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+The Project Gutenberg EBook of Surgical Experiences in South Africa,
+1899-1900, by George Henry Makins
+
+This eBook is for the use of anyone anywhere at no cost and with
+almost no restrictions whatsoever.  You may copy it, give it away or
+re-use it under the terms of the Project Gutenberg License included
+with this eBook or online at www.gutenberg.org
+
+
+Title: Surgical Experiences in South Africa, 1899-1900
+       Being Mainly a Clinical Study of the Nature and Effects
+       of Injuries Produced by Bullets of Small Calibre
+
+Author: George Henry Makins
+
+Release Date: May 3, 2007 [EBook #21280]
+
+Language: English
+
+Character set encoding: ASCII
+
+*** START OF THIS PROJECT GUTENBERG EBOOK SURGICAL EXPERIENCES ***
+
+
+
+
+Produced by Jonathan Ingram, Josephine Paolucci and the
+Online Distributed Proofreading Team at https://www.pgdp.net
+
+
+
+
+
+
+
+
+[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 INJURIES
+PRODUCED BY BULLETS OF SMALL CALIBRE
+
+
+BY
+
+GEORGE HENRY MAKINS, F.R.C.S.
+
+SURGEON TO ST. THOMAS'S HOSPITAL, LONDON
+JOINT LECTURER ON SURGERY IN THE MEDICAL SCHOOL OF ST. THOMAS'S HOSPITAL
+MEMBER OF THE COURT OF EXAMINERS OF THE ROYAL COLLEGE OF
+SURGEONS OF ENGLAND, AND LATE ONE OF THE CONSULTING SURGEONS
+TO THE SOUTH AFRICAN FIELD FORCE
+
+
+LONDON
+SMITH, ELDER, & CO., 15 WATERLOO PLACE
+1901
+
+
+
+
+TO
+
+SURGEON-GENERAL W. D. WILSON
+
+PRINCIPAL MEDICAL OFFICER TO THE SOUTH AFRICAN FIELD FORCE
+
+THE MEMBERS OF THE ROYAL ARMY MEDICAL CORPS
+EMPLOYED IN SOUTH AFRICA
+
+AND TO THE
+
+CIVIL SURGEONS TEMPORARILY ATTACHED TO THAT CORPS
+
+These Experiences are Dedicated
+
+AS AN EXPRESSION OF APPRECIATION
+OF THE INVARIABLE KINDNESS AND SYMPATHY EXTENDED
+TO THE AUTHOR
+WITHOUT WHICH THE BOOK COULD NOT
+HAVE BEEN WRITTEN
+
+
+
+
+PREFACE
+
+
+A word of explanation is perhaps necessary as to the form in which these
+experiences have been put together. The matter was originally collected
+with the object of sending a series of articles to the _British Medical
+Journal_. Various circumstances, however, of which the chief was the
+feeling that extending experience altered in many cases the views
+adopted at first sight, prevented the original intention from being
+carried into execution, and the articles, considerably expanded, are now
+published together.
+
+As to the illustrative cases introduced in support of various statements
+made in the text, only those have been chosen from my notes which were
+under my own observation for a considerable time, and many of these have
+been 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 have
+been quoted since their character is sufficiently indicated in the text.
+These remarks seem necessary since the mode of selection has resulted in
+the inclusion of a number of cases of exceptional severity, and any
+attempt to draw statistical conclusions from them would be most
+misleading.
+
+The first two chapters have been added with a view to affording some
+information, first, as to the conditions under which a great part of the
+surgical work was done, and, secondly, as to the mechanism and causation
+of the injuries, which would not readily be at hand in the case of the
+general surgical reader. For much of the information contained in
+Chapter II. I must express my indebtedness to the work of MM. Nimier and
+Laval, so frequently quoted.
+
+The only other object of this Preface is to express my thanks to the
+many who have aided me in the task of amplifying the observations on
+which the articles are founded, and I think no writer ever received more
+sympathetic and kindly help in such particulars than the author.
