of the cases ofcerebral abscess we met with:-- (70) _Fronto-parietal abscess. _--Wounded at Magersfontein (Mauser). _Entry_, 1-3/4 inch above the line from the lower margin of the orbit to the external auditory meatus, and 1-3/4 inch behind the external angular process; _exit_, a little posterior to the left parietal eminence. There was right hemiplegia. The wounds were explored, and a large number of fragments of bone and pulped brain were removed, especially from the anterior wound. No great improvement followed, and the patient was sent to the Base. At this time there was a large hernia cerebri at the anterior wound which was suppurating. A further operation was here performed (Mr. J. J. Day). The hernia cerebri was removed, also several fragments of bone which were found deeply imbedded in the brain. The patient then improved, but a month later his temperature rose, and on exploration an abscess was discovered in the frontal lobe and drained. Subsequently the patient suffered with Jacksonian seizures, sometimes starting spontaneously, sometimes following interference with the wound. The convulsions commenced in the muscles of the face, and the twitchings then became general. Meanwhile the right upper extremity remained weak, although the fist could be clenched, and all movements of the limb made in some degree. Some difficulty was experienced in maintaining a free exit for the pus, which was however overcome by the use of a silver tube. All twitchings ceased about a month after the opening of the abscess, the man improved steadily, and he left for England fifteen weeks after the reception of the injury, walking well, with a firm hand-grip, and the wounds soundly healed. (71) _Frontal injury. Secondary abscess. _--Wounded at Modder River. Aperture of _entry_ (Mauser), just external to the centre of the right eyebrow; _exit_, above the centre of the right zygoma. The wound did not render the man immediately unconscious, but he lost all recollection of what had happened to him for the next three or four days. The wounds were explored on the second day, at which time the patient was in a semi-conscious drowsy state, the pupils contracted and the pulse slow. A number of fragments of bone and pulped brain matter were removed. Subsequently to the operation the patient showed more signs of cerebral irritation than usual, lying in a semi-conscious state and more or less curled up. He answered questions on being bothered. He improved somewhat, and was sent to the Base, where the improvement continued, but he suffered much from headache. Later the headache became much more severe, and eleven weeks after the injury the man complained of great pain both locally and over the whole right hemisphere; he lay moaning, with the temperature subnormal, and the pulse very slow. At times there was nocturnal delirium. The wound had remained closed and apparently normal, but now a small fluctuating pulsating nipple-like swelling developed in the situation of the aperture of entry. This was incised, and two ounces of sweet pus evacuated (Professor Dunlop). A tube was introduced, and removed later on the cessation of discharge. Removal of the tube was followed by a recurrence of the same symptoms, and this occurred on no fewer than six occasions whenever the wound closed. At the end of twenty weeks the patient appeared quite well, the wound had been closed six weeks, the previously irritable mental state was replaced by placidity, and he was sent home. _Diagnosis. _--The importance of proper exploration of scalp wounds todetermine the condition of the bone has already been insisted upon. Thelocalisation of the position and extent of the injury to the cranialcontents depended simply on attention to the symptoms, and needs nofurther mention here. _Prognosis. _--This subject can only be very imperfectly considered atthe present time, since only the more or less immediate results of theinjuries are known to us, while the more important after consequencesremain to be followed up. As to life the immediate prognosis has been already foreshadowed in thesection on the anatomical lesions. It is there shown that the firstpoint of general importance is the range of fire at which the injury hasbeen received. At short ranges, as evidenced by the history, thecharacters of the wounds, and the severity of the symptoms, theimmediate prognosis was uniformly bad, a very great majority of thepatients dying, and that at the end of a few hours or days. The rapidity with which death followed depended in part on the actualseverity of the wound, and still more on the region it affected; thenearer the base and the longer the track the more rapidly the patientsdied, and this always with signs of failure of the functions of theheart and lungs due to general concussion, pressure from basalhæmorrhage, or rapid intracranial oedema. In my experience no patientssurvived direct fracture of the base in any region but the frontal, although many, no doubt, got well in whom fissures merely spread intothe middle or posterior fossa. Patients with very extensive injuries ata higher level, on the other hand, often survived days, or even a week, then usually dying of sepsis. The actual relative mortality of these injuries I can give little ideaof, but it was a high one both on the field and in the Field hospitals;thus of 10 cases treated in one Field hospital, after the battle atPaardeberg Drift, no less than 8 died; while of 61 cases from variousbattles who survived to be sent down to the Base during a period of somemonths, only 4 or 6. 55 per cent. Died. Many of the latter, as is seenfrom the cases here recorded which were among the number, were none theless of a very serious nature. The early causes of death in patientsdying during the first forty-eight hours have been already mentioned;the later one was almost always sepsis. As in civil practice the best immediate results were seen in injuries tothe frontal lobes, and after these in injuries to the occipital region. In the latter permanent lesions of vision were, however, common. Theabove injuries apart, the prognosis depended on the severity and depthof the lesion. The frequency and extent of radiation symptoms often madeit possible to give a more hopeful prognosis than the immediateconditions seemed to warrant, if the exact situation of the lesion, andthe probable velocity at which the bullet was travelling, were takeninto account; since the actual destructive lesion, when the velocity hadbeen insufficient to cause damage of a general nature, was often verystrictly localised. Another very important point in the immediate prognosis was the primaryunion of the scalp wound; if this could only be ensured, few cases wentwrong afterwards. Such remote effects as I witnessed were mainly theresults of the actual destructive lesion, such as paralyses andcontraction. I know of only one case in which early maniacal symptomsclosely followed on a frontal injury, and here the symptoms accompaniedthe development of an abscess. Some patients were depressed andirritable, and some were blind or deaf, probably from gross lesion; inone patient the mental faculties generally were lowered. In spite of the surprising immediate recoveries which occurred, and thesmall amount of experience I am able to record as to remote ill effectsof these injuries, I feel certain that a long roll of secondary troublesfrom the contraction of cicatricial tissue, irritation from distantremaining bone fragments, as well as mental troubles from actual braindestruction, await record in the near future. Since my return to England I have heard of four cases of injury to thehead, which died on their return, as the result of the formation ofsecondary residual abscesses; and of one who died suddenly, soon afterhis return to active service in South Africa apparently well. Theseoccurrences are sufficiently suggestive. It may be of interest to add here two cases of secondary traumaticepilepsy of differing degree:-- (72) _Gutter fracture over left temporo-sphenoidal lobe. Traumatic epilepsy. _--A trooper in Brabant's Horse was wounded at Aliwal North, in March, in several places. A Mauser bullet entered the head 1-1/2 inch above the junction of the anterior border of the left pinna with the side of the head. The exit wound was situated just below and behind the left parietal eminence. The patient stated that the shot was fired by a man he recognised in a laager 150 yards distant from him. The man remained unconscious eleven days, and when he came round paralysis of the right upper extremity, and weakness of both lower extremities, were noted. There was also ataxic aphasia. The wounds healed, but two months later the man began to suffer from fits every few days. He spoke of them as fainting fits, but they were accompanied by general twitchings. The patient was shown to me in July by Major Woodhouse, R. A. M. C. The strength of the right upper extremity was then good, and he walked well. Speech was slow, but correct. The pupils were equal, and acted normally. The mental condition was weak, and the temper irritable. The man had hallucinations, and was very obstinate: there was complete deafness of the left ear. He refused surgical treatment, but was really hardly a responsible individual. (73) _Gutter fracture in right frontal region. Traumatic epilepsy. _--Wounded at Pieter's Hill. Gutter fracture crossing the outer aspect of the frontal lobe, immediately above the level of the right Sylvian fissure. The wound was perforating at the central part, but only reached as far back as the lower end of the ascending frontal convolution. The patient was rendered unconscious and was removed to Mooi River. He was there seen by Sir William MacCormac, who removed a number of fragments of bone. The patient rapidly recovered consciousness after the operation, but was completely hemiplegic. After a month he suddenly found he was able to move his lower extremity, and later the paralysis became steadily less. On his return home the man obtained employment as a Commissionaire, but nine months after the injury, while his wife was helping him on with his coat one morning, he was suddenly seized with a fit; the paralysed arm was jerked up, and convulsions became general, a wedge needing to be inserted to prevent the tongue suffering injury. When admitted into the hospital, the cicatrix of the wound was considerably depressed, and the central part was evidently continuously attached to the surface of the brain. Pulsation was both visible and palpable, there was little or no tenderness on examination, and the patient did not complain of pain. Little trace of the left facial paralysis remained. The man walked well, but with foot-drop. The left upper extremity was rigid, but chiefly from the elbow downwards. The fingers were flexed, but a slight increase of grip could be effected. No other active movements of hand. The elbow was held flexed, but could be straightened to about 3/4 range on effort. The shoulder could be slightly abducted, but wide movements were made by the scapular muscles. Sensation was dull over the left side of the face, also over the left side of the neck. There was complete loss of cutaneous sensibility over the lower half of the forearm and hand, and a similar patch in the left axilla. Over the rest of the extremity the sensation was better on the flexor than on the extensor aspects. There was little alteration in the common sensation elsewhere, except that the contrast between that of the dorsum and sole of the foot was somewhat more marked than usual. The temperature of the insensitive axilla was one degree higher than that of the right. The left knee jerk was somewhat exaggerated. On December 15 an incision was made through the old cicatrix directly over the defect in the skull. On separating the skin it was found directly adherent to the cicatrised dura, and when this was incised a large vicarious arachnoid space was opened up. The space was crossed by a number of strands of connective tissue, and the cavity had no epithelial lining. The fluid ran out freely, and the space was evidently in free communication with the general arachnoid cavity. A trephine crown was taken out at the posterior end of the gutter, and the surface of the brain explored, but no fragments of bone were found. I therefore replaced the crown, and closed the bony defect in the floor of the gutter with a plate of platinum fitted into a groove made in the bony margin. The wound was then sutured. Primary union took place, and there was no constitutional disturbance beyond one temperature of 100° on the evening of the second day; otherwise the temperature remained normal, and the pulse did not rise above 75. On the second evening a fit occurred, coming on while the patient was apparently asleep. It lasted about a quarter of an hour and was general, the patient becoming for a short time unconscious, and passing water involuntarily. On the third morning two similar fits occurred, the first a severe one, during which the patient passed a motion involuntarily. The commencement of all three fits was observed by the nurse only, but in each the convulsions apparently commenced in the face and then became general. Three months later no further fits had occurred, and the patient, who throughout had said he felt remarkably well, complained of nothing. The upper extremity was apparently slightly less rigid than before the exploration, and the patient said he walked somewhat better than before. The closure of the skull was perfect. _Treatment. _--The treatment of fractures of the skull possesses a degreeof surgical interest that attaches to no other class of gunshot injury, since operative interference is necessary in every case in whichrecovery is judged possible. The injuries are, without exception, of thenature of punctured wounds of the skull, and the ordinary rule ofsurgery should under no circumstances be deviated from. An expectantattitude, although it often appears immediately satisfactory, exposesthe patient to future risks which are incalculable, but none the lessserious. Happily the operations needed may be included amongst the mostsimple as well as the most successful, and expose the patient withordinary precautions to no increase of risk beyond that dependent on theoriginal injury. Cases of a general character, or in which the base has been directlyfractured other than in the frontal region, are seldom suitable foroperation, since surgical skill is in these of no avail; but in allothers an exploration is indicated. I use the word 'exploration'advisedly, since what may be called the formal operation of trephiningis seldom necessary except in the case of the small openings due towounds received from a very long range of fire; in all others there isno difficulty, but very great advantage, in making such enlargement ofthe bone opening as is necessary with Hoffman's forceps. The scalp should be first shaved and cleansed; if for any reason anoperation is impossible, this procedure at least should be carried out, with a view to ensuring, as far as possible, future asepsis, infectionin head injuries being almost the only danger to be feared. The shavingmay need to be complete, but local clearance of the hair suffices inmany cases. The hair having been removed, the scalp is cleansed with allcare, a flap is raised of which the bullet opening forms the centralpoint, and the wound explored. In slight cases the entry opening is theone of chief importance, and the exit may be simply cleansed anddressed. In some instances, as in direct fracture of the roof of theorbit from above, the exit should not be touched. The flap having been raised, if the wound be a small perforation, a1/2-inch trephine crown may be taken from one side; but it is rare forthe opening to be so small that the tip of a pair of Hoffman's forcepscannot be inserted. The trephine is more often useful in cases ofnon-penetrating gutter fractures where space is needed for exploration, and the elevation or removal of fragments of the inner-table. Loosefragments may need to be removed from beneath the scalp, but theimportant ones are those within the cranium. These may either be of somesize, or fine comminuted splinters of either table, often at as great adistance as 2 inches or more from the surface. The cavity must bethoroughly explored and all splinters removed. I have seen more thanfifty extracted in one case of open gutter fracture. The brain pulp andclot should then be gently removed or washed away, and the wound closedwithout drainage. Fragments of bone, as a rule, are better not replaced, but complete suture of the skin flap is always advisable in view of thegreat importance of primary union, and the fact that a drainage openingexists at the original wound of entry, and that the wound is readilyre-opened to its whole extent, should such a step be advisable. The detection of fragments is easiest and most satisfactorily done withthe finger, and in all but simple punctures the opening should be largeenough to allow thoroughly effective digital exploration; the remarksalready made as to the factors determining the size of fragments are ofinterest in this connection. The determination of the amount of brainpulp which should be removed is somewhat more difficult; one can onlysay that all that washes readily away should be removed, and its placeis usually taken up by blood. Few fractures of the base are suitable for treatment; the only ones Isaw were those of direct fracture of the roof of the orbit or nose, produced by bullets passing across the orbits; here the advisability ofinterference with the injured eye led to opening of the orbit, andsometimes exposed the fracture. Some patients recovered, even when thedamage had been sufficient to cause escape of pulped brain into theorbit. The after treatment simply consisted in keeping the patients as quiet ascircumstances would permit, and the administration of a fluid diet. Insome cases recurring symptoms pointed to the continued presence of bonefragments; these were usually indicated by signs of irritation, or oftenof local inflammation, in the latter case infection taking the greatershare in the causation. Such cases needed secondary exploration, and thewonderful success of this operation, even when the wound was evidentlyinfected, was perhaps one of the most striking experiences of thesurgery in general. I should add a word here as to the most satisfactory time for theperformance of these operations; as in all cases the earlier they couldbe undertaken the better, but in the head injuries the advantages ofearly interference were more evident than in any other region. Thisdepended on the fact that, as in civil practice, the scalp is one of themost dangerous regions as far as auto-infection of the wound isconcerned, and one of the most difficult to cleanse, except by thoroughshaving. Beyond this the extreme simplicity of the operative procedureneeded, called for few precautions beyond those for asepsis, and verylittle armament in the way of instruments, &c. When on the march from Winberg to Heilbron with the Highland Brigade wehad some five days' continuous fighting, and on this occasion severalperforating fractures of the skull were brought in. The coldness of thenights at that time made evening operations an impossibility; hence theoperations on these men were performed at the first dressing station, inthe open air, at the side of the ambulance wagons, often during theprogress of fighting around. Of several cases so operated on, all healedby primary union without a bad symptom of any kind, except one (see p. 249), in whom a very large entrance opening over the right corticalmotor area led down to an extensive destruction of the brain, complicated by a fracture of the base in the middle fossa. This wound, from the first considered hopeless, became septic during the four days'travelling in an ambulance wagon that was necessary, and the man died atthe end of fourteen days. As the whole cortical motor area wasdestroyed, death was, perhaps, the end most to be desired; but the fightthat this man made for recovery, and the fact that his death, after all, was due to general infection and not to any local extension of theinjury, very strongly impressed me with the possibility of recovery, even in such extensive cases, if only an aseptic condition can bemaintained. I saw many other cases of the same nature, particularly inmen who, as a result of unfortunate circumstances, were necessarily leftout on the field for more than twenty-four hours. In some of thesemaggots were found in the wounds only thirty-six hours after theinfliction of the injury. I have said nothing as to the treatment of the large primary herniæcerebri in wounds of an explosive nature, since these were rarelysubjects suitable for operation; but in the instances of minor severitythey were treated as the other cases where the pulped brain lay mostlywithin the skull. In cases where the wounds were in the frontal or fronto-parietalregions, and hemiplegia existed, the rapid improvement in the paralyticsymptoms, after operation, was very marked, showing that the signs weremainly, or entirely, due to 'radiation' injury. I am inclined to thinkthat temporary injury of this kind from vibratory disturbance and smallparenchymatous hæmorrhages, were far more often the cause of theparalysis than surface hæmorrhage, since the latter was rarely found inlarge quantity. Large clots, however, no doubt growing in both size andfirmness, occasionally occupied the area of destroyed brain, and thesesometimes manifestly exercised pressure that was at once relieved bytheir evacuation. In cases where inflammatory hernia cerebri developed, a secondaryexploration was often indicated for the removal of fragments of bone orthe evacuation of pus, otherwise the condition was best treated by drydressings and gentle support. Abscess of the brain was treated by simple evacuation and drainage bymetal or rubber tubes: the operations were always of extreme simplicity, since the abscess in every case I saw was in the direct line of thewound track, and was readily opened by the insertion of a director orblunt knife. The only trouble in the after treatment was that alreadyreferred to, of preventing premature closure of the drainage opening. I have made no special reference to the method of dressing, since it wasof the ordinary routine kind. The most important factor in success wasthe efficient primary disinfection of the scalp; a piece of antisepticgauze and some absorbent wool, efficiently secured, was all that wasneeded later. As usual the consideration of the treatment of cases in which the bulletwas retained may be considered last. Such accidents were distinctlyrare. I operated in only one (No. 54, p. 260) in whom the indicationsboth for localisation and interference were obvious, since the bullethad palpably fractured the bone, although it had not retained sufficientforce to enable it to leave the skull. In two other cases that I saw, inone the bullet was lodged in the zygomatic fossa, in the second justbelow the mastoid process. The former patient died; the latter exhibitedsymptoms indicative of injury to the occipital lobe (No. 68), and wassuccessfully treated by Mr. J. E. Ker. I never happened to see a case inwhich a retained bullet in the skull was localised by the X rays, butsuch might have been possible in case No. 64, p. 275. In no case isprimary interference indicated, unless a fracture exists where thebullet has tried to escape, or secondary symptoms develop pointing toirritation. Under ordinary circumstances, moreover, the indications for removal of abullet are not likely to be sufficiently imperative to necessitate theoperation being undertaken until the patient can be placed under thebest conditions that can be secured. This is the more advisable sincesuch operations need the infliction of an additional wound, requiregreat delicacy, and may be very prolonged in performance. The experienceof civil practice has already sufficiently proved the small amount ofinconvenience likely to follow the retention of a bullet in the skull. I may again mention the fact that in explorations for the removal ofbone fragments, fragments of lead, from breaking or setting up of thebullet, are sometimes found. Taken as a whole, the operations on the head were extremely satisfactoryfrom a technical point of view; the large depressed pulsating cicatrixso often left was the chief defect observed. The circumstances underwhich many of the operations had to be performed militated strongly, however, against the successful replacement of separated bone fragments, which might have rendered the defects less serious. Secondary operations for traumatic epilepsy scarcely come within thescope of these experiences. In case 73, p. 292, it is of interest tonote the manner in which the cavity due to loss of brain substance wasfilled up. No doubt a similar vicarious arachnoid space develops in allcases in which a soft pulsating swelling fills an aperture in the bonesof the skull. WOUNDS OF THE HEAD NOT INVOLVING THE BRAIN _Mastoid process. _--The most important wound of the cranium not alreadymentioned was that involving the mastoid process and the bony capsule ofthe ear. Wounds of the mastoid process obtained their chief interest inconnection with paralysis of the seventh nerve. This nerve rarely ornever escaped, and, as far as my experience went, the facial paralysiswas permanent (see cases 111-114, p. 355). I think the same prognosisholds good with regard to the deafness resulting from these injuries, and it is difficult to believe, with our experience of the effect ofvibration on other nerve centres and organs, that the internal ear couldever escape permanent damage. In a number of cases the tympanum itself, or the external auditorymeatus, was directly implicated in tracks; in these, also, loss ofhearing was the rule. Wounds of the pinna when produced by undeformed bullets were usually ofthe same slitlike nature remarked in perforations of the cartilages ofthe nose, and healed with equal rapidity. _Wounds of the orbit. _--Injuries to the orbit were very numerous andserious in their results, both to the globe of the eye and thesurrounding structures. _Anatomical lesions. _--The wound tracks, with regard to the injuriesproduced, may be well classified according to the direction they took;thus--vertical, transverse, and oblique. Vertical wound tracks were on the whole the least serious, but thismainly from the fact of limitation of the injury to one orbital cavity. They were usually produced by bullets passing from above downwardsthrough the frontal region of the cranium, and were received by thepatients while in the prone position. Transverse and oblique wounds owed their greater importance to the factthat both eyes were more likely to be implicated. Besides these tracks, which actually crossed the cavities, a numberinvolved the bony boundaries, producing almost as severe lesions in theglobe of the eye, many of the patients being rendered permanently blind. The only difference in nature of such cases was the escape of orbitalstructures, and this was of minor importance in the presence of thegraver lesion to vision. The following is an illustrative case:-- (74) Wounded at Colenso. _Entry_ (Mauser), 1 inch below the centre of the margin of the right orbit; _exit_, behind the right angle of the mandible. Fracture of lower jaw, and development of a diffuse traumatic aneurism of the external carotid artery. The common carotid artery was tied for secondary hæmorrhage (Mr. Jameson) some three weeks later. Vision was affected at the time of the accident; the fingers could be seen, but not counted. After ligation of the carotid the condition was possibly worse, and this needs mention as transitory loss of power in the left upper extremity also followed the operation. Fractures of the bony wall were of every degree. The most severe that Isaw were two in which lateral impact by a bullet crossing the cranialcavity caused general comminution of the whole orbital roof. Fissures ofthe roof were common in connection with 'explosive' exit apertures inthe frontal region of the skull. Pure perforations usually accompaniedthe vertical or transverse wounds of the cavity, fragments at theaperture of entry then being projected into the orbit, sometimespenetrating the muscles. Occasionally the margin of the cavity was merely notched. The ocular muscles were often divided more or less completely, andoccasionally some difficulty arose in determining whether loss ofmovement of the globe in any definite direction depended on injury tothe muscle itself, or to the nerve supplying the muscle. The followingcase illustrates this point:-- (75) _Entry_ (Mauser), 2 inches behind the right external canthus; the bullet pierced the external wall and traversed the floor of the right orbit beneath the globe, crossed the nasal cavity, and a part of the left orbit; _exit_, at the lower margin of the left orbit, beneath the centre of the globe of the eye. Complete loss of sight followed the injury, and persisted for one week. Modified vision then returned. Three weeks later there was diplopia; loss of function of the right external and inferior recti, although the ball could be turned downward to some extent by the superior oblique when the internal rectus was in action. Movements of the left globe were not seriously affected. The pupils were immobile and moderately dilated, but atropine had been employed two days previously. A year later the condition was as follows: There is some weakness of the right seventh nerve, as evidenced by want of symmetry in all the folds of the face, and in narrowing of the palpebral fissure. When at rest the right eye is somewhat raised and turned outwards. Active movements outwards or downwards are restricted. There is diplopia, and the vision of the right eye is much impaired; the man can see persons, but cannot count fingers with certainty, although he sees the hand. Putting on one side the loss of free movement, there is no obvious external appearance of injury to the eye. Mr. J. H. Fisher reported as follows: Ophthalmoscopic examination shows the left eye and fundus to be normal. The right disc is not atrophied, but the whole of the lower half of the fundus is coated with masses of black retinal pigment. There is atrophy in spots of the capillary layer of the choroid, and the larger vessels of the deeper layer are exposed between the interstices of the pigment masses. There is no definite choroidal rupture. The lesion encroaches upon and implicates the macular region. The injury is a concussion one, not necessarily resulting from contact, and certainly not due to a perforation. The loss of movement and faulty position are the result of injury to the muscles, and not to nerve implication. The man complained that when he blew his nose the left eye filled with water and air came out. The left nasal duct was however shown to be intact, as water injected by the canaliculus passed freely into the nose. Intra-orbital bleeding, subconjunctival hæmorrhage with proptosis andecchymosis of the lids were usually well marked. The latter wassometimes extreme. Injury to the nerves was naturally of a very mixed character. In manyinstances the branches of the first two divisions of the fifth nervewere obviously implicated and regional anæsthesia was common. This wasoften transitory when the result of vibratory concussion, contusion, orpressure from hæmorrhage. In other cases it was more prolonged as aresult of actual division of the nerve. As is usually the case, when asmall area of distribution only was affected, sensation was rapidlyregained from vicarious sources, even when section had been complete. As individual injuries, those to the optic nerve were the mostfrequently diagnosed. I am sorry to be unable to attempt adiscrimination of injuries to the nerve alone from those in which bothnerve and globe suffered, but the globe can rarely have escaped injury, either direct or indirect, when the bullet actually traversed theorbital cavity. (A few further remarks concerning injuries to the opticnerve will be found in Chapter IX. ) Injuries to the globe of the eye, either direct or indirect, accompaniedmost of the orbital wounds. In some the lesion was of the nature of concussion. In such the boneinjury was usually at the periphery of the orbit, or to the bones of theface in the neighbourhood. The loss of vision might then be temporary, persisting from two to ten days, then returning, often with somedeficiencies. In other similar external injuries, the lesion of the globe was moresevere, and permanent blindness followed. In variability of degree of completeness, these lesions of the globecorresponded exactly with those produced in other parts of the nervoussystem by bullets striking the bones in their vicinity, and they were nodoubt the result of a similar transmission of vibratory force. In a third series of cases the globe suffered direct contusion, and in afourth was perforated and destroyed. In cases in which permanent blindness was produced without solution ofcontinuity of the sclerotic coat, the nature of the lesion was probablyin most cases vibratory concussion and the development of multiplehæmorrhages from choroidal ruptures of a similar nature to those seen inthe brain and spinal cord. The actual hæmorrhagic areæ varied in size;but, as far as my experience went, gross hæmorrhages into the anteriorchamber did not occur without severe direct contact of the bullet. In the vast majority of the cases blindness, whether transitory orpermanent, developed immediately on the reception of the injury, and waspossibly in its initial stage the result of primary concussion. Cases were, however, seen occasionally in which the symptoms were lesssudden, of which the following is an example. I did not think that themode of progress seen here could be referred to simple orbitalhæmorrhage, although this existed, but rather to intravaginal hæmorrhageinto the sheath of the optic nerve. On external inspection the globesappeared normal. (76) Wounded at Paardeberg. _Entry_ (Mauser), over the centre of the right zygoma; the bullet traversed the right orbit, nose, and left orbit. _Exit_, immediately above the outer extremity of the left eyebrow. The patient stated that he could 'see' for thirty minutes with the right eye and for an hour with the left, immediately after the injury. He then became totally blind, and has since remained so. During the next three weeks there were occasional 'flashes of light' experienced, but these then ceased. At the end of three weeks the condition was as follows: Ocular movements good in every direction except that of elevation of the globe. The levator palpebræ superioris acted very slightly; the right, however, better than the left. There were marked right proptosis, less left proptosis, and slight patchy subconjunctival hæmorrhage of both eyes. The pupils were dilated, motionless, and not concentric. The patient was invalided as totally blind (November, 1900). Mr. Lang, who saw this patient on his return to England, kindlyfurnishes me with the following note as to the condition. There wasextensive damage to both eyes, hæmorrhage, and probably retinaldetachment as well as choroidal changes. The quotation of a few illustrative examples typical of the ordinaryorbital injuries may be of interest:-- (77) _Vertical wound. _--_Entry_, into left orbit in roof posterior to globe, and internal to optic nerve; _exit_, from orbit through junction of inner wall and floor into nose. Complete blindness followed the injury, but upon the second day light was perceived on lifting the upper lid. There was marked proptosis, subconjunctival ecchymosis, swelling and ecchymosis of the upper lid, and ptosis. Anæsthesia in the whole area of distribution of the frontal nerve. At the end of three weeks, fingers could be recognised, but a large blind spot existed in the centre of the field of vision. The general movements of the globe were fair, but the upper lid could not be raised. The proptosis and subconjunctival hæmorrhage cleared up. Little further improvement occurred; six months later the patient could only count the fingers excentrically. A very extensive scotoma was present. The optic disc was much atrophied, the calibre of the arteries diminished and the veins full (Mr. Critchett). The ptosis persisted. It was doubtful in this case whether the ptosis depended on injury to the nerve of supply, or on laceration and fixation of the levator palpebræ superioris. The latter seemed the more probable, as the superior rectus acted. The absence of any sign of gross bleeding into the anterior chamber is opposed to the existence of a perforating lesion of the globe in this case. (78) _Entry_ (Mauser), from cranial cavity, just within the centre of the roof of the right orbit; _exit_, from the orbit by a notch in the lower orbital margin internal to the infra-orbital foramen; track thence beneath the soft parts of the face to emerge from the margin of the upper lip near the left angle of the mouth. Collapse of globe, proptosis, subconjunctival hæmorrhage, oedema and ecchymosis of lids. Shrunken ball removed on twenty-fourth day (Major Burton, R. A. M. C. ). (79) _Entry_ (Mauser), at the posterior border of the left mastoid process, 3/4 inch above the tip; _exit_, in the inner third of the left upper eyelid. Globe excised at end of seven days. Facial paralysis and deafness. (80) _Entry_ (Mauser), from cranial cavity through centre of roof of orbit; _exit_, through maxillary antrum. Total blindness. Movements of ball good, no loss of tension. Proptosis, subconjunctival hæmorrhage, ecchymosis of eyelids. No improvement in sight followed. One month later the globe suppurated and was removed. The bullet had divided the optic nerve and contused the ball. _Prognosis and treatment of wounds of the orbit. _--Except in those casesin which return of vision was rapid, the prognosis was consistently badin the injuries to the globe. When the globe was ruptured it, as a rule, rapidly shrank. The case (80) quoted above is the only one in which Isaw secondary suppuration. With regard to active treatment, the majority of the cases werecomplicated by fracture of the roof of the orbit, and in many instancesconcurrent brain injury was present. In all of these, as a general rule, it was advisable to await the closure of the wound in the orbital roofprior to removal of the injured eye, if that was considered necessary. The only exception to this rule was offered by instances in which thebullet passed from the orbit into the cranium; in these primary removalof fragments projecting into the frontal lobe was preferable. As alreadyindicated, such wounds were comparatively rare except in the case ofbullets coursing transversely or obliquely. The wounds were, as a rule, followed by considerable matting of theorbital structures. _Wounds of the nose. _--I will pass by the external parts, with theremark that perforating wounds of the cartilages were remarkable fortheir sharp limitation and simple nature. I remember one case shown tome in the Irish Hospital in Bloemfontein by Sir W. Thomson, in which atthe end of the third day small symmetrical vertical slits in each alaalready healed were scarcely visible. This case very strongly impressedone with the doctrine of chances, since on the same morning I was askedto see a patient in whom a similar transverse shot had crossed bothorbits, destroying both globes and injuring the brain. A retained bullet in the upper portion of the nasal cavity has alreadybeen referred to (fig. 60). This accident was naturally a rare one; inthat instance the bullet had only retained sufficient force to insertitself neatly between the bones. Wounds crossing the nasal fossæ were comparatively common. Theinterference with the sense of smell often resulting is discussed inChapter IX. _Wounds of the malar bone_ were not infrequent. The small amount ofsplintering was somewhat remarkable considering the density of structureof the bone. In this particular the behaviour of the malar correspondedwith what was observed in the flat bones in general. A case quoted inChapter III. P. 87, illustrates the capacity of the hard edge of thebone to check the course of a bullet, and cause considerable deformityand fissuring of the mantle. _Wounds of the jaws. Upper jaw. _--A large number of tracks crossing theantrum transversely, obliquely, or vertically were observed. In thefirst case the nasal cavity, in the others the orbital or buccal cavity, were generally concurrently involved. It was somewhat striking that Inever observed any trouble, immediate or remote, from these perforationsof the antrum. If hæmorrhage into the cavity occurred, it gave rise tono ultimate trouble. I never saw an instance of secondary suppurationeven in cases where the bullet entered or escaped through the alveolarprocess with considerable local comminution. The branches of the seconddivision of the fifth nerve were sometimes implicated. In one instance abullet traversed and cut away a longitudinal groove in the bones, extending from the posterior margin of the hard palate, and terminatingby a wide notch in the alveolar process. A good example of a troublesome transverse wound of the bones of theface 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 somepeculiarities, the chief of which were the liability of any part of thebone to be damaged, and the absence of the obliquity between the cleftin the outer and inner tables so common in the fractures seen in civilpractice. The neck of the condyle I three times saw fractured; in each instancepermanent stiffness and inability to open the mouth resulted. Thisstiffness was of a degree sufficient to raise the question whether thebest course in such cases would not be to cut down primarily and removea considerable number of loose fragments, and thus diminish the amountof callus likely to be thrown out. Fractures of the ascending ramus and body were more frequent. They wereaccompanied by considerable comminution, but all that I observed healedremarkably well, and in good position, in spite of the fact that many ofthe 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 thesefractures were at the lower margin of the bone, the buccal cavityoccasionally escaped in spite of considerable comminution, the latterconfining itself to the basal portion of the bone. When the base of the teeth, or the alveolus, was struck, a wedge wasoften broken away, and from the apex of the resulting gap a fractureextended to the lower margin of the bone. When fractures of the latter nature resulted from vertically coursingbullets, much trouble often ensued. I will quote two cases inillustration:-- (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 hæmorrhage 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 fromthe bullet to the teeth, and bears on the theory of explosive action. In the treatment of fractures of the upper jaw, interference was rarelyneeded. In the case of the mandible, a remark has already been made asto the advisability of removing fragments when the neck of the condylehas suffered comminution. The removal of loose fragments is necessary inall cases in which the buccal cavity is involved. Experience in fractureof the limbs has shown a tendency to quiet necrosis when comminution wassevere, in spite of primary union. This is no doubt dependent on thevery free separation of fragments on the entry and exit aspects fromtheir enveloping periosteum. In the case of the mandible, considerablenecrosis is inevitable, and much time is saved by the primary removal ofall actually loose fragments. A splint of the ordinary chin-cap type with a four-tailed bandage meetsall further requirements, but the patients often object to them. Casesin which the fragments could be fixed by wiring the teeth were notcommon, as the latter had so frequently been carried away. The usualprecautions as to maintaining oral asepsis were especially necessary. The results of fractures of the mandible were, in so far as myexperience went, remarkably good, as deformity was seldom considerable. The absence of obliquity and the effect of primary local shock were nodoubt favourable elements, little primary displacement from muscularaction occurring. Wounds of the _cheek_ healed readily, and the same was noticeable of thelips. Wounds of the _tongue_ healed with remarkable rapidity when of thesimple perforating type, often with little or no swelling or evidence ofcontusion. At the end of a few days it was often difficult to localisethem. In connection with this subject a remarkable case which occurred at thefighting at Koodoosberg Drift is worthy of mention, although theprojectile 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 septicæmia 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 septicæmia secondary to wound of the tongue. WOUNDS OF THE NECK Wounds of the neck were not unfrequent and were of the gravestimportance; there can be little doubt that they accounted for aconsiderable proportion of the deaths on the field. On the other hand, the neck as a region offered some of the most striking examples ofhairbreadth escape of important structures. Consideration of a number ofthe vascular lesions (see cervical aneurisms, p. 135) also showsconclusively that in no region did the small size of the bullet morematerially influence the result, since no doubt can exist that all thesewounds would have proved immediately fatal if produced by projectiles oflarger calibre. In this place only a few general considerations will be entered into, asmost of the important cases are dealt with under the general headings ofvessels, nerves, and spine; but it is convenient to include here the fewremarks that have to be made concerning the cervical viscera. The wounds of the soft parts might course in any direction, but verticaltracks from above downwards were rare. In point of fact, these occurredonly in connection with perforations of the head, and as vertical woundsof the latter were received in the prone position, usually when the headwas raised, the necessary conditions for longitudinal tracks were seldomoffered. One case of a complete vertical track in the muscles of theback of the neck has been already quoted (No. 69, p. 286). Tracks coursing upwards from the trunk were somewhat more frequent inoccurrence; thus a considerable number traversing the thorax were seen. In such instances the aperture of exit was generally situated in theposterior triangle, and some of the brachial nerves often suffered. The commonest forms of wound were the transverse or the oblique. A largenumber of cases with such tracks will be found among the cases of injuryto the cervical vessels and nerves. In some instances the course wasrestricted to the neck alone, in others the trunk or upper extremity wasalso implicated. The favourable influence of the arrangement of the structures of theneck, which allows of the ordinary displacement excursions necessary fordeglutition, respiration, and their cognate movements, was very stronglymarked. Thus in several cases the bullet traversed the neck behind thepharynx and oesophagus without injuring either viscus, and the escapeof the main vessels and nerves was equally striking. In such wounds thewedge-like bullet without doubt separated and displaced all thesestructures, causing mere superficial contusion. In connection with the latter statement, the rarity of direct sagittalwounds in the hospitals should be mentioned. This is probably to beexplained by the facts that wounds in the mid-line of the neckimplicated the cervical spinal cord, and that sagittal woundsimplicating the vessels were apt to lead more directly to the surface, and thus external hæmorrhage was favoured. A few examples of cervicaltracks will suffice to illustrate these remarks:-- (85) _Entry_ (Lee-Metford), below angle of scapula; _exit_, centre of posterior triangle. Injury to the lung, and hæmothorax. 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 thepharynx; in each the injury was in the nasal or buccal segment of thecavity, and in each the soft palate was injured, in two instances thewound 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. Thesecond was under the charge of Mr. Bowlby, and will no doubt be morefully recounted by him, as interesting signs of injury to the cervicalcord were present. In the third the occipital neuralgia was the onlytroublesome symptom. In both cases 90 and 91 the high position of the wound in the fixedportion of the pharynx no doubt accounted for the absence of anyinfective 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 hæmorrhage. 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. Hæmorrhage 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 eitherside at the level of the Pomum Adami. Transitory hæmorrhage and signs ofoedema were the only signs referable to the wound, but in addition thebullet contused the left vagus and gave rise to temporary laryngealparalysis. The same course was observed in a second case of perforationof the larynx of which I was told. _Wounds of the trachea. _--The two cases recounted below are the onlytracheal injuries I met with; in one the oesophagus was alsoimplicated. This patient died from mediastinal emphysema. In the secondcase the wide development of emphysema was prevented by the earlyintroduction 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 hæmorrhage 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. CHAPTER VIII INJURIES TO THE VERTEBRAL COLUMN AND SPINAL CORD Every degree of local injury to the constituent vertebræ and thecontents of the spinal canal was met with considerable frequency. Pureuncomplicated fractures of the bones were of minor importance, except inso far as they exemplified the general tendency to localised injury insmall-calibre bullet wounds. Injuries implicating the spinal medulla, onthe other hand, were proportionately the most fatal of any in the wholebody to the wounded who left the field of battle or Field hospitalalive, and these cases formed one of the most painful and distressingfeatures 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 ofthe cord or nerves in the wound track; secondly, the degree of velocityretained by the bullet at the moment of impact with the spine. Observation of the serious ill effects produced by bullets passing inthe immediate proximity of large strongly ensheathed peripheral nervessurrounded by soft tissue, such as those of the arm or thigh, would leadone to expect that a comparatively thin-clad bundle of delicate nervetissue like the spinal cord, enclosed in a bony canal so well disposedfor the conveyance of vibrations, would suffer severely, and such provedto be the case. _Fractures in their relation to nerve injury_ will be first dealt with, and secondly injuries to the cord itself. Isolated fractures of the processes were not uncommon, the determinationof the injury to anyone being naturally dependent on the position anddirection taken by the wound track. For implication of the _transverse processes_ sagittal wounds coursingin varying degrees of obliquity were mainly responsible. Such injuriesmight be unaccompanied by any nerve lesion. Thus a Boer received aLee-Metford wound at Belmont which passed from just below the tip of theright mastoid process across the pharynx and through the opposite cheek. No bone damage was at first suspected; suppuration in the neck, however, followed infection from the pharynx, and when a sinus which persistedwas opened up later, a number of small comminuted fragments were founddetached from the transverse process of the axis. In other cases more orless severe symptoms of nerve lesion were observed, varying fromtransient hyperæsthesia, due to implication of the issuing nerves, tosymptoms of spinal hæmorrhage, such as are portrayed in the following:-- (94) A private in the Black Watch was wounded at Magersfontein from within a distance of 1, 000 yards. Among other wounds, one track entered 1 inch to the right of the second lumbar spinous process, and emerged 1 inch internal to the right anterior superior iliac spine. There were signs of wound of the kidney, and in addition, retention of urine, incontinence of fæces, complete motor and sensory paralysis of the right lower extremity, and total absence of all reflexes. Anæsthesia existed over the whole area of skin supplied by the nerves of the sacral plexus, hyperæsthesia over that supplied by the lumbar nerves. On the tenth day subsequent to the injury, the hyperæsthesia in the area of lumbar supply was replaced by normal sensation, motor power began to be slowly regained in the muscles supplied by the anterior crural and obturator nerves, and the patellar reflex returned. At this time lowered sensation returned in the area supplied by the sacral plexus, but no improvement in motor power took place, and no control was regained over the bladder and rectum. 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 theprocess and laminæ, were not uncommon. Isolated separation of thespinous process was usually the result of wounds crossing the backobliquely 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 advancingon the enemy. Cervical injuries, owing to the comparatively sheltered position of themore deeply sunk spines, and from the fact that the head was usuallyunder cover of a stone or ant-heap, were less common; in one instancehyperæsthesia was noted in one upper extremity as the result of acrossing bullet having struck the fourth cervical spine. In a manwounded at Paardeberg Drift the bullet entered at the centre of thebuttock, traversed the bones of the pelvis, and, leaving that cavityabove the crest of the ilium, crossed the spine to emerge in theopposite loin. Suppuration occurred, and when the wound was laid openthe third and fourth lumbar spinous processes were found to be loosened, but still connected to the surrounding soft parts. There were no nervesymptoms in this case; these would not have been expected, since by thetime that the bullet had traversed the bones of the pelvis its velocitymust have been considerably lessened, even if high at the moment ofprimary impact. In another case a dorsal spine, together with itslamina, was separated and moveable; the only nerve symptoms were slightpain and a crop of herpes on the line of distribution of thecorresponding intercostal nerve, the bullet having probably struck thenerve in passing across the intercostal space. In one instance of aretained bullet lying beneath the skin of the back, its passage betweentwo contiguous dorsal spines without fracture of either was determinedduring an extraction operation. When the prone position was assumed by the men, more or lesslongitudinal wounds in the course of the spine were naturally liable tooccur. These tracks assumed somewhat greater importance than thetransverse ones, because the injury to bone was more often multiple, andthe laminæ were frequently implicated. The relative importance of suchinjuries was dependent on the velocity of the bullet and the depth atwhich it travelled. As an instance of a more serious character thefollowing 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 inthe back in any of our men, neither was I ever able to detect an injuryto the articular processes as a localised lesion. Injuries to the _centra_ were very frequent, but differedextraordinarily in their importance. Perforation by bullets travellingat a relatively low grade of velocity, but still one sufficient to allowthem to pass through the body, produced in many instances no symptomswhatever when the track did not lie in immediate contiguity to thespinal 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 cancelloustissue of the centrum, with no comminution beyond slight splintering ofthe compact tissue at the aperture of exit. In one instance the bulletpassed in a coronal direction so close to the back of the centrum as toleave a septum of only the thickness of stout paper between the trackand the spinal canal. In this case signs of total transverse lesion werepresent. I never happened to meet with a case in which the canal wasencroached upon from the front by displaced bone. In some cases at theend of six weeks there was difficulty in determining the position of theopenings, and section of the bone was necessary in order to assureoneself as to the direction of the track. In some instances the centra were pierced in the coronal direction withvarying degrees of obliquity; in others the direction was more sagittal;in two of the latter the bullet was retained in the spinal canal. Thetracks were sometimes confined to one vertebra, but often implicatedtwo. 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 ofpressure or irritation of the nerve roots, transient signs of spinalconcussion, signs of contusion and hæmorrhage, or to evidence of totaltransverse lesion. Instances of all these conditions will be quotedunder the heading of injuries to the cord or nerves. _Signs of injury to the vertebræ. _--Separation of the spinous processeswas often indicated by slight deformity, either evident or palpable, local pain, tenderness, mobility, and crepitus. In some cases theselocal signs were reinforced by evidence of cord injury. Fracturesinvolving the laminæ differed merely in the degree to which the abovesigns were developed. Fractures of the transverse processes weregenerally only to be assumed from the position and direction of thewounds, the assumption being sometimes strengthened in probability byevidence of injury to the cord and nerves. Fractures of the centra were also frequently only to be assumed from thedirection of the wound tracks, and possibly from evidence of nerveinjury. When no paralysis supervened, interference with the movements ofthe back, or pain, was so slight as to be inappreciable, especially inthe presence of concurrent injury to other parts, which was seldomabsent. I only once saw any angular deformity from this injury, and thatslight, and not apparent before the end of three weeks. In thisparticular a very striking difference exists between injuries fromsmall-calibre bullets and larger ones such as the Martini-Henry. In theonly instance of Martini-Henry fracture of the spine that came under mynotice, the centrum was severely comminuted and deformity was obvious. Still, as in so many particulars, the difference was only one of degree, since comminution of the centra in gunshot wounds has always beenobserved to be slight in nature compared with what is met with in thecompression fractures of civil life. A few words will suffice to dismiss the questions of diagnosis, prognosis, and treatment of the above injuries. The diagnosis dependedon attention to the signs above indicated, the prognosis almost entirelyon the concurrent injury to the nervous system, which will be consideredlater, and the treatment consisted in enforcing rest alone. INJURIES TO THE SPINAL CORD ACCOMPANYING SMALL-CALIBRE BULLET WOUNDS OFTHE VERTEBRÆ _Anatomical lesions. _--In introducing the subject of the nature of thelesions of the spinal cord and membranes, I should again enforce thestatement that their character and degree, in comparison with the slightaccompanying bone damage, are pathognomonic of gunshot wounds, and thatthese characters find their completest exemplification in injuriesproduced by bullets of small calibre, endowed with a high grade ofvelocity. Again, that the varying degrees of damage depend comparativelyslightly on the position of the bone lesion, apart from actualencroachment on the canal, while the degree of velocity retained by thebullet at the moment of impact is all-important. In no other way are thedivergent results to be explained which follow an apparently identicalinjury, in so far as extent, position, and external evidence of damageto the spinal column are concerned. Injuries to the nerve roots of the nature of concussion and contusion, are dealt with in Chapter IX. _Pure concussion_ of the spinal cord may, I believe, be studied from abetter standpoint in the case of small-calibre bullet injuries than inany others, since in many instances it is, I think, possible to excludeany complications such as wrenches and strains of the vertebral column, and ascribe the symptoms to the pure effect of extreme vibratory forcecommunicated to the cord by its enveloping bony canal. The conditionmust be considered under the two headings of slight and severe. In _slight concussion_ the usually transient effects of the injury, andits happy tendency not to destroy life, place us in a state ofuncertainty as to the occurrence of anatomical changes, since noopportunity of post-mortem examination occurred. The clinical conditionincluded under this term corresponds with that implied in 'spinalconcussion' in civil practice. One point of extreme interest, whetherthe subjects of small-calibre bullet spinal concussion will in thefuture suffer from the remote effects common to similar sufferers incivil life from other causes such as railway collisions, still remainsfor future determination. An ample field for such observations has atany rate been created by the present war. In _severe concussion_ a far more highly destructive action is exerted. This condition may be followed by complete disorganisation of the cord, accompanied or not by multiple parenchymatous hæmorrhages into itssubstance. Either or both of these pathological conditions are producedby the impact of the bullet with the spine, given a sufficiently highdegree of velocity, and it is difficult to separate clinically theresulting symptoms. This is a matter perhaps of less importance, sinceit stands to reason that a vibratory force, capable of rupturing thespinal capillaries, would at the same time damage the nervous tissue. In speaking of concussion of this degree, it should be clearlyrecognised that a general condition, such as is indicated by the use ofthe term 'concussion of the brain, ' is in no wise implied. The conditionis really far more nearly allied to one of contusion, a strictlylocalised portion of the spinal cord undergoing the destructive processwhich affects the segments below only in so far as it interrupts thenormal channels of communication with the higher centres. Case 102 is an instance of such a lesion, the post-mortem examinationshowing clearly that the spinal canal was not encroached upon by thebullet. The cord in this instance appeared little changedmacroscopically, and this fact was observed in other instances, bothduring operations and post mortem. _Contusion. _--This condition is very closely allied to the last. Incases 101 and 103 the spinal canal was as little encroached upon as in102, but the bullet struck the somewhat elastic neural arch in eachcase, and post mortem an adhesion between the cord and the envelopingdura opposite the point at which impact of the bullet was closestsuggests that, in spite of the escape of the bone from fracture, it mayhave been momentarily depressed to a sufficient degree to contuse thecord, or the latter may have suffered a _contre-coup_ injury. For thesereasons the inclusion of the cases as instances of pure concussion isnot warranted. In both Nos. 99 and 100 the neural arch had actuallysuffered fracture, and although the bone was not depressed or exercisingpressure at the time of the autopsies, it was no doubt driven intemporarily at the moment of impact of the bullet. At the post-mortem examinations of injuries of this nature it was commonto find one to four segments of the spinal cord completely disorganised. At the end of some five weeks, the common duration of life, thestructure of the cord was represented by a semi-diffluent yellowishmaterial, the consistence of which was so deficient in firmness as toallow the partial collapse of the membranes covering the affectedportion, so as to exhibit a definite narrowing when the whole was heldup (see fig. 79). In such cases traces of extra- or intra-duralhæmorrhage sometimes still persisted. _Hæmorrhage. _--This occurred as surface extravasation and in the form ofparenchymatous hæmorrhages. I saw the former both in the extra-dural andperi-pial forms, but never in sufficient quantity to exert a degree ofpressure calculated to produce symptoms of total transverse lesion. Hereagain, however, it is difficult to speak with confidence since theconditions which regulate the tension within the normal spinal canal areso complicated and liable to variation, that it is very difficult toestimate the effect of any given hæmorrhage discovered. My friend Mr. R. H. Mills-Roberts described to me one fatal case underhis care in the Welsh Hospital in which extra-dural hæmorrhage was soabundant as, in his opinion, to have taken a prominent part in theproduction of the paralytic symptoms. Examples of both extra- and intra-dural (peri-pial) hæmorrhage areafforded by cases 99, 102, and 103; in none was it large in amount orwidely distributed. The condition was probably also frequentlyassociated in varying degree with that to be immediately describedbelow. _Intra-medullary hæmorrhage_ (_hæmato-myelia_). --The importance of thiscondition is lessened in small-calibre bullet injuries by the factalready alluded to, that it is almost invariably accompanied byconcussion changes. In one instance in which death took place at the endof eight days, partly as the result of concurrent injury, in a man inwhom signs of total transverse lesion of the cord were present, thesubstance of the cord was found to be closely scattered over withhæmorrhages of various sizes and extending for a longitudinal area ofsome three inches. As to the frequency with which hæmorrhage into the substance of the cordoccurred, I regret to be unable to give an opinion. In the latepost-mortem examinations I witnessed, a yellow discoloration of thesoftened cord was the only macroscopic evidence of hæmorrhage. Hæmorrhages of this nature may, however, account for the grave paralyticsymptoms in some cases of partial or total transverse lesion not due todirect compression or laceration. The conditions of concussion, contusion, or hæmatomyelia were, Ibelieve, responsible for at least nine-tenths of the cases in which atotal transverse lesion was indicated by the symptoms. The extremeimportance of realising this fact and the rarity of the production ofsymptoms by continuing compression both from the prognostic and thetherapeutic point of view is obvious. The analogous injuries termed generally in Chapter IX. Nerve contusion, although frequently accompanied by tissue destruction, may be followedby reparative change, and are capable of complete or almost completespontaneous recovery; while the lesions in the spinal cord arepermanent, and complete recovery is only witnessed in the parts affectedby the remote pressure or irritation from blood extravasation, or inthose influenced by concussion. I include below short abstracts of all the cases of lesion of the spinalcord which terminated fatally, in which I had the opportunity ofwitnessing the post-mortem conditions. In a considerable proportion ofthe cases at the end of six weeks the spinal cord was softened over anarea of from two to four segments in such degree as to have practicallylost all continuity. Although the autopsies were made on patients whohad died slowly and in summer weather, often twelve to sixteen hoursafter death, I think it can be but fair to assume, when the consistencyof the remaining portion of the spinal cord is considered, that thesoftening was only in slight degree if at all exaggerated by post-mortemchange. Again symptoms of secondary myelitis and meningitis had beenobserved in some of the fatal cases prior to death. I had but one opportunity of observing a case in which a retained bulletexercised compression, and none in which this was due to displaced bonefragments. I also only once came across a case of complete section, butno doubt both bone pressure and section may have occurred with greaterfrequency amongst patients dying on the field or shortly after. The caseof section is illustrated in fig. 80. It will be noted that, althoughthe section is complete, the bullet lies to one side of the canal, andhence the bullet, as fixed in its course by the bone of the centrum, directly struck but half of the whole width of the cord. It was striking how little secondary change in the cord had occurred inthe neighbourhood of the spot of division. This well illustrates thecomparatively slight vibratory effect of a bullet travelling with adegree of velocity insufficient to completely perforate the vertebralcolumn. _Symptoms of injury to the spinal cord. _--In _slight spinal concussion_these exactly resembled those of the more severe lesions, except intheir transitory nature. They consisted in loss of cutaneoussensibility, motor paralysis, and vesical and rectal incompetence. Thephenomena persisted from periods of a few hours to two or three days, return of function being first noticeable in the sensory nerves, andoften with modification in the way of lowered acuteness, or minor signsof irritation, such as formication, slight hyperæsthesia or pain, pointing to a combination with the least extensive degrees ofhæmorrhage; later, motor power was rapidly regained. The subjects ofsuch symptoms often suffered from weakness and unsteadiness in movementfor some days or weeks; a sharp line of discrimination between suchcases and those described in the next paragraphs is manifestlyimpossible. _Spinal hæmorrhage. _--The symptoms of this condition developeddifferently according to whether concurrent concussion existed. Occasionally very typical instances of pure hæmorrhage were observedwith transient symptoms:-- (96) A private in the Yorkshire Light Infantry was wounded at Modder River; the bullet entered between the eleventh and twelfth ribs, just posterior to the left mid-axillary line, emerging in the posterior axillary fold, at its junction with the right side of the trunk. On the second day after the injury the lower extremities became drawn up, the knees and hips assuming a flexed position, and this was followed shortly by the advent of complete motor and sensory paraplegia, accompanied by retention of urine. Two days later, the patient again passed water normally, and gradual and rapid return of both sensation and motor power took place. At the end of fourteen days no trace of the condition remained, and the patient was shortly after sent home. The symptoms, however, were rarely so simple as in this example; it wasvery much more common to meet with an admixture of signs of primaryconcussion, or at any rate symptoms of radiation. The following is anextreme but excellent example of more complicated and prolonged effects: (97) A lance-corporal of the Black Watch was wounded at Magersfontein at a range of from 400 to 500 yards. The bullet entered over the left malar bone 2-1/2 inches from the outer canthus, while the aperture of exit was 2-1/4 inches above the inferior angle of the right scapula, 3/4 of an inch anterior to its axillary margin. Very shortly after the injury complete motor and sensory paralysis developed in both upper extremities, followed by the development of a similar condition in the left lower limb, and retention of urine and fæces, but the latter unaccompanied by the marked abdominal intestinal distension so characteristic in cases of total transverse lesion. The right side of the chest continued to work well, but the intercostals of the left side were paralysed. No disturbance of the normal action or condition of the pupils was noted. After the first few days the condition began to improve. Three weeks later, the chest was moving symmetrically and well, sensation and motor power had returned in considerable degree in the left lower extremity, with marked increase in both the plantar and patellar reflexes; sensation had returned in both upper extremities, a slight amount of motor power was regained in the right, but the left remained entirely flaccid and incapable of movement. At the end of a month power was regained over both bladder and rectum, some slight movement of the left thumb was possible, and a certain degree of hyperæsthesia developed over the back of the forearm. At the end of six weeks there was little further alteration, but that in the direction of improvement. There was some wasting of the muscles of the left upper extremity, and this was most marked in the muscles supplied by the ulnar nerve. At the end of ten weeks the patient had been up some days; he could stand and walk, but was unable to rise from the sitting posture without help. The plantar and patellar reflexes were much exaggerated, and there was ankle clonus, most marked in the left limb. The right upper extremity was normal, but weak; there was wrist-drop on the left side and the deltoid was wasted and powerless; on the other hand the fingers could be flexed, and although the elbow could not be, there were signs of returning power in the biceps, and some movements of the shoulder could be performed by the capsular muscles. It was remarkable that common sensation was more acute in the left than the right lower extremity, but I attributed this to the remains of hyperæsthesia on the left side. The patient left for home shortly after the last note. In both these cases the absence of marked hyperæsthesia or pain pointsto medullary hæmorrhage (hæmato-myelia) as the pathological conditionproduced by the injury. In this particular they contrast well with case94 quoted on page 315, where the degree of both hyperæsthesia and painindicated a combination of pressure and irritation of the nerve roots bysurface hæmorrhage on the affected side. In case 97 the persistence forfour weeks of paralysis of the bladder and rectum suggested medullaryhæmorrhage in addition, while the return of patellar reflex in theparalysed limb negatived the occurrence of an extensive destructivelesion. In view of the extreme interest of these cases I will shortly detail oneother in which the cauda equina alone was affected. I must confess my inability to place the case definitely in thecategory either of concussion or medullary hæmorrhage. As so oftenhappened, both conditions probably took part in the lesion. Theimmediate development of the primary symptoms is no doubt to be referredto concussion, while the patchy nature of the prolonged lesion andgradual recession of the symptoms point to the presence of hæmorrhages. We find here the link most nearly connecting the spinal cord and theperipheral systemic nerves. Such a case goes far to show that thecondition which I have in the next chapter often referred to as nervecontusion may in fact be produced by an injury far short of actualcontact. (98) A trooper in the Imperial Yeomanry, while advancing in the crouching attitude, was struck by a bullet from his left front, at an estimated distance of 300 yards. The bullet traversed the right arm anteriorly to the humerus, entered the trunk in the line of the posterior axillary fold, 1-1/2 inch below the level of the nipple, crossed the thoracic and abdominal cavities, deeply striking the lumbar spine, and finally lodged beneath the skin over the venter of the left ilium. The skin was broken, but the force of the bullet was not sufficient to cause it to pass through, and it was later expressed from the wound by the surgeon. The bullet was a Mauser, and not in any way deformed, although it must at any rate have struck the spine and perforated the ilium. Immediate paraplegia resulted, both sensation and motor power were completely abolished, but there was no trouble either with the bladder or rectum. No symptoms of injury to either thoracic or abdominal viscera were noted. Three days after the injury sensation and some return of motor power were observed in the left extremity, and some power of movement in the toes of the right foot. During the next eight weeks steady but slow improvement took place; during the last three weeks of this period he made the voyage to England. Ever since the injury some elevation of temperature was noted, a rise at night to 100° or at times to 102°; for this no definite cause was discovered. In the tenth week the condition was as follows: The temperature has become normal. The patient has lost flesh to a considerable extent since the reception of the injury. The lower extremities are much wasted, especially the peroneal muscles. Patellar reflexes can be obtained, but the knee jerks are uncertain. Unevenly distributed paralysis exists in both lower extremities. Left--Sensation fairly good throughout. Quadriceps very weak; does not react to electrical stimulation. Calf muscles act fairly. Anterior tibial and musculo-cutaneous groups are paralysed. Right--Quadriceps acts better than on left, muscles below the knee paralysed, and in the same area there is complete absence of sensation. The patient complains of shooting pains in both legs, and there is some deep muscular tenderness. Three weeks later an abundant crop of vesicles appeared over the front of the right thigh and leg, above and below the knee. Sensation in the limb at the same time returned to a considerable degree, anæsthesia persisting on the outer aspect of the thigh only. At the end of four months very considerable improvement had taken place, but there was no return of motor power in the right leg, or the muscles supplied by the peroneal nerve in the left leg. There was some general oedema of the legs, especially of the right, possibly in connection with the herpetic eruption which was now disappearing. Muscular tenderness had disappeared. There was also definite improvement in the size and tone of the peroneal muscles, although no motor power was regained. At the end of five months, slight gradual improvement was still taking place, but the loss of power was nearly as extensive as when the last note was taken. The skin of the right leg was glossy, that of the left apparently normal. At times some hyperæsthesia of the soles was noted, and the plantar reflex was very brisk. The right anterior tibial and musculo-cutaneous groups of muscles reacted to the strongest faradic current, not to any galvanic current below 20-25 m. A. , contraction very sluggish. The same muscles in the left leg also reacted to the strongest faradic current, but only locally, with no sort of effect on the tendons. Similar contractions could be induced in the right quadriceps, but none in the left (Dr. Turney). Appreciation of heat and cold applied to the skin was fair, but, in the case of heat, distinctly slow in the right leg and foot. At the end of seven months improvement was still taking place; the patient could now stand, walk a little with crutches, and even ascend and descend a staircase. * * * * * _Severe concussion, contusion, or medullary hæmorrhage producing signs of total transverse lesion, and complete transverse section. _--The symptoms of these conditions will be taken together, because, with very slight variations, they may be considered as lesions of equal degree as to severity, bad prognosis, and unsuitability for active interference. All were characterised by the exhibition of the same essential phenomena, symmetrical abolition of sensation and motor power on either side of the body, absence of any signs of irritation in the paralysed area, and loss of patellar reflex. In a small number of the cases of medullary hæmorrhage some return of sensation was observed prior to death; in a still smaller, traces of motor power, and in one or two irritability of the muscles or feeble reflexes pointed to the fact that destruction of the cord was not absolute. As abstracts of a series of cases are appended on page 330, it is only necessary to add a few remarks as to any slight peculiarities which seemed directly dependent on the mode of causation. It may be first stated that these severe injuries were accompanied by signs of a very high degree of shock. In fact, the shock observed in them was more severe than in any other small-calibre bullet injuries that I witnessed. The patients lay still with the eyes closed, great pallor of surface, sometimes moaning with pain, the sensorium much benumbed, or occasionally early delirium was noted. The pulse was small, often slow and irregular, and the respiration shallow. The originally quiet state was often changed to one of great restlessness of the unparalysed part of the body, with the appearance of reaction. The degree of primary pain varied greatly, but as a rule it was considerable; in some cases it was excruciating in the parts above the level of the totally destructive lesion, and commonly of the zonal variety. A hyperæsthetic zone at the lower limit of sensation usually existed. In the majority of the cases pain must have depended on meningeal hæmorrhage. In one of the cases related, positive evidence was offered as to this particular by the autopsy, although this was made as long as six weeks after the original injury, since no other source of pressure or irritation was discovered. When I first saw this patient some twenty-four hours after the injury he was moaning with pain, although a strong and plucky man; I hastened to give him an injection of morphia, and assured him that it would relieve his suffering: as I left I heard him say to his neighbour: 'That is no use; they gave me three last night, and I was no better, ' and his remark proved true. In high dorsal and cervical injuries the temperature rose high, in one case to 108° F. ; I had no opportunity, however, of observing the temperature in any case immediately before and after death. During the hot weather the profuse sweating of the upper part of the body contrasted very strongly with the dry skin of the paralysed part. The heart's action was often particularly irregular in the dorsal injuries, and the respiration slow and irregular; as these cases, however, were often complicated by severe concurrent injuries to internal organs, the irregularities could hardly be ascribed to the spinal-cord lesion alone. In cases of pure diaphragmatic respiration, the rate did not as a rule exceed the normal of 16 or 20 to the minute, and it was quite regular; this was noted soon after the injury and persisted throughout the course of the cases. As is usually the case, both respiration and the heart's action were most embarrassed in the cases in which abdominal distension was a prominent feature. In some of the neck cases the Cheyne-Stokes type of respiration was very strongly marked. In cases of low dorsal injury intestinal distension was extreme, and I think more troublesome than the same condition as seen in civil practice. The distension was accompanied by most persistent vomiting, continuing for days, and in the cases that lived for some time severe gastric crises of the same type occurred in some instances. Priapism was a common symptom; but, as is seen from the cases quoted, was rarely due to any gross direct laceration of the cord. Trophic sores were both early to develop, and extensive; primary decubitus occurred in all the cases I saw, and steady extension followed. In one case a remarkable symmetrical serpiginous ulceration developed in the area of distribution of the cutaneous branches of the external popliteal nerve on the outer side of the leg. The paralysis in nearly every case was of the utterly flaccid type, and wasting of the muscles was early and extreme. This was occasionally accentuated by the supervention of myelitis. Opportunities for making observations on the quantity of urine secreted were not great, and I can offer no remark as to the occurrence of polyuria. In one rapidly fatal case, however, suppression of urine occurred. (99) _Lumbar region. Transverse lesion. _--Range under 1, 000 yards. Wound of _entry_ (Mauser), over the seventh rib 1 inch from the left posterior axillary fold; _exit_, over the centre of the right iliac crest. Complete symmetrical motor and sensory paralysis of lower extremities, entire abolition of reflexes, retention of urine. On the ninth day there was some return of sensation in the lower extremities, and a cremasteric reflex was to be obtained. A large bedsore had developed over the sacrum. No further change occurred in the lower extremities. The patient became progressively emaciated and exhausted, cystitis persisted, the bedsore deepened. The man eventually developed signs of a large basal abscess in the left lung, and died on the forty-second day. At the _post-mortem_ a fracture of the first lumbar lamina was discovered, with some splintering of the bone; the lumbar spinous process was attached and in its normal position. Opposite the centre of the cauda equina were the remains of a considerable hæmorrhage, both extra- and intra-dural, the nerves appearing somewhat compressed, but of normal consistency. The muscles of the back were infiltrated with putrid pus on both sides. A pulmonary abscess cavity the size of a hen's egg occupied the upper part of the lower lobe of the left lung. The kidneys were congested, and the bladder thickened and chronically inflamed. (100) _Cervico-dorsal region. Total transverse lesion. _--Wound of _entry_ (Mauser), to the right of the sixth cervical vertebra: the bullet was removed on the field from the left of the seventh dorsal spinous process, which was somewhat prominent. Complete motor and sensory paralysis extended upwards to the third intercostal space; the breathing was almost entirely diaphragmatic. Retention of urine. Entire abolition of reflexes in lower limbs and trunk. Hyperæsthesia was present in both upper extremities, with a zone of hyperæsthesia around the chest. The patient suffered greatly for some weeks from pain in the hyperæsthetic area, he developed severe cystitis and later incontinence of urine. A large trophic sacral bed-sore steadily increased in depth and size. About ten days before death, which occurred on the fifty-third day from exhaustion and septicæmia, the patient complained of pains in his legs; but there was no return of sensation, motion, or reflexes. At the _post-mortem_, the seventh dorsal spinous process was found to be loose and the laminæ of the fifth, sixth, and seventh vertebræ were separated from the pedicles, and somewhat depressed on the left side. These laminæ were adherent to the dura, as were also a few small separated bony spiculæ. There was no sign of old hæmorrhage. The spinal cord was practically gone between the levels of the fourth and seventh dorsal vertebræ, and diffluent from myelitis up to the third cervical. (101) _Dorsal region; total transverse lesion. _--Wound of _entry_ (Mauser), in the left supra-spinous fossa of the scapula; _exit_, between the eleventh and twelfth ribs of the right side. Complete motor and sensory paralysis, with absence of reflexes from mid-dorsal region downwards. Upper intercostals working. Retention of urine, penis turgid. Sensation perfect to lower extremity of sternum. Early trophic sacral bed-sores developed and steadily increased in depth and extent, slighter ones developed on the heels. The paralysis was flaccid throughout. The patient gradually emaciated with fever, and died on the seventy-eighth day. At the _post-mortem_ the wound proved not to have penetrated the thorax, and both the vertebral spines and laminæ were intact, no trace of bony injury being discoverable. Opposite the sixth dorsal vertebra, for a distance of 1-1/2 inch, the cord and dura were adherent, and over the same area the cord was represented by soft custard-like material. There was no sign of old hæmorrhage. (102) _Dorsal region; total transverse lesion; slight extra-dural hæmorrhage. _--Wound of _entry_ (Mauser), at the posterior aspect of the right shoulder; _exit_, 2 inches to the left of the spine below the ninth rib. Complete motor and sensory paralysis below the site of the lesion, with absence of superficial and deep reflexes. Retention of urine. Great abdominal distension, pain, and vomiting. Bed-sores over the sacrum developed on the third day; meanwhile the vomiting continued on and off for a week, and very severe girdle pain persisted. One month later when seen at the Base hospital considerable improvement had occurred. Sensation had returned in both lower limbs; but flaccid paralysis persisted and both were wasted, especially the left. There was no return of reflexes in the lower limbs, the urine was passed in gushes, and the patient was cognisant when these occurred. The sacral bed-sores were, however, very extensive and becoming larger and deeper. At the end of the fifth week slight power was regained in the flexors and abductors of the right thigh, and the same muscles of the left limb could be made to contract feebly. Meanwhile the patient suffered with severe fever, accompanied by frequent rigors and profuse sweats; the bed-sore continued to extend, and the urine was foul and contained pus. The patient continued in a similar condition, progressive emaciation and exhaustion taking place, and at the end of six weeks he died. At the _post-mortem_ the bullet was found to have tracked beneath the right scapula, entering the chest by the fifth intercostal space and lacerating the right lung; thence it entered the eighth dorsal centrum and tunnelled both this and the ninth diagonally, to escape beneath the ninth rib. On opening the spinal canal the tunnel was found to be separated only by the compact tissue of the centrum from the cavity, while a thin extra-dural hæmorrhage separated the dura from the bones anteriorly. The spinal cord exhibited no sign of pressure and was firm and continuous, but up to the lower limit of the dorsal region there was septic myelitis and meningitis, the result of pus having tracked up the canal from the sacral bedsore. Suppurative cystitis and pyelitis were present. The patient was the subject of an old urethral stricture which had given rise to trouble during treatment. (103) _Dorsal region; total transverse lesion; slight intra-dural hæmorrhage. _--Wound of _entry_ (Mauser), below spine of scapula, close to right axilla; _exit_, 2-1/2 inches to left of tenth dorsal spinous process. Complete motor and sensory paralysis below ensiform cartilage, with well-marked hyperæsthetic zone around trunk. All reflexes absent. Retention of urine. Incontinence of fæces. Bed-sores in sacral region developed during the first two days, and seventeen days later well-developed serpiginous trophic sores developed on the outer side of each leg and continued to increase slowly until death. The paralysis remained of the absolutely flaccid variety. Great emaciation occurred, accompanied by hectic fever, the temperature ranging from normal to 102. 5°. During the third week double pleurisy developed. At the _post-mortem_ no bone injury could be detected. The cord and dura-mater were adherent over an area corresponding to the fifth to the eighth dorsal vertebræ, and opposite the seventh the cord was soft and of the consistence of butter. A small intra-dural hæmorrhage was still evident below the main lesion, not extensive enough to give rise to serious compression. General adhesions in each pleura. Cystitis. [Illustration: FIG. 79. --Appearance of Spinal Cord enclosed in membranesin case 103 after removal from the canal. When the membranes were openeda white custard-like substance took the place of the cord. Slightevidence of extra-dural hæmorrhage existed] (104) _Dorsal region; section of cord; retained bullet. _--Wound of _entry_ (Mauser), in seventh right intercostal space, 4-1/2 inches from the dorsal spinous processes, oval in outline; bullet retained. Complete motor and sensory paralysis, with absence of reflexes below umbilicus. Retention of urine, incontinence of fæces. Large sacral bed-sore developed rapidly. Right hæmothorax. The patient emaciated rapidly, and for the last fourteen days the temperature ranged to 104°, the bed-sore steadily increasing in size. Death occurred on the forty-second day. At the _post-mortem_ a Mauser bullet was found embedded in the centrum of the twelfth dorsal vertebra. The bullet was slightly curved; its anterior extremity had passed across the spinal canal, and wounding the dura posteriorly rested against the left lamina. The plating of the mantle of the bullet was stripped from half the area of the tip. The dura was not adherent, and the cord was softened for half an inch above the point of section; above this it was normal, the vessels coursing normally to the softened spot. Below the point of section the cord was blanched, but offered no other macroscopic evidence of disease. No evidence of either intra- or extra-dural hæmorrhage was detectible. [Illustration: FIG. 80. --Complete division of Spinal Cord. The bullet isretained, and from its position can be seen to have struck the righthalf of the cord only. The nickel plating of half of the tip of thebullet is stripped off. Case No. 104] The right pleura contained a large quantity of dark cocoa-like fluid. Extensive adhesions were present in both pleural cavities. The spleen was much enlarged. At the base of the bladder a large submucous hæmorrhage had occurred, the blood-clot had assumed a dark orange colour, and on first opening the viscus the appearance was that of a mass of fæces. The mucous lining elsewhere was slaty grey, with small hæmorrhages. The kidneys were large, but no abscesses or pyelitis were present. (105) _Cervico-dorsal region; total transverse lesion. _--Wound of _entry_ (Mauser), opposite right sixth cervical transverse process; _exit_, on left side of third dorsal spinous process. Slight grasping power was present in the hands, and the patient could hold his arms across his chest. Complete motor and sensory paralysis, with absence of all reflexes below. The pupils were moderately contracted. Retention of urine. On the second day blebs appeared on each buttock, and the patient complained of very severe pain in the neck: the temperature rose to 103°, and on the third day he died suddenly. No _post-mortem_ examination was made. I observed two similar cases in the Field Hospital at Orange River, thepatients dying on the third day; pain and high temperature wereprominent symptoms in both. In one patient early delirium was present. (106) _Dorsal region; Martini-Henry wound. _--Wound of _entry_, oval, 1 inch × 3-1/4 inches; long axis obliquely crossing infra-spinous fossa of right scapula; bullet retained (Martini-Henry). Spine of third dorsal vertebra loose, and a distinct thickening to its right side. Complete symmetrical paralysis extending up to upper extremities. No sensation on surface of trunk below cervical area. Respiration entirely diaphragmatic. Retention of urine, penis turgid. Total absence of reflexes, superficial and deep. Reddening of buttocks, but no bullæ. General hyperæsthesia of upper extremities, with severe spasmodic attacks of pain. On the third day an exploration was decided upon, in view of the local deformity, and the severe pain in the upper extremities. The third dorsal spine was found to be loose, as a result of bilateral fracture of the neural arch; the bullet had crossed the right limit of the spinal canal, and destroyed the body of the vertebra, and passing onwards had entered the left pleural cavity, into which air entered freely from the operation wound. The patient was relieved from his pain by the exploration, and lived four days. On the second day after operation, however, the temperature rose to 107°, while on the last two days the temperature was normal in the mornings, rising to 105° in the evenings. No alteration resulted in the trunk symptoms. _Diagnosis. _--The pure question of the fact of injury of the spinal cordneeds no discussion; but it is necessary to make some remarks on thediscrimination between concussion, contusion and hæmorrhage, meningealand medullary hæmorrhage, the latter condition and compression, and onpartial and complete severance of the cord. The sharp discrimination of cases of concussion from those of slightmedullary hæmorrhage was necessarily impossible. I think the only pointsof any importance in diagnosing pure concussion were the transitorynature of the symptoms, and the uniformity of recovery, withoutpersistence of any signs of minor destructive lesion. In medullaryhæmorrhage the tendency for a certain period was towards increase ingravity in the signs. It goes almost without saying that the latterpoint was seldom accurately determined in patients struck on the fieldof battle; these perhaps lay out for hours before they were brought in, and when they were placed in the Field hospital the rush of work did notusually allow the careful observation necessary to clear up thisdifference in the development of the symptoms. Nevertheless it ispreferable to consider the cases in which transitory symptoms persistfor a period of hours, or even a couple of days, as instances of pureconcussion, unless the existence of this condition can be disproved byactual observation. Extra-medullary hæmorrhage, accompanied by only slight encroachment onthe spinal canal, certainly results with some frequency fromsmall-calibre wounds. Some of the quoted cases show this decisively by_post-mortem_ evidence, others by such clinical signs of irritation aspain and hyperæsthesia. I think its presence may also be assumed incases of total transverse lesion due to medullary hæmorrhage or severeconcussion, accompanied by well-marked pain and hyperæsthesia above thelevel of paralysis. As affecting treatment, however, determination ofits presence is of small importance. The important conditions for discriminative diagnosis are those of localcompression, actual destructive lesion, whether from concussion changes, contusion, or medullary hæmorrhage, and partial and total section of thecord. First, with regard to compression of the cord, the possible sources arethree; (i) extra-dural hæmorrhage, which may, I think, be dismissed withmention as rarely capable of producing severe symptoms. (ii) Thedisplacement of bone fragments. This is of less importance than in civilpractice, because an injury by a bullet of small calibre, capable ofseriously displacing fragments, has probably at the same time producedgrave changes in the cord. In the presence of severe immediate symptomswe may tentatively assume that a simultaneous destructive lesion hasbeen produced. In such injuries pain, combined with a tendency toimprovement in the paralytic symptoms and return of reflexes, is theonly point in favour of bone pressure, unless considerable deformity ofthe spinal column can be detected by palpation or examination with theX-rays. (iii) Pressure from the bullet. This is the most important form ofcompression, because the mere fact of retention of the bullet isevidence of a low degree of velocity, and therefore opposed to theexistence of the most severe form of intramedullary lesion. In a case ofapparent transverse lesion with retained bullet, shown to me at No. 3General Hospital by Mr. J. E. Ker, the pain was very severe, and sogreatly aggravated by movement that an anæsthetic had to be administeredprior to the renewal of some necessary dressings. The general conditionof this patient precluded a projected operation, and after death thebullet was found to be pressing laterally upon a cord not materiallyaltered on macroscopic inspection. In the case of retained bulletrecorded (No. 104), the slight degree to which the severed ends of thecord appeared altered has been already remarked upon. Beyond this we are helped by the position of the aperture of entry, andits shape, as evidence of the direction in which the bullet passed, thepresence of pain, and positive proof may be obtained by examination withthe X-rays. Lastly, we come to the discrimination of total or partial section, destruction by vibratory concussion or contusion, and severeintramedullary hæmorrhage. Except in the case of partial section withlocalised symptoms, which must be rare, I believe this to be impossiblefrom the primary symptoms, although some indication of possibleencroachment on the canal may be obtained from careful consideration ofthe course of the wound, as evidenced by the position and shape of theopenings, the position of the patient's body at the time of reception ofthe injury being taken into consideration. Later we may get some aidfrom the possible improvement in the symptoms in the case of hæmorrhage. In cases with signs of total transverse lesion, however, thediscrimination of the conditions is of little practical importance, since either is equally unfavourable and unsuitable for surgicaltreatment. In closing these remarks reference must be made to the occasionaloccurrence of paraplegic symptoms of an apparently purely functionalnature. I saw these on one or two occasions, of which the following isa fair example. A man was wounded in the lower extremity and fell. Whenbrought into the hospital he complained of loss of power in the legs andinability to straighten his back. No very definite evidence was presentof serious impairment either of motor or sensory nerves, and the man wasgot up and walked with crutches. While moving about the hospital camp, another man pushed him down, and the patient then became completelyparaplegic. He was placed in bed, and the next day moved his limbswithout any difficulty, and gave rise to no further anxiety. _Prognosis. _--In slight concussion the importance of prognosis is as toremote effects, and upon this no opinion can be given at the presenttime. The same may be said concerning cases in which transient symptomsfollowed the slighter degrees of surface and medullary hæmorrhage. Inthe case of the latter, however, I think it would be rash to give a tooconfident opinion as to the future non-occurrence of secondary changes. Severe concussion is probably irrecoverable. Meningeal hæmorrhage of either form is one of the slighter lesions, andless dangerous, both as an immediate condition and as to theprobabilities of after trouble. None the less the possibilities ofsecondary chronic meningitis, or chronic trouble from adhesions, must bekept in mind. Cases of medullary hæmorrhage with incomplete signs are favourable inprognosis, as far as life is concerned; as to complete recovery, however, this is hardly possible; in many cases serious functionaldeficiency at any rate will remain, while in others the healing of thelacerated tissue and subsequent contraction can scarcely fail toinfluence unfavourably an already imperfect recovery. I think it must be a rare occurrence for pressure from bone fragments tobe able to be regarded as a favourable prognostic condition, since inthe very large majority of cases the velocity of the bullet causing theinjury will have been such as to inflict irreparable damage on the cord. Still, cases may occasionally be met with where the velocity has beensufficiently low, or contact with the bone slight enough, to allow ofthe comparative escape of the cord. In this relation cases in which thebullet is retained, especially if the symptoms of transverse lesion areincomplete, may be regarded as relatively favourable. Cervical and high dorsal injuries, as in civil practice, offered theworst prognosis. In cases in which symptoms of total transverse lesionwere present, as far as my experience went, it was, however, only amatter of importance as to the prolongation of a miserable existence. All the patients eventually died; those with higher lesions at the endof a few days; the lower ones, at the completion on an average of sixweeks of suffering. The actual causes of death resembled exactly those met with in civilpractice, except in so far as it was more often influenced or determinedby concurrent injuries, a complication so characteristic of moderngunshot wounds. Thus exhaustion, septicæmia from absorption fromsuppurating bed-sores or from severe cystitis, secondary myelitis, andpulmonary complications, carried off most of the patients. _Treatment. _--The general treatment of the cases demanded nothingspecial to military surgery, except in so far as it was modified by thedisadvantage to the patient of necessarily having to be transported, often for some distance. The ill effects of this, particularly in casesof hæmorrhage, are obvious, but in so far as fracture was concerned thequestion of transport did not acquire the importance that it does incivil practice, since the nature of the fractures and their strictlocalisation did not render movement either painful or particularlyhurtful. It was indeed striking how little pain movement, made for thepurposes of examination, caused these patients. The treatment ofbed-sores, cystitis, or other secondary complications possessed nospecial features. The importance of insuring rest in the early stages of the cases ofhæmorrhage is self-evident; hence, if the possibility exists of notmoving the patient, its advantage cannot be too strongly insisted upon. Again, if transport is inevitable, the shorter distance that can bearranged for the better. It should be borne in mind, also, that from thepeculiar nature of causation of the injuries, stretcher or wagontransport for short distances is preferable to the vibratory movementsof a long railway journey. Beyond this the administration of opium, andin some cases the assumption of the prone position, are both useful inthe recent or possibly progressive stage of hæmorrhage. Lastly, as to active surgical treatment by operation. In no form ofspinal injury is this less often indicated, or less likely to be useful. It is useless in the cases of severe concussion, contusion, or medullaryhæmorrhage which form such a very large proportion of those exhibitingtotal tranverse lesion, and equally unsuited to cases of partial lesionof the same character. Extra-medullary hæmorrhage can rarely beextensive enough to produce signs calling for the mechanical relief ofpressure; the section of the cord cannot be remedied. In one case withsigns of total transverse lesion, in which a laminectomy was performed, no apparent lesion was discovered, and this would frequently be thecase, since the damage is parenchymatous. The experience was indeedexactly comparable to that which followed early exposure of theperipheral nerves. Only three indications for operation exist. 