+
+My first thanks, those due to the Members of the Royal Army Medical
+Corps, I endeavour to express by the dedication of this volume. Any
+attempt to make individual acknowledgment to either the Members of the
+Service, or to the Civil Surgeons temporarily attached, would be
+impossible. I have, however, tried to associate the names of many of
+those in charge of cases in the recital of histories and treatment
+throughout.
+
+My thanks are not less due to the Military Heads of Departments at the
+War Office, who have helped me in the collection of details as to the
+subsequent course of many of the cases described, and in the acquisition
+of information regarding the weapons and ammunition treated of. I should
+particularly express my gratitude to Colonel Robb, of the
+Adjutant-General's Department, and Colonel Montgomery, of the Ordnance
+Department.
+
+I am greatly indebted to my former colleague Mr. Cheatle for two of the
+illustrations of wounds, and for permission to quote some of his other
+experience, and to Mr. Henry Catling, to whose skill I owe the majority
+of the skiagrams of the fractures under my observation at Wynberg and
+elsewhere.
+
+I must also express my thanks to Mr. Danielsson and his artist, Mr.
+Ford, for the trouble they have taken in converting my rough sketches
+into 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 read
+the whole book for the press and suggested many improvements and
+modifications.
+
+47 CHARLES STREET, BERKELEY SQUARE, W.
+
+_February_ 1901.
+
+
+
+
+CONTENTS
+
+
+                                                                       PAGE
+CHAPTER I
+
+INTRODUCTORY
+
+Itinerary--Surgical outfit--Personal transport--General health of the
+troops--Climate--Consideration of the number of men killed and
+wounded--Transport of the wounded--Vehicles--Trains--Ships--Hospitals     1
+
+
+CHAPTER II
+
+MODERN MILITARY RIFLES AND THEIR ACTION
+
+General type--Calibre, length, and weight of
+bullet--Velocity--Trajectory--Revolution--Varieties of rifle in common
+use by the Boers--Penetration--Comparison of bullets--Use of
+wax--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 wound
+track--Multiple wounds--Small bore and sharp localisation of
+tracks--Clinical course--Mode of healing--Suppuration--Wounds of irregular
+type--Ricochet--Mauser bullet--Lee-Metford bullet--Expanding bullets--Altered
+bullets--Large sporting bullets--Symptoms--Psychical disturbance and
+shock--Local shock--Pain--Haemorrhage--Diagnosis--Prognosis--Treatment    55
+
+CHAPTER IV
+
+INJURIES TO THE BLOOD VESSELS
+
+Nature of lesions; contusion, laceration, perforation--Results of
+injuries--Primary haemorrhage--Recurrent haemorrhage--Secondary
+haemorrhage--Treatment of haemorrhage--Traumatic aneurisms--Arterial
+haematoma--True traumatic aneurism--Aneurismal varix and varicose
+aneurism--Conditions affecting development--Effects of aneurismal varix
+or varicose aneurism on the general circulation--Prognosis and treatment
+of aneurismal varix--Prognosis and treatment of varicose
+aneurism--Gangrene after ligation of arteries                           112
+
+
+CHAPTER V
+
+INJURIES TO THE BONES OF THE LIMBS
+
+Nature of wounds--Explosive wounds--Types of fracture of shafts
+of long bones--Stellate, wedge, notch, oblique, transverse,
+perforating--Fractures by old types of bullet--Lesions of the short and
+flat bones--Special character of the symptoms in gunshot fracture, and
+of the course of healing--Prognosis--Treatment--Special fractures--Upper
+extremity--Pelvis--Lower extremity                                      154
+
+
+CHAPTER VI
+
+INJURIES TO THE JOINTS
+
+General character--Vibration synovitis--Wounds of
+joints--Classification--Course and symptoms--General treatment--Special
+joints                                                                  225
+
+
+CHAPTER VII
+
+INJURIES TO THE HEAD AND NECK
+
+Anatomical lesions--Scalp wounds--Fracture of the skull without evidence
+of gross lesion of the brain--Fractures with concurrent brain
+injury--Classification--General injuries--Effect of ricochet--Vertical
+or coronal wounds in frontal region--Glancing or oblique wounds of any
+region--Gutter fractures--Superficial perforating fractures--Fractures
+of the base--Symptoms of fracture of the skull, with concurrent injury
+to the brain--Concussion--Compression--Irritation--Frontal
+injuries--Fronto-parietal and parietal injuries--Occipital