1. Excessive pain in thearea of the body above the paralysed segment; operation is here ofdoubtful practical use, except in so far as it relieves the immediatesufferings of the patient. 2. An incomplete or recovering lesion, when such is accompanied byevidence furnished by the position of the wounds, pain, and signs ofirritation of pressure from without, or possibly palpable displacementof parts of the vertebra, that the spinal canal is encroached upon byfragments of bone. 3. Retention of the bullet, accompanied by similar signs to thosedetailed under 2. In both the latter cases the aid of the X-rays should be invoked beforeresorting to exploration. Operation, if decided upon, in either of the two latter circumstances, may be performed at any date up to six weeks; but if pressure be theactual source of trouble, it is obvious that the more promptly operationis undertaken the better for early relief and ulterior prognosticchances. In only one case of the whole series I observed did it seem possible toregret the omission of an exploration. CHAPTER IX INJURIES TO THE PERIPHERAL NERVE TRUNKS The occurrence of these injuries has undoubtedly increased in frequencywith the employment of bullets of small calibre, and no other class ofcase more strikingly illustrates the localised nature of the lesionsproduced by small projectiles of high velocity. Again, no other seriesof injuries affords such obvious indications of the firm and resistentnature of the cicatricial tissue formed in the process of repair ofsmall-calibre wounds, and in none is the advantage of a conservative andexpectant attitude so forcibly impressed upon the surgeon. Implicationof the nerves may be primary, or secondary to an injury which left themoriginally unscathed. _Nature of the anatomical lesions. _--In degree these vary inmathematical progression, but the extent of the lesion is not alwaysreadily differentiated by the early clinical manifestations, and againthe actual damage is not to be estimated by the gross apparentanatomical lesion alone; but, in addition, consists in part in changesof a less easily demonstrable nature, varying with the velocity withwhich the bullet was travelling and the consequent comparative degree ofvibratory force to which the nerve has been subjected. In theseinjuries, as in those of every part of the nervous system, the degree ofvelocity appears to gain especial importance both in regard to thegeneral symptoms and the local effect on the functional capacity of thenerve. This is perhaps a fitting place for the introduction of a few furtherremarks as to the significance of the term 'concussion' in connectionwith the injuries produced by bullets of small calibre, since the moststriking exemplification of the results following the transmission ofthe vibratory force of the projectile is afforded by the behaviour ofthe comparatively densely ensheathed and supported peripheral nerves. As already pointed out in Chapters VII. And VIII. The chief concussioneffects on the nervous tissue of the brain and spinal cord are of adestructive nature, far exceeding those accompanying the injuriesdesignated by the same term seen in the ordinary accidents met with incivil practice, and this damage is comparatively localised in extent. In the case of the peripheral nerves I have still employed the terms'concussion' and 'contusion' to designate certain groups of symptoms andclinical phenomena, but any sharp distinction between the two conditionson a morbid anatomical basis is impossible. The results of severevibratory concussion may, in fact, be more generally destructive thanthose of contusion, and the subsequent effects more prolonged. A certainlength of the affected nerve is apparently completely destroyed as aconductor of impulses, the connective-tissue element alone remainingintact. Under these circumstances a nerve, the subject of the mostserious degree of vibratory concussion, which, if cut down upon, mayexhibit no macroscopic change, may take a longer period to recover thanone in which the presence of considerable local thickening points todirect contact with the bullet, with resulting hæmorrhage into the nervesheath and perhaps partial gross rupture of nerve fibres. The therapeutic and prognostic importance of the above remarks, ifcorrect, is obvious. The course of the nerve is preserved by its intactconnective-tissue framework, and ultimate recovery by a regeneration ofthe nerve fibres is more likely to be complete, and will be just asrapid, if nature be relied on and the nerve be left untouched by thehand of the surgeon. It is, I think, undeniable that nerve trunks may escape severe orirrecoverable injury by lateral displacement. The mere fact that thetrunk itself may be perforated by a slit in its long axis would suggestthe possibility of displacement of the whole structure, and this nodoubt occurred with some frequency. Displacement would naturally be mostfrequent in the case of nerves, such as those of the arm, which run longcourses in comparatively loose tissue. In a remarkable case alreadynarrated, an exploratory operation showed the musculo-spiral nerve inthe upper part of the arm to have been driven into a loop whichprojected into, and provisionally closed, an opening in the brachialartery. I. _Simple concussion. _--Anatomically, or histologically, no informationexists as to the changes which give rise to the often transitorysymptoms dependent on this condition. We are reduced to the sametheories of molecular disturbance and change which have been invoked toaccount for similar affections of the central nervous system. Thecausation of concussion is, however, materially influenced in its degreeby the velocity of flight of the bullet and consequent severity of thevibratory force exerted. Hence actual contact of the bullet with thenerves is not necessary for its production, as is seen in the temporarycomplete loss of functional capacity in the limbs in many cases offracture, where the vibrations are rendered still more far-reaching andeffective as the result of their wider distribution from the largersolid resistance afforded by the bone. The relative density andresistance offered by the different parts of the bone acquire greatsignificance in this relation, since local shock due to nerve concussionis far more profound when the shafts are struck than when the cancellousends furnish the point of impact. The form of concussion which most nearly interests us in this chapter isthat affecting single nerve trunks in wounds of the soft parts alone, and here the passage of the bullet is, as a rule, so contiguous to thenerve that there is difficulty in drawing a strict line of demarcationbetween such cases and those dealt with in the next paragraph. II. _Contusion. _--Clinically this was the form of nerve injury both ofgreatest comparative frequency and of interest from the points of viewboth of diagnosis and prognosis. The seriousness of a contusion depends on two factors: first, therelative degree of violence exerted upon the nerve, which is dependenton the force still retained by the travelling bullet; and, secondly, onthe extent of tissue actually implicated. The range of fire at which theinjury was received determines the importance of the first factor; thesecond varies with the degree of exactness with which the nerve isstruck, and on the direction taken by the bullet. Naturally transversewounds affect a small area; while an oblique or longitudinal directionof the track may indefinitely increase the extent of injury to the nervetrunk, and hence acquire prognostic significance in direct ratio to theamount of tissue which needs to be regenerated. As to the actual anatomical lesion resulting in the cases which wedesignated clinically as contusion I can give no information. On manyoccasions when the symptoms were considered of such a nature as torender an exploration advisable, no macroscopic evidence of gross injurywas obtained. It was therefore impossible to draw a definite line ofdemarcation between such cases and those which we considered merelyconcussion. It could only be assumed that the vibration transmitted tothe nerve had occasioned such changes as to destroy its capacity as aconductor of impressions. In some cases the presence of a certain amount of interstitial bloodextravasation was suggested clinically by early hyperæsthesia and signsof irritation; in others the paralysis was of such a degree as to leadto the inference that a complete regeneration of the existing nervewould be necessary prior to the restitution of functional capacity. In a certain proportion of the injuries the development of a distinctfusiform swelling in the course of the nerve pointed to the existence ofconsiderable tissue damage, while in others this was evidencedclinically by early signs of neuritis. III. _Division or laceration. _--The varying mechanical conditionsaffecting the last class of injury play a similar rôle here. Thus thedegree of laceration depends on the direction of the wound track, and asall lacerations are accompanied by contusion, the relative velocityretained by the travelling bullet assumes the same importance. I saw every degree of injury to the trunks, from notching to completesolution of continuity, and in some cases destruction and disappearanceof pieces from one to two or more inches in length. Such lesions as thelatter were most common in the forearm. In this segment of the limbstracks of varying degrees of longitudinal obliquity are readilyproduced, whether the patient be in the upright or prone position, since the upper extremities are commonly in forward action whicheverposition is assumed. The most peculiar form of injury consisted in perforation of the trunkwithout gross destruction of its fibres, and without in many casesprolonged or permanent loss of functional capacity. I cannot speak withany confidence as to the comparative frequency of occurrence of thisform of injury, but judging by the analogous perforations of thevessels, it is probably not uncommon in trunks large enough to allow ofits production. The trunk nerves of the arm, and the great sciaticnerve, were probably the most frequent seats of such wounds. As, however, a very short experience of the futility of early interferencein the case of nerve lesions warned me against exploration before a dateat which observations of this nature were unsatisfactory, I gained lessexperience on this point than I could have wished. In the case of completely divided nerves the development of a bulbousenlargement on the proximal end was constant, and very marked in degree. I saw few cases in which primary effects could be certainly referred topressure or laceration by bone spicules, excepting in some fractures ofthe humerus, and perhaps some injuries of the seventh nerve accompanyingperforating wounds of the mastoid process. IV. _Secondary implication of the nerves. _--This was a strikingcharacteristic in many at first apparently simple wounds of the softparts. In such cases it was due to implication of the contiguous trunkin the process of cicatrisation, and its importance varied with the sizeof the nerve in question. In the smaller sensory trunks it was oftenevidenced by the occurrence of neuralgic pain, especially liable to beinfluenced by climatic changes; in the larger, by signs of more or lesssevere motor, sensory, and trophic disturbance. Musculo-spiral paralysisfrom implication in, or pressure from, callus in cases of fracture ofthe humerus was very frequent. This would naturally be expected from theextreme degree the comminution of the bone often reached, and theconsequently large amount of callus developed. The effect of cicatrisation of the tissues surrounding the nervesvaried somewhat according to the degree of fixation of the individualnerve implicated. Thus if a nerve lay in a fixed bed some form ofcircular constriction resulted; if, on the other hand, the nerve wasreadily displaceable, the cicatrix often drew it considerably out of itscourse; in either case symptoms corresponding with those of pressureresulted. _Symptoms of nerve lesion_. --These differed little in character fromthose common to such injuries in civil practice, except in the relativefrequency with which they assumed a serious aspect. After all in civilpractice nerve concussion is most familiar to us in the degree commonafter knocking the elbow against a hard object, and the same may be saidin regard to the allied injury of contusion. It is in small-calibrebullet wounds alone that the occurrence of such severe and sharplylocalised injury to deep parts as was observed is possible. _Concussion_. --Temporary loss of function was often observed in thelimbs, corresponding to the distribution of one or more nerve trunkswhen wound tracks had passed in their vicinity. Interference withfunction sometimes amounted to loss of sensation alone: in others toloss of both sensation and motor power. Such symptoms were of atransitory character, lasting for a few days or a week; if bothsensation and motion were impaired, sensation was usually the first tobe regained. In these cases secondary trouble was not uncommon, sincethe near proximity of the track to the originally affected nerve offeredevery chance for implication of the latter in the resulting cicatrix. This sequence was often observed, and its symptoms are described underthe heading of secondary implication below. Equally striking were theinstances of concussion in the case of the nerves of special sense andtheir end organs, temporary loss of smell, vision, or hearing being notuncommon, often passing off in the course of a few days with no apparentulterior ill-effect. One of the most interesting illustrations of the occurrence ofconcussion was furnished by cases in which complete paralysis of a limbrapidly cleared up with the exception of that corresponding to a singleindividual nerve of the complex apparently originally implicated. Instances of severe contusion or division of one nerve of the arm, forinstance, accompanied by transient signs of concussion of varyingdegrees of severity in all the others, were by no means uncommon. _Contusion_. --The symptoms of contusion were somewhat less simple, since, in addition to lowering or loss of function, signs of irritationwere often observed. In the slighter cases irritation was often a markedfeature, as was evidenced by hyperæsthesia and pain combined with lossof power. In cases in which pain and hyperæsthesia were primarysymptoms, these were often transitory. I will quote an illustrative casewhich, though affecting the nerve roots, is characteristic of theeffects of slight contusion in the case of the nerve trunks in any partof their course:-- (107) _Contusion of cervical nerve roots_. --Range probably about 1, 000 yards. Wounded at Belmont. Aperture of _entry_ (Lee-Metford), immediately posterior to the right fifth cervical transverse process; _exit_, immediately anterior to the space between the third and fourth left cervical transverse processes. The movements of the neck were perfect, there was neither pain nor difficulty in swallowing. Extreme hyperæsthesia was present in both palms and down the front of the forearms. The grip in either hand was weak, this being possibly explained in part by the hyperæsthesia of the palms, as all movements of the upper extremities could be made, although not with full power. On the fourth day the condition was much improved on the left side, and at the end of a week the left upper extremity was normal; the right (side of entry, and therefore exposed to greater force from the bullet) improved more slowly, becoming normal only at the end of three weeks. I observed an identical case of injury to the cervical roots, and manysimilar instances in injuries of the nerve trunks of the limbs in whichthe course was exactly parallel. In the more severe, pain was oftenadded to hyperæsthesia. In the most severe cases the signs corresponded in all particulars, except in the early entire loss of reaction of the muscles toelectricity, with those of complete section. Loss of sensation andmotion was immediate, complete, and prolonged, the limbs being loweredin temperature, flaccid, and powerless. General systemic shock was alsosevere. In the case either of plexus or multiple contusions, or wherethe injury was more local, correspondingly complete signs were presentin the area supplied by the affected nerves. In the cases in which the contusion was not of extreme degree, hyperæsthesia often developed as a later sign, and was probably due tothe irritation of hæmorrhage, when the sensory portion of the nervebegan to regain functional capacity. The date of appearance of thehyperæsthesia varied from a few days to a week or later. It might thenpersist for weeks or many months. In a few instances large blebs rose on the back of the hand, or patchesof vesicles appeared over the terminal distribution of the nerve, pointing to early trophic changes. The period of recovery varied greatly; in some instances of verycomplete paralysis, function was regained and became apparently normalat the end of three or four weeks; in others, even after severe wastingof muscles for weeks, rapid improvement occurred often suddenly, whilein some there was no apparent recovery at the end of months. In cases oflong-deferred improvement, wasting of the muscles became a veryprominent feature; but this without complete loss of reaction of themuscles to electrical stimulation. Recovery of sensation usually preceded by some time that of motion, theformer often reappearing in some degree at an early date, and, even ifvery modified in character, it formed a most useful and valuable aidboth in diagnosis and prognosis. When in a position allowing of direct examination, the contused portionof the nerve sometimes developed a palpable fusiform thickening, manipulation of which might give rise to formication in the area ofdistribution--a favourable prognostic sign. Many of the cases bore a very marked resemblance in character to thosein which paralysis results from tight constriction of the limb, as inthe arm after the application of an Esmarch's tourniquet. _Laceration. _--If incomplete, the signs corresponded very nearly tothose of severe contusion, since partial section is impossible withoutthe occurrence of the latter. The condition indeed was only to bedistinguished by the partial nature of the recovery, and even thislatter might be only more prolonged. The same remarks hold good with regard to perforation of the nervetrunks; but, as regards function, these injuries are not so serious inprognosis as very much more limited transverse divisions or merenotching, and in some cases the disturbance of function was by no meansprofound or prolonged. Absolute loss of reaction to electrical stimulus from above was the onlypathognomonic sign of actual section, unless the position of the nervewas such as to allow of palpation, when the presence of a bulbous end atonce settled the difficulty. In many cases of superficial tracks withdivision of such nerves as the long or short saphenous, the earlydevelopment of bulbs in the course of the trunks gave positiveinformation, and these were often observed. _Traumatic neuritis. _--This was a common sequence of contusion of thenerve itself, or of its subsequent inclusion in a cicatrix or callus. Itwas evidenced by hyperæsthesia both superficial and deep, pain, contracture, wasting of the muscles, local sweating, and the developmentof glossy skin. Examples of this condition were seen in the case of nearly every nervein the body. In frequency of occurrence, degree of severity, and in itsselection of individual nerves considerable variation was met with. Withregard to the two former points, personal idiosyncrasy, and degree of orpeculiarity in the nature of the injury, are the only explanations I cansuggest. Perhaps in some instances exposure to wet or cold in the earlystages of the injury was of some import. Thus, I saw several severecases of musculo-spiral neuritis in men who were wounded during thetrying and wet march on Bloemfontein. I did not observe that suppurationor wound complications seemed important explanatory moments, as most ofthe cases occurred in wounds that healed rapidly. With regard to the question of selection; the same nerves that appearparticularly liable to suffer from idiopathic inflammations, toxicinfluences, or to be the seat of ascending changes (e. G. Ulnar, musculo-spiral, and external popliteal), were those most often affectedby secondary neuritis. Many of the most severe cases I saw were in themusculo-spiral nerve. _Scar implication. _--The signs of this most commonly commenced withneuralgia, or painful sensations when such movements were made as to putthe cicatrix on the stretch. Although such neuralgia might not beconstant, it was often observed to be troublesome when the patients wereexposed to cold in sleeping out at night, or to extra fatigue, as inlong marches. The results in many cases stopped at this point, but thesize and wide distribution of certain nerves rendered even such slightsymptoms of importance; while in others well-marked signs of neuritisdeclared themselves, such as glossy skin, pain, muscular wasting, andparalysis. _Ascending neuritis. _--In a few cases I observed very remarkableinstances of ascending neuritis, after comparatively slight wounds. Iwill quote three of these as illustrations and make no further remarksas to the symptoms. It will be observed that one is a case of ulnar, both the others of external popliteal, neuritis:-- (108) _Ulnar nerve: secondary ascending neuritis. _--Boer wounded at Elandslaagte. Wound of hand, implicating anterior two-thirds of third metacarpal bone. This bone, together with the middle finger, was removed, and healing took place by granulation slowly. The resulting gap allowed considerable overlapping of the fingers, and shortening of the corresponding digit; the index finger also became flexed as a result of destruction of the extensor tendons. Three months later the man was still in hospital in consequence of the tardiness with which the wound had healed: at this time pain was noted, which became very severe in the whole course of the ulnar nerve; superficial hyperæsthesia and deep muscular tenderness developed, but no wasting. Several crops of herpetic vesicles also developed over the distribution of the radial nerve in the hand. This pain was followed by spastic contracture, first of the ulnar fingers and later of the wrist and elbow, which could only be straightened by the application of considerable force. The limb was, therefore, kept straight by the application of a splint; and warm baths, and a blister applied over the course of the ulnar nerve, were resorted to: under this treatment the condition improved until the patient was well enough to be transferred as a prisoner, and I saw him no more. (109) _Peroneal nerve branches. _--Wounded at Colenso. _Entry_, at the anterior margin of the fibula 5 inches above the external malleolus; the track crossed the anterior aspect of the leg obliquely, to its _exit_ 1 inch above the centre of the ankle joint. Incomplete paralysis of the peronei muscles followed, combined with progressive wasting of the whole limb, which at the end of a month was marked, and then commenced to improve. (110) In a second case the wound took a similar course in the centre of the leg, crossing the line of the branches of the musculo-cutaneous nerve. Motor paralysis of the peronei followed, together with general lowering of tactile sensation in the musculo-cutaneous area. _Traumatic neurosis. _--In connection with the cases just quoted, mentionmust be made of the fact that the functional element was often somewhatprominent. The influence of this factor was not to be neglected in case108; again, its presence was a feature in cases 132 and 134, of injuryto the sciatic nerve and of peripheral injury to the seventh nerve (p. 355). A remark has been made as to the occurrence of functionalparaplegia on p. 337. Again, in the case of the organs of special sense. Case 66, of injury to the occipital lobes, showed that a mixture oforganic and functional phenomena might be a source of error, even in thedetermination of the visual field in the subject of an undoubteddestructive lesion. On more than one occasion an injury was accompaniedby loss of the power of speech; thus a patient who received a slightwound of the neck did not speak again until the application of a batteryby my colleague, Mr. H. B. Robinson. A patient was also for a short timean inmate of No. 1 General Hospital, Wynberg, who had become deaf anddumb as a result of the explosion of a shrapnel shell over his head. This patient also did not recover his powers until he returned to themother-country. In many other cases of nerve concussion or contusion, the recovery ofpower and sensation, or the disappearance of neuralgia or contractures, was so sudden and rapid after prolonged continuance of the symptoms, asto suggest a very strong functional element in their origin. Theinfluence of the general shock to the nervous system received by thepatients had an important bearing on these phenomena, and their interestfrom a prognostic point of view was very great. INJURIES TO SPECIAL NERVES _Cranial nerves. _--It will be convenient first to make a few remarksconcerning the nerves of special sense. _Olfactory. _--I observed temporary loss of smell on three occasions. Intwo instances this accompanied transverse wounds of the bones of theface in which the upper third of the nasal cavities was crossed; in thethird a track passing obliquely downwards from the frontal region passedthrough the inner wall of the orbit, and crossed the nose at a lowerlevel. In view of the small area of the olfactory distribution which wasdirectly implicated, I was at first inclined to regard the loss of smellas dependent on the presence of dried blood on the surface of the mucousmembrane, or on obstruction of the cavities from the same cause. Furtherobservation, however, appeared to show that it was due to concussion ofthe branches of the olfactory nerve, since the loss of functionpersisted when the cavities were manifestly clear. In all these cases we were confronted with the same difficulty which wasexperienced both in lesions of sight and hearing, the determination asto whether the concussion was of the branches or of the olfactory bulb. When the symptom was the accompaniment of a fracture of the roof of theorbit, the possibility of concussion of the olfactory lobe was manifest. In all, again, it was difficult to say what part the accompanyingconcussion of the branches of the fifth nerve took in the production ofthe symptom. In all three cases mentioned the return of function wasgradual, but apparently fairly complete at the end of three weeks. Inone it was noted that at first the patient was conscious of an odourbefore he was able to discriminate its actual nature; later he coulddetermine the latter readily. _Optic. _--Some remarks concerning lesions of the optic nerve havealready been made under the heading of wounds of the orbit. Concussionand contusion of the nerve both occurred, but I was unable todifferentiate between the effects of these on the nerve itself, apartfrom the effects on the globe of the eye, which usually accompaniedwounds of the orbit. In some cases the nerve was directly divided in orbital wounds, andeither pressure on or division of the nerve in the intra-cranial portionof its course, or as it traversed the optic foramen, was not uncommon. _Auditory. _--Loss of hearing was also not infrequent; thus itaccompanied all three wounds of the mastoid process quoted under theheading of the seventh nerve, also two cases of fracture of theoccipital bone near the ear quoted on p. 278. In all these instances itwas impossible to attribute the deafness to lesion of the nerve alone, as the causative injury equally affected the internal ear, and in atleast two the bullet implicated the tympanum as well in its course. Thedeafness was absolute in each case, and in none had any improvementoccurred at the end of nine months. Deafness was a symptom in a certainnumber of the more severe cerebral injuries in which the course of thebullet was not so near to the internal ear: probably some of these werecentral in origin. I only once observed any interference with the sense of taste. _Remaining cranial nerves. _--I have little to say regarding the _third_, _fourth_, and _sixth_ nerves. In the case of the third nerve, ptosis wasoccasionally seen in wounds of the skull involving the roof of theorbit, but the relative parts taken by injury to nerve and laceration orfixation of muscle respectively, were usually hard to determine. Again, the fourth and sixth nerves may have been damaged in some of the moreextensive orbital wounds, especially those in which the globe sufferedinjury, but the signs under such circumstances were difficult todiscriminate, and the injury was of slight practical importance, in viewof the major injury to the globe itself. _Fifth nerve. _--Concussion, contusion, or laceration of the differentbranches of the three divisions of the fifth nerve were common in woundsof the head, but most frequent in fractures of the upper or lower jaws. Localised anæsthesia was common from one or other of these causes, butfor the most part transitory in the cases of contusion or concussion. Isaw no case of entire loss of function in any one division, symptomsbeing mostly confined to certain branches, as the supra-orbital, thetemporo-malar, the dental branches of the second division, theauriculo-temporal nerve, and the lingual, dental, and mental branches ofthe third division. I did not observe any cases in which modification ofthe special senses accompanied these injuries beyond those mentioned inthe remarks already made on the subject of anosmia, and one case inwhich some modification of the sense of taste accompanied an injury tothe floor of the mouth. It was a matter of surprise, considering thefrequency with which subsequent neuritis was met with in the nervesgenerally, that trifacial neuralgia in some form was not more often metwith. I never observed any serious case. Perhaps this is one of thefields in which a longer after-period may increase our knowledge. Lastly, I never observed motor paralysis in the case of the thirddivision, although sensory symptoms in some of the branches were common, evident proof that injuries to the trunk were rare. _Seventh nerve. _--Facial paralysis was most commonly observed in casesof wound of the mastoid process, apart from central cortical facialparalyses, of which several are quoted in the chapter on injuries of thehead. All the wounds of the mastoid process were, in addition, accompanied by absolute deafness. I am sorry to be unable to give anydetails as to the electrical condition of the muscles in these cases, but I believe that in the great majority the paralysis was mainly theresult of nerve concussion, since the perforations were clean incharacter and not obviously accompanied by comminution. Pressure fromhæmorrhage into the Fallopian canal may, of course, have been present, and in some instances, particularly those in which the bullet traversedthe tympanic cavity, spicules of bone may have caused laceration. Inevery case, however, all the branches were equally affected; theparalysis was absolute, and in none did any improvement occur while thecases were under my observation. The following are a few illustrative examples:-- (111) Boer wounded at Belmont. _Entry_, immediately above zygoma; the bullet passed through the temporal fossa, fractured the neck of the mandible, traversed the mastoid process, and emerged at the lower margin of the hairy scalp, 1 inch from the median line. Facial paralysis was complete, and there was no improvement at the end of ten weeks. (112) Wounded at Magersfontein. _Entry_, at the posterior border of the left mastoid process, 1/2 an inch above the tip; _exit_, through the right upper lip at the junction of the middle and outer thirds. There was considerable hæmorrhage from the left ear. The injury was followed by complete deafness, and facial paralysis, which showed no sign of improvement. There was complete anæsthesia over the area of distribution of the third division of the fifth nerve; this improved rapidly, and at the end of five weeks was hardly to be detected; neither at that time could any impairment of power on the part of the muscles of mastication be detected. No impairment of the sense of taste was noted. (113) _Entry_, above the anterior extremity of the zygoma, bullet retained. Primary hæmorrhage from ear. Complete facial paralysis and deafness. Anæsthesia over distribution of temporal branch of temporo-malar nerve, part of supra-orbital area, auriculo-temporal nerve, and small occipital cervical nerve. The muscles of mastication acted well. Ecchymosis below the right mastoid process. (114) Wounded at Paardeberg. 300 yards. _Entry_, at the posterior border of the right mastoid process, 3/4 of an inch above the tip; _exit_, the inner third of the left upper eyelid. (Eye destroyed. ) Complete right facial paralysis; deaf, on right side cannot hear tick of watch either held close or in contact. Purulent otitis media. In this place I might mention two other cases of lesion of the seventhnerve secondary to wound of peripheral branches. In one a patient wasstruck by several fragments of lead from a bullet which broke up againsta neighbouring stone. These for the most part lodged in the skin overthe left orbicularis muscle, but one also lodged in the conjunctiva andwas removed. Some ten days later the patient complained that he couldnot lift the upper lid. The levator palpebræ was normal, but spasm ofthe orbicularis held the eye firmly closed. The condition did notimprove, and the patient was invalided home. He recovered later. In another patient a bullet entered above the right zygoma and traversedthe orbits, without wounding the globes. At the time no want of power ofthe muscles of the face was noted, but a year later there was evidentweakness of the whole of the muscles of the right side of the face, withloss of symmetry. In the former case the functional element was strong, but in both anascending neuritis was probably present. _Tenth nerve. _--The pneumogastric was implicated in many wounds of theneck. I never observed an uncomplicated case, but laryngeal paralysiswas temporarily present in two of the cases of cervical aneurism inwhich the wound crossed above the level of origin of the recurrentlaryngeal branch, while in two others the recurrent branch itself was inclose contact with the wall of the aneurism (p. 135). In all such casessigns of concussion or contusion of the nerve would be expected, judgingfrom the similar results observed in the brachial nerves when theneighbouring artery was implicated. The only obvious symptoms occurring, however, were laryngeal paralysis and acceleration of the pulse. As thelatter symptom was often observed in the cases of arterio-venouscommunication, wherever situated, and as the sympathetic nerve also layin close contiguity to the wound track, it was difficult to ascribe itwith certainty solely to the vagus lesion. In the two cases of highvagus injury the laryngeal paralysis steadily improved, and at the endof six months was apparently well; in the two others it persisted at theend of three months and a year respectively. The nerve must have been very frequently damaged in wounds of the neck;it is possible that this injury may have been an important factor in thedeath of some of the patients with cervical wounds upon the field. _Eleventh nerve. _--I append the only case of localised spinal accessoryparalysis I observed. This was one of my earliest experiences, and whenI examined the neck, in the Field hospital, I assumed from thecompleteness of the sterno-mastoid and trapezius paralysis that thenerve was severed. The patient, however, made such a rapid recoverythat it became evident that the nerve had been contused only, and thatthe recovery of function was not due, as is so often the case, tovicarious compensation by the cervical supply to the muscles. (115) _Entry_, immediately to the right of the fourth cervical spinous process; _exit_, at the anterior border of the left sterno-mastoid opposite the angle of the mandible. The left shoulder was depressed, the head inclined to the injured side. There was evident spinal accessory paralysis, and marked hyperæsthesia of the whole left upper extremity, most severe in the circumflex area. The hyperæsthesia gradually disappeared in a few days, and was clearly due to concussion and possibly slight contusion of the cervical nerve roots. The spinal accessory paralysis improved, so that the patient returned to the front at the end of a month: when I saw him some four months later the shoulders were held quite symmetrically. The _twelfth nerve_ was occasionally damaged in wounds of the floor ofthe mouth. I saw no case of permanent paralysis. _Injury to the systemic nerves. _ _Cervical plexus. _--Evidence of injuryto the superficial branches of the cervical plexus was not rare; thus Isaw cases of small occipital anæsthesia, and great occipital neuralgia, but none of motor paralysis from injury to the deeper muscular branches. I take it that the smallness of the branches, and the multiple supplypossessed by many of the muscles of the neck, would both take part inrendering certain evidence of the injury of an individual motor nerverare. _Brachial plexus. _--Injury to this plexus in the neck was common; themain peculiarity observed was the partial nature of the damageinflicted. Thus injury to a single nerve, or to a complex of two or more, was farmore common than one implicating the whole plexus. Again, while completeparalysis might affect one set of nerves, another might simply exhibitsigns of irritation in the form of hyperæsthesia or pain. The wounds producing these injuries varied much in direction; thus somecrossed the neck transversely, some were obliquely transverse, whileothers took a more or less vertical course. These same remarks hold good in the case of the nerves of the arm. Inthe upper half, especially, complex injury was not rare, while in thelower third affection of individual nerves was more common. Anotherimportant difference must be mentioned in regard to the upper and lowersegments of the course of the brachial nerves; they are not only morewidely distributed below, but also more fixed in position, a factantagonistic to the escape of the nerve by displacement and liable toexpose it to more severe contusion. The latter point holds good in the forearm also; here, individualinjuries often occurred. While at work in the Field hospital alone I gained the impression thatthe musculo-spiral nerve would not retain the unenviable character ofbeing the most vulnerable nerve of the upper extremity, since thechances of each individual nerve seemed about equal, putting thequestion of the long course of the musculo-spiral nerve against thehumerus out of question. This expectation was, however, not confirmed, since the musculo-spiral itself, if not primarily affected, was so oftenthe seat of secondary mischief in fractures of the humerus. Theposterior interosseous branch seemed to exhibit a similar vulnerabilityto slight injuries, to be referred to later under the external poplitealof the lower extremity. Again, in complex injuries of the brachialplexus, or nerve trunks, the musculo-spiral branch rarely escaped beinga member, if not individually singled out. Of the _thoracic nerves_ I have little to say. They must have been ofteninjured in the thoracic wounds, yet, as far as my experience went, intercostal neuralgia was uncommon, or at any rate not a specialfeature. One observation of interest, however, does exist; in the casesin which the ribs were fractured by bullets travelling across themwithin the thorax, pain was distinctly a prominent feature. This was nodoubt referable to the facts that in such instances the intercostalnerves were especially liable to direct injury, and that this was oftenmultiple. On one occasion a crop of herpetic vesicles developed alongthe course of a dorsal nerve in an injury implicating a singleintercostal space posteriorly. _Lumbar plexus. _--Although not quite so well arranged to escape bulletwounds as the thoracic nerves, the lumbar, by reason of their deepposition and the comparatively wide area they cover, together with therarity of wounds taking a sufficiently longitudinal direction to crossthe course of more than one or two branches, were also comparativelyrarely damaged. I never saw an uncomplicated case of anterior cruralparalysis, and rarely cruralgia. I think this is to be explained in twoways: first, that the trunk course of the nerve is short; secondly, thatit lies in the inguinal fossa. The second fact is of importance, sincewounds in this region were in my experience responsible for aconsiderable percentage of the deaths on the field or shortlyafterwards. Such deaths probably occurred from internal hæmorrhage fromthe iliac arteries, and it was in such cases that the anterior cruralnerve stood in greatest danger of injury. I also never saw a case oflocalised obturator paralysis. On the other hand, anæsthesia orhyperæsthesia in the area of distribution of the lumbar nerves in thegroin, the external cutaneous and the long saphenous in the thigh, werenot uncommon. Hyperæsthesia developed in more than one case in whichinjury to the psoas had led to hæmorrhage into the muscle sheath. _Sacral plexus. _--The sacral plexus is far more liable to extensivedirect injury than either of the two preceding. Its cords are larger, gathered up into a much smaller space, and more liable to injury, fromthe fact that the slope in which they lie is more readily followed by abullet track. Again, the cords rest for a considerable portion of theircourse on a bony bed, a particularly dangerous position in gunshotwounds, since the nerves are not only exposed to the danger of directwound, or pressure from bony spicules, but also readily receivetransmitted vibrations secondary to impact of the bullet with the bone. None the less I had few occasions to observe extensive injuries of theplexus. In one instance damage particularly affecting the lumbo-sacralcord occurred, but this was complicated by signs of irritation of theanterior crural and obturator nerves, as the result of retro-peritonealhæmorrhage and injury to the psoas muscle. Two cases in which thesacro-coccygeal plexus suffered isolated injury on account of theircharacteristic nature as gunshot injuries will be shortly quoted: (116) _Sacro-coccygeal plexus. _--_Entry_, at the junction of the middle and posterior thirds of the left iliac crest; the bullet passed obliquely downwards through the pelvis to lodge 3 inches below the right trochanter major. Incontinence of soft fæces persisted for five weeks, and retention of urine during three weeks. This patient subsequently died on the homeward voyage, but I am unable to say from what cause. (117) _Entry_, over third sacral vertebra; _exit_, 2 inches from the median line, and 1-1/2 inch above Poupart's ligament on the anterior abdominal wall. Incontinence, with involuntary passage of fæces, persisted during the first twenty-four hours, and for two days the urine had to be withdrawn with a catheter. No further signs of nerve injury were noted. The same explanation of the comparative rarity of injuries to the sacralplexus that has been already given in the case of the anterior cruralnerve holds good--viz. That in a great many of the pelvic woundsinvolving the plexus early death followed from the severity of theconcurrent injuries. Injuries to the great sciatic nerve outside the pelvis, or to one of itsconstituent elements, on the other hand, formed one of the most familiarof the nerve lesions. The wounds giving rise to these were of the mostdiverse character; some crossed the buttock in a vertical, transverse, or oblique direction; others travelled through the thigh incorresponding directions, while a third series involved both buttock andthigh. The size of the great sciatic nerve renders complete laceration by abullet of small calibre a matter almost of impossibility; hence completedivision may almost be left out of consideration in the case of thisnerve. On the other hand, partial division, perforation, and severecontusion are each and all favoured by the same factor. With an extended thigh the nerve is in a state of comparatively slighttension, and this may be still lessened if the knee be flexed. Thisfactor, together with the density of the sheath of the nerve, favoursthe possibility of displacement, and this occurrence is more likely inthe lower segment than in the upper, which is comparatively fixed inposition. Clinical experience appeared to illustrate the importance of theseanatomical factors, as the worst cases of sciatic injury that I saw werein connection with wounds of the buttock or the junction of that segmentof the trunk with the thigh. The most striking observation with regard to the injuries of the greatsciatic nerve was the comparatively frequent escape of the poplitealelement and the severe lesion of the peroneal. This was so pronounced asto amount to as high a proportion of peroneal symptoms as 90 per cent. , and often when the whole nerve was implicated the popliteal signs wereof the irritative, the peroneal of the paralytic type. When bulletscrossed the popliteal space, given wounds of equal severity incorresponding degrees of contiguity to the respective nerves, theperoneal element always suffered in greater degree. Again, the peronealnerve symptoms were more obstinate and prolonged, and instances ofascending neuritis were more common than in the case of any other nerveof the lower extremity, and the trophic wasting of muscles was moremarked. The peroneal nerve, therefore, acquires the same unenviable degree ofimportance in the lower extremity enjoyed by the musculo-spiral in theupper. Here, again, we are confronted with the fact that the peronealelement of the great sciatic nerve is the more prone to idiopathicinflammations or toxic influences, and hence we can only assume it topossess a special vulnerability. The peroneal element is of coursesomewhat the more exposed, as lying posterior; but it seems unreasonableto assume that so large a proportion of the injuries can implicate theposterior segment of the nerve as to make the startling difference inthe incidence of degeneration explicable. In this relation we may bearin mind that the muscles supplied by this nerve suffer most in thedegeneration subsequent to anterior polio-myelitis, and again that incerebral hemiplegia or spinal-cord injuries they are the last torecover. Unfortunately no explanation of these remarkable facts, soforcibly impressed by the large series of cases with peroneal symptomsseen in a short time, is forthcoming. I may dismiss the other branches of the sacral plexus in a few words. The small sciatic was occasionally injured in its course in the buttock, and the small saphenous in the leg. When either element of the latterwas injured, it was surprising how sharply the imperfections in theanæsthesia corresponded with the composite character of the nerve. CASES OF NERVE INJURY The following cases are added mainly to give some idea of thecomparative frequency with which the individual nerves were injured, andalso to exemplify the more common forms of complex injury met with. Circumstances, unfortunately, did not always allow of extendedobservation at the time, and I have not been very fortunate in myattempts to obtain subsequent information on this series since myreturn. A certain amount of prognostic information is, however, furnished by some of the records, and I am very much indebted to mycolleague, Dr. Turney, for help in this matter. (118) _Brachial plexus. _--_Entry_, 2 inches above the clavicle at the anterior margin of the trapezius; _exit_, first intercostal space, 1 inch from the sternal margin. Heavy dull pain developed at once, extending down the upper extremity. A fortnight later this pain still persisted; there was lowered sensation in the ulnar area with formication, also lowered sensation in the internal cutaneous area of distribution; sensation in the lesser internal cutaneous area was normal. The patient went home with the nerve symptoms well at the end of a month. (119) _Brachial plexus injury. _--Wounded at Magersfontein. _Entry_, at the anterior border of the sterno-mastoid opposite the pomum Adami; _exit_, through the ninth rib below and 1/2 an inch external to the scapular angle. Emphysema and considerable blood extravasation developed in the posterior triangle of the neck, also loss of power in the musculo-spiral distribution, but no anæsthesia. At the end of the first fortnight there was evident wasting of the muscles, but some power was returning in the triceps. At the end of a month the man left for England, with fair power in the triceps, but well-marked wrist-drop. A year later the wrist-drop still persisted. (120) _Plexus injury. _--Wound of _entry_, over pomum Adami; _exit_, below scapular spine, about centre. Complete median and musculo-spiral paralysis. (121) _Median, musculo-cutaneous, and musculo-spiral nerves. _--The wound traversed the axilla from just beneath the anterior fold; three weeks later a firm mass in the axilla corresponded to the wound track. Hyperæsthesia developed in the area of median distribution, with deep pain in the muscles. There was rigidity of the biceps cubiti and slight wasting in the radial extensors. The patient improved slowly, and eventually was discharged and passed out of sight. (122) _Brachial nerves. _--Wounded at Paardeberg. Range 500 yards. _Entry_, at the front of the arm, 2 inches below the junction of the anterior axillary fold; _exit_, a little lower, at the back of the arm, in the line of junction of the posterior axillary fold. Considerable shock attended the primary injury; when reaction had taken place, complete motor and sensory paralysis was noted of the whole upper extremity, with the exception of some power of movement of the posterior interosseous group of muscles. Three weeks later the patient could extend the wrist, but sensation was imperfect in the arm, and completely absent in the forearm and hand. The track was now hard and palpable, but there was no hyperæsthesia in any area; when the track was manipulated slight formication in the hand was experienced. The biceps and triceps were equally paralysed. There was no wasting in any of the muscles. (123) _Brachial nerves. _--Wounded at Modder River. _Entry_, through the anterior axillary fold at its junction with the arm; _exit_, on the posterior wall of the thorax, 1/2 an inch from the median line at a level with the angle of the scapula. Complete musculo-spiral paralysis; hæmothorax. Three weeks later, radial sensation returned; but the triceps was very weak, and wrist-drop was complete. There was some wasting of the muscles supplied by the median and ulnar nerves, and complete obliteration of the radial pulse. A year later the musculo-spiral paralysis still persisted. (124) _Musculo-spiral and median. _--Wounded at Magersfontein. _Entry_, 3 inches below the anterior axillary fold, on the inner aspect of the arm; track passed obliquely downwards behind the humerus to a point on the outer aspect of the arm 1-1/2 inch below the level of the entry. The humerus escaped injury. Musculo-spiral paralysis was complete; hyperæsthesia in the distribution of the median followed some days later. One month subsequently radial sensation had returned, and a feeling of numbness had taken the place of the median hyperæsthesia. The triceps and marginal muscles were much wasted, and only interosseous extension was possible in the fingers. (125) _Brachial nerves. _--Wounded at Magersfontein. _Entry_ and _exit_, in the upper third of the arm internal to the humerus. Complete median paralysis, anæsthesia in the ulnar area, and in the radial supply to the dorsum of the middle and ring fingers. Could flex, extend, and adduct and abduct the wrist; some power of flexion in index finger, in others none. The flexion of the wrist was dependent on the ulnar supply to the muscles of the forearm. No wasting of the interossei, skin normal except for a large trophic blister on the dorsum of the hand. Little improvement had taken place in this patient at the end of a year. (126) _Brachial nerves. _--Wounded at Magersfontein. The wound traversed the lower part of the upper third of the arm, fracturing the humerus. Immediate complete loss of power in the arm was experienced, together with loss of all sensation. Three weeks later the humerus was united; the fracture was evidently the result of passing contact, and not of direct impact. The paralysis was still complete in the distribution of the median, ulnar, and musculo-spiral nerves. There was considerable wasting of the hand and forearm, and a good deal of thickening in the lower third of the arm. Four months after the original injury, the nerves were explored by Mr. Eve, who kindly gives me the following information. All the nerves and vessels of the arm were united into one firm bundle by cicatricial tissue. When dissected clear, the median nerve was found to be thickened and enlarged for about 1-1/2 inch of its length; the ulnar was not completely freed, but was found to be continuous and indurated; the musculo-spiral was also intact, but at its entrance into the humeral groove a mass of callus was felt. A sclerosed and thickened portion of the median nerve 3-1/2 inches in length was resected, also 1 inch of sclerosed ulnar nerve, and both were sutured. The musculo-spiral nerve was left for future exploration. A small traumatic aneurism was found on the brachial artery, and the vessel was ligatured above it. Ten months later no improvement in the median or ulnar nerves. Electrical reaction present in musculo-spiral group of muscles. (127) _Musculo-spiral. _--Transverse wound through arm posterior to humerus. Slight suppuration. Triceps weakened only, complete paralysis of radial extensors and posterior interosseous group. Radial sensation lowered only. (128) _Musculo-spiral. _--_Entry_, 2 inches above and 1/2 an inch behind the external humeral condyle; _exit_, at the inner edge of the biceps, 1/2 an inch lower in the arm than the entry. It is doubtful whether the paralysis was noted at first, but a few days later complete posterior interosseous paralysis and lowered radial sensation were remarked. No change except a deepening of the anæsthesia, and the development of formication on manipulation of the wound occurred, and at the end of three weeks the nerve was exposed (Mr. Watson), and it was found that a notch had been cut in its outer border, which had opened out into a V shape. The margins of this notch were refreshed and the gap closed. Ten days later radial sensation was fairly good, but the motor symptoms remained unchanged. Nine months later steady but very slow improvement was reported. (129) _Ulnar and musculo-cutaneous nerves. _--_Entry_, back of forearm; the bullet passed between the bones and was retained at the posterior aspect of the arm. Three weeks later the hand was glossy and stiff, the fingers extended and adducted, the thumb was held stiffly in the palm with no power of extension. The forearm was held semiprone, and the elbow flexed by a rigid biceps. Six months later the same position was maintained, but the contracture disappeared under an anæsthetic. (130) _Median and posterior interosseous. _--_Entry_, over the external margin of the radius at the centre of the forearm; _exit_, at the inner margin of the olecranon 1-1/2 inch below the tip. Lowered cutaneous sensation in median distribution, and loss of median flexion of wrist and fingers. Complete wrist-drop. The triceps supinator longus and extensor carpi radialis longior were perfect. Twelve days later the wrist could be raised into a direct line with forearm, but there was no change in the median symptoms. A week after this the anæsthetic median area became hyperæsthetic both as to skin and on deep pressure over the muscles. (131) _Sacral plexus. Great sciatic nerve. _--Wounded at Modder River. _Entry_, in left loin; _exit_, at lower margin of buttock. The wound was followed immediately by complete peroneal paralysis, both motor and sensory. Fourteen days later hyperæsthesia developed in the area of distribution of the internal popliteal nerve, the superficial pain being greatest in the sole; the muscles of the calf were also very tender on manipulation. The pain increased, and at the end of twenty-four days the patient's sufferings were so great that Mr. Thornton cut down upon and exposed the nerve. It was found embedded in firm cicatricial tissue close to the sciatic notch; this compressed the nerve to such a degree that a waist was apparent upon it. The nerve was freed and resumed its normal outline. For a few days the patient was much relieved, but the neuralgia then returned in greater intensity than ever. Morphia was injected hypodermically, and other hypnotics employed, but with little effect, the patient developing the hysterical condition so common in the subjects of severe sciatica. Some five weeks later a sudden improvement took place, the morphia was decreased, and the patient became sufficiently well to return to England, but there was still deep tenderness in the calf, and well-marked hyperæsthesia of the sole. A year later the patient had been discharged from the Service, but was earning his living in a shop. He walked fairly well, but still with foot-drop, and complained of tenderness in the sole. I am indebted to Dr. Turney for the following report on the condition of the muscles. Calf muscles practically normal. In the anterior tibial and peroneal groups the faradic irritability is much diminished, that in the peroneus longus being the lowest of all. Contraction can be induced in the extensor longus hallucis, extensor longus digitorum, and peroneus brevis; but reaction is doubtful in the case of the tibialis anticus and peroneus longus. With the galvanic current contraction is sluggish, and the irritability diminished. No serious changes are present except in the peroneus longus. ACC > KCC at 10 M. A. (132) _Great sciatic. _--_Entry_, at outer aspect of the thigh, just above the centre; _exit_, at the junction of the inner and posterior aspects of thigh, about 2 inches lower. The wound was produced by a ricochet bullet, and beyond the perforation of the sciatic nerve the femur was fractured obliquely (see plate XVI. ). Hyperæsthesia of the sole was noted early, and when I saw the patient three months later, there was wasting of the muscles of the leg, and foot-drop, although he walked with a stick. These symptoms persisted, and on his return to England an exploration was made by Sir Thomas Smith, and the two fragments of mantle seen in the skiagram were removed from the substance of the sciatic nerve. Eight months after the injury, the patient still walked with foot-drop; there was modified sensation in the musculo-cutaneous area, and a feeling as if the bones of the foot were uncovered when he walked. The circumference of the affected leg was more than 1 inch less than that of the sound one. Steady but slow improvement was taking place. (133) _Great sciatic_. --In a third patient with a buttock track, the symptoms were identical with those observed in case 131. In this an exploration showed that the nerve had been perforated. Although the symptoms were never so severe as in No. 131, yet recovery was very much slower and less complete, the muscular weakness remained more marked, and the skin exhibited more evidence of trophic lesion. Some contracture of the knee and rigid foot-drop took place, and at the end of twelve months the patient walked poorly with a stick. Improvement is, however, continuing. (134) _Great sciatic_. --Wounded at Ladysmith. _Entry_, immediately below left buttock fold; _exit_, at anterior aspect of thigh, 3-1/2 inches below Poupart's ligament. The left leg was paralysed, and patient was sent down to the Base, where he remained two months. The wound closed by primary union, the paralysis improved, and the man rejoined his regiment. After he had been in camp four days, his leg gave way, and he returned to hospital, where he contracted enteric fever. Later, he was sent home, and eight months after the reception of the injury his condition was as follows: Left lower limb somewhat wasted, a diminution of 1 inch in the circumference of the leg and 1/2 an inch in the thigh being found. The patient walks with foot-drop, and the flexor muscles of the knee are weak. On examination the peroneal muscles reacted but sluggishly to faradic irritation. There is complete anæsthesia of the foot to above the ankle, and up to the knee tactile sensation and appreciation of pain were dulled. The left plantar reflex was absent, the right slight, the left patellar reflex was abnormally brisk. There was neither ankle nor patellar clonus, and the other reflexes were present and normal. The gait was spastic, and the patient was more troubled by a contraction of the calf muscles, which prevented his putting the heel to the ground, than by the foot-drop. Beyond these local phenomena there was marked tremor of the upper extremities on any exertion, and slight lateral nystagmus. The patient was not sure that this had not been present ever since he recovered from the enteric fever, but it was sufficiently marked to give rise to the suspicion of the development of disseminated sclerosis. The patient was a hard-headed, sensible man. He remained in the hospital under the care of Dr. Turney, to whom I am indebted for notes of the case, forty-six days. During this period he was treated by faradic electricity, and, with some checks, notably the development of passive effusion into the left knee-joint, and a fugitive attack of redness over the dorsum of the foot, both suggesting trophic changes, steadily improved. The anæsthesia became limited to the outer half of the leg, at the end of one month was limited to the dorsum of the foot only, and at the end of six weeks entirely disappeared. Meanwhile the tendency to drawing up of the heel by the calf muscles became less, and the gait improved. The man left the hospital at the end of two months, very satisfied with his condition, although the tremor of the hands was still present in a lessened degree. (135) _External popliteal. _--Wounded at Magersfontein, 250-300 yards. _Entry_, at the outer side of the thigh, 5 inches above the lower extremity of the external condyle; _exit_, at the inner margin of the adductors, at a level 4 inches higher in the thigh. The track crossed behind the femur. Complete peroneal motor paralysis and anæsthesia, except in the hinder part of the region supplied by the mixed external saphenous. Slight hyperæsthesia of the sole. Improving at the end of three weeks, but paralysis still nearly complete. (136) _External popliteal. _--Wounded at Magersfontein. _Entry_, 5 inches below the highest part of the right iliac crest, on outer aspect of hip; _exit_, at the posterior margin of the gracilis, 2 inches from the perineum. Complete peroneal paralysis followed, which rapidly improved, and on the twenty-second day was nearly well. (137) _Internal popliteal. Secondary anæsthesia_. --_Shell_ wounds of the right popliteal space. Wounded at Belmont. Anæsthesia of the outer side of the calf, the leg and sole of foot. No motor paralysis. As cicatrisation progressed, the anæsthesia became more marked and was complete over the whole of the external saphenous area. (138) _Internal popliteal. _--Wounded at Paardeberg. 400-500 yards. _Entry_, about the centre of the outer half of the patella; _exit_, at the centre of the calf, about 2 inches from the popliteal crease. Five days after the injury severe burning pain developed in the sole. A fortnight later the pain was much less severe, but varied in degree with the heat of the weather, being worse when cool. At this date, however, rubbing became comforting. (139) _External popliteal. _---Wounded at Magersfontein. _Entry_, 1 inch above the upper end of the internal margin of the patella; _exit_, at the margin of leg, just below the outer tuberosity of the tibia. Complete peroneal paralysis followed the injury. A month later the nerve was bared and found slightly thickened. An improvement in cutaneous sensation followed quickly, and a much slower improvement in the motor power commenced. (140) _External popliteal nerve. _--Wounded at Beacon Hill. A _bayonet_ entered over upper quarter of fibula, and passed between the bones of leg into the calf. An aneurismal varix of the calf vessels developed, also incomplete peroneal paralysis. The scar was raised from the nerve (Major Simpson, R. A. M. C. ) six weeks later, and at the end of a fortnight the power and sensation were both much improved and the patient returned to England. (141) _External popliteal. _--Wounded at Modder River. _Entry_, 1/2 an inch above the internal border of the patella; _exit_, 1-1/2 inch from the head of the fibula and over that bone. The wound was followed by peroneal paralysis. Six weeks later sensation was still diminished in the anterior tibial and musculo-cutaneous nerve areas, and marked foot-drop, little improved, persisted. The patient came to England, and at the end of twelve months is reported as very little improved. (142) _Anterior tibial. _--_Entry_, 1 inch in front and below the external malleolus; _exit_, at the centre of the sole, just anterior to the bases of the metatarsal bones. Wasting and paralysis of extensor brevis digitorum. (143) _Small sciatic and small saphenous. _--Wounded at Magersfontein. 200 yards. Two wounds: (i) _Entry_, below the centre of the twelfth rib on the left side; _exit_, immediately to the left of the buttock furrow at upper part, (ii) _Entry_, in the right loin, midway between the last rib and iliac crest; _exit_, just within the centre of the left buttock; the two wounds crossed diagonally. Hyperæsthesia in area of distribution of small saphenous and small sciatic nerves, which rapidly improved. (144) _Lumbar plexus. _--Boer, wounded at Magersfontein. _Entry_, eleventh interspace, posterior axillary line; _exit_, tenth interspace, right mid-axillary line. Impaired sensation in area of distribution of external cutaneous and crural branch of genito-crural nerves. At the end of a fortnight anæsthesia was less apparent, but a feeling of numbness persisted, which soon disappeared. _Prognosis and treatment. _--In considering the prognosis in cases ofnerve injury, several of the points already raised as to the nature ofthe lesion are of importance. Short of actual section, it may be broadlystated that no lesion is too serious to render ultimate recoveryimpossible. In cases in which the injury has been produced by a bullet fired at ashort range, or in which contact with the nerve has been close, thereturn of functional activity is very slow. In such instances thecondition probably resembles that in which a divided nerve has beensutured, with the additional disadvantage that a considerable portion ofthe nerve, both above and below the point actually struck, has beendestroyed as far as the conduction of nervous impulses is concerned. This may reasonably be concluded in the light of the evidence offered bythe injuries of the spinal cord, in which several segments usuallysuffered if the velocity of the bullet was great, and also if the factis remembered that, when thickening takes place, a considerable lengthof the nerve is usually implicated. Recovery is notably slow in the case of certain nerves, _e. G. _musculo-spiral and peroneal, even when the injury has not been ofextreme severity. Again, these same nerves are apparently more seriouslyaffected by moderate degrees of damage than are others. As favourable prognostic elements we may bear in mind: low velocity onthe part of the travelling bullet, and with this a lesser degree ofcontiguity of the track to the nerve. The early return of sensation is afavourable sign, and in this relation the development of hyperæsthesia, whether preceded by anæsthesia or no, points to the maintenance ofcontinuity of, and a moderate degree of damage to, the nerve. The earlyreturn of sensation, even if modified in acuteness, was always a veryhopeful sign; also the production of formication in the area ofdistribution of the nerve on manipulation of the injured spot. As in thecase of nerve injuries of every nature, the disposition and temperamentof the patient exerted considerable influence on the course of thecases. Complete section of the nerves in these bullet wounds only obtainedspecial importance in two ways: first, in that a considerable portion ofthe trunk might be shot away in oblique tracks, and, secondly, in thatvery severe contusion might affect the nerve for a considerabledistance beyond the point actually implicated. In point of fact, complete section when treated by suture was often more rapidly recoveredfrom than an injury in which only a portion of the width of a trunk wasdivided. This was no doubt to be explained on the theory that thecontiguous portion of the nerve suffered less when tension andresistance were lessened by complete severance of the cord. _The treatment_ of slight nerve contusion was simple; rest alone wasnecessary, and in the course of hours or days paralysis was recoveredfrom. The symptoms were most troublesome in patients of a neurotictemperament, or those who had suffered from severe systemic shock. In severe concussions and contusions the first care had to be devoted tothe discrimination of the lesion from that of division. A period of restthen needed to be followed by one of massage and movement, to maintainthe nutrition of the muscles. In a considerable portion of the cases astage of neuritis had to be expected. In all cases, either of severeconcussion, contusion, or complete section, accompanied by the fractureof a bone, especial care was necessary that the bandaging and fixationof the limb were not sufficiently tight to add the dangers of muscularischæmia to those of the nerve injury already present. Neuritis, whether dependent on local injury, implication in the scar, pressure from callus, or of the ascending variety, needed the sametreatment: rest, preservation of the limb from cold or damp, and thelocal application of anodynes, as belladonna, or hot laudanumfomentations. In some cases a general anodyne, as morphia, waspreferable; then always to be used with caution, as the patients sooncraved inordinately for it, and were unwilling to give it up. Later, local blisters in the line of the nerve trunk, careful massage andexercise when muscular and cutaneous tenderness had subsided, theapplication of the continuous current to the nerves, and perhapsfaradisation of the muscles, were all useful. Splints were often temporarily required to resist contracture, or theassumption of false positions; in either case they needed to befrequently removed, and movement &c. Made, in order to avoid any chanceof troublesome stiffness. _Operative treatment. _--Early interference was only warranted bypositive knowledge that some source of irritation or pressure could beremoved; thus a bone spicule, or a bullet, or part of one, particularlyportions of mantles. In case of contusion the expiration of three months is the earliest dateat which any operation should be taken into consideration, andinterference is only then advisable if there is good prospect of freeingthe nerve from compressing adhesions. The two strongest indications foroperation are (1) signs pointing to the secondary implication of thenerve in a cicatrix, especially when these are of such a nature as toindicate local tension, fixation, or pressure; (2) the possibility ofthe irritation being the result of the presence of some foreign body, such as a bone spicule, or portions of a bullet mantle; in such casesthe X rays will often give useful help. With regard to the early exploration of cases of traumatic neuralgia, itmay be pointed out that when this was undertaken the results were as arule very temporary. In many cases in which the measure was resorted to, either no macroscopic evidence of injury to the nerve was discovered, ora bulbous thickening was met with of such extent as to make excisioninadvisable, even if it were considered otherwise the most suitabletreatment. Even when complete section of the nerve was assured by the absence ofany power of reaction to stimulation by electricity from above on thepart of the muscles, operation was better not undertaken untilcicatrisation had reached a certain stage. If done earlier than at theend of three weeks, the sutured spot became implicated in a hardcicatrix, and any advantage to be obtained by early interference waslost. When partial division of a trunk was determined, the same date wasthe most favourable one for exploration, the gap in the nerve beingfreshened and closed by suture. There is little doubt, however, that insome cases such injuries were recovered from spontaneously. In view of the uniformly bad results observed in the case of the seventhnerve, I am inclined to think that the above rules might be tentativelyrelaxed, and the nerve primarily explored by an operation resemblingthat for mastoid suppuration. It is of course doubtful whether thetrouble does not generally result from the vibratory concussion alone;but as this is not certain, and the operation would only have to beperformed on patients already permanently deaf, it might be worth whileat any rate opening the Fallopian canal with the object of relievingtension. It is not probable that in any of the cases quoted muchsplintering of the bone had occurred, as the wounds appeared to be ofthe nature of pure perforations. CHAPTER X INJURIES TO THE CHEST In regard to Prognosis wounds of the chest furnished the most hopefulclass of the whole series of trunk or visceral injuries. Cases of woundof the heart and great vessels afforded the only exceptions to an almostuniversally favourable course, both as regards life and thenon-occurrence of serious after-effects. This was mainly explicable on two grounds: first, the sharply localisedcharacter of the lesion produced by the bullet of small calibre; and, secondly, the fact that the lung, the most frequently injured organ, isnot materially affected by the grade of velocity with which the bulletstrikes. In point of fact, wounds of this organ probably afford aninstance in which high grades of velocity are distinctly favourable tothe nature of the injury, and this is possibly true in the case ofwounds of the chest-wall also. The significance of the calibre of the bullet in wounds of the chest isevident. The late Mr. Archibald Forbes, in one of his letters from theseat of the Franco-German war, remarked that in crossing a battlefieldit was easy to recognise the patients who had suffered a wound of thelung from the fact that the whistle of the air entering and leaving thechest was plainly audible. This was, indeed, not uncommonly the case inwounds produced by the older bullets of large calibre, but with theemployment of the smaller projectile it has become an experience of thepast. Some evidence as to the comparative severity of wounds produced bythe larger forms of bullet was, moreover, afforded by the presentcampaign, since Martini-Henry wounds were occasionally met with. Of someinstances observed by myself, in one, external hæmorrhage was aprominent symptom; in another, a piece of lung was prolapsed from awound in the back, and twice I observed pneumothorax, an uncommonsequela to wounds from bullets of small calibre. It may be remarked, however, that all these more serious injuries wererecovered from, also that when we consider that the patients werecomparatively young and healthy subjects, the favourable prognosis waswhat might have reasonably been expected. When, as occasionallyhappened, a patient of more mature years, with enlarged facialcapillaries, received a wound of the lung, the course was in no way sofavourable as that witnessed in the case of the younger men. In support of this opinion I may add that wounds from shrapnel andfragments of shell also did remarkably well, although they sometimesgave rise to more troublesome symptoms than did wounds produced bybullets of the Mauser type. Again, these injuries as a whole were ofnothing like so serious a nature as the lacerations of the lung producedby fractured ribs, which we commonly have to treat in civil practice, and are not accustomed to regard as especially dangerous. It is also a striking fact that the most common and troublesomecomplication of wounds of the chest, hæmothorax, was usually the resultof the wound of the chest-wall and not of the lung. I preface theseremarks to the detailed account of the thoracic injuries, because Ithink the favourable course usually taken by patients with wounds of thelung has been accorded somewhat greater prominence than thecircumstances warranted. _Non-penetrating wounds of the chest-wall. _--Surface wounds were notvery common, and were chiefly of interest in so far as they illustratedthe very superficial course that may be occasionally taken by a bulletwithout breach of the integument, and as sometimes affording opportunityfor the exercise of diagnostic skill when the track traversed theaxilla. The most common situation for tracks taking a long course on the surfaceof the thoracic skeleton was the back. Such wounds were usually receivedwhile the patients were prone on the ground; thus I might instance acase in which the bullet entered the posterior aspect of the shoulder 3inches above the spine of the scapula, passed downwards, pierced thatprocess, and emerged 2 inches below the inferior angle of the bone. Wounds of a similar nature coursing in transverse and obliquedirections, and not implicating bone, were also seen. Those implicatingthe vertebræ have been already dealt with. The scapular region was alsoa favourite one for the lodgment of retained bullets, some resting inthe supra- and infra-spinatus muscles, others lying beneath the boneitself. On the anterior aspect of the chest, bullets coming from the frontsometimes traversed and fractured the clavicle, and then took a shortcourse downwards, emerging over the ribs or sternum. Figure 81represents a particularly long track in this region. In other cases theprecordial region was crossed, but I never witnessed any serious effecton the heart's action in any such injury at the time the patients cameunder my notice. Wounds received with the arm outstretched and traversing the axillasometimes gave considerable trouble in excluding with certainty aperforation of the thoracic cavity. Thus a bullet entered below thecentre of the right clavicle and emerged 2-1/2 inches below, above theangle of the scapula, at its axillary margin. The arm was outstretchedat the moment of the reception of the injury; but when the wound wasviewed with the limb placed alongside the trunk, it seemed almostimpossible that the chest cavity could have escaped. In some cases ofthis kind the difficulty was at once cleared up by noting evidence ofinjury to the axillary nerves. A word will suffice as to the treatment of these wounds. The onlyspecial indication was to keep the scapula at rest for a sufficientperiod. I have dealt with the anatomy of them at such length onlybecause in their extreme form they are so highly characteristic of thenature of the injuries which may be produced by bullets of smallcalibre. _Penetrating wounds of the chest. _--Tracks crossing the thoracic cavityin every direction were common. When the erect attitude was maintained, frontal and sagittal wounds, pure or oblique, were received; when theprone position was assumed, longitudinal tracks, either purely orobliquely vertical, were the rule. Experience of wounds of the latterclass was extensive in the present campaign, from the fact that so manyof the advances were made in prone or crawling attitudes. The verticaland transverse tracks each possessed the special characteristic offrequently implicating both the thoracic and abdominal cavities, but thevertical were often prolonged into the neck, or even downwards throughthe pelvis. The vertical wounds in addition sometimes exhibited one veryimportant feature, the fracture of several ribs from within, often at avery considerable distance from the aperture of either entry or exit. [Illustration: FIG. 81. --Superficial Track in anterior Wall of Trunk] _Characters of the apertures of entry and exit. _--As has already beenmentioned, the chest-wall was one of the situations in which theaperture of entry was often large, and the oval form due to obliquity ofimpact on the part of the bullet was particularly well marked. The exitwounds were often smaller than those of entry, especially if the bulletemerged by an intercostal space; even when the ribs were comminuted, thefragments were, as a rule, too small to occasion more than a slightlyenlarged and irregular aperture. Taken as a class, however, and puttingaside explosive exit wounds, wounds of the chest afforded more numerousexamples of irregular outline and variation in size than were met within any other region of the body. When the tracks penetrated the broad upper intercostal spaces, aninteresting feature, due to the tense and rigid nature of the musclesclosing the intervals, and their large admixture of fibrous tissue, wassometimes noticed. The bullet, especially if passing obliquely, was aptto cut a slit in the muscles far exceeding in size the opening in theoverlying integument, with the result of leaving a palpable subcutaneousdefect. Under these circumstances the yielding spot was often noticed torise and fall with the movements of respiration, external palpation metwith an absence of normal resistance, and there was impulse on coughing. _Fractures of the ribs. _--These injuries were produced in eithertransverse or longitudinal coursing tracks, their special feature beinga sharp localisation of the lesion of the bone. In tracks crossing the chest transversely the injury to the ribs mightconsist in notching, perforation, or complete solution of continuity, sometimes with fine comminution. In the incomplete injuries someimportance attached to the localisation of the lesion to the upper orlower border of the rib, in so far as the intercostal artery wasconcerned. Comminution at the wound of entry was, as a rule, not soextensive as at the aperture of exit, and in any case was less apparent, since the fragments were driven inward. The wider comminution at theexit aperture depends on the lesser degree of support afforded by thethoracic coverings to the convex outer surface of the rib, and on thefact that the velocity of the bullet has been lowered by its passagethrough the opposite rib and the chest cavity. The splinters of comminuted ribs are small, and wide-reaching fissuresrare. These characters depend on the elastic nature of the resistanceoffered by the curved rib to the passage of the bullet, which iscalculated to preserve the bone from the full force of impact, except atthe point actually impinged upon. Fractures of the ribs, produced from within by bullets taking alongitudinal course through the thorax, were still more special incharacter. They were also more important, as giving rise to troublesomesymptoms. In these, again, the degree of injury to the bones varied considerably. In some cases the bones were merely grooved internally, without anyexternal deformity; in other cases a sort of green-stick fracture wasproduced, accompanied by the projection of a tender salient angleexternally; in others complete solution of continuity was effected. Another feature of importance was the occasional implication of severalribs. In this case the symptoms accompanying the injury were very muchmore like those observed in the corresponding injuries resulting fromindirect violence seen in civil practice. Injuries to the _costal cartilages_ closely resembled those to the ribs. Perforation, bending from injury to the inner aspect, and comminutionwere observed. The latter condition differed from the similar one seenin the case of the ribs only in so far as the tougher consistence of thecartilage did not lend itself to such free comminution, and thesplinters remained in great part attached. The nature of the fractures, in fact, somewhat resembled that seen on breaking a piece of cane. I saw no fracture of the _sternum_ except of the nature of a pureperforation; these were not uncommon in the hospitals, either in theupper or the extreme lower portions of the bone. Fractures in otherportions were no doubt usually associated with fatal injuries to theheart. The openings were usually so small as to be difficult ofpalpation, and I never had the opportunity of examining one _postmortem_. Perforations of the body of the _scapula_ were common, but they were oflittle importance in symptoms or prognosis. _Symptoms of fracture of the ribs. _--Fractures accompanying transversewounds of the chest were characterised by the insignificance of thesymptoms produced. Every common sign of fracture of the rib was in factabsent. Neither pain, stitch on inspiration, nor crepitus, eitheraudible or palpable, was, as a rule, present. This absence of signs wasaccounted for by the nature of the lesion: thus in perforations ornotchings there was no loss of continuity, while in the freelycomminuted fractures the loss of continuity was so absolute as to allowno possibility of the main fragments rubbing together. Again, part ofthe symptoms attending these injuries, as seen in civil practice, depends upon contusion and laceration of the surrounding structures--acondition precluded by the localised nature of the application of theviolence by a bullet of small calibre. In order to establish adiagnosis, therefore, we were in many cases reduced to palpation, andoccasionally to direct examination of the wound. Fractures accompanying longitudinal tracks formed a class rather apartin the matter of symptoms. In these mere groovings might also beaccompanied by no signs, or at the most by slight local pain andtenderness. When, however, the grooving was sufficiently deep to beaccompanied by deformity, or a complete solution of continuity waseffected, the signs were often severe. The tender salient angle, or, inthe absence of this, a highly tender localised spot, often pointed tothe less severe injuries, and when the fractures were complete ormultiple, pain was a very prominent symptom, both constant and in theform of inspiratory stitch. The severity of the pain was probably to bein part ascribed to implication of the intercostal nerves, which inthese injuries was direct and often multiple. Again, severe contusion oractual laceration of the nerves, with resulting anæsthesia, was lesscommon than when the bullet directly implicated the nerves in transversewounds. Free comminution and absolute solution of continuity were alsoless common than in the fractures accompanying transverse wounds; hencepain from rubbing of the fragments on inspiratory movement or palpationwas more common, and crepitus, either on auscultation or palpation, wasmore often met with. Patients with this class of fracture often sufferedgreatly from painful dyspnoea, and were unable to assume the supineposition. _External hæmorrhage_ of severity was rare from these thoracic wounds;in many cases it did not amount to more than local staining of theshirt; altogether I saw only one or two cases where any serious bleedingoccurred. Internal hæmorrhage into the pleura, in consequence of theposition of the intercostal arteries, was common, and often abundant;this will be treated of under the heading of hæmothorax. _Treatment of fractured ribs. _--Transverse wounds of the thorax, with nosymptoms of fractured ribs, needed to be dealt with as wounds of thesoft parts alone. In multiple fractures accompanying longitudinal tracks, bandaging orstrapping for the purpose of fixation was necessary to relieve pain. Afew fragments of bone sometimes needed primary removal, and occasionallysmall sequestra were removed at a later date; but necrosis was rare, unless some complication led to the development of a fistula. Retained bullets were occasionally met with in the chest wall. In suchcases the last remaining energy of the bullet often seemed to have beenspent in diving under the margin of a rib and turning longitudinally upor down. Removal was sometimes necessary, either from the prominenceproduced, the presence of pain, or the continuance of suppuration. Someof the specimens removed offered interesting evidence of the capacity ofthe ribs to withstand considerable violence from a bullet. These wereslightly bent, and marked by a half-spiral groove. I saw such bulletsremoved from the thoracic and the abdominal wall, and the evidenceseemed rather against the groove having been produced prior to theirentrance into the body. [Illustration: FIG. 82. --Spirally grooved Mauser Bullet] _Wounds of the diaphragm. _--Perforations of the diaphragm were veryfrequent, and as a rule of small significance. When, however, the coursetaken by the bullet was parallel with that of the slope of thediaphragm, a more or less extensive slit was the result. I saw such awound still gaping, and 2 inches in length, in the body of a patientwho died three weeks after the infliction of a fatal abdominal injury. In several other obliquely transverse thoracic wounds there was reasonto assume the existence of similar slits. Certain signs were more orless constant under these circumstances. These consisted in shallowrespiration, often accompanied by a groan or the slightest degree ofhiccough on inspiration, and considerable increase in respiratoryfrequency. In one patient the respirations were at first 48, onlydropping to 36 some seventy hours after the reception of the injury. Insome of the cases in which the abdominal cavity was implicated, wound tothe diaphragm seemed a more likely explanation of early, frequent, andpainful vomiting than did visceral injury. The possibility of the laterdevelopment of diaphragmatic herniæ in some of these patients will haveto be borne in mind in the future. _Visceral injuries. _--The frequent escape of the thoracic viscera frominjury, putting aside the lungs which fill so great a part of thecavity, was very remarkable. I never saw a case in which I could assumeinjury to any of the posterior mediastinal viscera, although such mayhave occurred on the field of battle. An injury to the oesophagus, forinstance, would almost of necessity be accompanied by wound of eitherone of the large vessels, even the thoracic aorta, or the spinal column. I was somewhat surprised, however, to learn on enquiry from surgeons whohad seen a large number of the dead and dying on the field, thatthoracic wounds, putting aside those that directly implicated the heart, were responsible for but a small proportion of the fatalities. The escape of the posterior mediastinal viscera, the great vessels, andthe heart, is, I believe, to be explained by the fact that all aresupported and held in position by the loose meshed mediastinal tissue, which allows for their displacement after the manner observed in thecase of the vessels and nerves lying in the loose tissue of the greatvascular clefts. _Wounds of the heart. _--Perforating wounds of the heart were probablyfatal in all instances, in spite of the fact that, in some patients whosurvived, the position of wound apertures on the surface of the bodymade it difficult to believe that the heart had not been penetrated. (See cases below. ) In the case of this organ, we must bear in mind its constant variationsin bulk, its elastic compressibility, and its variations in position insystole and diastole. The variations in bulk and position would becapable of explaining the escape of the organ from injury at someparticular moment, when a second shot apparently through the same woundtrack might implicate it. Beyond this, reasoning from the case ofanalogous hollow viscera, as the arteries or the intestine, a bulletmight readily score the surface of the heart without perforating itscavity. Such accidents were observed. Thus, in a case examined by Mr. Cheatle, the patient died of suppurative pericarditis, secondary to a wound ofwhich the external apertures had closed. In this patient both auricleand ventricle were scored externally by the passage of the bullet. I am, however, disinclined to allow that many patients survived directblows on the heart, since I believe that in the majority if not in allcardiac wounds the actual cause of death was not hæmorrhage, but suddenstoppage of the heart's action. This is to be inferred from the factthat severe external hæmorrhage did not occur; in some cases the shirtwas hardly stained, and in all death occurred in the course of a veryfew minutes. Again, in none of the patients whom I saw who had receivedpossible wounds of the heart-wall were there evident signs ofhæmo-pericardium. In view of the difficulty of detecting this conditionfrom physical signs, this argument is naturally not of great weight, butmust be allowed. One or two death scenes from cardiac wound were described to me. In onethe patient muttered 'They have got me this time, ' and died quietly; ina second the patient's face became ghastly pale, he lay on his back withthe knees flexed, clutching the ground, gasping for breath, and diedonly after some minutes of evident great agony. The absence of any_post-mortem_ details as to the condition of the heart in these injuriesis much to be regretted. (145) _Entry_, in the seventh left intercostal space, in the posterior axillary line; _exit_, immediately below the ninth costal cartilage, close to the position of the gall bladder. This track in all probability involved the diaphragm twice, both lungs and pleuræ, and passed immediately beneath the heart. The liver was also perforated, but the spleen and stomach probably escaped as far as could be judged from the symptoms. The patient afterwards developed a pneumo-hæmo-thorax on the right side. The immediate symptoms were great distress in breathing and rapid irregular pulse. The difficulty in respiration was probably in part accounted for by the injuries to the lung and diaphragm. The pulse remained from 112 to 120 for three days, at first soft and hardly perceptible, later very irregular, and dropping one every fifth or sixth beat; and it seemed fair to attribute this to the shock to the nervous mechanism of the heart. The patient recovered from the chest injury. In some other patients in whom the track passed close below the heart a disturbance of the pulse rate was noted, but this was in some cases a slowing, not below 48, in others quickening to 100, with irregularity both in force and beat. (146) _Entry_, in the fourth right interspace, 3 inches from the middle line; _exit_, in the seventh left interspace, in the mid-axillary line. This wound was received at a distance of 500-600 yards, but the bullet penetrated both sides of a stout silver cigarette case and some cigarettes before entering the body. There were minor signs of pulmonary injury, 'coughing day and night, ' and slight discoloration of the sputum on three or four occasions. The respirations were quickened to 32, and as much as ten days after the injury the pulse only beat 48 to the minute; it then rose to 56, but beat in a very deliberate manner. In other cases the signs were almost nil. (147) _Entry_, in the fourth right intercostal space 3/4 of an inch from the sternum; _exit_, in the sixth left interspace in the posterior axillary line. This patient had no symptoms, beyond quickening of the pulse to 100, and a 'feeling of tightness at the heart. ' He shortly returned to active duty. (148) _Entry_, situated in the third right interspace 3 inches from the sternal margin; _exit_, in the fourth left space 2-3/4 inches from the sternal margin. In this case the bullet without doubt passed through the anterior mediastinum, and slight injury to the lung was evidenced by transient hæmoptysis. Some remarks regarding wounds of the thoracic vessels have already beenmade in Chapter IV. , where instances of injury to the innominate andleft subclavian arteries are recounted. The escape of the large trunkswas generally quite as astonishing as in other parts of the body, especially in the superior mediastinum. (149) _Entry_, over the first right intercostal space beneath the centre of the clavicle; _exit_, at left anterior axillary fold. The great vessels must have been crossed here in immediate contact, and considerable hæmorrhage from the wound of entry caused great anxiety; this ceased spontaneously, however, and, beyond transient hæmoptysis and a right pneumo-thorax, no further trouble occurred. (150) _Entry_, in the ninth interspace, just anterior to the anterior axillary line; _exit_, through the right half of the sternum, 1/2 an inch below the upper border. No primary hæmorrhage of importance followed, but I believe this patient subsequently died. The wound was received at a range of within fifty yards. _Wounds of the lungs. _--Numerically, pulmonary wounds formed the mostimportant series of visceral injuries met with in the thorax, thefrequency of incidence corresponding with the proportionate sectionalarea occupied by the organs. Although these injuries did well, andneeded little interference on the part of the surgeon, many points ofinterest were raised by them. Thus the comparative importance of the wound in the chest-wall to thatin the lung itself, was scarcely what, without actual experience, wouldhave been expected, the former proving so very much the more importantelement of the two. The question of velocity on the part of the bullet took a very secondaryposition in these injuries. I saw a number of cases in which thepatients estimated the range at which they received their wounds as from30 to 50 yards, and although some of the wounds were of a severe type, the increased gravity depended rather on the injury to the chest-wallthan to that of the lung. If the bullet passed by the intercostal space, avoiding the rib, I very much doubt if the relative velocity was of anyimportance, further than from the fact that a sufficiently low degree toallow of lodgment of the bullet was distinctly unfavourable. In view of the general lack of significance in these injuries it wasinteresting to note how very definite was the ill effect of earlytransport on the after course. This depended on the frequent developmentof parietal hæmothorax in patients who were not kept absolutely at rest. The tracks produced in the lungs by the bullets were very minute, and inthe few cases in which opportunity arose for their examination _postmortem_ some little time after the infliction of the wound, there wasgreat difficulty in localising them. The slight damage incurred by thepulmonary tissue is due to its elasticity and non-resistent character. Pulmonary hæmothorax was distinctly rare. Reasoning from the analogouswounds of the liver, tracks scoring the surface of these organs might bemuch more to be feared than clean perforations. The elasticity of thelung tissue, however, must make such lesions rare. In point of fact, there is no reason why a perforation by a bullet of small calibre shouldbe much more feared than a puncture from an exploring trocar, and thedanger of the two wounds is probably very nearly the same. The only points of importance as to the particular region of the lungtraversed were the distance from the periphery as affecting the probablesize of the vessels injured, and perhaps the implication of the base orapex of the organ respectively. I am under the impression that wounds inthe apical region were somewhat more liable to be followed by thedevelopment of pneumothorax, and possibly hæmothorax, while wounds atthe base gained their chief importance from the frequency of concurrentinjury to the abdominal viscera. I had no experience of the immediateresults of wound of the great vessels at the root of the lung, butassume that they led to speedy death. _Symptoms of wound of the lung. _--I shall describe the whole complexusually observed, although it is obvious that the wound of thechest-wall is responsible for a large proportion of the signs. The majority of these injuries were accompanied by a certain degree ofsystemic shock, and this was more marked in wounds received at a shortrange. The shock was, however, rather to be attributed to the injury tothe chest-wall and thoracic concussion than to that to the lung itself. I think it may also be stated that few patients were inclined to walkor remain in the erect position after receiving these wounds; thisfeature was also noted in horses in whom a bullet passed through thelungs. The remarks made as to the pain accompanying fractures of the ribs applyequally here. Pain was not a prominent symptom, except in so far as theactual impact caused temporary suffering. It was striking how oftenpatients who received wounds through the arm prior to the same bullettraversing the chest appreciated the chest wound only, yet the chestmight pass unnoticed when a still more sensitive part was struck later, as has been already mentioned in the section on wounds in general. Dyspnoea was not a prominent primary symptom. The patients sometimeshad 'all the wind knocked out of them' at the moment of impact, but whenseen at the Field hospitals a short time later, the respirations wereshallow, but easy and regular, and only moderately quickened; thus 24was a not uncommon rate. Naturally if accumulation of blood in thepleura began early and continued, these remarks do not hold good; andagain in some older men of full-blooded type and the subjects ofrecurrent attacks of bronchitis, a considerable degree of pain, dyspnoea, and even cyanosis was sometimes present soon after theinjury. The complication of wound of the diaphragm has already beenreferred to in this relation. Local respiratory immobility of the thoracic parietes and consequentasymmetry of movement were constant. This was especially a markedfeature when the upper part of the chest was implicated on one sideonly. It rather corresponded, however, to the local shock observed inwounds of the limbs than to the instinctive immobility accompanyingfractures of the ribs; since, as already explained, small-calibre bulletwounds of the ribs are not necessarily painful on movement, and the signexisted even when the bullet had passed by an intercostal space. Thissign was naturally a transitory one. Hæmoptysis was a fairly constant sign, but sometimes quite absent whenno doubt could exist as to the perforation of the lung. As a rule, aconsiderable quantity of blood might be coughed up shortly after theinjury; but I never knew this to be sufficient in amount to give riseto any misgivings as to danger from the hæmorrhage. After the firstevacuation of blood from the wounded lung, the sign varied much; in themajority of instances the patients continued to expectorate smallquantities of blood mixed with mucus, for some three or four days, theblood gradually assuming a coagulated condition. Sometimes only theprimary hæmoptysis was noted, and still more rarely the expectoration ofclots was continued for a week, or even longer. This probably dependedpartly on personal idiosyncrasy, partly on the size of the vessels whichhad been implicated in the track. Cough was not commonly the troublesome symptom noted in the contusedwounds of the lung seen in civil practice accompanying fracture of theribs. Moist sounds were usually audible on auscultation, but in manycases over a very limited area and only on the first few days. Cellular emphysema was distinctly rare, and usually limited in extent:thus I saw it in the posterior triangle of the neck alone in an apicalwound; over about a third of the upper part of the thorax in anotherwound through the second intercostal space, and in this case oddlyenough the emphysema was the only sign of injury to the lung; and veryoccasionally widely distributed--in the latter case there were alsousually multiple fractures of the ribs. Neither issue of air from theexternal wound nor frothy blood was ever seen with small-calibre wounds, but I saw one instance in a case of Martini-Henry wound. _Pneumothorax_ was also rare. I saw pneumothorax three times out ofabout half a dozen Martini-Henry wounds, but I do not think it occurredas often in 100 small-calibre wounds. The Martini-Henry wounds allrecovered; but convalescence was very prolonged, and the same remark toa less degree holds good in the small-calibre cases. That the slow recovery in cases of pneumothorax in the Martini-Henrywounds was due mainly to the size of the opening in the thoracicparietes was, I think, proved by the fact that in the small-calibrebullet wounds, followed by the development of pneumothorax, the externalwounds were usually large and irregular in type; also, that in the onlypneumothorax which I saw produced during an extraction operation, theair was very rapidly absorbed. In the latter case, however, there