+injuries--Forms of hemianopsia--Abscess of the brain--General
+diagnosis--General prognosis--Traumatic epilepsy--General
+treatment--Wounds of the head not involving the brain--Mastoid
+process--Orbit--Globe of the eye--Nose--Malar bone--Upper
+jaw--Mandible--Wounds of the neck--Wounds of the pharynx, larynx, and
+trachea                                                                 241
+
+
+CHAPTER VIII
+
+INJURIES TO THE VERTEBRAL COLUMN AND SPINAL CORD
+
+Fractures in their relation to nerve injury--Transverse
+processes--Spinous processes--Centra--Signs of fracture of
+the vertebra--Injuries to the spinal cord--Effects of high
+velocity--Concussion, slight, severe--Contusion--Haemorrhage,
+extra-medullary, haematomyelia--Symptoms of injury to the spinal
+cord--Concussion--Haemorrhage--Total transverse lesion--Diagnosis of form
+of lesion--Prognosis--Treatment                                         314
+
+
+CHAPTER IX
+
+INJURIES TO THE PERIPHERAL NERVES
+
+Anatomical lesions--Concussion--Contusion--Division or
+laceration--Secondary implication of the nerve--Symptoms of nerve
+injury--Traumatic neuritis--Scar implication--Ascending
+neuritis--Traumatic neurosis--Injuries to special nerves--Cranial
+nerves--Cervical, brachial, lumbar, and sacral plexuses--Cases of nerve
+injury--General prognosis and treatment                                 341
+
+
+CHAPTER X
+
+INJURIES TO THE CHEST
+
+Non-penetrating wounds of the chest wall--Penetrating wounds, special
+characters of entrance and exit apertures--Fracture of the ribs,
+symptoms, treatment--Wounds of the diaphragm--Wounds of the
+heart--Wounds of the lung, symptoms--Pneumothorax--Haemothorax--
+Empyema--Diagnosis, prognosis, and treatment of haemothorax--Cases
+of haemothorax                                                           374
+
+
+CHAPTER XI
+
+INJURIES TO THE ABDOMEN
+
+Introductory remarks--Wounds of the abdominal wall--Penetration of
+the intestinal area without definite evidence of visceral injury--Wounds
+of explosive character--Anatomical characters of intestinal wounds--Wounds
+of the mesentery---Wounds of the omentum--Results of intestinal
+wounds, faecal extravasation, peritoneal infection, septicaemia--Reasons
+for the escape of severe injury in wounds traversing the
+abdomen--Wounds of the stomach--Wounds of the small intestine--Wounds
+of the large intestine--Prognosis in intestinal injuries--Treatment
+of intestinal injuries--Wounds of the urinary bladder--Wounds
+of the kidney--Wounds of the liver--Wounds of the spleen--General
+remarks on the prognosis in abdominal injuries--Wounds of
+the external genital organs--Wounds of the urethra                      407
+
+
+CHAPTER XII
+
+ON SHELL WOUNDS
+
+Varieties of shells employed--Large shells--Wounds produced by different
+varieties--Pom-Pom shells--Wounds produced by fragments and
+fuses--Shrapnel--Boer segment shells--Leaden shrapnel bullets--Treatment
+of 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 HAEMOTHORAX          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 HAEMATOMA, BLOOD TEMPERATURE                119
+
+2. CASE OF HAEMOTHORAX WITH RECURRENT HAEMORRHAGES               395
+
+3. PRIMARY AND SECONDARY RISES OF TEMPERATURE IN HAEMOTHORAX,
+   RECOVERING SPONTANEOUSLY                                    402
+
+4. SECONDARY RISE OF TEMPERATURE IN HAEMOTHORAX                 403
+
+5. FALLS OF TEMPERATURE IN HAEMOTHORAX FOLLOWING PARACENTESIS   404
+
+6. SECONDARY HAEMOTHORAX, SPONTANEOUS FALL OF TEMPERATURE       405
+
+
+
+
+SURGICAL EXPERIENCES
+
+IN
+
+SOUTH AFRICA
+
+
+
+
+CHAPTER I
+
+INTRODUCTORY
+
+
+The following pages are intended to give an account of personal
+experience of the gunshot wounds observed during the South African
+campaign in 1899 and 1900. For this reason few cases are quoted beyond
+those coming under my own immediate observation, and in the few
+instances where others are made use of the source of quotation is
+indicated. It will be noted that my experience was almost entirely
+confined to bullet wounds, and in this respect it no doubt differs from
+that of surgeons employed in Natal, where shell injuries were more
+numerous. This is, however, of the less moment for my purpose as there
+is probably little to add regarding shell injuries to what is already
+known, while, on the other hand, the opportunity of observing large
+numbers of injuries from rifle bullets of small calibre has not
+previously been afforded to British surgeons.