waslittle reason to conclude that wound of the lung had occurred primarily, and certainly no opening existed at the time the thorax was incised. _Hæmothorax. _--This was the most frequent and also the most interestingof the complications of wound of the chest. In 90 per cent. Or more ofthe cases, the hæmorrhage was of parietal source, and due either todirect injury to the intercostal vessels by the bullet or to lacerationby spicules of comminuted ribs. For this reason, the passage of thebullet whether by an intercostal space, or through a rib, provided thewound was not at the posterior part of the space where the arterycrosses, was a point of considerable prognostic importance. Exclusion ofthe lung as the source of hæmorrhage was, I think, amply justified bythe absence of continuous recurrent or progressive hæmoptysis in themajority of the cases, and by the very small trace of injury found inthe lungs of patients who died some weeks after the injury. In such itwas difficult to discriminate the tracks at all. I only happened to seeone case where free hæmoptysis, during the course of development of ahæmothorax, pointed to the lung as the source of the blood. Hæmorrhage into the pleural cavity occurred in some degree in a verylarge proportion of the chest wounds, but it was especially interestingto note how greatly its extent was influenced by the amount of transportto which the patients were subjected in the early stages after theinjury. During the early part of the campaign, on the western side, Isaw a large number of chest wounds, and had I been asked my opinion asto the relative frequency of occurrence of hæmothorax I should haveplaced it at about 30 per cent. The patients in these early battlesneeded little wagon transport, and when sent down to the Base travelledin comfortable ambulance trains. After the commencement of the marchfrom Modder River to Bloemfontein, however, these conditions werechanged, and all the chest as other cases were exposed to the necessityof three days and nights' journey to the Stationary hospitals andafterwards to the long journey to Cape Town. Of these patients, atleast 90 per cent. Suffered with hæmothorax of varying degrees ofseverity. In some cases, the least common, signs of considerable intra-pleuralhæmorrhage immediately followed the wound; in others, the accumulationof blood was gradual, and only manifest in any degree at the end ofthree or four days, when it became stationary if the patient was kept atrest. In a second series the hæmorrhage was of the recurrent variety;these cases differing little in character from those of slightcontinuous hæmorrhage. In a third, the bleeding was definitely of asecondary character, corresponding with one of the classes of secondaryhæmorrhage described in Chapter IV. , and occurring on the eighth ortenth day from giving way of an imperfectly closed wounded vessel. Ineither of the two latter classes the development of the hæmothorax oftencorresponded with a journey, or with allowing the patient to get up. The general course of these effusions was towards spontaneous absorptionand recovery. Coagulation of the blood took place early, the fluid serumseparated, and tended to undergo absorption with some rapidity, leavinga small amount of coagulum at the base, which evidenced its presence formany weeks by a persistence of a certain degree of dulness onpercussion. Early coagulation, I think, accounted for the usual absenceof gravitation ecchymosis as a sign. The course to recovery was sometimes broken by signs of slight pleuriticinflammation, which, as affecting the amount of effusion, will be spokenof under the heading of symptoms. In some cases the amount of blood wasso great as to necessitate means being taken for its removal; in these areaccumulation often took place. Occasionally an empyema followed incases thus treated. The nature of the blood evacuated on tapping varied much. In very earlyaspirations unchanged blood was often met with, but clot sometimes madeevacuation difficult and necessitated a second puncture. In the tappingsdone at the end of a week or more a dark porter-like fluid was common, while when suppuration was imminent a brick-red-coloured grumous fluidreplaced normal blood. In the cases where early incision was resortedto, blood both fluid and in clots was often mixed with a certainproportion of lymph flakes, perhaps indicating the part taken byinflammatory reaction to the irritation of the clot in producing therise of temperature. _Symptoms of hæmothorax. _--In the more severe cases of primary bleedingthe symptoms did not, as a rule, reach their full height until the thirdor fourth day after the injury. The patients then often sufferedseverely. The pulse and temperature rose, and to general symptoms ofloss of blood were added: occasional lividity of countenance; severedyspnoea, accompanied by inability to lie on the sound side or toassume the supine position; absence of respiratory movement on theinjured side; pain, restlessness, cough, and sometimes continuance ofhæmoptysis, small clots usually being expectorated. Accompanying these symptoms were the usual physical signs of fluid inthe pleura in differing degrees and combination. Dulness of varyingextent up to complete absence of resonance on one side, oftenaccompanied in the incomplete cases by well-marked skodaic resonanceanteriorly. Loss of vocal resonance, and fremitus; oegophony, tubularrespiration over the root of the lung or at the upper limit of thedulness, and more or less extensive displacement of the heart. Obviousincrease in girth, fulness of the intercostal spaces, or gravitationecchymosis was rare. The latter was most common in instances in whichmultiple fracture of the ribs existed (see fig. 83). I think the rarityof the last sign must have been due to the early coagulation of theblood, and its retention by the pleura, as I saw well-marked gravitationecchymosis in one or two cases of mediastinal hæmorrhage. The above complex of symptoms was common to all the cases, but in theslighter ones they gave rise to little trouble, and cleared up withgreat rapidity. [Illustration: FIG. 83. --Gravitation Ecchymosis in a case of Hæmothorax, accompanying fracture of three ribs from within. The influence of thefractures on the development of the ecchymosis is shown by the lineararrangement of the discoloration] The most interesting feature was offered by the temperature, as this wasvery liable to lead one astray. A primary rise always occurred with thecollection of blood in the pleura, this reaching its height on the thirdor fourth day, usually about 102° F. In well-marked cases; it then fell, and in favourable instances remained normal. In a large number of cases, however, where the amount of blood was considerable, this was not thecase, the primary fall not reaching the normal, and a second riseoccurred which reached the same height as before or higher. The secondrise was accompanied by sweating, quickened pulse, and the probabilityof the development of an empyema had always to be considered. I believein most cases this secondary rise was an indication of a furtherincrease in the hæmorrhage, for the dulness usually increased in extent, and such rises were often seen when the patient had been moved or takena journey. Again, the temperature often fell to normal afterparacentesis and removal of the blood, to rise again with a freshaccumulation, which was not uncommon. I have already mentioned the largeproportional incidence of hæmothorax observed in the patients who hadto travel down from Paardeberg, and I might instance another caserelated to me by Dr. Flockemann of the German ambulance, which was verystriking. A Boer, wounded at Colesberg, developed a hæmothorax whichquieted down, and he was removed to Bloemfontein; on arrival at thelatter place the temperature rose, and other signs of fever suggestedthe development of an empyema; an exploring needle, however, onlybrought blood to light. After a short stay at Bloemfontein the symptomsentirely subsided, and the man was sent to Kroonstadt, when an exactlysimilar attack resulted, again quieting down with rest. Similar recurrent attacks of hæmorrhage and fever occurred, however, inpatients confined to their beds without moving after the first journey. Some temperature charts, in illustration of this point, are added to thecases quoted later. The explanation of the recurrent hæmorrhages is, Ithink, to be found in the reduction of the intra-thoracic pressure withcoagulation and shrinkage of the clot in the pleura in the patients keptquiet in bed, while in the patients who had to travel it was probablythe result of direct mechanical disturbance. In many of these cases a pleural rub was audible at the upper margin ofthe dulness with the development of the fresh symptoms. Whether this wasdue to actual pleurisy or to the rubbing of surfaces rough from thebreaking down of slight recent adhesions which had formed a barrier tothe effusion, I am unable to say, but the signs were fairly constant. Insome instances the increase in the amount of fluid was, no doubt, due topleural effusion resulting from irritation from the presence ofblood-clot, or perhaps the shifting of the latter; in these thesecondary rise of temperature may well be ascribed to the development ofpleurisy. I am inclined to believe, however, that the primary rise of temperaturewas similar to that seen when blood accumulates in the peritoneal cavityas the result of trauma, and the secondary rises in most cases to thosewhich we saw so frequently accompanying the interstitial secondaryhæmorrhages spoken of in Chapter IV. , and are to be explained on thetheory of absorption of a blood ferment. The secondary rises alwaysoccurred with a fresh effusion, often of blood, occasioning anextension, which broke down probable light adhesions and exposed a fresharea of normal pleural membrane to act as a surface for absorption. It is, of course, manifest that the fever might also be ascribed to theinfection of the clot or serum from without, and in the first cases Isaw I was inclined to take this view, since we had in every case theprimary wounds of chest-wall, and possibly of lung, and in some theaddition of a puncture by an exploring needle between the first andsecond rise. After a wider experience, however, I abandoned theinfection theory, as it seemed opposed by the very infrequent sequenceof suppuration. The effect of simple removal of the blood or serum wasalso often so striking as to strongly suggest that it alone wasresponsible for the fever. Exactly the same result, moreover, followedevacuation of the interstitial blood effusions already mentionedelsewhere. The common course of all the cases of hæmothorax was to spontaneousrecovery, the rapidity of the subsidence of the signs depending mainlyon the quantity of the primary hæmorrhage, and the occurrence of furtherincreases. The blood serum tended to collect at the upper limit of theoriginal blood effusion (as was often proved on tapping), and this wasfirst absorbed; the clot deposited on the pleural surface and at thebasal part of the cavity was, however, not absorbed with the samerapidity. In the majority of the patients when they left the hospitals, at the end of six weeks on an average, some dulness and deficiency ofvesicular murmur always remained, and the clot and the surroundingsurface, irritated by its presence, will, no doubt, be responsible forpermanent adhesions in many cases. That such adhesions do form in themajority of cases I feel certain, as, although these patients when theyleft the hospital were to all intents and purposes apparently well, fewof them could undertake sustained exertion without getting short ofbreath, and sometimes suffering from transitory pain, and for thisreason it became customary to invalid them home. In a small proportion of the cases empyema followed; but I never sawthis in any case that had neither been tapped nor opened, and I sawonly one patient die from a chest wound uncomplicated by other injuries. This case was an interesting one of recurrent hæmorrhage followed byinflammatory troubles:-- [Illustration: TEMPERATURE CHART 2. --Secondary Hæmorrhages in a case ofHæmothorax. Case No. 151] (151) The wound was received at short range, probably at from 100 to 200 yards. _Entry_, 1 inch from the left axillary margin in the first intercostal space; _exit_, at the back of the right arm 1-1/2 inch below the acromial angle; both pleuræ were therefore crossed. The patient expectorated at first fluid, then clotted, blood in considerable quantity. When brought into the advanced Base hospital on the third day, there were signs of blood in the left pleura, cellular emphysema over the right side of the chest, and signs of collapse of the right lung. The temperature chart gives shortly the course of the case: the right pneumo-thorax cleared up spontaneously, also the emphysema; but the left pleura needed tapping to relieve symptoms of pressure on four occasions, the 13th, 15th, 19th, and 25th days respectively. On the first two occasions blood was removed, on the third blood serum only, and on the last pus. The patient was relieved after each aspiration; after the third, the temperature fell to normal, the general condition also improved, and he promised to do well. None the less, reaccumulation took place, the evacuated fluid assumed an inflammatory character, and an incision to evacuate pus was eventually followed by death on the twenty-seventh day. The amount of hæmoptysis throughout was considerable, and the case was possibly one of pulmonary hæmothorax, as after death no source of hæmorrhage could be localised in the intercostal space. The track in the lung was almost healed, and although a part of it allowed the introduction of a probe for about an inch, it could be traced no further even on section of the organ, and no special vessel could be located as the original bleeding spot. _Empyema. _--I may here add the little that I have to say on thissubject. During the whole campaign the single case of primary empyemathat I saw was the one recorded below, which deserves special mention asillustrating the disadvantage of extracting bullets on the field. Underthe conditions which necessarily accompanied this operation theensurance of asepsis was impossible, and the additional wound no doubtproved the source of infection. (152) _Entry_, at the posterior margin of the sterno-mastoid muscle, 2 inches above the clavicle; the bullet came to the surface beneath the skin over the fifth rib, in the nipple line of the right side. There was never any hæmoptysis, but the patient suffered with some dyspnoea throughout. After a three days' stay in the Field hospital, where the subcutaneous bullet was removed, the patient was transported by wagon and train to the Base, a journey of about 600 miles. On the fifth day pus escaped from the extraction wound, and when the case was examined at the Base, the temperature was 101°, the pulse over 100, the respirations 30, and the whole side of the chest was dull, with the exception of a patch of boxy resonance over the apex anteriorly. On the following day the chest was drained, and a considerable amount of pus evacuated, which was mixed with breaking-down blood-clot. A fortnight later a second operation had to be performed to improve the drainage, and the patient made a tedious recovery. The following case well illustrates the symptoms in a severe case ofhæmothorax, and empyema following aspiration:-- (153) The patient was wounded at Paardeberg at a range of from 500 to 700 yards. _Entry_, just to the left of the episternal notch; _exit_, in the fifth left interspace posteriorly, midway between the spine and vertebral margin of the scapula. A quantity of bright blood was brought up at once, and later blood was coughed up in clots. There was no great pain at the moment of the injury; the man again got up to the firing line, and later walked two miles to the Field hospital without aid. He remained here a week, when he was sent down to the Base, and during the first three days' journey in the wagon he began to get worse. On the fourth day cough began to be very troublesome. When he arrived at the Base, fifteen days after the original injury, there was much dyspnoea; the temperature was 102°, and the pulse 110. The left side of the chest was dull throughout; an aspirating needle was introduced, and a pint of very dark liquid blood drawn off. The whole of the blood was not removed on account of the very severe cough and pain which the evacuation occasioned. The man appeared to steadily improve until three weeks later, when the temperature, which throughout had been uneven, became consistently high, and signs of fluid at the base increased. An aspirating needle was introduced, and 16 ounces of pus were drawn off. Two days later a piece of rib was resected (Mr. Pegg) and another pint of pus evacuated. After this, rapid improvement took place, and in ten days the man was able to be up and dressed, although a small amount of discharge still persisted. He eventually made an excellent recovery. Secondary empyemata not uncommonly followed incision of the chest, orexcision of a rib for draining a hæmothorax. These operations in theearly part of the campaign were more freely undertaken on thesupposition that rise of temperature and other symptoms of fever pointedto incipient breaking down of the clot. Subsequent experience showedthis not to be the case, and early operations for drainage ceased to beundertaken. In these operations a primary difficulty was met with ineffectively clearing out the clot, a drain had to be left, andsuppuration occurred later in a considerable proportion. Thesuppurations were most troublesome; local adhesions formed, and the puscollected in small pockets, which were difficult to find and to drain, and even when the collections seemed to have been successfully dealtwith at the time, residual abscesses often followed at a very late date. Thus, I saw a case with a contracted chest and a fresh abscess the daybefore I left Cape Town, in whom I had advised and witnessed anoperation for the evacuation of clot in the presence of signs of fever aweek after my arrival in the country, nine months previously. I sawanother case where general infection followed incision of a hæmothorax, but the patient fortunately recovered. The question of _pleurisy_ has already been mentioned in connection withhæmothorax; it no doubt accounted for secondary effusion in some cases, and beyond this I have nothing to add to what has been there said. _Pneumonia_ was rare; there were occasionally signs of consolidation, but, I think, quite as often in the opposite lung as in the one injured. I never saw a fatal case, and I am inclined to think that when itoccurred it was as often the result of cold and exposure as of theinjury to the lung. Abscess of the lung I only saw once, and that in acase in which the injury to the chest was complicated by paraplegia fromspinal injury and septicæmia, and it was possibly pyæmic. _Diagnosis. _--No difficulties special to small-calibre wounds wereexperienced, except such as have been already dealt with. The only classof case which frequently gave rise to difficulty was hæmothorax. Heretwo points especially needed consideration. (1) _The source of thehæmorrhage as parietal or visceral. _ As has been already foreshadowed, this was mainly to be decided by the amount and persistence of thehæmoptysis, but naturally free hæmoptysis did not negative concurrentparietal bleeding. Then the actual source of the bleeding other thanfrom the lung had to be considered; in the great majority of cases theintercostal vessels were responsible, and attention to the course of thetracks often allowed this to be definitely decided upon. A case included in the chapter on Injuries to the Blood Vessels (No. 5, p. 127) is of great interest in this particular; in that instancefeebleness of the radial pulse, together with the position of the wound, was a valuable indication of injury to the subclavian artery, butweakened somewhat by the fact of retention of the bullet, and henceuncertainty as to the exact course that it had taken, and as to whetherthe bullet itself was not responsible for pressure on the vessel. Suchindications, however, should make one very chary of interference with ahæmothorax, even with extremely urgent symptoms, in the light of ourpresent knowledge of the nature of the lesions to the great vesselsproduced by small-calibre bullets, and their tendency to be incomplete. (2) _The imminence of suppuration or its actual occurrence. _--In mostcases it sufficed to preserve an expectant attitude, and in thepersistence or increase of symptoms, to have recourse to an exploratorypuncture as the best means of solution of the difficulty. _Prognosis. _--The prognosis both as to life and as to subsequentill-effects was remarkably good; in many cases of uncomplicated injuryto the lung the patients rejoined their regiments at the end of a monthor six weeks. In the more serious cases complicated by the collection ofblood in the pleura, convalescence was more prolonged, and an averagetime of six to eight weeks often elapsed before the patients could besafely discharged from hospital. In the more serious a certain amount ofdulness always persisted at this time over the base of the lung, and thechest was usually somewhat contracted on the injured side, with evidencein the way of decreased vesicular murmur that the lung was still notfree from compression. With regard to the persistence of dulness onpercussion, it is well to bear in mind that a thin layer of bloodapparently produces as serious impairment of resonance as a much largerquantity of serum. The signs appeared to favour the view that the spacenecessary for the location of the hæmorrhage had been obtained at theexpense of the lung rather than by distension of the thoracic parietes, and also, I think, denoted the presence of adhesions. Possibly they willentirely disappear with the return of full excursion movements ofrespiration, the latter being often still somewhat restricted when thepatients left hospital. All the patients with such signs were liable toattacks of pain and shortness of breath on actual bodily exertion. Ihappened to meet with an officer, the subject of a Lee-Metford wound ofthe thorax, sustained five years previously, and he told me that he wasnine months before he could take active exercise without feeling shortof breath. As to the cases of hæmothorax and empyema which needed drainage, all didwell; but expansion of the lung was much less satisfactory than wouldhave been expected, probably on account of especially firm adhesions. The importance of concurrent injury I need hardly dwell on; but I mightadd that perforation of one or both arms, the most common one, did notmaterially affect the general statements above made. _Treatment. _--In the early stages of the pulmonary wounds rest was theall-important indication, and when this was assured few serious cases ofhæmothorax occurred. Beyond simple rest, the administration of opiumwith a view to checking internal hæmorrhage was used with good effect. The wounds needed simple dressing only. The treatment of hæmothorax at a later date, however, was of muchinterest and difficulty. I think the following lines may be laid downfor guidance in such cases:-- (i) Hæmothorax, even of considerable severity, will undergo spontaneouscure. An early rise of temperature may be disregarded. (ii) Tapping the chest is indicated when pressure signs on the lung aresufficiently severe to cause serious symptoms, and the removal of theblood undoubtedly shortens the period of recovery, as well as relievessymptoms. In such cases the collection of blood has usually been rapid andcontinuous; hence a fresh hæmorrhage is always probable when the localpressure has been removed. Tapping therefore should not necessarily meancomplete evacuation, and should be followed by careful firm binding upof the chest, the administration of opium, and the most stringentprecautions for rest. (iii) Tapping may be needed as a diagnostic aid, and in suchcircumstances as much fluid as can be removed should be evacuated withthe same precautions as mentioned in the last paragraph. (iv) Tapping may be indicated for the evacuation of serum expressed fromthe blood-clot, or due to pleural effusion, on the same lines as in anyother collection of fluid in the pleural cavity. (v) Early free incision is, as a rule, to be steadfastly avoided. Somecases already quoted fully illustrate its disadvantages. (vi) Cases in which an incision and the ligature of a parietal arteryare indicated are very rare. I never saw such a one myself. (vii) If a hæmothorax suppurates, it must be treated on the ordinarylines of an empyema. In view of the constant formation of adhesions anddifficulty in drainage, a portion of a rib should always be resected inorder to ensure sufficient space for after-treatment. The cavities, as arule, are better irrigated, the usual precautions being taken wherethere is any reason to fear that the lung is still in communication withthe cavity. Care in carrying out asepsis in tapping, which should be performed withan aspirator, need hardly be more than mentioned. It will be noted thatin some of the cases quoted suppuration followed tapping, but it must beremembered that in these the two primary wounds already existed aspossible channels of infection. Retained bullets of small calibre in the thoracic cavity were notcommon, unless the lodgment had occurred in the bodies of the vertebræ. I saw very few. Shrapnel bullets and fragments of shells, however, were, in proportion to the frequency of wounds from such projectiles, morecommonly retained. The rules to be followed in such cases do notmaterially deviate from those to be observed in the body generally. When the bullet is causing no trouble, and is lodged in either the boneof the spine or the lung substance, no interference is advisable. When, on the other hand, the bullet as viewed by the X-rays is seen to be inthe pleural cavity, and any symptoms of its presence exist, it may bejustifiable to remove it. I saw this done in one case for the removal ofa shrapnel bullet from the lower reflexion of the pleura on account offixed pain and tenderness complained of by the patient. The bullet, ashrapnel, had perforated the arm, which the patient was sure was by hisside at the moment of injury, and the X-rays showed it to lie at thebottom of the pleural cavity, where we assumed it had fallen. When, however, the bullet was removed by Mr. Watson, he found that the fixedpain and tenderness had been the result of a fracture of a rib from theinner side, not involving loss of continuity; hence the actualindication for the operation had been a delusive one, since the bullethad not fallen, but expended its last force in injuring the rib. Thepatient made an excellent recovery, and rejoined his regiment at the endof six weeks. I saw several cases in which the bullet was lodged ineither the lung or bones of the spine do well with no interference. Thegreat disadvantage of primary removal in inducing an artificialpneumo-thorax and in laying open a hæmothorax is obvious. In case of lodgment of the bullet in the lung, bearing in mind theinfrequency of untoward symptoms, the latter should be watched for priorto interference. The following cases illustrate some typical instances of wound of chestaccompanied by the development of hæmothorax:-- [Illustration: TEMPERATURE CHART 3. --Primary Hæmothorax, with rise oftemperature. Secondary rise, with fresh effusion and pneumonia. Spontaneous recovery. Case No. 154] (154) _Severe hæmothorax. Spontaneous recovery. _--Wounded at Modder River at a distance of 30 yards. _Entry_, at the junction of the left anterior axillary fold with the chest-wall; _exit_, immediately to the left of the seventh dorsal spinous process. The patient arrived at the Base with signs of an extensive hæmothorax, accompanied by a temperature which reached 102° on the fourth day, and on the evening of the tenth 103°. The man was very ill, and an exploring needle was inserted, by which about an ounce of blood was evacuated. The signs of fluid in the left pleura were accompanied by those of consolidation over the lower fourth of the right lung, and the sputa were rusty. Evidence of perforation of the left axillary artery existed in feebleness of the radial pulse; and there was musculo-spiral paralysis. After the preliminary puncture, the man refused any further operative treatment, although a second rise of temperature commenced on the fifteenth day, culminating in a temperature of 103. 2° on the eighteenth. The further treatment of the patient consisted in the ensurance of rest and the alleviation of pain. A steady fall in the temperature extended over another three weeks, together with diminution in the signs of fluid in the pleura. At the end of seventy-four days the man was sent home, some slight dulness at the left base, and contraction of the chest sufficient to influence the spine in the way of lateral curvature, being the only remaining signs. [Illustration: TEMPERATURE CHART 4. --Primary Hæmothorax. Secondary riseof temperature, with increase in the effusion. Spontaneous recovery. Case No. 155] (155) _Severe hæmothorax. Secondary effusion. Spontaneous recovery. _--Wounded at Koodoosberg Drift, at a distance of 200 yards. _Entry_, at angle of the right scapula; _exit_, at the junction of the left anterior axillary fold with the chest-wall. No signs of spinal cord injury. The patient was brought in from the field twelve miles by an ambulance wagon on the second day, and in crossing the Modder River he was accidentally upset into the stream. For the first four days there was no hæmoptysis, but for the succeeding nine days small brightish red clots were expectorated. There was some tenderness over the ribs from the fifth to the ninth in the axillary line, and on the ninth day some gravitation ecchymosis appeared over the same region. Cough was an early troublesome symptom in this case, and when admitted to the Base hospital, about the seventh day, there was evidence of fluid extending about a third of the way up the back. On the tenth day after admission a pleural rub was detected at the upper margin of the dulness, and the latter shortly extended upwards over a little more than half the back. Meanwhile, there was no further hæmoptysis, respiration was fairly easy, 24 per minute, but accompanied by slight dilatation of the alæ nasi, and the temperature, which had been ranging from 99° to 100°, began to rise steadily, on the fifteenth day reaching 102. 5°. The patient refused even an exploratory puncture, and was treated on the expectant plan. The temperature slowly subsided, with a steady improvement in the physical signs, and at the end of about ten weeks he left for home with only slight dulness and incapacity for active exertion remaining. (Now again on active service. ) [Illustration: TEMPERATURE CHART 5. --Hæmothorax, primary and secondaryrises of temperature, on each occasion falling on the evacuation of theblood. Case No. 156] (156) _Severe hæmothorax. Recurrent secondary effusion. Tapping on two occasions. Cure. _--The patient was wounded at Paardeberg, and arrived at the Base on the eighteenth day. _Entry_, below the first rib, just external to its junction with the costal cartilage; _exit_, through the ninth rib, just within the posterior axillary line. The whole right side of the chest was dull, with signs of the presence of fluid, the heart being displaced to the left. There was considerable distress; the respirations averaged 40, the pulse 100, and the temperature reached 101. 5° the first evening after arrival. On the nineteenth day the thorax was aspirated (Mr. Hanwell) and 50 ounces of dirty red-coloured fluid, half clot, half serum, were evacuated. Considerable relief was afforded; the respirations became slightly less frequent; the heart returned to a normal position, and distant tubular respiration was audible. The temperature dropped to normal the third day after evacuation of the fluid, but on the sixth day it again commenced to rise, and meanwhile fluid again began to collect. On the twenty-sixth day a second aspiration resulted in the evacuation of 35 ounces of bloody fluid in which flakes of lymph were found. Three days later the temperature became normal. The respirations fell to 22, and the patient made an uninterrupted recovery. [Illustration: TEMPERATURE CHART 6. --Wound of Lung. Secondarydevelopment of Hæmothorax, with rise of temperature. Spontaneousrecovery. Case No 157] (157) _Moderate hæmothorax. Secondary effusion at the end of twenty days. Spontaneous recovery. _--Wounded at Paardeberg; range from 700 to 1, 000 yards. _Entry_, in the centre of the second right intercostal space, anteriorly; _exit_, at the level of the sixth rib posteriorly, through the scapula, close to its vertebral margin. The patient arrived at the Base on the sixth day; he said he expectorated some blood at the end of about ten minutes after being shot, and experienced a 'half-choking sensation. ' A small quantity of phlegm and occasional clots had been expectorated since. He had walked about a good deal; movement occasioned cough, and he became 'blown' very rapidly. On admission there were signs of fluid in the lower third of the pleural cavity, but no general symptoms beyond an evening rise of temperature to an average of 99°. About the twentieth day the temperature commenced to rise, and on the twenty-third and four following evenings reached 102°. The fever was accompanied by some distress, and a well-marked increase in the physical signs of the presence of fluid in the chest. The pulse rose to 96, and the respirations considerably above the average of 24, which was at first noted. A strictly expectant attitude was maintained, and the temperature steadily fell in a curve corresponding to the rise, gradually reaching the normal at the end of a week. The physical signs at the base steadily cleared up, and at the end of six weeks the patient returned to England convalescent. CHAPTER XI INJURIES TO THE ABDOMEN Perhaps no chapter of military surgery was looked forward to with moreeager interest than that dealing with wounds of the abdomen. In none wasgreater expectation indulged in with regard to probable advance inactive surgical treatment, and in none did greater disappointment lie instore for us. Wounds of the solid viscera, it is true, proved to be of minorimportance when produced by bullets of small calibre; but wounds of theintestinal tract, although they showed themselves capable of spontaneousrecovery in a certain proportion of the cases observed, afforded butslight opportunity for surgical skill, and results generally deviatedbut slightly from those of past experience. Such success as was met withdepended rather on the mechanical genesis and nature of the wounds thanupon the efforts of the surgeon, and operative surgery scored but fewsuccesses. It is true that to the Civil Surgeon accustomed to surroundings repletewith every modern appliance and convenience, and the possibility ofexercising the most stringent precautions against the introduction ofsepsis from without, abdominal operations presented difficulties onlyfaintly appreciated in advance; but this alone scarcely accounted forthe want of success attending the active treatment of wounds of theintestine when occasion demanded. Failure was rather to be referred tothe severity of the local injury to be dealt with, or to the operationsbeing necessarily undertaken at too late a date. Many fatalities, again, were due to the association of other injuries, a large proportion of thewound tracks involving other organs or parts beyond the boundaries ofthe abdominal cavity. The frequent association of wounds of the thoracic cavity with those ofthe abdomen afforded many of the most striking examples of immunity fromserious consequences as a result of wound of the pleura. It must beconceded that in a large number of such injuries only the extreme limitsof the pleural sac were encroached upon, yet in some the tracks passedthrough the lungs, although without serious consequences. Under theheading of injury to the large intestine a somewhat special form ofpleural septicæmia will be referred to. It may at once be stated that such favourable results as occurred inabdominal injuries were practically limited to wounds caused by bulletsof small calibre, and that, although in the short chapter dealing withshell injuries a few recoveries from visceral wounds will be mentioned, I never met with a penetrating visceral injury from a Martini-Henry orlarge sporting bullet which did not prove fatal. _Wounds of the abdominal wall. _--It is somewhat paradoxical to say thatthese injuries possessed special interest from their comparative rarityof occurrence, since they were not of intrinsic importance. Theirinfrequency depended on the difficulty of striking the body in such aplane as to implicate the belly wall alone, and their interest in thediagnostic difficulty which they gave rise to. In many cases the position of the openings and the strongly oval orgutter character possessed by them were sufficient proof of thesuperficial passage of the bullet; in others we had to bear in mind thatthe position of the patient when struck was rarely that of rest in thesupine position, in which the surgical examination was made, andconsiderable difficulty arose. Some superficial tracks crossing thebelly wall have already been referred to in the chapter on wounds ingeneral and in that dealing with injuries to the chest, in which theabove characters sufficed to indicate that penetration of the abdominalcavity had not occurred. In other instances a definite subcutaneousgutter could be traced, and often in these a well-marked cord in theabdominal wall corresponding to the track could be felt at a later date. Again, limitation to the abdominal wall was sometimes proved by theposition of the retained bullet, or sometimes by the presence in thetrack of foreign bodies carried in with the projectile. See case 160. Fig. 84 illustrates an example where the limitation to the abdominalwall was evident on inspection. Here the division of the thick musclesof the abdominal wall had led to the formation of a swelling exactlysimilar to that seen after the subcutaneous rupture of a muscle, and twosoft fluctuating tumours bounded by contracted muscle existed in thesubstance of the oblique and rectus muscles. [Illustration: FIG. 84. --Wound of Abdominal Wall (Lee-Metford). Divisionof fibres of external oblique and rectus abdominis muscles. Case 159] The cases which presented the most serious diagnostic difficulty in thisrelation were those in which the wound was situated in the thickermuscular portions of the lower part of the abdominal and pelvic walls. Such a case is illustrated in the chapter on fractures (see fig. 55, p. 191). I saw one or two such instances, in which only the explorationnecessary for treatment of the fracture decided the point. In many ofthe wounds affecting the lateral portion of the abdominal wall thequestion of penetration could never be definitely cleared up, as woundsof the colon sometimes gave rise to absolutely no symptoms. In a certain proportion of the injuries the peritoneal cavity was nodoubt perforated without the infliction of any further visceral injury, and in these also the doubt as to the occurrence of penetration wasnever solved. (158) _Wound of belly wall. _--Wounded at Modder River. _Entry_ (Mauser), 2 inches below the centre of the left iliac crest; _exit_, 1-1/2 inch above and internal to the left anterior superior iliac spine. The patient was on horseback at the time of the injury and did not fall; he got down, however, and lay on the field an hour, whence he was removed to hospital. Probably the track pierced the ilium, and remained confined to the abdominal wall. There were no signs of visceral injury. (159) Cape Boy. Wounded at Modder River. _Entry_ (Lee-Metford), immediately above and outside right anterior superior spine; _exit_, 1-1/2 inch below and to right of umbilicus. A well-marked swelling corresponded with division of the fibres of the oblique muscles and of the rectus, and on palpation a hollow corresponding with the track was felt. The abdominal muscles were exceptionally well developed (fig. 84). (160) Wounded at Magersfontein while lying prone. _Entry_, irregular, oblique, and somewhat contused, over the eighth left rib, in the anterior axillary line; _exit_, a slit wound immediately above and to the left of the umbilicus. The bullet struck a small circular metal looking-glass before entering, hence the irregularity of the wound. The patient developed a hæmothorax, but no abdominal signs; the former was probably parietal in origin, secondary to the fractured rib, and the whole wound non-penetrating as far as the abdominal cavity was concerned. (161) Wounded at Magersfontein. _Entry_ (Mauser), 1-1/2 inch external to and 1/2 inch below the left posterior superior iliac spine; _exit_, 1 inch internal horizontally to the left anterior superior spine. No signs of intra-peritoneal injury were noted, but free suppuration occurred in left loin; the ilium was tunnelled. The same patient was wounded by a Jeffrey bullet in the hand; the third metacarpal was pulverised, although the bullet, which was longitudinally flanged, was retained. (162) Wounded outside Heilbron. _Entry_, below the eighth right costal cartilage; _exit_, below the eighth cartilage of the left side. The wound of entry was slightly oval; that of exit continued out as a 'flame'-like groove for 2 inches. A week later the wound track could be palpated as an evident hard continuous cord. _Penetration of the intestinal area without definite evidence ofvisceral injury. _--This accident occurred with a sufficient degree offrequency to obtain the greatest importance, both from the point of viewof diagnosis and prognosis, and as affecting the question of operativeinterference. Amongst the cases reported below a number occurred inwhich it was impossible to settle the question whether injury to thebowel had occurred or not, and I will here shortly give what explanationI can for the apparent escape of the intestine from serious injury. We may first recall the general question of the escape of structureslying to one or other side of the track of the bullet. I believe thatthere can be no doubt as to the accuracy of the remarks already made asto the escape of such structures as the nerves by means of displacement, and that the occurrence of such escapes is manifestly dependent on thedegree of fixity of the nerve or the special segment of it implicated. The general tendency of the tissues around the tracks to escapeextensive destruction from actual contusion has also been referred to, and is, I think, indisputable. If these observations be accepted, I think there can be no difficulty inallowing that the small intestine is exceptionally well arranged toescape injury. First of all, it is very moveable; secondly, it is soarranged that in certain directions a bullet may pass almost parallel tothe long axis of the coils; thirdly, it is elastic, capable ofcompression, and light, and hence offers but a small degree ofresistance to the passage of the bullet across the abdominal cavity. Certain evidence both clinical and pathological supports the contentionthat the small intestine may escape injury from the passing bullet. First of all, the fact may be broadly stated that injuries to the smallintestine were fatal in the great majority of certainly diagnosed cases, while, on the other hand, many tracks crossed the area occupied by thesmall intestine without serious symptoms of any kind resulting. Secondly, experience showed that when the bullet crossed the line of thefixed portions of the large intestine the gut rarely escaped, and that, although a considerable proportion of these cases recoveredspontaneously, in a large number of them immediate symptoms, orsecondary complications, clearly substantiated the nature of theoriginal injury. As far as my experience went, however, I never saw anyinstance in which an undoubted injury of the small intestine wasfollowed by the development of a local peritoneal suppuration andrecovery, a sequence by no means uncommon in the case of wounds of thelarge intestine. Although, therefore, I am not prepared to deny thepossibility of spontaneous recovery from an injury to the smallintestine, under certain conditions which will be stated later, Ibelieve that in the immense majority of cases in which a bullet crossedthe small intestine area without the supervention of serious symptoms, the small intestine escaped perforating injury. Beyond the clinical evidence offered above, certain pathologicalobservations support the view that the intestine escapes perforation bydisplacement. Most of my knowledge on this subject was derived from thelimited number of abdominal sections I performed on cases of injury tothe small intestine, and may be summed up as follows. The small intestine may present evidence of lateral contusion in theshape of elongated ecchymoses, either parallel, oblique, or transverseto its long axis. These ecchymoses resemble in extent and outline thosewhich ordinarily surround a wound of the intestinal wall produced by abullet (see fig. 87, p. 418). The wall of the small intestine may be wounded to an extent short ofperforation, either the peritoneal coat alone being split, or the woundimplicating the muscular coat and producing an appearance similar tothat seen when the intestine is dragged upon during an operation, butwithout so much gaping of the edges (see fig. 85, p. 416). I met with these conditions in association with co-existing completeperforations of the small intestine, and in one case of intra-peritonealhæmorrhage in which no complete perforation was discoverable (No. 169, p. 432). The implication and perforation of the small intestine are to someextent influenced by the direction of the wound. A striking case isincluded below, No. 201, in which a bullet passed from the loin to theiliac fossa on each side of the body, approximately parallel to thecourse of the inner margin of the colon, and I also saw some otherwounds in this direction in which no evidence of injury to the smallintestine was detected, and which got well. Again wounds from flank toflank were, as a rule, very fatal; but I saw more than one instancewhere these wounds were situated immediately below the crest of theilium, in which the intestine escaped injury (see case 171). A verystriking observation was made by Mr. Cheatle in such a wound. Thepatient died as a result of a double perforation of both cæcum andsigmoid flexure; none the less the bullet had crossed the smallintestine area without inflicting any injury. The sum of my experience, in fact, was to encourage the belief that, unless the intestine was struck in such a direction as to render lateraldisplacement an impossibility, the gut often escaped perforation. As a rule, the wounds of the abdomen which from their position provedthe most dangerous to the intestine were-- 1. Wounds passing from one flank to the other were very dangerous, ascrossing complicated coils of the small intestine, and two fixedportions of the colon. This danger was most marked when the wounds weresituated between the eighth rib in the mid axillary line and the crestof the ilium; above this level the liver, or possibly liver and stomach, were sometimes alone implicated, and the cases did well. Again, when thewounds crossed the false pelvis the patients sometimes escaped allinjury to viscera. 2. Antero-posterior wounds in the small intestine area were very fatalif the course was direct; in such the small intestine seldom escapedinjury. 3. Wounds with a certain degree of obliquity from anterior wall toflank, or from flank to loin, were on the other hand comparativelyfavourable, as the small intestine often escaped, and if any gut waswounded, it was often the colon. 4. Vertical wounds implicating the chest and abdomen, or the abdomen andpelvis, were on the whole not very unfavourable. For instance, when thebullet entered by the buttock and emerged below the umbilicus, a numberof patients escaped fatal injury; this depended on the comparativelygood prognosis in wounds of the rectum and bladder. A good manypatients in whom the bullet entered by the upper part of the loin, andescaped 1-1/2 inch within the anterior superior spine of the ilium, alsodid well. The same holds good when the wounds either entered or emergedunder the anterior costal margin of the thorax, either prior to or aftertraversing the thorax. Wounds passing directly backward from the iliac regions were in myexperience very unfavourable; but I believe mainly as a result ofhæmorrhage from the iliac arteries. _The occurrence of wounds of the abdomen of an 'explosive'character. _--The vast majority of the abdominal wounds observed in theStationary or Base hospitals were of the type dimensions. A certainnumber of the abdominal injuries which proved fatal on the field orshortly afterwards were described as explosive in character, and werereferred by the observers to the employment of expanding bullets. A few words on this subject seem necessary, because it seems doubtfulwhether such injuries could be produced by any of the forms of expandingbullet of small calibre in use, unless the track crossed one of thebones in the abdominal or pelvic wall. That this was sometimes the casethere is no doubt: thus I saw two cases in which the splenic flexure ofthe colon was wounded, in which the external opening was large, and acomminuted fracture of the ribs of the left side existed. One can wellbelieve that bullets passing through the pelvic bones might 'set up' toa considerable extent, and although I never happened to see such a case, an explanation of some of the wounds described by others might be foundin this occurrence. In instances in which the soft parts alone were perforated, I amdisinclined to believe that bullets of small calibre, either regulationor soft-nosed, were responsible for the injuries. I had the opportunityof examining two Mauser bullets of the Jeffreys variety which crossedthe abdomen and caused death. In the first (figured on page 94, fig. 40)very little alteration beyond slight shortening had occurred. In thesecond the deformity was almost the same, except that the side of thebullet was indented, probably from impact with some object prior to itsentry into the body. In each case the bullet was of course travelling ata low rate of velocity; hence no very strong inference can be drawnfrom either. In the case of the second specimen, which was removed byMr. Cheatle, a remarkable observation was made, which tends to throwsome light on one possible mode of production of large exit apertures. This bullet crossed the cæcum, making two small type openings; butlater, when it crossed the sigmoid flexure, it tore two large irregularopenings in the gut. This might be explained on the ground that thevelocity was so small as only just to allow of perforation, whichtherefore took the nature of a tear. I am inclined to suggest, as a morelikely explanation, that the spent bullet turned head over heels in itscourse across the abdomen, and made lateral or irregular impact with thelast piece of bowel it touched. A slightly greater degree of force wouldhave allowed a similar large and irregular opening to be made in theabdominal wall also. In this relation the question will naturally be raised as to how far theexplosive appearances may have been due to high velocity alone on thepart of the bullet. I am disinclined from my general experience tobelieve that explosive injuries of the soft parts were to be thusexplained. On the other hand, I believe that the possession of a lowdegree of velocity very greatly increased the danger in abdominalwounds. I believe that the bowel was, under these circumstances, lesslikely to escape by displacement, and was more widely torn when wounded;again, that inexact impact led to increase of size in the externalapertures, and the bullet was of course more often retained. Mr. Watson Cheyne[19] published a very remarkable instance of one of thedangers of an injury from a spent bullet, in which, in spite ofnon-penetration of the abdominal cavity, the small intestine wasruptured in two places. I believe the majority of the wounds designated as explosive were theresult of the passage of large leaden bullets, either of theMartini-Henry or Express type. The small opportunity of observing suchinjuries in the hospitals of course depended on the fact that themajority were rapidly fatal. _Nature of the anatomical lesion in wounds of the intestine. _--Theopenings in the parietal peritoneum tended to assume the slit or starforms, probably on account of the elasticity of the membrane. A diagramof one of these forms is appended to fig. 89. In this instance theopening in the peritoneum was made from the abdominal aspect, prior tothe escape of the bullet from the cavity, and on the impact of the tip, the long axis of the bullet was oblique to the surface of the abdominalwall. In the intestinal wall the openings varied in character according to themode of impact. In some cases the gut was merely contused by lateral contact of thepassing bullet. The result of this was evidenced later by the presenceof localised oval patches of ecchymosis. These were identical inappearance with the patches shown surrounding the wounds in fig. 87. [Illustration: FIG. 85. --Lateral Slit in Small Intestine produced bypassage of bullet. Slit somewhat obscured by deposition of inflammatorylymph. (St. Thomas's Hospital Museum)] More forcible lateral impact produced a split of the peritoneum, or ofthis together with the muscular coat. Such a lateral slit is shown infig. 