+
+I think the general trend of the observations goes to show that the
+employment of bullets of small calibre is all to the advantage of the
+men wounded, except in so far as the increased possibilities of the
+range of fire may augment the number of individuals hit; also that such
+variations as exist between wounds inflicted by bullets of the
+Martini-Henry and Mauser types respectively, depend rather on the form
+and bulk of the projectile than on any inherent difference in the nature
+of the injuries. Thus in the chapter devoted to the general characters
+of the wounds, it will be seen that most of the older types of entry
+and exit aperture are produced in miniature by the small modern bullet,
+and that the main peculiarity of the deeper injuries is the frequent
+strict localisation of the direct damage to an area of no greater width
+than that crossed by narrow structures of importance such as arteries or
+nerves.
+
+It is to be regretted that I am unable to furnish any important
+statistical details, but incomplete numbers, such as are at my disposal,
+would be of little value. In view, however, of the considerable interval
+which must elapse before the Royal Army Medical Corps is able to arrange
+and publish the large material which will have accumulated, it has
+seemed unwise to defer publication until the completion of a report
+which will deal with such matters thoroughly.
+
+It may be of interest to premise the opportunities which I enjoyed of
+gaining experience during the campaign. I arrived in South Africa on
+November 19, 1899; two days later I proceeded to Orange River with
+Surgeon-General Wilson, and on the day three weeks after leaving home
+performed some operations in the field hospitals on patients from the
+battle of Belmont. I remained at Orange River during the three next
+engagements, Graspan, Enslin, and Modder River, and on the day of
+Magersfontein I went forward to the Field hospitals at Modder River,
+arriving during the bringing in of the patients from the field of
+battle. I returned to Orange River with the patients and remained there
+a further period of three weeks, during which time the patients were
+gradually transferred to the Base hospitals at Wynberg. At Christmas I
+followed the patients down to the base, and thus was able to observe the
+course of the cases from their commencement to convalescence. I remained
+at Wynberg six weeks, during which time a number of cases from the
+neighbourhood of Rensburg and some from Natal were received. On February
+7, I left Wynberg, following Lord Roberts up to my old quarters at
+Modder River, where I saw a few wounded men brought in from the
+engagements at Koodoosberg Drift. On Lord Roberts's departure for
+Bloemfontein he requested me to return to Wynberg to await the wounded
+who might be sent down from the fighting which might occur during his
+advance. I therefore had the disappointment of seeing the start of the
+army, and then returning to Wynberg, where I remained for another six
+weeks in attendance at Nos. 1 and 2 General Hospitals.
+
+During this period a very large number of the wounded from Paardeberg
+Drift and other battles were sent down and treated, after which surgical
+work 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 Company
+of the IX. Division at the Waterworks.
+
+On May 4, I left Bloemfontein with Lord Roberts's army, and shortly
+after joined the IX. Division, with which I journeyed until the
+commencement of June, seeing a good deal of scattered work in the field
+and Field hospitals, and in the small temporary improvised hospitals in
+the towns of Winberg, Lindley, and Heilbron. Early in June I left
+Heilbron with Lord Methuen's division, and spent the next four weeks
+with this division in the field. Thence I journeyed to Pretoria and
+Johannesburg, seeing a small number of wounded in each town, and on July
+10, with Lord Roberts's consent, I started for home, visiting a number
+of the hospitals in the Orange River Colony and Natal on my way down to
+Cape Town. During the movements briefly recorded above, which absorbed a
+period of nine months, my time was fairly evenly divided between Field,
+Stationary, and Base hospitals; hence I had opportunities of observing
+the patients in every stage of their illnesses, and in all some
+thousands 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 surgical
+equipment was not of an extensive nature. It may be of interest,
+however, to shortly recount what it consisted in, since it proved an
+ample one, and yet was carried in a small satchel. The plan of selection
+adopted consisted in carefully going through the equipment of the
+British Field Hospital, and then adding such other instruments as seemed
+to me likely to be useful. With few exceptions, therefore, designed to
+meet emergencies, my set of instruments formed a supplement to the
+actual necessities carried by the Service hospitals, and was as
+follows:--4 trephines, Horsley's elevator, brain knife and seeker. 2
+pairs of Hoffman's and 1 pair of Lane's fulcrum gouge forceps, 3 bone
+gouges, 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 aneurism
+needles, 1 bullet probe, 1 pair Egyptian Army pattern bullet forceps. 4
+Lane's and 3 pairs Makins's bowel clamps, Nos. 3 4 and 5 Laplace's
+bowel forceps, 6 Murphy's buttons, 1 pair Morris's retractors, 6 dozen
+intestine needles, 2 Macphail's needle-holders, Nos. 4 5 6 Thomas's
+slot-eyed needles, 1 mouth gag, 1 Durham's double raspatory, 3 strong
+plated raspatories, 1 pair tongue forceps, 1 tracheal dilator, 1 pair
+hernia needles, 1 hernia and 1 ordinary steel director, 1 transfusion
+set with metal funnel, and a stock of Messrs. Burroughes and Wellcome's
+compound saline infusion soloids. 1 antitoxin syringe. 6 scalpels, 2
+blunt-pointed curved bistouries, 6 forcipressure forceps, 1 pair Jordan
+Lloyd's retractors, 1 pair ordinary retractors, 2 pairs of forceps, 3
+pairs of Scissors, 1 skin-grafting razor and roll of perforated tin
+foil, 1 metal pocket case, and 1 hypodermic syringe with tabloids. A
+stock of silkworm gut, horsehair and silk ligatures, the latter prepared
+and sterilised for me by Miss Taylor, the Theatre Sister at St. Thomas's
+Hospital. Some pairs of McBurney's india-rubber, and cotton-thread
+operating gloves.
+
+[Illustration: FIG. 2.--Instrument Holdall rolled]
+
+The instruments were packed in sets in small linen holdalls suggested
+and made by Messrs. Down Bros., who also devised my satchel. In the
+light of the experience gained I should have preferred a tin case to the
+satchel, as it never needed to be carried on horseback.
+
+For dressings I trusted entirely to the Royal Army Medical Corps, and at
+my request Colonel Gubbins, R.A.M.C., sent out to the Cape a quantity
+of sterilised sponges and pads made by Messrs. Robinson & Co. Ltd. of
+Chesterfield, which fully met all requirements in this direction.
+
+[Illustration: FIG. 3.--Tin Water-bottle for the march (Military
+Equipment Company)]
+
+This equipment was superfluous at the Base hospitals, but when in the
+field with the troops proved very useful. In the early part of the
+campaign I was able to do all my travelling by train, but later I
+travelled by road only. I received the greatest kindness and help in
+this particular. General Sir William Nicholson, Chief Director of
+Transport, provided me with a buggy, a pair of horses, and a driver, and
+Prince Francis of Teck, the Chief Remount Officer, selected a pony
+suitable to my equestrian powers. The buggy proved a very great success;
+the box seat carried my instruments and dressings, the front a 4-gallon
+tin water-bottle for emergency operations, and the rear shelf my
+personal belongings. The water-bottle was lent to me by the Portland
+Hospital. (Fig. 3.)