85, although the clearness of outline is somewhat impaired by thepresence of a considerable amount of inflammatory lymph. Fig. 86 exhibits a lateral injury of a more pronounced form. The bullethere struck the most prominent portion of the under surface of thebowel, and produced a circular perforation not very unlike one producedby rectangular impact, except in the lesser degree of eversion of themucous membrane. Here again the appearance is somewhat altered by thepresence of a considerable amount of lymph, but this is of lessimportance in this figure because the lymph is localised to the portionof the bowel in the immediate neighbourhood of the opening which hadsuffered contusion and erasion. [Illustration: FIG. 86. --Gutter Wound of Small Intestine caused bylateral impact. Position of shallow portion of gutter indicated bydeposition of inflammatory lymph. Circular perforation. (St. Thomas'sHospital Museum)] Fig. 87, A B, illustrates a symmetrical perforation of the smallintestine; the aperture of entry (A) is roughly circular, and a ring ofmucous membrane protrudes and partially closes the opening. The apertureof exit is a curved slit, again partially occluded by the mucousmembrane. The same amount of difference between the two apertures didnot always exist; in many cases both were circular, and apparentlysymmetrical. Beyond this I have seen three apertures in close proximity, two lying on the same aspect of the bowel, and the first of these was nodoubt an opening due to lateral impact similar to that seen in fig. 86. In the recent condition little difference existed between the threeapertures. The localised ecchymosis surrounding the apertures is quitecharacteristic of this form of injury, and is a valuable aid to findingthe openings during an operation. Fig. 88 shows the interior of the same segment of bowel, as fig. 87. Itshows the localised ecchymosis as seen from the inner surface, hererather more extensive from the fact that the blood spreads more readilyin the submucous tissue. [Illustration: FIG. 87. --Perforating Wounds of Small Intestine. A. Entry; note circular outline and eversion of mucous membrane. B. Woundof exit; curved slit-like character, eversion of mucous membrane. Notethe localised ecchymosis, more abundant round exit aperture. (St. Thomas's Hospital Museum)] It will be noted that the main feature of the form of injury is theregular outline and the small size of the wounds. Another feature notillustrated by the figures should also be mentioned. In the ruptures ofintestine with which we are acquainted in civil practice the wound inthe gut is almost without exception situated at the free border of thebowel, but in these injuries it was just as frequently at the mesentericmargin. The importance of this factor is considerable, since woundsnear the mesenteric edge are much more likely to be accompanied byhæmorrhage, and thus the opportunity for diffusion of infection isconsiderably multiplied, to say nothing of the danger from loss ofblood. Beyond these more or less pure perforations, long slits or gutters wereoccasionally cut. I saw instances of these in the case of the ascendingcolon, and in the small curvature of the stomach. The comparative fixityof the portion of bowel struck is a matter of great importance in theproduction of this form of injury. [Illustration: FIG. 88. --The same piece of Intestine as that shown infig. 87, laid open to show the ecchymosis on the inner aspect of theBowel. The two indicating lines lead to the openings, which appearslit-like, and are sunk at the bottom of folds. (St. Thomas's HospitalMuseum)] It may be well to add that, although the figures inserted are all takenfrom small-intestine wounds, the nature of the wounds of theperitoneum-clad part of the large intestine in no way differed fromthem, except in so far as fixity of the bowel exposed it to a moreextensive wound when the bullet took a parallel course to its long axis. A more important point in the injuries to the large intestine was thepossibility of an extra-peritoneal wound. I saw several such lesions ofthe colon, every one of which ended fatally. I became still more fullyconvinced of the greater seriousness of extra- to intra-peritonealrupture of this portion of the gut than I was when I expressed a similaropinion in a former paper. [20] It will be seen later that the results ofintra- and extra-peritoneal wounds of the bladder fully confirm thisview, as all extra-peritoneal injuries died, while many intra-peritonealperforations recovered spontaneously. _Wounds of the mesentery. _--I had little experience of this injury; infact, case 169, on which I operated, was my sole observation. It standsto reason, however, that injuries to the mesentery would be much morefrequent proportionately to wounds of the gut than is the case in theruptures seen in civil practice, since the whole area of the mesenteryis equally open to injury. Viewing the extreme danger of hæmorrhage intothe peritoneal cavity in these injuries, I should be inclined to expectthat a considerable proportion of those deaths from abdominal woundswhich took place on the field of battle were due to this source. _Wounds of the omentum. _--Here, again, I am unable to express anyopinion, although the supposition that hæmorrhage from this source tookplace is natural. Prolapse of omentum was comparatively rare, except in cases with largewounds; it was apparently seen with some frequency among patients whodied rapidly on the field of battle. I only saw it twice, and on eachoccasion in shell wounds. The wounds from small-calibre bullets were asa rule too small to allow of external prolapse. Fig. 89, however, illustrates a very interesting observation. A patientin the German Ambulance in Heilbron, under Dr. Flockemann, died as aresult of suppuration and hæmorrhage secondary to an injury to thecolon. At the autopsy a portion of the omentum was found adherent in thewound of exit, but it had not reached the external surface. The chiefinterest of the observation lies in the light it throws on the mechanismof these injuries. It is impossible to conceive that a small-calibrebullet coming into direct contact with the omentum could do anything butperforate it. It, therefore, appears clear that in a displacement likethat figured, only lateral impact occurred with the omentum, which wascarried along by the spin and rush of the bullet into the canal of exit, where it lodged. [Illustration: FIG. 89. --Great Omentum carried by the bullet into anexit track leading from the abdominal cavity. A. Outline of opening inthe peritoneum] _Results of injury to the intestine. _ 1. _Escape of contents andinfection of the peritoneal cavity. _--I think there is little special tobe said on this subject. The escape of contents into the peritonealcavity was by no means free, unless the injury was multiple. Thus in onecase of injury to the small intestine, No. 166, on which I operated, there was absolutely no gross escape until the bowel was removed fromthe abdominal cavity, when the contents spurted out freely. In one caseof very oblique injury to the colon there was a considerable quantity offæcal matter in a localised space, but as a rule the ordinary conditionbest described as 'peritoneal infection' from the wound was found. Thebad effect of anything like free escape was well shown in multipleperforations; in these suppurative peritonitis rapidly developed and thepatients died at the end of thirty-six hours or less. A typical case isquoted in No. 168. 2. _Peritoneal infection, and general septicæmia. _--As is evident fromthe results quoted among the cases, the degree which this reached variedgreatly. It may of course be assumed that in some measure it occurred inevery case in which the bowel was perforated, but it was sometimes soslight as to be scarcely noticeable. This may be said to have been mostcommon in injuries to the large intestine. Wounds of the cæcum, ascending and descending colon, the sigmoid flexure, or the rectum, weresometimes followed by no serious symptoms, either local or general. Again in these portions of the bowel the development of local signs, andthe later formation of an abscess, were by no means uncommon. In the case of the small intestine I never observed this sequence, andthe same may be said of the transverse colon, which in its anatomicalarrangement and position so nearly approximates to the small bowel. Insuspected wounds of these portions of the bowel either the symptoms wereso slight as to render it doubtful whether a perforation had occurred, or marked signs of general peritoneal septicæmia developed, and deathresulted. The condition of the peritoneum in fatal cases varied much. In some adry peritonitis, or one in which a considerable quantity of slightlyturbid fluid was effused, was found. In others a rapid suppurativeprocess, accompanied by the effusion of large quantities of plasticlymph, was met with. My experience suggested that the latter conditionwas the result of free infection from multiple wounds of the gut, theformer the accompaniment of single wounds. Hence I should ascribe thedifference mainly to the extent of the primary infection. This is perhaps a suitable place to further discuss the explanation ofthe escape of a considerable number of the patients who received woundsof the abdomen, possibly implicating the bowel. Although this was not, Ithink, so common an occurrence as has been sometimes assumed, yet manyexamples were met with. Several reasons have been advanced. (1) Great importance has been given to the fact that many of the menwere wounded while in a state of hunger, no food having been taken fortwelve or more hours before the reception of the injury. In view of thewell-proved fact in these, as in other intestinal injuries, that freeintestinal escape does not occur, and that it is usually a mere questionof infection, this explanation, in my opinion, is of small importance. It might with far more justice be pointed out that many of these woundedmen were for them in the happy position of not having friends freelydosing them with brandy and water after the reception of the injury, andthis was possibly an element of some importance. Some of the men did, however, drink freely, and in one case whichterminated fatally a comrade gave a man wounded through the belly animmediate dose of Beecham's pills. (2) Mr. Treves has suggested that the effect of the severe trauma on themuscular coat of the bowel is to cause a cessation of peristalticmovement. This, as in the case of 'local shock' elsewhere, may no doubtbe of importance, and to it should be added the simultaneous cessationof abdominal respiratory movements in the segment of the belly wallcovering the injured part. The occurrence of general cessation ofperistaltic movement is, however, to some extent opposed by the factthat in a certain number of the cases early passage of motions was seenjust as happens in the intestinal ruptures seen in civil practice. I should be inclined to ascribe the escape from serious infection inthese injuries to the same cause which accounts for their comparativeinsignificance in other regions--namely, the small calibre of the bulletand consequent small size of the lesion: in point of fact to the minimalnature of the primary infection. I very much doubt if any patient whohad more than one complete perforation of the small intestine got wellduring the whole campaign. This opinion is, moreover, supported by thefact that the prognosis was so far better in cases of injury to thelarge than to the small intestine, in which former segment of the bowelwe have the advantages of a position beyond the region in whichintestinal movement is most free, the unlikelihood of multiple injury, and a drier and more solid type of fæcal contents. In the instances in which recovery followed perforating injuries withoutany bad signs we can only assume a minimal infection, and sufficientirritation and reaction on the part of the bowel to produce rapidadhesion between contiguous coils, and thus provisional closure. The other mode of spontaneous recovery which I saw several times takeplace in the injuries to the large bowel consisted in the limitation ofthe spread of infection by early adhesions and the development of alocal abscess. The non-observance of this process in any case of injuryto the small intestine raises very great doubts in my mind as to thefrequent recovery of patients in whom the small intestine wasperforated. INJURIES TO THE INTESTINAL TRACT 1. _Wounds of the stomach. _--A considerable number of wounds in such asituation as to have possibly implicated the stomach were observed, andof these a certain number recovered spontaneously. The only twoinstances that came under my own observation are recorded below. It willbe noted that in each the special symptoms were the classic ones ofvomiting and hæmatemesis. In the first case blood was also passed peranum, and in the second the diagnosis was reinforced by the escape ofstomach contents from the external wound. The second case was a surgical disappointment. No doubt the fatal issuewas mainly dependent on the fact that the external wound had to be keptopen to allow of the escape of the abundant discharge from the woundedliver. In the absence of the hepatic wound, however, I believe it wouldhave been possible for this patient to have got well spontaneously, inview of the firm adhesions which had formed around the opening in thestomach, and the consequent localisation which had been effected. Another unfortunate element in this case was the comminuted fracture ofthe seventh costal cartilage, which maintained the patency of theaperture of exit. The latter point, however, was of doubtful importancefrom this aspect, as the vent provided for the gastric and biliarysecretions may have been the safety-valve that had allowed localisationto develop. I believe that the secondary hæmorrhage was the main element in robbingus of a success in this case, and that this depended on the digestion ofthe wound by the gastric secretion. The early troubles which arose inthe treatment of this patient well illustrate the difficulties by whichthe military surgeon is at times met; but the patient was admirablyattended to and nursed by my friend Mr. Pershouse, and an orderly whowas specially put on duty for the purpose. (163) Wounded at Rensburg. _Entry_ (Mauser), in ninth left intercostal space in posterior axillary line; _exit_, a transverse slit 1/2 an inch in length to left of xiphoid appendage. Patient was retiring when struck; he did not fall, but ran for about 1, 000 yards, whence he was conveyed to hospital. He vomited half an hour after the injury (last meal bread and 'bully beef, ' taken two hours previously), and during the evening three times again, the vomit consisting mainly 'of dark thick blood. ' He was put on milk diet, and not completely starved; on the third day a large quantity of dark clotted blood was passed per rectum with the stool, and this continued for two days. Ten days after the injury the temperature was still rising to 100°, and did not become normal till the fourteenth day. The pulse averaged 80. The abdomen, meanwhile, moved fairly well, respirations 18 to 20. Some tenderness was present in the epigastrium and towards the spleen. Resonance throughout. Ordinary diet was now resumed, and beyond slight epigastric pain on deep inspiration, no further symptoms were observed, and the patient left for England at the end of the month. The spleen may have been traversed in this patient, as well as the lower margin of the right lung. (164*) Wounded at Enslin. _Entry_ (Mauser), 3/4 of an inch from the spine, opposite the eighth intercostal space; _exit_, through the seventh left costal cartilage, 1 inch from the median line. The patient was lying in the prone position when shot: he vomited blood freely, and the bowels acted three times before he was seen forty hours after the accident, each motion containing dark blood. On the commencement of the third day the patient's expression was extremely anxious, and he was suffering great pain. Pulse 96, temperature 100°. Tongue moist, occasional vomiting, bowels open yesterday. Has taken fluid nourishment since injury. The abdomen moved with respiration, but was moderately distended, especially in the line of the transverse colon; it was tympanitic on percussion, there was no dulness in the flanks, and only moderate rigidity of the wall on palpation. Frothy fluid stained with bile and fæcal in odour was escaping from the wound of exit, and the everted margins of the latter were bile-stained. A vertical incision was carried downwards from the wound for 4 inches. A rugged furrow was found on the under surface of the left lobe of the liver; the stomach was contracted and firmly adherent by recent lymph to the under surface of the liver and the diaphragm. The transverse colon was much distended. On separating the stomach a slit wound was found at the lesser curvature, immediately to the right of the oesophagus. This wound was closed with some difficulty with two tiers of sutures; the cavity was mopped out, and then irrigated with boiled water; a plug was introduced along the line of the furrow in the liver, and the lower part of the abdominal incision closed. The patient stood the operation well, and was removed to his tent; during the day, however, two thunder showers occurred during each of which water, several inches if not a foot deep, rushed through the camp. After the second flood he was removed to the operating room, the only house we had, and slept there. The pulse rose to 120, and respiration to 26, and there was pain, which was subdued by 1/3 grain of morphia, administered subcutaneously. A fair amount of urine was passed, and the bowels acted once, the motion containing blood. On the second day after operation there was some improvement; the pulse still numbered 116, and the temperature was raised to 100°, but the belly moved fairly, and pain was moderate. Abundant foul-smelling, bile-stained discharge came from the wound when the plug was removed. Rectal feeding was supplemented by small quantities of milk and soda by the mouth. The condition did not materially change, but on the fourth day it was evident that the suturing of the stomach wound had given way, and liquid food escaped readily when taken. The discharge remained bile-stained and very foul. No extension of inflammation to the general peritoneal cavity occurred, but it was evident that the patient was suffering from constitutional infection from the foul wound, the lower part of which opened up somewhat after the removal of the stitches on the seventh day. The wound was irrigated three times daily with 1-300 creolin lotion, but remained very foul. The man slowly lost strength, although escape from the stomach considerably decreased. On the tenth day a sudden severe hæmorrhage occurred, presumably from a large branch of the coeliac axis. The bleeding was readily controlled by a plug, and did not recur; but the patient rapidly sank, and died on the twelfth day after the operation, and fourteen days after reception of the injury. No _post-mortem_ examination was made. 2. _Wounds of the small intestine. _--These were comparatively common, but offered little that was special either in their symptoms or theresults attending them. Wounds were met with in every part of the smallgut; but I saw no case in which an injury to the duodenum could bespecially diagnosed. As to the symptoms which attended these injuries, it is somewhatdifficult to speak with precision, and it must be left to my readers toform an opinion as to how many of the cases recounted below were reallyinstances of perforating wounds. My own view is that in the majority ofthe cases that got well spontaneously, the injury was not of aperforating nature, and that for reasons which have been already setforth. It will, however, be at once noted that in all the five cases inwhich the injury was certainly diagnosed in hospital death occurred. The cases of injury to the small intestine are perhaps best arranged inthree classes. 1. Those who died upon the field, or shortly after removal from it. Inthese the external wounds were often large, the omentum was not rarelyprolapsed, and escape of fæces sometimes occurred early. Shock from theseverity of the lesion, and hæmorrhage, were no doubt important factorsin the early lethal issue in this class. Many of the injuries were nodoubt produced by bullets striking irregularly, by ricochets, by bulletsof the expanding forms, or by bullets of large calibre. As being beyondthe bounds of surgical aid, this class possessed the least interest. 2. Cases brought into the Field, or even the Stationary hospitals, withsymptoms of moderate severity, or even of an insignificant character, in which evidence of septic peritonitis suddenly developed and deathensued. 3. Cases in which the position of the wounds raised the possibility ofinjury to the intestine, but in which the symptoms were slight or ofmoderate severity, and which recovered spontaneously. The whole crux in diagnosis lay in the attempt to separate the twolatter classes, and, personally, I must own to having been no nearer aposition of being able to form an opinion on this point, in the latethan in the early stage of my stay in South Africa. The advent ofperitoneal septicæmia was in many instances the only determining moment. On this matter I can only add that, in civil practice, an exploratoryabdominal section is often the only means of determination of a ruptureof the bowel wall. With regard to the cases of suspected injury to the bowel whichrecovered spontaneously, the symptoms were somewhat special in theircomparative slightness, and in the limited nature of the local signs. Thus the pulse seldom rose to as much as 100 in rate, 80 was a commonaverage. Respiration was never greatly quickened, 24 was a common rate. The temperature rarely exceeded 100°. Vomiting was occasionally severe, but usually not persistent, ceasing on the second day. A good quantityof urine was passed. As to the local signs, these again were of alimited nature; distension did not occur, or was slight; movement of theabdominal wall was only restricted in the neighbourhood of the wound, the affected area amounted to a quarter, or at most half, the abdominalwall, and rigidity was localised to a similar segment. Local tendernessusually existed; but, as a rule, there was little or no dulness to pointto the occurrence either of fluid effusion or a considerable depositionof lymph. Again many of the patients suffered with very slight symptoms ofconstitutional shock, although there was considerable variation in thisparticular. (165*) Wounded at Graspan, sustaining a compound fracture of the fibula. While being carried off the field, a second bullet (Lee-Metford) entered immediately outside the left posterior superior iliac spine, perforated the pelvis, and emerged 1-1/2 inch within the left anterior superior spine. The patient was then put down and left on the field ten hours; later he was carried to shelter for the night, and arrived at Orange River on the second day. He suffered with some pain in the abdomen, especially during the journey in the train, but was not sick; the bowels were confined. When seen on the third day at 6 P. M. , some pain was complained of in the abdomen, which moved freely in the upper part, but was motionless below the umbilicus. No distension. Tenderness around wound of exit and some rigidity. The bowels had acted four times during the day; motions loose, dark brown, and containing no blood. Face not anxious, eyes bright, temperature 102°. Pulse 96, regular, and of good strength. Tongue moist and little furred. The abdomen was opened at 5 A. M. On the fourth day, as the local signs had become more pronounced, and the patient had passed a restless night in great abdominal pain. A local incision was chosen, as the wound was presumably in the sigmoid flexure. The sigmoid flexure was adherent to the abdominal wall opposite the wound of exit, and a dark ecchymosed patch was found, but no perforation could be detected. Foul pus and gas escaped freely from the pelvis, but no wound of the large bowel could be discovered here. On enlarging the incision upwards three openings were found in a coil of jejunum, probably that about five feet from the duodenal junction usually provided with the longest mesentery. No fourth opening could be found. The openings were circular, about 1/3 inch in diameter, clean cut, with a ring of everted mucous membrane, and the wall of the bowel in the neighbourhood was thickened. All three openings were included within a length of 2-1/2 inches. There was no surrounding ecchymosis of the bowel wall. Very little escaped intestinal contents were found in the situation of the bowel. The latter had apparently been retracted upwards, and lay to the left of the lumbar spine. The wounds were readily closed by five Lembert's sutures, three crossing the openings, and one at each end. The belly was then washed out with boiled water and closed. The delay in finding the wounds due to the mistaken impression that they would be found in the pelvis materially prolonged the operation, which lasted an hour and a half. The patient never rallied, and died seventeen hours later. It is possible that a wound in the sigmoid flexure was present which had already closed at the time of operation. (166*) Wounded at Magersfontein. _Entry_ (Mauser), opposite central point of left ilium; _exit_, 1-1/2 inch above the centre of the right Poupart's ligament. Vomiting commenced soon after the injury, and this was continuous until the patient's arrival in the Stationary hospital on the fourth day, when the condition was as follows:-- Face extremely anxious in expression. Temperature 101°, sweating freely. Pulse 110, fair strength. Tongue moist. Abdomen much distended, rigid, motionless, tympanitic throughout. Bowels confined. No urine had been passed for twenty-four hours, [Symbol: ounce]ij in bladder on catheterisation, clear, and containing no blood. Abdominal section. Median incision. A considerable quantity of bloody effusion was evacuated. Intestine generally congested and distended. No lymph. Two wounds were found in the ileum on the opposite sides of one coil; the openings were circular, with the mucous membrane everted. No escape of fæcal matter was visible until the intestine was delivered, when intestinal contents spurted freely across the room. The openings were sutured with five Lembert's stitches. The bowel was punctured in two places to relieve distension, and then returned into the belly, after washing with boiled water. Four pints of saline solution were infused into the median basilic vein, and 1/30 grain strychnine sulph. Was injected hypodermically. The patient did not rally, and died twelve hours after the operation. (167*) Wounded at Graspan. _Entry_ (Lee-Metford), midway between the umbilicus and pubes; _exit_, 1 inch to the left of the fifth lumbar spine. The patient was seen on the third day in the following condition: in great pain, expression extremely anxious, vomiting constantly. Pulse 150 running, respirations 48. Temperature 100°, sweating freely. Great distension, rigidity, and general tenderness of immobile abdomen. No improvement followed the administration of brandy and hypodermic injection of strychnine 1/30 grain, and operation was deemed hopeless. In the evening the patient was apparently dying. Face blue and sunken and covered with sweat, eyes dull, speechless, pulse imperceptible, restlessness extreme, bowels acting involuntarily, no urine in bladder. The man was placed in a tent by himself, and to my surprise was alive and better the next morning; the expression was still anxious, but the face brighter and not sweating; the pulse only numbered 100, but was very weak, and the hands and feet were cold. The condition of the abdomen was unaltered, but the thoracic respiration had decreased in rapidity from 48 to 28. His condition still seemed to preclude any chance of successful intervention, but none the less life was retained until the morning of the seventh day, the state alternating between a moribund one and one of slight improvement. He was lucid at times, although for the most part wandering, and was so restless that no covering could be kept upon him. Vomiting was continuous, so that no nourishment could be retained; the bowels acted frequently involuntarily, and little or no urine was passed. Meanwhile, the abdomen became flat, then sunken, an area of induration and tenderness about 6 inches in diameter developing around the wound of entry. Slight variations in the pulse, and from normal to subnormal in the temperature, were noted, and death eventually occurred from septicæmia and inanition. (168*) Wounded at Driefontein. _Entry_ (Mauser), above the posterior third of the left iliac crest, at the margin of the last lumbar transverse process (probably through ilio-lumbar ligament); _exit_, 1 inch below and to the left of the umbilicus. The patient was wounded at 3 P. M. , but not brought into the Field hospital until 9 P. M. , when the temperature of the tents was below 28°F. He was considerably collapsed, suffering much pain, and vomited freely. The abdomen was flat, but very tender. Bowels confined. The column had to move at 5 A. M. The next morning, when the temperature was still near freezing, and during the day continuous fighting prevented any chance of operation. The man steadily sank during the day, and died thirty-six hours after the reception of the injury. _Post-mortem condition. _--Belly not distended, dull anteriorly in patches, and right flank dull throughout. When the belly was opened, extensive adhesion of omentum and intestine enclosing numerous collections of pus were disclosed, and on disturbing the adhesions a large collection of turbid blood-stained fluid was set free from the right loin. The great omentum was much thickened and matted, with deposition of thick patches of lymph; very firm recent adhesions also united numerous coils of small intestine. The pus was foetid, but no appreciable quantity of intestinal contents was detected in it. The lower half or more of the small intestine was injected, reddened, and thickened. The wounds which were situated in the lower part of the jejunum and ileum were multiple, and seven perforations were detected; besides these the intestine was marked by bruises, and some gutter slits affecting the serous and muscular coats only. Considerable ecchymosis surrounded these latter. The clean perforations were circular, less than 1/4 inch in diameter, and for the most part closed by eversion of the mucous membrane. Intestinal contents were not apparent, but escaped freely on manipulation of the bowel. (169*) Wounded at Magersfontein. _Entry_ (Mauser), over the eighth rib in the anterior axillary line; _exit_, 1 inch to the left of second lumbar spinous process, just below the last rib. Vomiting commenced almost immediately after reception of the injury, and the bowels acted frequently. This condition persisted until the fourth day, when the patient was brought down to Orange River, and the signs were as follows. Considerable pain in left half of abdomen, pulse 110, fair strength, temperature 101°. Some general distension of abdomen with complete disappearance of hepatic dulness. Some movement of right half of abdomen, left half immobile, dulness extending from the flank as far forwards as linea semilunaris. An incision was made in left linea semilunaris, and Oj blood evacuated from the left loin. There was no lymph on the intestines nor sign of inflammation. No perforation was discovered in either stomach or intestine, but on two coils of jejunum there were deep slits 3/4 inch long, extending through both peritoneal and muscular coats. Beyond these wounds, on other coils oval patches of ecchymosis, due to direct bruising, were present. The peritoneal cavity was sponged free of all blood and irrigated with boiled water; no bleeding point was discovered, and the abdomen was closed. The next morning the patient was comfortable; temperature 100. 2°, pulse 100. Tongue clean and moist; he vomited once during the night. Some bloody discharge had collected in the dressing, and at the lower angle of wound there was a local swelling, apparently in the abdominal wall. The flank was resonant. During the afternoon the patient became faint, and when seen at 6 P. M. Was in a state of collapse, in which he shortly died. Death was apparently due to renewal of the previous hæmorrhage. No _post-mortem_ examination was made. (170*) Wounded at Magersfontein. _Entry_ (Mauser), 1/2 inch to the left of the second sacral spine; _exit_, immediately below the left anterior superior iliac spine; the patient was kneeling at the time, and the same bullet traversed his left thigh in the lower third. When seen on the third day, the lower part of the abdomen was motionless, tumid, and tender. The bowels had been confined for three days; there had been no sickness, and the tongue was moist and clean. Temperature 100°, pulse 90, fair strength, respirations 38. The patient had once had an attack of acute appendicitis, and he himself said he was sure he now had 'peritonitis, ' as he had pain exactly similar in the belly to that he had suffered in his previous illness. No further signs, however, developed under an expectant treatment, and he remained some two months in hospital, while the wound in the thigh and a third injury to the elbow-joint were healing. (171) _Entry_ (Mauser), at the highest point of the left crista ilii; _exit_, through the right ilium, 2 inches horizontally anterior to the posterior superior spine. Absolutely no abdominal symptoms followed. The bowels were confined five days, and then opened by enema. The patient complained of some stiffness in the lumbo-sacral region, but the right synchondrosis was no doubt implicated in the track. (172) Wounded at Paardeberg (range 800 yards). _Entry_ (Mauser), 2 inches diagonally below and to the right of the umbilicus; _exit_, not discoverable. For the first two days the patient had to lie out with the regiment; on the fourth he was removed to the Field hospital. During the first three days the patient vomited (green matter) frequently, and the belly was hard and painful; as biscuit was the only available food, no nourishment was taken. The bowels acted on the second night. At the end of a week the patient was sent by bullock wagon (three days and nights) to Modder River, and then down to Capetown, where he walked into the hospital on the thirteenth day, apparently well. Two days later the temperature rose to 104°, and enteric fever was diagnosed, no local signs pointing to the injury existing. The patient made a good recovery. (173) Wounded at Colenso. _Entry_ (Mauser), at junction of outer 2/5 with inner 3/5 of line from right anterior superior iliac spine to umbilicus; _exit_, at upper part of right great sacro-sciatic foramen, in line of posterior superior iliac spine. Advancing on foot when struck; he then fell and crept fifty yards to behind a rock, where he remained seven and a half hours. For two days subsequently he vomited freely; the bowels acted nine hours after the injury, and then became constipated. No further symptoms were noted, and at the end of three weeks the abdomen was absolutely normal. The man is now again on active service. (174*) Wounded at Modder River while retiring on foot. _Entry_ (Mauser), at highest point of right iliac crest; _exit_, 2-1/2 inches to right of and 1/2 inch above level of umbilicus. The injury was not followed by sickness, and the bowels remained confined. During the first two days 'pain struck across the abdomen' when micturition was performed. When the patient came under observation on the third day the condition was as follows:--Complains of little pain, temperature normal, pulse 72, respirations 24, tongue moist, bowels confined. Rigidity of abdominal wall and deficient mobility of nearly whole right half of belly, the whole lower half of which moves little with respiration. No track palpable in abdominal parietes. No dulness, no distension. The temperature rose to 99. 5° at night. On the fourth day the bowels acted freely, the pulse fell to 60, the respirations were 24, and the temperature normal. Tenderness and rigidity persisted in the right flank to the end of a week, after which time no further signs persisted. (175*) Wounded at Modder River while lying on right side. Range 500 yards. Walked 400 yards after injury. _Entry_ (Mauser), at the junction of the posterior and middle thirds of the right iliac crest; _exit_, 3 inches to right of and 1/2 inch below the level of the umbilicus. The injury was followed by no signs of intra-abdominal lesion; on the third day the temperature was normal, pulse 80, and the tongue clean and moist. Some soreness at times and tenderness on pressure were complained of, but the man was discharged well at the end of one month. (176*) Wounded while doubling in retirement at Modder River. _Entry_ (Mauser), immediately above the junction of the posterior and middle thirds of the left iliac crest; _exit_, 1 inch below costal margin (eighth rib), 3 inches to the right of the median line. The bullet was lying in the anterior wound, whence it was removed by the orderly who applied the first dressing on the field. The patient remained on the field seven and a half hours, and when brought into hospital at once commenced to vomit. The ejected matter, at first green in colour, during the next forty-eight hours changed to a dirty brown. Meanwhile, the abdomen was somewhat painful. When seen on the third day he had ceased to vomit for three hours. The face was slightly anxious, and the patient lay on the ground with the lower extremities extended. Temperature 99°, pulse 72, fair strength. Respirations 32, shallow. Tongue moist, lightly furred, bowels not open for four days. He slept fairly last night. Abdomen soft, moving well with respiration, no distension, slight tenderness below and to the right of the umbilicus, and local dulness in right flank. The next day the pulse fell to 60 and the bowels acted, but there was no change in the local condition. The man looked somewhat ill until the end of a week, but was then sent to the Base, and at the expiration of a month was sent home well. (177*) Wounded at Modder River. Two apertures of _entry_ (Mauser); (_a_) below cartilage of eighth rib in left nipple line; (_b_) 2 inches below and 4-1/2 inches to the left of the median line. No exit wound discovered, and no track could be palpated between the two openings, which were both circular and depressed. When seen on fourth day there was tenderness in the lower half of the abdomen, and the left thigh was held in a flexed position. Respirations 20, respiratory movement confined to upper half of abdominal wall. Pulse 70, temperature 99°. Tongue moist, covered with white fur; bowels confined since the accident; no sickness. The patient remained under observation thirteen days, during which time pain and difficulty in movement of the left thigh persisted, also slight tenderness in the lower part of the abdomen; but at the end of a month he was sent to England well, but unfit to take further part in the campaign. I thought the bullet might be in the left psoas, but it was not localised. (178*) Wounded at Modder River. _Entry_ (Mauser), 3-1/2 inches above and 1-1/2 inch within the left anterior superior iliac spine; _exit_, 1-1/2 inch to the right of the tenth dorsal spinous process. The same bullet had perforated the forearm just above the wrist prior to entering the abdomen. No local or constitutional signs indicated either bowel injury or perforation of liver. The man, however, was suffering from a slight attack of dysentery, passing blood and mucus per rectum with great tenesmus. He was sent to the Base at the end of a week, and returned to England well three weeks later. He attributed his dysentery to the wound, as the symptoms did not exist prior to its reception; but as the disease coincided exactly with what was very prevalent amongst the troops at the time, I do not think there was any connection between it and the injury. (179) Wounded near Thaba-nchu. _Entry_, over the centre of the sacrum at the upper border of fourth segment; _exit_, 1-1/2 inch above left Poupart's ligament, 2 inches from the median line. Aperture of entry oval, with long vertical axis. Exit wound a transverse slit, with slight tendency to starring (see fig. 19, p. 58). One hour after being shot the patient vomited once. There was some evidence of shock and considerable pain. The bowels acted involuntarily simultaneously with the vomiting, and incontinence of fæces and retention of urine persisted for four days. The vomit was bilious in appearance; no blood was seen either in it or the motions. Forty-six hours after the injury the condition was as follows: Face slightly anxious and pale; skin moist, temperature 100. 4°; pulse 116, regular and of fair strength; respirations 24; abdomen slightly tumid; tenderness over lower half, especially on left side; the lower half moves little with respiration. Twenty-four hours later the patient had improved. He was comfortable and hopeful; slept well with morphia 1/3 grain hypodermically. Tongue moist, covered with white fur; has been taking milk only, [Symbol: ounce]ij every half-hour. No sickness. Temperature 99°. Pulse 104. Respirations 24. Abdomen flatter; general respiratory movement; tenderness now mainly localised to an area 2-1/2 inches in diameter, to the left of the umbilicus, above exit wound. The patient continued to improve, and on the fifth day travelled six hours in a bullock wagon to Bloemfontein. Soon after arrival his temperature was normal: pulse 80, respirations 16, with good abdominal movement. Local tenderness persisted in the same area, but was less in degree. Tongue rather dry, bowels confined. Micturition normal. Two drachms of castor oil and an enema were given. On the ninth day patient was practically well, except for slight deep tenderness. He remained in bed on ordinary light diet, but at the end of the third week he was seized by a sudden attack of pain, the temperature rising to 103° and the pulse to 140, the abdomen becoming swollen and tender. He was then under the charge of Mr. Bowlby, who ordered some opium, and the symptoms rapidly subsided. Although this wound crossed the small intestine area, it is probable that the symptoms may have been due to an injury of the rectum or sigmoid flexure. 3. _Wounds of the large intestine. _--Injuries to every part of the largebowel were observed, and spontaneous recoveries were seen in all partsexcept the transverse colon, which, as already remarked, is near akinto the small intestine with regard to its position and anatomicalarrangement. The only case of perforation of the vermiform appendix that I heard of, one under the care of Mr. Stonham, died of peritoneal septicæmia. Several cases of recovery from wounds of the cæcum and ascending colonare recounted below. The only points of importance in the nature of thesigns of these injuries were their primary insignificance, and thecomparative frequency with which _local_ peritoneal suppuration followedthem. The absence of a similar sequence in some of the cases in whichwounds of the small intestine were assumed, was, in my opinion, one ofthe strongest reasons for doubting the correctness of the diagnosis. Itis also a significant fact that injuries of the ascending colon--that isto say, of the portion of the large bowel which perhaps lies most freefrom the area occupied by the small intestine--were those which mostfrequently recovered. The following cases afford examples of the course followed in a numberof injuries to the large intestine, and illustrate both theuncomplicated and the complicated modes of spontaneous recovery. No. 180 affords a good example of an extra-peritoneal injury, and of theespecially fatal character of such lesions. This case was also one of mysurgical disappointments. Nos. 182, 183 are of great interest in several particulars. First, theaperture of exit was large and allowed the escape of fæces, not a verycommon feature in wounds not proving immediately fatal. Secondly, inneither were any peritoneal signs observed. Thirdly, in each the exitwound communicated with the pleura, and the patients died fromsepticæmia mainly due to absorption from the surface of that membrane(_Pleural septicæmia_). No. 190 is a most striking instance of spontaneous cure, since no doubtcan exist that both rectum and bladder were perforated. (180*) _Injury to the cæcum and ascending colon. _--Boer, wounded at Graspan while sheltering behind a rock, lying on his back. _Entry_ (Lee-Metford), in right thigh, 3 inches below and 1 inch within anterior superior spine of ilium; _exit_, in back, on a level with the fourth lumbar spinous process and 3 inches from that point. Half an hour after the wound the patient commenced to suffer severe stabbing pain; he lay on the field one hour; later he was taken to a Field hospital, and on the second day was sent by train a distance of twenty-five miles. When seen at the end of fifty hours the condition was as follows. Face anxious, complexion dusky. Great abdominal pain, especially about the umbilicus. Vomiting frequent and distressing; bowels confined since the accident; tongue dry and furred. Urine scanty. Pulse full and strong, 125; respirations, entirely thoracic, 30. Abdomen generally distended and tympanitic, wall rigid and motionless. Dulness in right flank, together with superficial oedema and emphysema. Abdominal section fifty-three and a half hours after accident. Incision in right linea semilunaris. Great omentum adherent to ascending colon, which was covered with plastic lymph. Gas and intestinal contents escaped from an opening at the line of reflexion of the peritoneum from the ascending colon; retro-peritoneal extravasation and emphysema extended the whole length of the ascending colon and around duodenum, the wall of the colon itself exhibiting subperitoneal emphysema. The colon was freed and the rent sewn up with interrupted sutures. About [Symbol: ounce] iv of foul fæcal fluid were evacuated from loin, and a free counter-opening made. The opening in the ilium by which the bullet had entered the abdomen was found at the brim of the pelvis; the loin and peritoneal cavity were sponged dry and flushed with boiled water; no lymph was seen on the small intestine. A large gauze plug was inserted into the posterior wound, one end of the plug being brought out of the operation incision. During the succeeding six days progress was not unsatisfactory: the abdomen became soft, moved with respiration, there was no sickness, and the bowels acted. The pulse fell to 90, respirations to 20, and the temperature did not exceed 102° F. The wound suppurated freely, however, and although there were no further signs of peritoneal septicæmia, it was evident that general infection had taken place, and on the sixth day a parotid bubo developed on the right side, which was opened. On the seventh day the patient suddenly commenced to fail rapidly; vomiting was almost continuous--at first curdled milk, later frothy watery fluid--and on the eighth day he died. The abdomen remained soft, sunken, and flaccid, and death no doubt resulted from general septicæmia rather than from peritoneal infection, absorption taking place from the large foul cavity behind the colon. As the cavity in part surrounded the descending duodenum, this possibly accounted for the attack of vomiting which preceded death. (181*) _Ascending colon. _--Wounded at Graspan while lying in prone position. _Entry_ (Mauser), over ninth rib in line of right linea semilunaris; _exit_, in right buttock, just below and behind the top of the great trochanter. The injury was followed by little abdominal pain, but a strange sensation of local gurgling was noted. The bowels acted as soon as the patient reached camp, some hours after being wounded. There was no sickness and nothing abnormal was noted in the motions, except that they were loose and light-coloured. On the evening of the third day the patient came under observation in the ambulance train for Capetown. He looked somewhat anxious and ill, but he complained of little pain; the temperature was 102°, pulse 88, fair strength, soft and regular. There was local dulness, tenderness, and deficiency of movement in the right iliac region. As it was night, he was removed from the train and an operation was performed the next morning. Prior to operation the condition was as follows: Pulse 84, temperature 100°; respiration easy, 20. Tongue moist, but thickly coated in centre. Abdomen moves fairly, and is resonant, except in right lower quadrant. No distension. Dulness, tenderness, and rigidity in right iliac region, marked to outer side of cæcum. Entry wound nearly and exit quite healed. Cannot flex right thigh. The following operation was performed. Appendix incision, about [Symbol: ounce]j of fæcal fluid and fæces in a localised cavity on outer and anterior aspect of cæcum evacuated; adhesions very firm. Cavity sloughy throughout and cæcum covered with dull grey lymph. The opening in the bowel was not localised, and it was considered wiser to treat the case like one of perforation from appendicitis than to run the risk of breaking down adhesions. A small awl-like opening was found in the ilium with powdered bone at its entrance leading to the wound of exit. The after-treatment of the case gave rise to no anxiety, but healing of the resulting sinus was slow; fæcal-smelling pus escaped for some days, and a number of small sloughs came away. On the twelfth day the patient was sent down to Wynberg, where he remained twelve weeks. A counter-incision was needed in the loin to drain the suppurating cavity three weeks after the primary operation, and five weeks after the operation an escape of gas and fæces took place from the anterior wound, while the bowels were acting, as a result of a dose of castor oil. No further escape of fæces occurred, and he left for England with a small sinus only. No extension of inflammation into the original wound track ever occurred, both openings and the canal healing by primary union. The sinus remained open, and occasionally discharged for a further period of six months, and then healed firmly; since when the patient has been in perfect health. (182*) _Splenic flexure, descending colon. _--Wounded at Magersfontein. _Entry_ (Mauser), in sixth left intercostal space in mid-axillary line; _exit_, in left loin, below last rib, at outer margin of erector spinæ. The patient remained in the Field hospital three days, during which time he exhibited no serious abdominal symptoms, but during the journey to Orange River (53-1/2 miles) he was sick. He remained at Orange River two days, and while there an enema was administered, producing a normal motion. The abdomen was slightly distended; it moved fairly, there was slight rigidity, but little tenderness. Temperature 100. 8°, pulse 120. No appearance of fæces in wound. When seen on the sixth day the condition was as follows:--Patient cheerful and not in great pain. Temperature 99. 2°; pulse 120; respirations 48, very shallow. Abdomen soft, moving freely, no distension or general tenderness. Fluid fæces escaping in abundance from the wound in loin. Redness of skin and swelling below level of wound, and cellular emphysema above. Fæcal-smelling fluid was also escaping from the thoracic wound. The wound was enlarged, but the patient rapidly sank, and died of septicæmia on the seventh day. (183*) An exactly similar case came under observation from the battle of Modder River, except that the opening in the loin was somewhat larger, and earlier and freer escape of fæces took place from it. In this also fæcal matter passed freely into the left pleural cavity, and fæcal matter was expectorated, while there was an almost complete absence of abdominal symptoms. Death occurred on the fourth day. No _post-mortem_ examination was made in either case, but I believe in both the extra-peritoneal aspect of the colon was implicated and that the septicæmia was in great part due to absorption from the pleural rather than the peritoneal cavity, since in neither case were the abdominal symptoms a prominent feature. (184) _Possible wound of cæcum. _--Wounded at Spion Kop. Bullet (Mauser) perforated the right forearm, then entered belly. _Entry_, 3 inches from the right anterior superior iliac spine, in the line of the supra-pubic fold of the belly wall (a transverse slit); _exit_, in right buttock, on a level with the tip of the great trochanter and 2 inches within it. The wound was received immediately after breakfast had been eaten. There was retention of urine and constipation for three days, but no sickness. Local pain and tenderness were severe, and at the end of three weeks there was still local tenderness, slight induration, and dragging pain on defæcation. The patient returned to England at the end of a month well, except for slight local tenderness. (185) _Possible wound of colon. _--Wounded at Paardeberg; range 200 yards. Walking at time. The bullet (Mauser) perforated the left forearm, just below the elbow-joint. _Entry_, into belly 1 inch anterior to the tip of the left eleventh costal cartilage; no exit. The injury was followed by pain in the left half of the abdomen and vomiting, which continued for two days. The bowels acted on the third day; no nourishment was taken for two days, but a small quantity of water was allowed. No further symptoms were noted, and at the end of a fortnight the patient was well, except for slight local tenderness. The bullet could not be detected with the X-rays. (186) _Wound of cæcum_. --Wounded at Paardeberg. _Entry_ (Mauser), 2 inches diagonally above and within right anterior superior iliac spine; _exit_, immediately to the right of the fifth lumbar spinous process; the patient was lying on his left side when struck. A burning pain down the right thigh immediately followed the accident, and lasted some days. There was no sickness, the bowels were confined three days, and there was pain across the back and down the thigh. On the tenth day he arrived at the Base, when he was lying on his back suffering considerable pain. The temperature ranged to 101°. There was diarrhoea and cystitis, with a considerable amount of pus in the urine, which was very offensive. A small fluctuating spot existed on the back, just to the right of the original exit wound which was firmly healed. The abdomen moved fairly with respiration in its upper part, but was motionless below, especially in the right iliac fossa; some induration was to be felt here. The right thigh was kept flexed. During the next few days the pus disappeared from the urine, and with this change the induration in the right iliac fossa increased. An incision (Mr. Gairdner) was made into the fluctuating spot behind, and pus evacuated. The patient recovered. (187) _Possible wound of cæcum. _--Wounded outside Heilbron. _Entry_ (Mauser), in the right loin, 2-1/2 inches above the iliac crest, at the margin of the erector spinæ; _exit_, 1-1/2 inch above and within the right anterior superior spine of the ilium. There was little shock. The patient was brought six miles in a wagon into camp, and slept comfortably with a small morphia injection. Prior to the accident the patient was suffering from diarrhoea, but afterwards the bowels were confined. The next morning there had been no sickness and little pain. The tongue was moist and clean, the pulse 80, the respirations 24, the belly moved generally, although inspiration was shallow; the temperature was 99°. Slight tenderness in the belly to the inner side of the exit wound, but no dulness. The patient was starved for the first thirty-six hours, a little warm water then being allowed. No symptoms developed, and a perfect recovery followed. (188) _Colon_, _liver_. --Wounded outside Heilbron. _Entry_ (Mauser), midway between the last right rib and the crista ilii; _exit_, below the eighth costal cartilage in nipple line. There were no serious primary symptoms, but ten days after the accident the temperature rose, swelling and pain developed in the right loin, and on the fourteenth day a large tympanitic abscess was opened (Dr. Flockemann, German Ambulance. ) Fæcal-smelling gas and pus were evacuated. There was no extension of the abscess forwards. A week later the patient had much improved, although there were evident signs of general absorption, and the discharge from the abscess cavity was abundant and very foul. On the thirteenth day a serious hæmorrhage occurred from the loin wound, which was opened up, but no evident source was discovered; hæmorrhage was repeated the next day, and the man died. At the _post-mortem_ examination a large quantity of chocolate-coloured fluid was found free in the abdomen and pelvis. A chain of small local abscesses was found surrounding the ascending colon, and a larger one over the front of the cæcum. The wall of the ascending colon was generally thickened, and from this, in three places, openings with rounded margins connected the abscess cavities with the lumen of the bowel. One of the openings, larger than the others, was possibly the aperture of entry of the bullet; the others were apparently spontaneous. At the anterior border of the right lobe of the liver an abscess cavity existed in connection with the wound of the liver, and this was continuous with the aperture of exit, although not discharging. The aperture of exit was plugged by a tag of omentum (see fig. 89). No obvious source of the hæmorrhage was forthcoming, but it probably originated in one of the large branches of the vena cava. The bullet had struck the transverse process of the lumbar vertebra, but had not given rise to any signs of spinal concussion. (189*) _Ascending colon. _--Wounded at Modder River. _Entry_ (Mauser), midway between the tip of the tenth right rib and the iliac crest. Bullet retained. A second wound existed over the centre of the left sterno-mastoid, and the bullet here was also retained and never localised. The patient stated that he brought up blood at short intervals for half an hour immediately after he was wounded. This might have been explained by the wound in the neck, but no difficulty in swallowing was noted. The bowels acted the day after he was shot, and, except for some local tenderness and immobility, no abdominal signs were noted. Three weeks later a swelling was obvious to the right side of the umbilicus, and a tympanitic abscess developed; this was opened, and a deformed Mauser bullet extracted. Foul pus, but no fæcal matter, was evacuated, and after discharging for a fortnight the wound closed, and the man was sent home as 'well. ' In this case I assumed a wound of the ascending colon had occurred. (190*) _Rectum and bladder. _--Wounded at Graspan, while retiring at the double. _Entry_ (Mauser), 1 inch to the right of the coccyx; _exit_, 1 inch above the junction of the middle and outer thirds of left Poupart's ligament. The man suffered with some pain in the abdomen, and for first two days with retention of urine. The urine was drawn off with the catheter, and contained blood. During the next five days micturition was hourly or more frequent; gas was passed _per urethram_, and the urine was very foul, containing evident fæcal matter. Micturition continued frequent, with purulent cystitis for one month. Local tenderness, pain, and immobility developed over the lower quarter of the abdomen, extending to the right iliac fossa. A local abscess pointed a little to the right of the mid line, and 2 inches above the symphysis, and from this foul-smelling pus, but no fæces, was discharged for three months, during which period the surrounding dulness and induration gradually decreased and the sinus healed. When the patient left for England there was still occasional slight discharge from the original wound of entry, and there was slight discomfort on micturition, but he was otherwise well. A year later the man had resumed active duty, and, except for occasional pain on stooping, considered himself well. The following cases are appended as of some general interest. The firsttwo (191, 192) illustrate extra-peritoneal injuries to the rectum. Inneither did positive evidence exist of wound of the bowel, but thesymptoms in each rendered this accident probable. Case 193 is anillustration of apparent escape of the anal canal in a wound in whichfrom the position of the external apertures this escape would haveappeared impossible. Wounds of the extra-peritoneal portion of the rectum, as a rule, appeared to have a somewhat better prognosis than would have beenexpected; in any case, the prognosis was far better than that obtainingin wounds of the base of the urinary bladder. My experience on thesubject of these wounds was, however, limited to the two cases quoted. Case 194 is inserted as an example of the complicated nature of theabdominal injuries not so very unfrequently met with. It illustrateswell the difficulty which may arise at any stage in the course oftreatment of an injury, in the certain determination or exclusion ofwound of a part of the alimentary canal. (191) Wounded at Magersfontein. _Entry_ (Mauser), in the right loin, immediately below the ribs in the mid-axillary line; _exit_, about the centre of the left buttock, on a level with the tip of the great trochanter. A second lacerated shell wound of back was present. All the wounds suppurated. For the first sixteen days following the injury all control was lost over the anal sphincter, and bloody fæces, and later slime, constantly escaped, but no fæcal matter ever escaped from the wound in the buttock. There was no history of previous dysentery, and rectal examination afforded no information. The buttock wound had to be opened up, disclosing a tunnel in the ilium. The wounds granulated slowly with continuous suppuration, but were healed, and the patient returned home at the end of fourteen weeks, the bowels acting normally. (192) Wounded at Paardeberg. _Entry_ (Mauser), at the junction of the middle and posterior thirds of the left iliac crest; the bullet was retained, and removed (Mr. Pegg) from the back of the right thigh, 3 inches below the back of the great trochanter. After the injury retention of urine followed, with incapacity to control loose motions, though solid ones could be retained. The retention was treated by catheterisation, which was followed by cystitis. The power of micturition was slowly recovered, and three weeks later he could pass water, at times in a dribbling stream only; the cystitis had improved. The man returned to England very much improved, but not quite well, at the end of five weeks. (193) Wounded at Modder River. _Entry_, in the right buttock, near the outer border at the upper part; _exit_, at the lower part of outer border of left buttock. The line of the wound exactly crossed the position of the anus, but no sign of injury to the rectum could be discovered. (194) Wounded at Magersfontein. _Entry_ (Mauser), 1/2 inch below the margin of the iliac crest, at the junction of its middle and posterior thirds, and on a level with the fifth lumbar spinous process; _exit_, below the cartilage of the eighth rib, just within the left nipple line. Struck while retiring; fell at once, and remained thirty hours on the field. Patient stated that he vomited 'blood like coffee grounds' six times while lying on the field, and twice after being brought in. His bowels were confined for three days. His right lower extremity was paralysed. On the fifth day there was considerable induration around the wound of exit, and the upper half of the abdomen was immobile and tender. The temperature rose to 100°, and the pulse was 96. Shortly afterwards a similar condition was noted in the lower half of the abdomen; the temperature continued to be raised and the pulse quickened, when on the thirteenth day a considerable quantity of pus was passed per rectum, and diarrhoea set in; this continued for three days, with marked improvement in the general symptoms. Micturition, which had been painful, became normal; the pulse and temperature fell, and the expression became less anxious. The patient continued to sleep badly, however, and complained of pain. At the end of the third week he still looked ill, but was easier. Temperature normal in the morning, 100° in evening, pulse 80. Tongue thickly furred, but moist. Still on milk diet; appetite bad; bowels irregular. The abdomen moved little in the lower half, induration persisted in the left iliac fossa, the left thigh continued flexed, and resonance was impaired to the left of the umbilicus. At the end of six weeks a distinct hard swelling in two parts, separated by a resonant area, was noted to the left of the umbilicus and in the left iliac fossa. The abdomen moved fairly, and there was little tenderness over the swelling. During the next week the swelling appeared to increase and to fluctuate; at the same time the temperature again began to rise to 100° and 101° at eve. The swelling was taken to be a localised peritoneal suppuration, and an incision was made over it; but this led down to a free peritoneal cavity, with a tumour pressing up from the posterior abdominal wall. The wound was therefore closed, and a fresh extra-peritoneal incision made, immediately above Poupart's ligament, when the swelling proved to be a large retro-peritoneal hæmatoma. As the cavity extended into the pelvis and up to the level of the costal margin, it was deemed wise only to evacuate a part of the blood-clot. The origin of the bleeding was not determined, and the wound was closed and healed by first intention. The man continued to improve, and left for home five weeks later. This patient has continued to improve since his return, but the left thigh is still somewhat flexed. _Prognosis in intestinal injuries. _--This was of a most discouragingcharacter compared with the prognosis in abdominal injuries as a whole. The cases were of two classes, however: those that died withintwenty-four hours, and those that died at the end of from three days toa week. Cases falling into the first category are obviously of little importancefrom the point of view of surgical treatment. Many of them died from thewidespread nature of the injury, and the shock produced by it; othersfrom hæmorrhage from the large abdominal vessels. It is unlikely thatany could have been saved, even under the most satisfactory conditions. In the following small table, therefore, I have included only the caseswhich have been already quoted, which survived long enough to beamenable to surgical treatment, and which were for some days under myown observation. Some of them, in fact almost all, I watched until theywere either convalescent, or died, and in six I performed operations. I am aware, and have short details of the histories of eight patientswounded in the same battles who died prior to the termination of thefirst thirty-six hours; but these are not included, for the reasonstated above, and also because I am uncertain whether all the injurieswere produced by bullets of small calibre. -------------------------+-----------+-------------+-----------+------+ | | Localised | | |Viscous wounded | Number of | Secondary | Recovered | Died | | cases | suppuration | | | | | occurred | | |-------------------------+-----------+-------------+-----------+------+Stomach certain | 2 | -- | 1 | 1 |Stomach possible | 1 | -- | 1 | -- |Small intestine certain | 5 | 0 | -- | 5 |Small intestine possible | 10 | 0 | 10 | -- |Large intestine certain | 8 | 4[21] | 4 | 4 |Large intestine possible | 4 | -- | 4 | -- |-------------------------+-----------+-------------+-----------+------+Bladder certain | 3 | 3 | 1 | 2 |Bladder possible | 1 | -- | 1 | -- |Liver | 6 | -- | 6 | -- |Kidneys | 6 | -- | 4 | 2 |Spleen | 3 | -- | 2 | 1 |-------------------------+-----------+-------------+-----------+------+ Total | 49[22] | -- | 34 | 15 |-------------------------+-----------+-------------+-----------+------+ Included in the above table are thirty instances of intestinal injury, and these are divided up according to the segment of the intestinalcanal implicated, and also as to whether the perforation was certain, oronly assumed from the position of the external apertures and thepresence of abdominal symptoms of a noticeable grade. From this analysis it appears clear-- 1. That wounds of the stomach have a comparatively good prognosis, andthat they may recover spontaneously. It is true that only two examplesare included in my table; but I was at various times shown patients withsimilar injuries and histories, and a number of cases which have beenpublished appear to substantiate the opinion. From our experience of theoccasional spontaneous recovery of gastric perforations from disease, Ithink we might be prepared to expect that the stomach would offer acomparatively favourable seat for these wounds. It may be pointed out, however, that hæmatemesis, the main feature in the symptoms pointing towound, is by no means direct proof of more than contusion. 2. That perforating wounds of the small intestine are very fatalinjuries; every patient in whom the condition was _certainly_ diagnoseddied. 3. That in the cases in which a perforation was inferred from theposition of the external apertures and the symptoms, not one patientsuffered from the secondary complications--_e. G. _ local peritonitis andsuppuration, which were common in the case of the large intestine, andwhich we are accustomed to see after perforation from disease. Thisrenders the occurrence of actual perforation in the majority of thecases a matter of very grave doubt. If spontaneous recovery does take place after this injury, it is only incases in which the wounds are single, and slight in character. 4. That in eight cases in which perforation of the large intestine wascertain, four recoveries took place; but in each instance suppurationoccurred. I am, however, quite prepared to believe that perforation mayhave occurred in some or all of the other four cases included as'possible, ' provided the wounds were intra-peritoneal. Wounds of the cæcum and ascending colon are those which have the bestprognosis, and after these of the rectum. The comparatively goodprognosis in these parts is what would be expected, on account of theirgreater fixity, and lesser tendency to be covered by the smallintestine. An extra-peritoneal wound of any of these portions of the bowel is moredangerous than an intra-peritoneal, and more likely to give rise tosepticæmia. Of the cases included in my table eighteen of the possible intestinalinjuries were observed among the wounded of the four battles of theKimberley relief force. These cases I saw early and followed to theirtermination, and I believe the list contains the great majority of allthe patients who received intestinal wounds in those battles. On inquiryI could not learn of others from the officers of the Field hospitals;but no doubt some patients died before their reception into hospital, and some may have been overlooked; again, I know of two cases in whichdeath took place within the first week, but which went direct to theBase and did not come under my observation. These exceptions being made, we have a fairly complete series, from which some deductions may bedrawn. The cases included are marked with an asterisk. Of the eighteen cases, eight or 44. 4 per cent. Died. These were made upas follows:--Stomach, one case; this patient died at the end of fourteendays, as a result of secondary hæmorrhage and septicæmia. It wascomplicated by a severe wound of the liver and also one of the lung. Small intestine, four certain cases; all died, two after operation inthe stage of septicæmia, and one after operation from recurrenthæmorrhage, possibly from the mesentery. Of the other six cases one canonly say that the position of the wounds was such as to render wound ofthe intestine possible, and that all suffered with abdominal symptoms ofsome severity. Large intestine. Of six cases in which wound was certain, three died, one after operation. One recovered after operation, two recovered withlocal peritoneal suppuration. In one case the injury could only bereturned as possible. In connection with this subject I have received permission from Mr. Watson Cheyne to quote the statistics published by him[23] concerningthe abdominal wounds observed after the fighting at Karree Siding, onMarch 29, which are as follows:-- 'The number of the wounded was 154, and in fifteen it was considered that the abdominal cavity had been penetrated. Of these patients, five had already died within twenty-four to twenty-eight hours after the injury, and I saw ten who were still alive. Of these nine were left alone, and four died within the next twenty-four or thirty-six hours; five were still alive when I left Karee on Sunday afternoon, April 1. On one I operated, but he died on April 2. The Karee statistics are really the only complete ones which I have as yet been able to obtain. The following are the notes of the cases above alluded to. Besides the five cases of abdominal wounds which had already died, and of which I could get no complete details, the following ten are cases which I saw from twenty-four to thirty hours after they were shot:-- CASES FROM THE ACTION AT KAREE CASE I. --The point of entrance was 2 inches to the right of the umbilicus, and the bullet was found lying under the skin far back in the left loin. The patient was pulseless, and there was much rigidity of the abdomen, tenderness, and vomiting. He died a few hours later. CASE II. --The bullet, coming from the side, had entered the abdomen 4 inches below and behind the right nipple. There was no exit wound. The patient had been vomiting a good deal, but not any blood; the abdomen was very rigid and tender. He was obviously very ill, and died the next morning. The bullet had probably perforated the liver and _stomach_. CASE III. --There was a large wound above the right anterior iliac spine (probably the point of exit), and a small opening behind and near the spine on the same side. There was great tenderness and rigidity of the abdomen. He died a few hours later. CASE IV. --In this case there was a transverse wound of the abdomen, the bullet having entered on the right side in the middle of the lumbar region and passed out on the left side, rather higher up and further back. All the symptoms of acute peritonitis were present. The patient died the next morning. CASE V. --The bullet had entered the anterior end of the sixth intercostal space on the left side, and was found lying under the skin over the seventh intercostal space on the right side and about 2 inches further back. He had vomited blood on the previous day. The bullet may have perforated the _stomach_. The epigastrium was somewhat tender, but there were no marked symptoms. On April 1 he was going on well. CASE VI. --The place of entrance of the bullet was 1 inch in front of the right anterior superior spine, and of exit behind the left sacro-iliac synchondrosis. There was much hæmorrhage at the time. His condition when I saw him was fair, and there was no marked abdominal tenderness. On April 1 his morning temperature was 101°. There were no signs of general peritonitis, and his condition was good. CASE VII. --The bullet had entered from behind, about the tip of the twelfth rib on the left side, and had left about the middle of the epigastrium, and rather to the left of the middle line. Vomiting was still going on, but not of blood. There was much tenderness and rigidity of the abdomen, and he was almost pulseless. On April 1 his general condition was better, but the abdomen was very rigid and tender. (Subsequently died. ) CASE VIII. --The point of entrance of the bullet was about 2 inches from the anterior end of the seventh left intercostal space, and of exit rather lower down and further back on the right side. The patient said that he had vomited brown fluid after the injury. There was much abdominal pain, but his general condition was fair. On April 1 there was still much pain, but his general condition was good. CASE IX. --The bullet had entered about 1-1/2 inch in front of the anterior inferior spine on the right side, had gone directly backwards, and had come out in the buttock. The patient, however, suffered very little. On March 31 there was slight tympanites and tenderness in the right iliac fossa. The bowels acted well, and no blood was passed. On April 1 he was very well, and it was considered very doubtful if any viscus was wounded. CASE X. --The point of entrance was in the middle of the right buttock, a little above the level of the trochanter; the exit was through the anterior abdominal wall in the right semilunar line at the level of the umbilicus. The patient was decidedly ill; the abdomen was a good deal distended, and pressure on it caused an escape of gas through the anterior opening. There was a good deal of abdominal tenderness and rigidity. I opened the abdomen outside the right linea semilunaris, and found a perforation in the anterior wall of the _ascending colon_, without any adhesions around, which was easily stitched up. The posterior opening was found about 2 inches lower down, with a piece of omentum firmly adherent to it and completely closing it. As the patient was in a bad state, I thought it better, instead of excising the piece of intestine beyond the holes or tearing off the omentum, to leave the wounds alone, merely cleaning out the peritoneal cavity as well as I could and arranging for free drainage. He rallied from the operation very well, and for twenty-four hours it looked as if he might get better; but he gradually got worse and died on April 2. ' The above statistics are particularly valuable, as they give theincidence of abdominal injuries compared with those in general in onedefinite battle. This amounted to the high number of 15 in 154 or 9. 74per cent. Wounded. I am inclined to think that this is a higherproportion than the average of the campaign, and that more of the menmust have been exposed in the erect position than was ordinarily thecase during the fighting. The statistics also show that 33. 33 per cent. Of the patients withabdominal injuries died within from twenty-four to twenty-eight hours, and that the percentage of deaths had risen to 73. 33 per cent. At theend of the third day. These numbers again seem high, but in thisrelation it may be noted that, as a small force only was present, and asall the patients were together, Mr. Cheyne had unusually goodopportunities for seeing all the cases. One other point is doubtful from the report, and that is what percentageof the wounds were caused by bullets of small calibre. In one case it isdefinitely stated that the wound was large, and in the second that gasescaped from the wound; both of these may have been instances in which alarge bullet, or some expanding form, had been employed, and there is nodoubt that the use of such projectiles was more common at this stage ofthe campaign than it was earlier. _Treatment of injuries to the intestine. _--Some general rules for theimmediate treatment of all cases may be laid down. First, the patientsmust be removed with as little disturbance as possible, and absolutestarvation must be insisted upon. If the patients be suffering fromsevere shock, hypodermic injections of strychnine should beadministered, or possibly some stimulant by the rectum. After a battle, when these cases may be brought in in considerablenumber, they should be collected and placed in the same tent. Theobjection to congregating a number of severely wounded patients togethermust be disregarded in the face of the manifest advantage of being ableto treat all alike in the matter of feeding. After the battles of theKimberley relief force, Surgeon-General Wilson, at my request, had allthe abdominal cases placed in a large marquee, where we were able tocarefully watch the whole of the patients from hour to hour, and littlechance existed for any indiscretion on the part of the patients in theway of eating or drinking. If possible, the patients should be kept absolutely quiet until they areevidently out of danger. A week's stay at Orange River sufficed for thisobject in the cases referred to. The avoidance of transport ismanifestly of extreme prognostic importance. When feeding is commenced at the end of twenty-four or thirty-six hours, it must be in the form at first of warm water, then milk administered intea-spoonfuls only. In doubtful cases the use of morphia must be avoided. Operative treatment is required in a certain number of the cases, but inthe majority of instances we are met with the extreme difficulty that ina very large proportion of the occasions upon which these wounds arereceived an exploratory abdominal section is not warranted inconsequence of the conditions under which it has to be performed. A word must be added as to these difficulties; they are in part purelyof an administrative nature, partly surgical. After a great battle thewounded are numerous, and amongst them a very considerable proportion ofthe wounds and injuries are of such a nature as to do extremely well ifpromptly dealt with, and each of these makes small demands on the timeof the staff. Abdominal operations, on the other hand, areunsatisfactory from a prognostic point of view, and their performancerequires much time and the assistance of a considerable number of themen, who are obliged to neglect the treatment of the more promisingcases for those of doubtful issue. This difficulty, although notsurgical in its nature, is nevertheless a practical one of greatimportance and appeals strongly to the Principal Medical Officers incharge of the arrangements. It is only to be avoided by an increase ofthe staff, which is not likely to be made except on very specialoccasions. Other difficulties are purely surgical. First, the difficultyof diagnosing with certainty a perforating lesion. In the presence ofthe fact that many incomplete lesions follow wounds crossing theintestinal area, and that these give rise to modified symptoms, Ibelieve this determination to be impossible without the aid of anexploratory incision. Here we are met with the remaining surgicaldifficulties--disadvantages such as the absence of sufficient aid to theoperating surgeon, difficulties connected with the temperature, wind, and dust, and as to the subsequent treatment of the patient. Againdifficulty in obtaining the most important adjunct, suitable water, orindeed any water in a sufficient quantity. It is of course obvious that conditions may exist in which all thesetroubles may be avoided. Again, the practical difficulty adverted toabove does not come in the way when a single man happens to sustain anabdominal wound on the march. Under such circumstances an explorationmay be not only justifiable, but obligatory, and the general rules ofsurgery must be followed rather than such incomplete indications as aresuggested below. My own experience led me to the following conclusions: 1. A wound in the intestinal area should be watched with care. In theface of the numerous recoveries in such cases, habitual abdominalexploration is not justified, under the conditions usually prevailing inthe field. 2. The very large class of patients excluded by this rule from operationleads us to a smaller and less satisfactory number to be divided intotwo categories: Patients who die during the first twelve hours. The whole of these arenaturally unfit for operation, and their general condition when seenoften precludes any thought of it. Patients with very severe injuries, as evidenced by the escape of fæces, or with wounds from flank to flank or taking an antero-posterior coursein the small intestinal area. These patients die, and the majority ofthem will always die whether operated upon or not. The undertaking ofoperations upon them is unpleasant to the surgeon, as being unlikely tobe attended with any great degree of success, whence the impression maygain ground that patients are killed by the operations. None the less, Ithink these operations ought to be undertaken when the attendantconditions allow, and it is from this class of case that the realsuccesses will be drawn in the future. The history of such injuries, after all, corresponds exactly with what we were long familiar with intraumatic ruptures in civil practice, and now know may be avoided by asufficiently early interference. The whole question here is one of time, and this will always be the trouble in military work. 3. The expectant attitude which is obligatory under the above rules indoubtful cases, brings us face to face with a large proportion ofpatients in the early or late stage of peritoneal septicæmia. Thesecases run on exactly the same lines as those in which the same conditionis secondary to spontaneous perforation of the bowel, in which weconsider it our duty to operate, and in which a definite percentage ofrecoveries is obtained. Hence another unpleasant duty is here imposedupon the surgeon. Two such cases on which I operated are recountedabove, and although I cannot say they give much encouragement, I shouldadd that in the only one I left untouched, I regretted my want ofcourage for the five days during which the patient continued to carry ona miserable existence. 4. The treatment of the cases in which an expectant attitude is followedby the advent of localised suppuration presents no difficulty; simpleincision alone is needed, and healing follows. As a rule this is a late condition. In one case of injury to theascending colon recounted above, however, considerable local escape offæces had occurred, and a successful result was obtained by a localincision on the third day without suture of the bowel. In this case Ibelieve the wound in the bowel to have been of the nature of a longslit, but the surrounding adhesions were so firm as to render anyinterference with them a great risk, and a successful result wasobtained at the cost of a somewhat prolonged recovery. I am convincedthat the best course was followed here. (No. 131. ) When the suppuration was of a less acute character, it was generallyadvisable to allow the pus to make its way towards the surface beforeinterference. 5. Cases of injury to the colon in which the posterior aspect isinvolved should be treated by free opening up of the wound, and eitherby suture of the bowel or else its fixation to the surface. I operatedon one such case, and although the patient eventually died on the eighthday, from septicæmia, he certainly had a chance. Two cases where theopening looked so free that one almost thought the wound could beregarded as a lumbar colotomy did badly; in both infection of thepleura took place, besides extension of suppuration into theretro-peritoneal areolar tissue. In the future I should always feelinclined to enlarge such wounds and bring the bowel to the surface. As regards actual technique the majority of the wounds are particularlywell suited to suture; three stitches across the opening and one ateither end of the resulting crease sufficed to close the openingeffectively. The openings in the small intestine were not as a ruledifficult to find, on account of the ecchymosis which surrounded them. From what I have seen stated in the reports given by other surgeons, there seems to have been more difficulty in discovering wounds in thelarge gut. Under ordinary circumstances the only instruments speciallyneeded are a needle and some silk. At my first two operations, as myinstruments had gone astray, the wounds were readily closed by a needleand cotton borrowed from the wife of a railway porter. If aseptic sponges or pads are not available, boiled squares of ordinarylint may be employed for the belly, and towels wrung out of 1 to 20carbolic acid solution used to surround the field of operation. Wheneverthere is any likelihood of the necessity for operations, water boiledand filtered should be kept ready in special bottles. When septic peritonitis was already present, the ordinary procedure ofdry mopping, followed by irrigation, was necessary, before closing thebelly. The after-treatment should be on the usual lines as to feeding, &c. I am unaware to what degree success followed intestinal operationsgenerally during the campaign. I saw only one case in which the smallintestine had been treated by excision and the insertion of a Murphy'sbutton in which a cure followed: this case was in the Scottish Royal RedCross hospital under the care of Mr. Luke. I heard of two cases in whichthe large intestine was successfully sutured, and of one other in whichrecovery followed the removal of a considerable length of the smallbowel for multiple wounds. In concluding these most unsatisfactory remarks, I should add that theimpressions are those that were gained as the result of the conditionsby which we were bound in South Africa, and which might recur even in amore civilised region. Under really satisfactory conditions nothing Isaw in my South African experience would lead me to recommend anydeviation from the ordinary rules of modern surgery, except in so far asI should be more readily inclined to believe that wounds in certainpositions already indicated might occur without perforation of the bowelwhen produced by bullets of small calibre; and further in cases where Ibelieved the fixed portion of the large bowel was the segment of thealimentary canal that had been exposed to risk, I should not be inclinedto operate hastily. A careful consideration of the whole of the cases that I saw leaves mewith the firm impression that perforating wounds of the small intestinediffer in no way in their results and consequences when produced bysmall-calibre bullets, from those of every-day experience, although whenthere is reason merely to suspect their presence an exploration is notindicated under circumstances that may add a fresh danger to thepatient. _Wounds of the urinary bladder. _--Perforating wounds of the bladder arethe injuries nearest akin to those we have just considered, but a greatgulf separates them, in so far as the escape of a few drops or even aconsiderable quantity of normal urine does not necessarily meanperitoneal infection. The difference in this particular was veryforcibly demonstrated in my experience, since an uncomplicatedperforation of the bladder in the intra-peritoneal portion of the viscusproved to be an injury that not infrequently recovered spontaneously, Ibelieve in a considerable proportion of the cases. I include only one such case in my list because it was the only examplewhich happened to be under my personal observation during its wholecourse, but from time to time I was shown several others in which theposition of the external apertures and the transient presence ofhæmaturia left little doubt as to the nature of the injury. The caserecounted above, No. 190, is of especial interest, since the patientrecovered from an injury which involved both the bladder and a fixedportion of the large intestine in contact with its posterior surface. In another, No. 194, a transient inflammatory thickening pointed to alocal inflammation of a non-infective character, since no suppurationensued, and this may have been a case of extra-peritoneal wound; on theother hand, the bladder may have entirely escaped injury. In wounds ofthe portions of the viscus not clad in peritoneum, as a rule, a verydifferent prognosis obtains. Two typical cases are related, which Ibelieve fairly represent the general results which follow when thebladder is either wounded behind the symphysis or at the base. The firstcase, No. 195, exemplifies a very characteristic form of wound whensmall-calibred bullets are concerned. The bullet, taking a course moreor less parallel to that of the wall of the viscus, cut a long slit inits anterior wall. This bullet in its onward passage comminuted thehorizontal ramus of the pubes, and lodged in the thigh. Into the latterregion the greater part of the extravasated urine escaped. I think thehistory of this case fully shows that I made a blunder in not performinga proper exploration, instead of contenting myself with an incision inthe thigh. My only excuse was that the patient at the time I saw him wasin a very collapsed state, and a severe grade of abdominal distensionsuggested that septic peritonitis was already in an advanced stage. Inpoint of fact, the patient at once improved, sufficiently so to be ableto undergo a second exploration at a later date by Mr. Hanwell at theBase, only dying of septicæmia at the end of twenty-one days. Even afree supra-pubic vent might, I believe, have given him a chance of life. When the perforation was at the base of the bladder, however, theprognosis was very bad, and, as far as I know, not a single patientescaped death. The increase of risk in an extra-peritoneal wound of thisviscus is indeed very great, while an intra-peritoneal perforation maybe considered an injury of lesser severity, provided the urine be ofnormal character. (194_a_) _Possible wound of the bladder. _--Wounded at Magersfontein. _Entry_ (Mauser), immediately above the symphysis pubis; _exit_, in the buttock, behind the tip of the left great trochanter. The man was struck while advancing, and fell, thinking at the time 'that he was struck in the foot. ' He lay twelve hours on the field, and passed water for the first time when the bearer removed him. During the next two days he passed urine only twice, and no blood was noticed. The bowels acted on the evening of the third day. When seen on the fourth day he complained of aching pain in the lower part of the belly, and a concentric patch of tender induration extended for about 1-1/2 inch around the wound. The abdominal wall was moving well. The tongue was clean and moist. There was no blood in the urine, and micturition was not frequent. Temperature 99. 4°. Pulse 80, good strength. The patient was then sent to the Base. At the end of seventeen days there was still a little tenderness in the left iliac fossa; but the man was otherwise well, and at the end of a month he was sent home. (195) _Extra-peritoneal wound of the bladder. _--Wounded at Magersfontein. _Entry_ (Mauser), at the fore part of the right buttock. No exit. The patient was seen on the third day. He had an expression of extreme anxiety, and complained of very great pain in the abdomen and thigh. The abdomen was greatly distended and tympanitic, and the left thigh and groin were very much swollen and oedematous, with some redness of surface. Temperature 100°, pulse 120. No sickness, tongue moist, bowels confined. Retention of urine. The condition of the patient was very grave; but he was anæsthetised, clear urine was withdrawn from the bladder by catheter, and an incision was made into the thigh just below the inner third of Poupart's ligament, where fluctuation was evident. Two pints of bloody urine were evacuated, and when a finger was introduced it passed over a fracture of the pubes into the pelvis, but not into the peritoneal cavity. In view of the patient's condition it was not thought wise to proceed further, and he somewhat improved later, and was sent to the Base. Loss of power in the right lower extremity pointed to injury to the anterior crural nerve. On the patient's arrival at Wynberg there were signs of local peritonitis in the lower half of the abdomen, and all his urine was passed from the wound in the left thigh. Some days later this wound was enlarged to allow of the freer exit of pus, and a fragment of bone was removed. The wound granulated healthily, but the man steadily emaciated and lost ground, with signs of chronic septicæmia, and he died on the twenty-first day. At the _post-mortem_ examination a transverse wound of the anterior wall of the bladder behind the pubes, below the peritoneal reflexion, was found gaping somewhat widely, and 2 inches in length. There was little sign of previous peritonitis. The retained bullet was discovered beneath the femoral vessels in the left thigh. (196) _Extra-peritoneal perforation of the bladder. _--Wounded at Paardeberg. _Entry_ (Mauser), 3 inches above the left tuber ischii; _exit_, above the symphysis, immediately over the right margin of the penis. The patient was retiring to fetch ammunition when shot. Urine was noted to escape from both apertures the day after, and this continued until he was sent down to the Base on the fourteenth day. The patient was then considerably emaciated, complained of great pain, especially down the left thigh (sciatic nerve), the temperature averaged 100°, the pulse 80, tongue clean and moist, bowels acted regularly, no sign of injury to the rectum. He was taking food fairly, but was very sleepless. Urine was passed per urethram, and also escaped by both wounds. The abdomen was flaccid and sunken, respiratory movements being confined to the upper half. As there was evidence of considerable infiltration in the buttock, the original entry wound was enlarged, and a catheter was tied into the bladder. Little change occurred in the symptoms and the local condition, urine and pus continued to escape freely from the posterior wound, and the patient gradually sank, dying on the thirty-eighth day. At the _post-mortem_ examination the peritoneum was found intact and unaltered, but there was extensive pelvic cellulitis around the bladder, a large slough and some pus lying in the cavum Retzii. An aperture of entry still open existed in the centre of the anterior wall of the bladder, and a patent exit opening at the base of the trigone. The bullet had passed out of the pelvis by the great sciatic notch. The above remarks and cases sufficiently set forth the prognosis inthese injuries. For the intra-peritoneal lesions an expectant plan oftreatment may be followed by uncomplicated recovery. Mention has alreadybeen made of a case in which a Mauser bullet was retained in the bladderand was subsequently passed per urethram. In such a case a cystotomywould be indicated were the bullet discovered in the viscus. As to extra-peritoneal injuries it is difficult to lay down guidinglines. I believe the ideal treatment would be a supra-pubic cystotomyand drainage of the bladder by a Sprengel's pump apparatus, such as weemploy at home. Under these circumstances, with the possibility ofkeeping the bladder actually empty, I believe good results might beobtained. Certainly drainage of the bladder by a catheter tied in provedworse than useless, and I very much doubt whether a simple supra-pubicopening would give any better results under the circumstances underwhich a patient has to be treated in a Field hospital. Cases might, however, occur in which oblique passage of the bullet cutsa groove and makes a large opening in the peritoneum-clad portion of theviscus. Under satisfactory conditions a laparotomy would be hereindicated. I take it that this condition would most probably beaccompanied by retention of bloody urine, which fact would arousesuspicion. INJURIES TO THE SOLID ABDOMINAL VISCERA _Wounds of the kidney. _--Tracks implicating the kidneys were ofcomparatively common occurrence. As uncomplicated injuries they healedrapidly, and without producing any serious symptoms beyond transienthæmaturia. The nature of the lesion appeared to vary with the direction of thewound. In many cases a simple puncture no doubt alone existed, an injuryno more to be feared than the exploratory punctures often made forsurgical purposes. In other cases the wounds may have been of the natureof notches and grooves. Two of the cases recounted below were of a more severe variety; in one(No. 201) both kidneys were implicated by symmetrical wounds of theloin, and in the case of the right organ a transverse rupture wasproduced, which was followed by the development of a hydro-nephrosis, and later by suppuration. This injury was probably the result of a woundfrom a short range, as the patient was one of those wounded in the earlypart of the day at the battle of Magersfontein. It was complicated by awound of the spleen and an injury to the spinal cord producingincomplete paraplegia accompanied by retention of urine. The lastcomplication was responsible for the death of the patient, sinceascending infection from the bladder led to the development ofpyo-nephrosis and death from secondary peritonitis. Case 202 is an instance of a transverse wound of the upper part of theabdominal cavity; it is impossible to say what further complicationswere present. The early development of a tympanitic abscess suggested aninjury to the colon, but this was not by any means certain. Thecondition of the kidney was very likely similar to that in the lastcase, but the ultimate recovery of the patient left this a matter ofdoubt. The case was also one dependent on a short-range wound, since thepatient, one of the Scandinavian contingent, was wounded atMagersfontein during close fighting. The common history of the symptoms after a wound of the kidney wasmoderate hæmorrhage from the organ, persisting for two to four days. Inone of the cases recounted below the hæmaturia was accompanied by thepassage of ureteral clots, but this was not a common occurrence. For the sake of comparison I have included one case of wound of thekidney from a large bullet, in which death was due to internalhæmorrhage. In this instance the injury was a complex one, the lungcertainly, and the back of the liver probably, being concurrentlyinjured. None the less if the same track had been produced by a bulletof small calibre I believe the injury would not have proved a fatal one. I never saw such free renal hæmorrhage in any of the Mauser orLee-Metford wounds. (197) _Wound of right kidney. _--Wounded at Modder River while lying in the prone position; retired 100 yards at the double with his company, and walked a further 1-1/2 mile. There was very slight bleeding. _Entry_ (Mauser), in the tenth right intercostal space in the mid-axillary line; _exit_, in eleventh interspace, 2 inches from the spinous processes. Cylindrical blood-clots, 3 inches in length, were passed on the first two occasions of micturition after the accident, and the urine contained blood. For four days he could only lie on the wounded side. When seen on the third day the urine was normal, and there were no signs of injury to either thoracic or abdominal viscera. He returned to England well at the end of a month. (198) _Wound of right kidney. _--Wounded at Modder River while kneeling to dress another man's wound. _Entry_ (Mauser), in the seventh right intercostal space in the nipple line; _exit_, 1 inch to the right of the twelfth dorsal spine. The man was carried off the field, and during the first day vomited frequently. For two days there was blood in his urine, and he passed water four to five times daily. He returned to duty at the end of three weeks. (199) _Wound of the left kidney. _--Wounded at Magersfontein. _Entry_ (Mauser), 2 inches to the left and 1 inch below the left nipple. No exit. Lying in prone position when struck. Bloody urine was passed at normal intervals for four days, when the hæmaturia ceased. No thoracic signs, and no other sign of abdominal injury. There was tenderness in the left loin below the twelfth rib for some days, possibly over the position of the bullet, but the latter was neither localised nor removed. (200) _Wound of the right kidney. _--Wounded at Magersfontein while retiring on his feet. _Entry_ (Mauser), immediately to the right of the second lumbar spinous process; bullet retained and lay beneath margin of ninth right costal cartilage. The man passed urine containing blood twelve times during the first day, and hæmaturia continued until the evening of the third day. On the third day the belly was tumid and did not move well; there was no dulness in the right flank. Pulse 120, fair strength. Temperature 99°. Respirations 20. Tongue moist, bowels confined for four days. The fifth day the pulse fell to 76, and the bowels were moved by an enema. Great tenderness over bullet. The tenderness persisted over the bullet and also in the right flank until the tenth day, when the bullet was removed. At the end of a month the patient returned to England well but during the third week there was occasionally blood in the urine. (201) _Wound of both kidneys (rupture of right) and spleen. _--Wounded at Magersfontein. _Entry_ (Mauser), (_a_) 1 inch to right of second lumbar spinous process; (_b_) above angle of left ninth rib: _exits_, (_a_) 1 inch internal to right anterior superior iliac spine; (_b_) in seventh intercostal space in mid-axillary line. The wound on the right side gave rise to a lesion of the lumbar bulb (see p. 315), and the patient suffered throughout with retention. There was complete paralysis of the right lower extremity, both motor and sensory. For ten days there was hæmaturia, and very severe cystitis developed, while the patient suffered with severe abdominal pain. The cystitis persisted, also retention, which gradually gave way to dribbling, while irregular rise of temperature and tenderness in the loins pointed to ascending inflammation in the ureters. The patient gradually lost ground, and a month later suddenly developed signs of peritonitis, severe vomiting, distension, and dulness in the right flank; and in two days he died. At the _post-mortem_ examination the following condition was found:--On the right side general pleural adhesions, recent lymph over ascending colon and cæcum, [Symbol: ounce]vj of bloody fluid in a localised cavity between colon, kidney, stomach, and liver. Lower quarter of right kidney in half its width separated from main part of organ, yellow in colour, and enveloped in disintegrating clot. Blood-staining of psoas sheath; no injury to vertebral column or to bowel detected. On the left side recent pleural adhesions and consolidation of base of lung, rent of diaphragm; spleen soft and disorganised and presenting a yellow cicatrix at its upper end, and at antero-external aspect of left kidney was a soft yellow puckered spot about the size of a florin, dipping 3/4 of an inch into the organ, which was otherwise healthy, beyond congestion. The capsules of both kidneys were adherent, but there was no sign of suppuration. (202) _Wound of right kidney. Traumatic hydronephrosis. _--Wounded at Magersfontein. _Entry_ (Lee-Metford), in the eleventh intercostal space in the posterior axillary line; _exit_, in the tenth right interspace, in mid axillary line. The patient was in the prone position when struck, and lay on the field from 5 A. M. Until 6 P. M. There was no sickness, and the bowels did not act. When seen on the fourth day he was cheerful, but in some pain. The abdominal wall moved well, but was rigid; there was some general distension, and very marked local distension of the gastric area extending across to the right, so that a depressed band extended between the upper and lower parts of the belly. There was marked local dulness in the right flank, which did not shift on movement; the abdomen was elsewhere tympanitic. Tongue furred, bowels confined; there has been no sickness, and no hæmatemesis. Urine normal, and in good quantity. Temperature 100°. Pulse 84, good strength. There was impairment of sensation in the area of distribution of the external cutaneous and crural branch of the genito-crural nerves. On the sixth day the bowels acted, after the administration of [Symbol: ounce]j of sulphate of magnesia, and the distension was much lessened, although the belly retained its unusual appearance. The dulness in the flank was unaltered. Temperature 100. 8°, pulse 92. A week later the man was much improved, suffering no pain. Temperature ranged from 99 to 100°, and the pulse about 80. The abdomen was normal in appearance, except for general prominence of the right thorax in the hepatic area. During the third week a large tympanitic abscess developed at the aperture of exit, and this was opened (Mr. S. W. F. Richardson) through the chest, and a large collection of foul-smelling pus, but no fæcal matter, evacuated. The patient again improved, but a fortnight later a swelling and apparent signs of local peritonitis developed in the right inguinal and lower umbilical and lumbar regions. An incision made over this, however, disclosed a normal peritoneal cavity and was closed. At the end of ten weeks the patient was sent to the Base hospital; a large firm swelling was then evident, extending from the liver to the inguinal region, and nearly to the median line. This gradually increased until it filled half the belly; it was at first thought to be a retro-peritoneal hæmatoma (similar to that described in case 194), but it became quite soft and fluctuating, and was then tapped, and [Symbol: ounce]50 of blood-stained fluid, which proved to be urine, were removed. The urine rapidly reaccumulated, and the cavity was then laid freely open. Urine continued to discharge in large quantity for two months, the man meanwhile remaining well, and passing a somewhat variable daily quantity of urine ([Symbol: ounce]xxiv-[Symbol: ounce]lx). At the end of six months the wound had healed, and the man was serving as an orderly in the hospital. (203) _Wound of right kidney and lung. _--Wounded near Paardekraal, while crawling on hands and knees. _Entry_ (Martini-Henry, or small bullet making lateral impact), just above the right nipple, opening ragged and large, bullet retained. There was very severe shock, accompanied by vomiting, but no hæmatemesis. Later there was some hæmoptysis. Pulse 120, respirations 48. Twenty-four hours later the vomiting had ceased; the patient had passed a restless night, in spite of an injection of morphia. He lay on his right side, pale and collapsed, but answered questions and was quite collected. Pulse imperceptible, respirations 56; the abdomen moved freely. The urine had been passed twice, and was chiefly blood. The patient died shortly afterwards, apparently mainly from internal hæmorrhage, although restlessness was not a prominent feature. As the Column was on the march no autopsy was possible. The treatment of uncomplicated wounds of the kidney consisted in theensurance of rest, either alone, or with the administration of opium ifthe hæmaturia was severe. The after-treatment in the event of thedevelopment of hydronephrosis is on ordinary lines. Tapping, or incisionfollowed by extirpation of the injured viscus, if the less severeprocedures failed. I never saw a case where renal hæmorrhage suggestedthe removal of the kidney as a primary step, and much doubt whether sucha case is likely to be met with, as the result of a wound from a bulletof small calibre. _Wounds of the liver. _--Wounds of the liver were, I believe, responsiblefor more cases of death from primary hæmorrhage than those of thekidney. I heard of a few cases in which this occurred, although I neversaw one. Case 204 is of considerable interest as illustrating the resultof an injury to one of the large bile ducts. Putting the deaths fromprimary hæmorrhage on one side, the prognosis in hepatic wounds was asgood as in those of the kidneys. A few fairly uncomplicated cases arequoted below, but wounds of the liver occurred in connection with alarge number of other injuries both of the chest and abdomen, and exceptin the case of wound of the stomach, recorded on page 425, No. 164, andin case 188, I never saw any troublesome consequences ensue. _Nature of the lesions. _--I never saw any case of so-called explosivelesion of the liver, such as have been described from experimentalresults; this may have been due to the fact that such patients rapidlyexpired, but such were never admitted into the hospitals. The most favourable cases were those in which a simple perforation waseffected; such were usually attended by a practical absence of symptoms, unless a large bile duct had been implicated, when a temporary biliaryfistula resulted. Biliary fistulæ were, however, much more common when the bullet scoredthe surface of the organ. One such case is recounted under the headingof injuries to the stomach, No. 164. Here a deep gaping cleft withcoarsely granular margins extended the whole antero-posterior length ofthe under surface of the left lobe, and the escape of bile was free. This was the nearest approach to one of the so-called explosive injuriesI met with. Case 207 is an example of a superficial injury from a bullet possibly ofsmall calibre in which a superficial groove was followed by temporaryescape of bile, and it is of interest to note a very similar conditionin a shell injury (No. 210) recorded on p. 477. Although both these cases recovered, I think notching and superficialgrooving must be considered much more serious injuries than pureperforation. (See case 188, p. 442. ) The symptoms observed in these injuries have been already indicated inthe above description of the nature of the lesions. They consisted inthe pure perforations of practically nothing, in the grooves or theperforations implicating a large duct in the escape of bile. In two ofthe cases in which a biliary fistula was present transient jaundice wasnoticed. In many cases the accompanying wound of the diaphragm gave rise to muchdiscomfort; again, in the transverse wounds the action of the heart wasoften affected by the local cardiac shock accompanying the injury. Inone case in which the colon was at the same time wounded (No. 188), anabscess formed at the site of the hepatic wound, as might have beenexpected. As uncomplicated injuries, these wounds were little to be feared. Exceptas a source of hæmorrhage in rapidly dying patients, I never heard of afatality. As a complication of other injuries, however, the wound of theliver, as has been shown, was sometimes of importance. It was remarkablein case 204 how little trouble the biliary fistula gave rise to, although the bile was discharged across the pleural cavity. The treatment consisted in rest, and morphia in the cases of suspectedprogressive hæmorrhage, or in the presence of great pain. In cases wherebile was escaping, it was important to ensure a free vent for thesecretion. (204) _Wound of liver. Biliary fistula. _--Wounded at Magersfontein. _Entry_ (Lee-Metford), below the seventh rib, in the left nipple line; _exit_, through the eighth rib, in the mid axillary line on the right side. The patient lay for seventeen hours on the field, during which time the bowels acted once, but there was no sickness. The bowels then remained confined. When seen on the third day the abdomen was normal and the chest resonant throughout on both sides; bile to the amount of some ounces escaped from the wound on the right side. Suffering no pain; temperature 99°, pulse 100. The bowels acted freely the following day. During the next fortnight there was little change; [Symbol: ounce]ii-iij of bile escaped daily, and there was occasional diarrhoea. At the end of that time, however, the temperature rose; there was local redness and evidence of retention of pus. The wound was therefore enlarged, some fragments of rib removed, and a drainage tube inserted. After this the temperature fell, and for the next two months the patient suffered little except from the discharge from the sinus; this persisted for three months, becoming less in amount and less bile-stained, the fistula eventually closing in the fourteenth week, when the patient was sent home on parole. (205) _Wound of liver_. --_Entry_ (Mauser), 1 inch below and to the left of the ensiform cartilage; _exit_, in the sixth right intercostal space, just behind the posterior axillary line. The trooper was sitting bolt upright on his horse at the time; both were shot and fell together. 'Stitch' on coughing or laughing was the only sign noted after the accident; this rapidly subsided. (206) _Wound of the liver. _--Wounded at Magersfontein. _Entry_ (Mauser), through the seventh left costal cartilage, 1 inch from the base of the ensiform cartilage; _exit_, below the twelfth rib 2 inches to the right of the lumbar spines. The patient lay on the field some hours and was brought in at night very cold, and suffering with much shock. No signs of abdominal injury developed, but the pulse remained as slow as 66 for some days, and there was some pain and stiffness about back and sides, or on taking a deep breath. These signs persisted some days, but no others developed, and in six weeks the patient returned to duty. Some three months later this patient suffered from a short severe attack suggesting local peritonitis, but he again returned to duty. (207) _Wound of the liver. _--Wounded at Tweefontein. _Entry_, in eighth intercostal space in right mid axillary line; _exit_, 1-1/2 inch below the point of the ensiform cartilage, 1/2 an inch to the right of the mid line. The wounds were large, and although the impact had been oblique, they were possibly produced by a Martini-Henry or Guedes bullet. On the second day bile began to escape from the exit aperture, and this together with a little pus continued to be discharged for a week, when the wound rapidly healed up. The only symptom which occasioned any trouble was a stitch on inspiration, probably attributable to the wound of the diaphragm. There was no fracture of the rib. (208) _Wound of the liver. _--Wounded outside Heilbron at a range of fifty yards. _Entry_ (Mauser), in the tenth right interspace 2 inches to the right of the dorsal spines; _exit_, through the gladiolus, immediately to the right of the median line, and just above the junction with the ensiform cartilage. There was considerable shock on reception of the injury, and a great feeling of dizziness. Continuous vomiting set in and persisted for the first two days, then became occasional, and ceased only at the end of a week. There was also occasional hiccough, and stitch on drawing a long breath. The respiration was shallow and rapid. The bowels acted twice shortly after the injury. The pulse was rapid and small, and a week after the injury was still above 100. The abdomen was then normal and moving symmetrically, and the respiration fairly easy. There were no signs of chest trouble, but some mucous expectoration. A slight icteric tinge existed. The patient made a good recovery. _Wounds of the spleen. _--Uncomplicated wounds of the spleen werenecessarily rare, and beyond this the strict localisation of a track tothe spleen is not a matter of great ease. None the less the spleen musthave been implicated in a considerable number of the wounds crossing thechest and abdomen. I know of only one case in which a wound whichcrossed the splenic area caused death from hæmorrhage, and of this I cangive no details, as I never saw the patient. In this instance, however, a wound of the spleen was diagnosed after death from the position of thewounds. The patient continued to perform his duty as an officer in thefighting line for at least an hour after being struck, and then diedrapidly apparently from an internal hæmorrhage. In case No. 201, included amongst the renal injuries, a wound of thespleen existed, but had given rise to no symptoms, and at the time ofdeath, some three weeks later, was cicatrised. The only other assertionof importance that I can make is, that, as far as I could judge, woundsof the spleen from bullets of small calibre were not, as a rule, accompanied by hæmorrhage, since I never saw a case in which dulness inthe left flank suggested the presence of extravasated blood, and in nocase that I saw was there any history of general symptoms pointing tothe loss of blood. This is only to be explained by our similar experience with regard towounds of the liver unaccompanied by puncture of main vessels, andperhaps hæmorrhage is still less to be expected in the case of thespleen, in consequence of the contractile muscular tunic with which theorgan is provided. I can quote no case of certain injury to the spleen, except that alreadyreferred to discovered at a _post-mortem_ examination, but many woundswere observed in positions of which the following may be taken as atype. _Entry_, through the seventh left costal cartilage, 3/4 of an inchfrom the sternal margin; _exit_, 2-1/2 inches from the left lumbarspines at the level of the last rib. As an instance of the doctrine of chances I might quote the position ofthe wound in the patient who lay in the next bed. Both patients werewounded while fighting at Almonds Nek. _Entry_, through right seventhcostal cartilage, 3/4 of an inch from the sternal margin; _exit_, 1-1/2inch from the lumbar spines, at the level of the last right rib. In neither of these cases did anything except the position of theexternal apertures point to the infliction of visceral injury. _General remarks as to the prognosis in abdominal injuries. _ Theprognosis in each form of individual visceral injury has been alreadyconsidered, but a few points affecting these injuries as a class shouldperhaps be further considered. First, as to the influence of range on the severity of the injuriesinflicted; I am not able to confirm the greater danger of short range, except in so far as there is no doubt that more shock attends suchinjuries, and possibly some of the most severely wounded were killedoutright as a direct consequence of the greater striking force of thebullet. Among the cases in which but slight effects were noted, however, manywere said to have been hit within a range of 200 yards, as for instancethe two injuries quoted under the heading of wounds of the spleen. I personally saw no cases in which explosive injuries of the solidviscera were to be ascribed to this cause. Secondly, as to the immediate prognosis in all abdominal injuries, theensurance of rest and limitation as far as possible of transport were ofthe highest importance, either in the case of wound of the alimentarycanal, or in wounds of the solid viscera in which hæmorrhage was apossible result. Thirdly, as to the later prognosis in these injuries; very few men arefit to resume active service without a prolonged period of rest. Inspite of the insignificance of the primary symptoms, or of thefavourable course taken by the injuries, active exertion was almostalways followed for some months by the appearance of vague pains andoccasionally by indications of recurrent peritoneal symptoms, pointingto the disturbance of quiescent hæmorrhages, or of adhesions. Wounds ofthe kidney are apparently those least liable to be followed by trouble. Lastly, the prognosis was influenced in the case of many of the visceraby coexisting injury to other organs or parts. For instance, at least thirty per cent. Of the abdominal wounds werecomplicated by wound of the thorax; and in the lower segment of theabdomen injury to the extra-peritoneal portions of the pelvic organs wascommon. Both the immediate and ultimate prognosis were influenced greatly bythis fact. As to the individual injuries: 1. Wounds in the intestinal area, except in certain directions, oftentraverse the abdomen without inflicting a perforating injury on thebowel. 2. If the alimentary canal is perforated, injuries in certain segments, even if perforating, may be followed by spontaneous recovery. I shouldsay the prognosis from this point of view is best in the ascendingcolon, then in the rectum; after these most favourable segments, Ishould place the others in the following order: stomach, sigmoidflexure, descending colon. As to perforating wounds of the transversecolon and small intestine, I believe spontaneous recovery to be veryrare. 3. Wounds of the solid viscera generally, usually heal spontaneously, and give no trouble unless one of the great vessels has been injured. Iinclude in this category all organs except the pancreas, of wounds ofwhich I had no experience. 4. Wounds of the bladder, if of the nature of pure perforations in theintra-peritoneal segment, often heal spontaneously. 5. As a rule, injuries to the organs in their intra-peritoneal coursehave a far better prognosis than those which implicate the organs intheir uncovered portions. 6. The small calibre of the bullet is alone responsible for thefavourable results observed. 7. The danger or otherwise of an intestinal injury depends mainly onmechanical conditions; for instance, the fixity of the ascending colon, and its comparative freedom from a covering of small intestine capableby movement of diffusing any infective material, account chiefly forsuch favourable results as are seen when that segment of the bowel isimplicated. WOUNDS OF THE EXTERNAL GENITAL ORGANS Wounds of the _scrotum_ were not uncommon, especially in connection withperforations of the upper part of the thigh. They offered no specialfeature, beyond the common tendency of every-day experience to thedevelopment of extensive ecchymosis. Wounds of the _testicles_ I saw on several occasions. I remember onlyone out of some half-dozen in which castration became necessary. I wastold of one case, for the accuracy of which I cannot vouch, in whichdestruction of one testicle was followed by an attack of melancholia, culminating in the suicide of the patient. Wounds of the _penis_ also occurred, but as a rule were unimportant. Iappend a case, however; in which the penile urethra was wounded, whichis of some interest. (209) Wounded at Heilbron. Range 1, 500 yards. _Entry_, 2-1/2 inches below the right anterior superior iliac spine; the bullet traversed the groin superficially in the line of Poupart's ligament, emerged, and crossed both penis and scrotum. The trooper was in the saddle when struck, and the penis probably somewhat coiled up. Three wounds were found, one at the junction of the penis and scrotum which opened the urethra, a second one about 3/4 of an inch along the under surface of the penis, and a third on the left side of the base of the prepuce. A considerable amount of oedema and ecchymosis of the scrotum developed, but no extravasation of urine. A catheter was kept in the urethra for some days, and the opening eventually closed by granulation. I only once saw a patient with an injury to the deep urethra; in thiscase concurrent injury to other pelvic organs led to death on the thirdday. As a good many of the patients with pelvic wounds died rapidly, theaccident may have been more common than my experience would suggest. FOOTNOTES: [19] _British Med. Journal_, May 12, 1900, i. 1195. [20] 'On Traumatic Rupture of the Colon. ' _Annals of Surgery_, vol. Xxx. 1899, p. 137. [21] Two of these died. [22] The cases of injury to the solid viscera are those only whichhappen to be quoted in the text, and give no idea of relative mortality. [23] _British Medical Journal_, May 12, 1900, vol. I. P. 1194. CHAPTER XII ON SHELL WOUNDS The title of this work hardly allows of its conclusion without a briefmention of the shell wounds observed during the campaign. As already pointed out, these formed but a very small proportion of theinjuries treated in the hospitals, and beyond this they possessedcomparatively small surgical interest, since, as a rule, the featurespresented were those of mere lacerated wounds, while the more severe ofthe cases which survived only offered scope for operations of themutilating class so uncongenial to modern surgical instincts. The fatal wounds consisted in extensive lacerations resulting in thedestruction of the head or limbs, the laying open of the abdominal orthoracic cavities, or the production of visceral injuries beyond thepossibility of repair. Of such injuries no further mention will be made. A very great variety of shells was employed during the campaign, especially on the part of the Boers, and the frontispiece gives someidea of these. The photograph was taken by Mr. Kisch after the relief ofLadysmith. For the want of more extended knowledge I shall confinemyself to the description of a few injuries caused by two classes oflarge shell, those of the Vickers-Maxim or 'Pom-pom, ' and two varietiesof shrapnel. The large shells employed may be divided into classes according to themetal used in their construction, and the nature of the explosive withwhich they were filled. These details are of some surgical import, because they affect the nature of the fragments into which the shellsare broken up. Fragments of shells constructed with cast iron and burst with powder, and also of forged steel exploded with lyddite, are depicted in fig. 90. [Illustration: FIG. 90. --A, B, D. Fragments of 200 lb. Forged SteelHowitzer Shell exploded by lyddite. C. Fragment of Cast-iron Shellexploded by powder. B exhibits transverse markings which might bemistaken for the lines seen in the Boer segment shells, but which reallycorrespond to the area of fixation of the copper driving band] Examination of fragment C of a cast-iron shell exploded by powder showsthe characteristic granular fracture, and edges, although sharp, yet ofa comparatively rounded nature. The fragment is also heavier for itssurface measurement, as the metal is thicker than that seen in theremaining fragments, although the cast-iron shell was of a much smallercalibre than the steel one. The lesser degree of penetrative power, andincreased capacity to contuse, possessed by such fragments are obvious. A B and D are fragments of a large forged steel howitzer shell explodedby lyddite, such as were cast by our guns. The photograph well shows themore tenacious structure of the metal in the incomplete longitudinalfissuring exhibited, while the margins are of a sharp knifelikecharacter, well calculated to penetrate or, in the case of superficialinjuries, to produce wounds of a more sharply incised character than thecast-iron shell. Fragments A and B also show an appearance suggestive ofpartial fusion, characteristic of high explosive action, in the turningof the prominent margins. The larger fragments of such shells were responsible for the mostserious mutilating injuries, while small fragments sometimes causedcomparatively simple perforating wounds. I remember a fragment of thefused character not larger than a small nut which had perforated thefront of the thigh of a Boer, and lodged near the inner surface of thefemur. Removal of the fragment was followed by a free gush ofhæmorrhage. When the wound was opened up an opening was found in theexternal circumflex artery, hæmorrhage from which had been controlled bythe impaction of the piece of shell. As an example of the cutting powerof sharp fragments of shell I might instance the case of another Boer inwhom light passing contact had been made by the missile. A gapingincised wound extended from above the angle of the scapula down to theouter surface of the buttock. The wound involved the latissimus dorsi, and the external and internal oblique muscles of the abdomen. Theseparate muscular layers were sharply defined in the lateral parts ofthe floor of the wound, and remained so for some time during the gradualcontraction of the large granulating surface produced. The degree ofcontusion was in fact slight, while the incised character was stronglymarked. In some cases the fragments merely struck the soldiers on the flatwithout producing any wound. In one such case a blow upon theepigastrium was, according to the patient, followed by the vomiting of aconsiderable amount of blood. A fluid diet was ordered, and no furtherill effects were noted. The following case illustrates an oblique blowof a perforating character, which was nevertheless recovered from. [Illustration: FIG. 91. --Various portions of Brass Percussion and TimeFuses] (210) _Shell-wound of abdomen. Injury to liver. _--Wounded at Paardeberg by a fragment of shell. Aperture of entry, a ragged opening in the median line. The fragment of shell was retained over the ninth costal cartilage in the nipple line. The wound bled freely, but the man was taken into camp, and then four miles on to the hospital, where he was anæsthetised and the fragment extracted. The wound of entry was at the same time enlarged, cleansed, and partly sutured. The patient vomited once after the anæsthetic, and the bowels remained confined for three or four days after the injury. The extraction wound healed readily, but a considerable amount of slimy, bile-stained discharge was still escaping from the ragged entrance wound on the man's arrival at the Base on the fourteenth day. The abdomen was then normal in appearance, and as to physical signs, except for a tympanitic note over the hepatic area to the right of the wound. The temperature was normal, the pulse 90, the tongue clean, and the bowels were acting. At the end of four weeks pleurisy, with effusion, developed on the right side; the chest was aspirated and [Symbol: ounce]xx of clear serum drawn off. The man then rapidly improved; the bile-stained discharge ceased at the end of five weeks, and a small granulating wound eventually closed at the end of two months, when the man returned to England. Fig. 91 is inserted to illustrate the multifarious nature of thefragments into which the component parts of shells may break up. Thepieces are for the most part of brass, and formed parts of either timeor percussion fuses. Fig. 92 represents the one-pound Vickers-Maxim shell in its actual size. The wounds produced by this shell are of some interest, since theVickers-Maxim may be said to have been on trial during this campaign. The general opinion seems to have been to the effect that the moralinfluence produced by the continuous rapid firing of the gun and theattendant unpleasant noise were its chief virtues. A considerable numberof wounds must, however, have been produced by it, which, if not ofgreat magnitude and severity, were, at any rate, calculated to put therecipients out of action, and these wounds, moreover, were slower inhealing than many of the rifle-bullet injuries. The shell is so small that it was said to occasionally strike the bodyas a whole, and perforate. I was shown a case in which a wounded officerwas confident that an entire shell had perforated his arm. The entrywound was at the outer part of the front of the forearm, the exit at theinner aspect of the arm, just above the elbow. Two ragged contusedwounds existed, which healed slowly, but no serious nervous or vascularinjury had been produced. Although it is probable that only a fragmentperforated in this case, it is of interest in connection with thefollowing. In a case shown to me by Sir William Thomson in the Irish Hospital atBloemfontein, an entire shell had passed between the left arm and bodyof a trooper, perforating the haversack, as also a non-commissionedofficer's notebook contained within it, without exploding. The onlyinjury sustained by the trooper was a contusion on the inner aspect ofthe elbow-joint, with slight signs of contusion of the ulnar nerve. Thecase is of some importance, as showing that a comparatively resistentbody can be perforated without necessary explosion on the part of theshell; hence the possibility of a similar perforation of the soft partsof the body. [Illustration: FIG. 92. --Unexploded 1-lb. Vickers-Maxim Shell. (Actualsize)] Fig. 93 is of a number of fragments of Vickers-Maxim shells, and it wasby such that the great majority of the wounds were produced. Wounds from fragments of these shells were, indeed, not at all rare. They were met with on any position; but, as far as my experience went, they were more common on the lower extremities than in other parts ofthe body, if the sufferers were in the erect position when wounded. Isaw a good many wounds in the neighbourhood of the knee, some of whichimplicated the joint. When the injuries were received by patients in thelying or crouching positions, any part of the body was equally likely tobe affected, or, again, the presence of large stones or rocks in thevicinity might determine the scattering of the flying fragments at amore dangerous height than when the shells burst from contact with theactual ground. The relation of one or two examples of wounds from pom-pom fragments maynot be without interest, the more so as they illustrate the favourableinfluence of a low degree of velocity on the part of a projectile. I sawthree wounds produced by the percussion fuses of these shells, anexperience which shows that they were not very uncommon. [Illustration: FIG. 93. --Fragments of Vickers-Maxim 1-lb. Shells. Thecentre fragment of the lower row is the point of a steel armour-piercingshell; although unsuitable for the purpose, they were occasionallyemployed in the field by the Boers] (211) _Perforating shell-wound of abdomen. _--Wounded at Magersfontein by the fuse screw of a small shell (Vickers-Maxim). Aperture of entry ragged, roughly circular, and 2 inches in diameter, with much-contused margins situated in the median line, nearly midway between the ensiform cartilage and umbilicus. The screw was lodged in the abdominal wall at the margin of the thorax, just outside the left nipple line. The aperture of entry was cleansed by Major Harris, R. A. M. C. , who determined the fact that penetration of the peritoneal cavity had occurred, and removed the fuse (see fig. 94) by a separate incision. The patient made an uneventful and uninterrupted recovery, the wound healing by granulation and leaving little weakness of the abdominal wall. He returned to England at the end of five weeks. In a second case the fuse, together with a fragment of the iron case, entered the buttock by a ragged opening. The fragment of iron escaped byan exit aperture of about the same size. When the patient arrived at theBase some days after the injury, a hard body was felt in the wound, andon exploration the fuse was found and removed. In a third case the fuse struck the side of the foot below the outermalleolus and comminuted the astragalus, and then passing forwardslodged beneath the extensor tendons of the toes. The wound was exploredat the time of the injury and some fragments of bone removed;considerable cellulitis supervened, and the fuse was only discoveredsome days later when the patient came under the care of Sir W. Thomsonin the Irish Hospital in Pretoria. It was there removed, together withsome more fragments of bone, and the wound slowly granulated. Thepatient then returned to England, when the wound rapidly healed afterthe removal of some further necrosed fragments of cancellous tissue. Theastragalus had been reduced to a mere shell of compact tissue, and theconvexity of the articular surface was altogether lost. The deformity, together with the formation of adhesions in the ankle-joint, led to thedevelopment of a firm anchylosis. [Illustration: FIG. 94. --Pom-pom Percussion Fuse, exact size] My friend Mr. Abbott removed a similar fuse from the substance of thelung after the lapse of nine months, the patient having developed anempyema, and a chronic fistula, which rapidly closed after the removalof the foreign body. [Illustration: PLATE XXV OBLIQUE FRACTURE OF THE HUMERUS CAUSED BY A FRAGMENT OF A VICKERS-MAXIMOR POM-POM SHELL The entire absence of comminution is very striking] I will add one further case, that illustrated by plate XXV. In this afragment of a pom-pom shell entered the outer aspect of the rightshoulder to escape on the inner aspect of the arm, just below theconfines of the axilla. An oblique, non-comminuted fracture of thehumerus resulted, which in spite of moderate suppuration united well inthe course of six weeks. The case is of particular interest asillustrating the nature of the fracture to be expected when the velocityretained by the missile is low. The above instances show that such peculiarities as belong to woundsproduced by pom-pom shells depend on the comparatively small size andweight of the fragments, and on the small degree of impetus with whichthey are propelled. [Illustration: FIG. 95. --Boer Segment Shell, or Shrapnel. The largefragment is a piece of the case, the smaller are two of the pieces ofiron packed within] Fig. 95 illustrates a form of shrapnel employed by the Boers, the caseof which is of cast metal arranged in definite segments, while theinterior is filled with small fragments of iron so shaped as to pack inconcentric layers. As to the wounds produced by the contained fragmentsI have no experience, since I never saw one of the pieces of ironremoved. This no doubt depended in part on the very unsatisfactorypractice made by the Boers with shrapnel generally. Even when they firedEnglish shrapnel, the shells were, as a rule, exploded far too high tocause any serious danger to the men beneath. I saw on one occasion alarge number of shrapnel shells exploded over a body of ImperialYeomanry, but as a result of the great height at which all the shellswere exploded, not a single casualty resulted. The segment casing of the shell, however, I several times saw removedfrom the body. The fragment shown in fig. 95 was removed from thebuttock of a man after one of Lord Methuen's early battles. It may beremarked that the buttock is rather a common, and also a favourable, seat for shell wounds with retention of the fragment. This no doubtdepends on the fact that the buttock is one of the few superficialregions in which sufficient depth of tissue exists for the retention orthe passage of so large an object as a fragment of shell. Fig. 96 is of a number of leaden shrapnel bullets from our own shells. Anormal undeformed bullet, such as was the usual cause of wounds, isshown at the left-hand upper corner. The remainder show common forms ofdeformity caused by striking on the ground or against rocks. I attributesmall importance to the deformed bullets, as I never saw one removed, and it is probable that a ricochet shrapnel bullet would rarely retainsufficient force to penetrate. The lower fragments are inserted toillustrate a fact that would scarcely have been assumed, that thesebullets on impact occasionally suffer a fracture of a somewhatcrystalline nature. The occurrence of this gross form of fracture is ofsome interest in relation to the extreme fragmentation sometimesundergone by the hardened leaden cores of the small-calibre bullets. A considerable number of wounds from leaden shrapnel bullets were metwith among our own men, as well as among the Boers. The wounds possessedlittle special interest, except from the fact that the bullets wereoften retained. I saw bullets in the chest on several occasions, also inthe abdomen, pelvis, the neighbourhood of joints, and in the limbs. I saw one patient who had suffered no less than six perforating woundsas the result of the bursting of one shrapnel shell. I will here quote one case of interest as completing the various formsof perforating wound of the abdomen met with during the campaign. [Illustration: FIG. 96. --Normal, Deformed, and Fractured Leaden ShrapnelBullets] (212) _Perforating shrapnel-wound of abdomen. _--Boer wounded at Graspan. Aperture of _entry_ (shrapnel), opposite eighth left costal cartilage, 1 inch external to nipple line. The opening was circular, and surrounded by an area of ecchymosis 4 inches in diameter; _exit_, 4-1/2 inches above and to the right of the umbilicus. Patient was at first in a Boer ambulance, and only seen by me on the ninth day. At that date he was dressed and walking with a gauze pad and bandage over the wounds. From the exit wound, which was 1 inch in diameter, protruded a piece of sloughing omentum, the margin of the wound being everted and raised over a circular indurated area. It was thought best to allow the sloughing omentum, which was very foul, to separate spontaneously, and then to return the stump. At the end of three weeks, however, the slough had not only separated, but the stump had retracted, and only a small granulating surface was left, which healed spontaneously. I have little to say regarding the treatment of shell wounds. Themutilating injuries, if not of a fatal character, necessitated treatmentof a corresponding nature to the damage. In all such cases the generalrules of surgery indicate the lines to be followed. In the case of shrapnel wounds the bullets were often better removed;but when in dangerous positions, as sunk deeply in the chest, abdomen, or pelvis, they were best left, unless some very special indication forremoval existed. Large fragments of shell always demanded removal. In conclusion I will only make the further remark, that shell wounds, with the exception of clean leaden shrapnel tracks, always suppurated. I make this closing statement with the view of emphasising the influenceexerted on the aseptic course of modern rifle wounds by the smallcalibre of the bullet, since both bullet and shell wounds were exposedto the same surrounding conditions. INDEX Abdomen, injuries to, 407 General prognosis in, 470 Abdominal wounds: Explosive, 414 Non-perforating, 409 Perforating, 411 Abscess of the brain, 287 Acetabulum, fracture of, 193 Acetylene light, 30 Ambulance: Foreign, 30 Trolly (McCormack-Brook), 18 Wagons, 19 Amputations: Effect of transport on, 110 for fracture, 177 Aneurisms: Effect of rest on, 127 Gangrene after, 152 Traumatic, 122 False, 123 True, 126 Treatment of, 127 Aneurismal varix: Arm and forearm, 147 Effect on circulation, 134 Carotid, 146 Femoral, 147 Mode of development, 130 Popliteal, 147 Prognosis in, 144 Signs of, 131 Treatment of, 144 Anosmia, 348 Antrum, wounds of, 306 Aphasia: Amnesic, 276 Ataxic, 273 Functional, 351 Arterial hæmatoma, 123 Prognosis in, 126 Treatment of, 126 Arteries: Compression by cicatrices, 113 Contusion of, 112 Division of, 114 Perforation of, 114 Arterio-venous aneurism: Arm and forearm, 150 Cervical, 149 Femoral, 150 Leg, 150 Popliteal, 151 Treatment of, 148 Biliary fistula, 467 Bladder: Wounds of, 443, 457 Extra-peritoneal, 458 Intra-peritoneal, 457 Retained bullet in, 110, 460 Bones. See Fractures Bowlby, Mr. : Retained bullets in joints, 229, 230 Wound of pharynx, 311 Brain: Abscess of, 287 Cerebral irritation, 269 Compression of, 267 Concussion of, 266 Effect of ricochet on, 249 Explosive injury of, 247, 248 Frontal injuries, 247, 249, 266 Fronto-parietal injuries, 273 Occipital injuries, 276 Parietal injuries, 273 Prognosis in cerebral injuries, 289 Treatment, 289 Bread, 7 Buck wagon, 21 Bullets: Characters directly affecting wounds: Aseptic nature, 70 Calibre, 41 Composition of, 51 Deformities of, 81 Fragmentation, 88 Length, 41 Mantles of, 52, 82, 83 Penetration, 49 Revolution, 45 Ricochet, 82 Shape, 42 Stability, 51 Striking force, 50 Velocity of flight, 42 Weight, 42 Effect of resistance of bones on, 86, 87, 88, 93 Retention of, 71, 79 Indications for removal of, 110 in bladder, 110, 460 in chest, 381, 401 in nasal fossa, 244 in or near joints, 229, 230 in skull, 244, 249, 260, 266, 284, 298 in spinal canal, 337 Reversal of, 81 Varieties of: Determination of, 105 Expanding, 91 Explosive, 95 Guedes, 48, 51 Krag-Jörgensen, 48, 51 Jeffreys, 94 Large leaden, 95 Lee-Metford, 52, 89 Mark IV. , 94 Mauser, 52, 83 Soft-nosed, 93 Tampered, 95 Tweedie, 94 Waxed, 52 Cauda equina, injury to, 325, 330 Cellulitis, 34 Cervical nerve roots, injury to, 107 Plexus, 357 Cheatle, Mr. G. L. : Entry and exit wounds, 72 First field dressing, 107 Wound of heart, 383 " " intestine, 413 Cheek, wounds of, 309 Chest, injuries to, 374 Character of wounds, 377 Influence of small calibre of bullet on, 374 Martini wounds, 374, 388 Non-penetrating wounds, 375 Penetrating wounds, 376 Cheyne, Mr. W. W. , F. R. S. : Abdominal wounds, 449 Spent bullets, 243, 449 Civil surgeons, 38 Climate, 8, 36, 71 Comparison of South African with other campaigns, 14 Compression of brain, 267 Spinal cord, 319 Concussion of brain, 266 Eye, 300 Joints, 226 Nerves, 341, 343 Spinal cord, 315 Contour wounds, 65 Contusion: Nerves, 343 Spinal cord, 316 Costal cartilages, fractures of, 379 Cox, Dep. Insp. -Gen. : Case of varix, 148 Day, Mr. J. J. : Fractures of the skull, 251 Deadliness of modern weapons, 16 Diaphragm, wounds of, 381 Displacement of structures by the bullet, 68 Abdomen, 411 Nerves, 342 Vessels, 382, 384 Viscera, 310, 382, 411 Drink, 8 Dust, 8, 35 Bacteriology of, 36 Empyema, 394, 396 Enteric fever, 9 Epilepsy, traumatic, 291 Equipment of foreign ambulances, 31 Surgical, 4 Erysipelas, 34 Expanding bullets, 91 Explosive bullets, 95 Explosive wounds: of abdomen, 414 of fractures, 155 of head, 245 of leg, 221 of soft parts, 97 of thigh, 197 Eye, injuries to, 299 Facial paralysis: Cortical, 273-277 Peripheral, 355 First field dressings, 107 Flies, 36 Flockemann, Dr. : Hæmothorax, 393 Injury to abdomen, 420 Fractures: Course of healing of, 172 Explosive wounds in, 155 into joints, 163, 228 Limb bones, 154 Local shock in, 172 Long bones, types of, 161 Longitudinal, 163 Notch, 165 Oblique, 165 Perforating, 166 Stellate, 161 Transverse, 166 Wedge, 165 Osteomyelitis in, 174 Pom-pom fractures, 483 Prognosis, general, in, 174 Special features of, 155 Special bones: Acetabulum, 193 Carpus, 183 Clavicle, 178 Femur, 193 Fibula, 219 Humerus, 178 Jaws, 306 Malar, 305 Mastoid process, 299 Metacarpus, 185 Metatarsus, 224 Orbital walls, 300 Patella, 215 Pelvis, 189 Radius, 183 Ribs, 377 Scapula, 177, 379 Skull: Base, 262 Glancing, 254 Gutter, 255 Perforating, deep, 245 Superficial, 259 Treatment of, 293 Spine, 314 Sternum, 379 Tarsus, 223 Tibia, 217 Short and flat bones, 168 Suppuration of soft parts in, 173 Symptoms of, 171 Treatment of: General, 175 Femur, 205 Leg, 221 Upper Extremity, 135 Variation in character during the campaign, 154 Fractures in Franco-German war (Sir W. MacCormac), 167 Fragmentation of bullets, 88 Fuses of shells, wounds by, 481 Gangrene: Acute traumatic, 34 After ligature of main vessels, 152 Genital organs, wounds of, 472 Guedes rifle, 65 Gutter wounds: of bladder, 458 of bones, 231 of intestine, 417 of joints, 231 of liver, 466 of pelvis, 189 of scalp, 242 of skull, 255 of soft parts, 157 Hæmarthrosis, 232 Hæmorrhage, 104, 114 Control by bullets, 116 by loop of nerve, 116 Deaths from, 116 Fever dependent upon, 118 Internal, 116 Interstitial, 118 Primary, 114 Recurrent, 117 Secondary, 117 Treatment of, 120 Hæmorrhoids, 10 Hæmothorax, 386, 389 Behaviour of blood in, 390 Course of, 390, 394 Diagnosis of, 398 Effect of transport on, 389 Empyema after, 394 Pleuritic effusion in, 390 Prognosis in, 399 Recurrent bleeding in, 393 Parietal, 389, 398 Pulmonary, 386, 389 Symptoms of, 391 Temperature in, 391, 393 Treatment of, 400 Head, injuries to, 241 Health of the troops, 7 Heart, wounds of, 382 in neighbourhood of, 384 Hemianopsia, 276 Altitudinal, 277 Lateral, 276 Hospitals: Field, 29, 37 Foreign, 30 General, 31, 38 Improvised, 28, 39 Indian Field, 29 Stationary, 27, 31, 33, 37 Varieties of, 28 Hospital ships, 24 Tents, 32 Trains, 23 Hydronephrosis, 464 Impact, irregular, 80, 82 Instruments, 4 Intestine, injuries to: Diagnosis of, 428 Difficulties of operation, 453 Indications for operation, 454 Lateral contusion, 416 Prognosis, 446 Treatment, 452 Wounds of, 415 Extra-peritoneal, 419 Large intestine, 436, 444 Results of, 421 Small intestine, 427 Irregular wounds, 97 Itinerary, 2 Jam, 7 Jaws, fractures of: Lower, 306 Upper, 306 Treatment of, 308 Jenner, L. L. , bacteriology of dust, 36 Joints, injuries to, 225 Arterial wounds in, 121, 233 Classification of, 229 Course after, 232 Fractures into, 228 Signs and symptoms, 232 Suppuration of, 233 Treatment, general, 235 Joints, retained bullets in or near, 229, 230 Joints, special: Ankle, 239 Elbow, 236 Hand, 237 Hip, 238 Knee, 238 Shoulders, 236 Tarsus, 240 Ker, J. E. , cases of aneurism, 152 Kidney, wounds of, 461 Krag-Jörgensen rifle, 65 Laminectomy, 335, 340 Larynx, wounds of, 312 Leaden bullets, 95 Lee-Metford rifle, 53, 64 Lewtas, Col. I. M. S. , cases of aneurism, 144 Lightning stroke, 10 Liver, wounds of, 466 Local shock, 103 in fractures, 172 Lower jaw, fractures of, 306 Lungs, wounds of, 385 Diagnosis, 398 Effect of velocity on, 385 Prognosis, 399 Retained bullets in, 401 Symptoms of, 386 Treatment of, 400 Lyddite shells, 475 MacCormac, Sir W. : Aneurism, 150 Fractures, 167 Malar bone, fractures, 305 Mandible, fractures, 306 Mantles, stability of, 51, 83 Martini-Henry rifle, 48 Wounds by, 96 Mastoid process, 299 Mauser rifle, 64 Meat, 7 Mediastinal wounds, 382, 384 Mesentery, wounds of, 420 Mills-Roberts, Mr. H. R. : Spinal hæmorrhage, 321 'Modders, the, ' 9 Mortality, general, 11 amongst officers, 14 in battles of Kimberley Relief Force, 12 Nasal _fossæ_, bullet in, 244 Neck, wounds of, 309 Nerves, injuries to, 341 Concussion, 341, 343, 346 Contusion, 343, 347 Displacement of, 342 Laceration, 344, 348 Perforation, 345 Prognosis in, 370 Scar, implication of, 345, 350 Section, 344 Symptoms of, 346 Treatment of, 371 Velocity in relation to, 341 Nerves, special: Cranial: Fifth, 353 Fourth, 353 Eighth, 353, 354 Eleventh, 356 Olfactory, 352 Optic, 352 Seventh, 354, 372 Sixth, 353 Tenth, 356 Third, 353 Twelfth, 357 Spinal: Brachial, 357 Cervical, 347, 357 Lumbar, 359 Sacral, 359 Sacro-coccygeal, 360 Thoracic, 358 Neuritis: Ascending, 350 Peripheral, 355 Traumatic, 349 Neurosis, traumatic 351 Nose, wounds of, 305, 348 Nurses, 38 Officers, mortality among, 14 Olecranon, fracture of, 183, 237 Omentum, wounds of, 420 Prolapse of, 420 Operations: Difficulties of, 35 in field, 296 in Field hospitals, 109 Orbit, wounds of, 299 Prognosis and treatment of, 304 Osteomyelitis in fractures, 174 Outfit, surgical, 3 Pain in wounds, 103 Paraplegia, functional, 337 Penetration of bullets, 49 Penis, wounds of, 472 Peritoneal infection, 412 Pharynx, wounds of, 311 Pleural septicæmia, 437 Pleurisy, 390, 398 Pneumonia, 9, 398 Pneumo-thorax, 388 Pom-pom shells, 478 Portland Hospital, 34 Psychical disturbance, 101 Rain, 9, 36 Range of fire: Difficulty of judging influence on mortality, 17 Rectum, wounds of, 443, 444 Removal of wounded from the field, 18 Respiration in spinal injuries, 329 Retained bullets. See Bullets Reversed bullets, 81 Revolution of bullet, 45, 46 Ribs, fractures of, 377 Signs of, 379 Ricochet, 82 Effect on wound type, 249 Lee-Metford, 89 Mauser, 84 Within body, Abdomen, 415 Skull, 249 Rifles: Bore, 41 Guedes, 47, 54 Krag-Jörgensen, 47, 54 Lee-Metford, 47, 64 Martini-Henry, 47, 97 Mauser, 47, 64 Modern principles of, 40 Trajectory, 44 Varieties employed, 47, 48 Scalp wounds, 242, 264 Scapula, fractures of, 177, 379 Scrotum, wounds of, 472 Septic disease, 34 Septicæmia: General, 34 in enteric fever, 9 Peritoneal, 421 Pleural, 437 Shells, 474 Varieties of, 475 Vickers-Maxim, 478 Lyddite, 476 Shrapnel, 483 Shell wounds: of abdomen, 480, 485 Proportionate occurrence of, 11 Shell fuse wounds, 481 Ships, hospital, 24 Shock: General, 101 Local, 103 Treatment of, 110 Shrapnel, 483 Simla, 25 Skull. See Fractures Fractures independent of gross brain lesion, 242 with brain lesion, 248 Spinal column: Injuries to, 314 Fractures of centra, 317 Spinous processes, 315 Transverse processes, 314 Spinal cord, injuries to, 315 Compression by bullets, 319 Concussion, 319 Contusion, 320 Diagnosis, 335 Hæmato-myelia, 322 Section of, 323 Shock accompanying, 328 Signs of, 323 Transport of, 339 Treatment of, 339 Spinal hæmorrhage: Epidural, 321 Hæmato-myelia, 322 Peri-pial, 321 Spleen, wounds of, 469 Splints: Aluminium, 177 Field cane, 209, 221 Hodgen's, 211 Wire gauze, 187 Sternum, fractures of, 379 Stevenson, Col. W. F. : Local shock, 106 Explosive wounds, 159 Stokes, Sir W. : Treatment of aneurism, 151 Stomach, wounds of, 424 Stonham, Mr. C. : Wound of vermiform appendix, 437 Sunstroke, 10 Suppuration of wounds, 78 in fracture, 173 Synovitis, vibration, 226 Temperature of air, 8, 36 in blood effusions, 118, 391, 393 Tents, 32 Testicle, wounds of, 472 Tetanus, 34 Thirst, 8 Thomson, Sir W. : Pom-pom wounds, 479 Wound of nose, 305 Thoracic vessels, wounds of, 384 Tonga, the, 19 Tongue, wounds of, 309 Trachea, wounds of, 312 Traction engines, 23 Trains, hospital, 23 Trajectory, 44 Transport: after battles, 26 of wounded men from field, 18 of wounded of the Kimberley Relief Force, 25 of chest injuries, 386 of fractures, 176 of spinal injuries, 339 Traumatic aneurism. See Aneurism Traumatic epilepsy, 291 Traumatic gangrene, 34 Traumatic neurosis, 107, 351 Treves, Mr. F. : on cessation of intestinal peristalsis, 423 Trolly (McCormack-Brook), 19 Upper jaws, 306 Urethra, wounds of, 472 Urinary Bladder. See Bladder Varix. See Aneurismal varix Vegetables, 7 Veldt sores, 10 Velocity of bullet: Circumstances influencing, 43 Initial, 42, 49 Remaining of various rifles, 49 Velocity, influence of: on fractures of long bones, 163 on fractures of short and flat bones, 168 on wounds of abdomen, 414 of chest, 385 of joints, 226, 230 of lungs, 385 of nerves, 341 of skull, 251 of spine, 319 Vermiform appendix, wounds of, 437 Vibration synovitis, 226 Vickers-Maxim shell, 478 Vomiting in spinal injuries, 329 Wagons: Ambulance, 20 Buck, 22 Ox, 20 Warfare, deadliness of, 40 Water in South Africa: Character of, 8, 36 Transport of, 5 Waxed bullets, 52 Wobble, 80, 81, 251 Wounded men, removal from the field, 18 Wounds, general: Aperture of entry, 55, 72 Aperture of exit, 58, 74 Climate, influence on, 71 Clinical, course of, 69 Contour tracks, 65 Direct nature of tracks, 63 Directions of tracks, 66 Displacement of structures, 68 Explosive exit wounds, 97 Foreign bodies in, 71 First field dressing, 107 Hæmorrhage, 104 Irregular types of, 80, 97 Mode of healing, 72 Multiple character, 67 Nature of tracts, 68 Pain, 103 Prognosis, 106 Psychical disturbance, 101 Shock, 101 Small bore, 67 Superficial tracts, 65 Suppuration, 69, 78 Symptoms, 100 Tracks, nature of, 68 Treatment, 107 * * * * * PRINTED BYSPOTTISWOODE AND CO. 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