+
+The cart was able to cross any drifts or dongas, and when an engagement
+was in progress was able to accompany the Ambulance wagons, so that I
+had all my necessaries on the spot, even at the first dressing station.
+In point of fact when with the Highland Brigade, on some occasions, we
+did all necessary operations on the spot during the progress of
+fighting; a most useful performance, since fighting on several days did
+not cease till dark, and the evenings were much too cold to allow of
+operations being done with safety to the patients. The great advantage
+of the buggy was its lightness and smallness. On one occasion it
+accompanied me between 500 and 600 miles without a single accident,
+beyond the fact that one night I was relieved of both my horses by some
+troopers whose own were worn out.
+
+[Illustration: FIG. 4.--My Buggy on the veldt at Bloemfontein. (Photo by
+Mr. Bowlby)]
+
+With regard to the general health of the troops as subjects of surgical
+wounds, I suppose a better class of patient could scarcely be found. The
+men were young, sound, well set and nourished, and hard and fit from
+exercise in the open air. Beyond this, in spite of the scarcity of
+vegetables, a certain amount of fruit, rations of jam, and lime juice
+made any sign of scurvy a rare occurrence--I never saw a case during the
+whole of my wanderings. The meat was good, especially in the early part
+of the campaign, when it was for the most part brought from Australia
+and New Zealand, and we enjoyed the two collateral advantages of getting
+plenty 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 to
+need destruction or prove a source of danger. When bread was to be got
+it was fairly good, and the biscuit was at all times excellent. Except
+on the advance from Modder River to Bloemfontein, as far as I could
+judge, no large bodies of the men ever really suffered from shortness of
+food, and then only for a few days. Drink was a more serious problem: in
+the early days beer was to be got at the canteens, but with the increase
+of numbers and difficulties of transport this ceased to be the case, and
+water was the sole fluid available. This was often muddy, and the
+soldiers would take very little care what they drank unless under
+constant supervision; hence a great quantity of very undesirable water
+was drunk. None the less I think the water was more often the cause of
+sand diarrhoea than of enteric fever. A large quantity of fluid was by
+no means a necessity if the men would only have exercised some
+self-control. During the first week I spent at Orange River, I drank
+lime juice and water all day, but after that time, by a very slight
+amount of determination, I thoroughly broke myself of the habit, and
+drank at meal-times only. Most of the men however emptied their
+water-bottles during the first hour of the march, and the rest of the
+day endured agony, seizing the first opportunity of drinking any filthy
+water they met with. When, for instance, we camped near a vlei, and the
+General took the greatest care that the mules and horses should be
+watered at one spot only, in order to preserve the cleanliness of the
+rest of the pool, the men would often go and fill their water-bottles
+amongst the animals' feet rather than take the trouble to walk the few
+necessary yards round. In such particulars they needed constant
+supervision.
+
+The climate on the western side was a great element no doubt both in the
+general healthiness of the men and in the general good results seen in
+the healing of wounds. The days were often hot; thus even in November at
+Orange River the thermometer registered 115 deg.F. in the single bell tents,
+but on the other hand the nights were cool and refreshing. The air was
+very pure and exceedingly dry, while the constant sunshine not only kept
+up the spirits, but also proved the most efficient disinfector of any
+ground fouled to less than a serious extent. Dust was our principal
+bugbear; and when a camp had been settled for a few days, flies; both of
+these evils increasing rapidly as the stay on any one spot was
+prolonged. My personal experience of rain was small, but I was twice in
+camp, once at Orange River and once at Bloemfontein, when very heavy
+rain fell, and this was sufficient to make the camps terribly
+uncomfortable for a few days.
+
+Under these conditions, as might be expected, until the outbreak of
+enteric fever the health of the men was remarkably good, minor ailments
+alone prevailing. One of the most troublesome of these was diarrhoea,
+which gained the appellation of 'the Modders,' already a classical name
+as far as South Africa is concerned. This most frequently, I think,
+depended on errors of diet, combined with the swallowing of a large
+amount of sand with the food as dust, and in the water drunk. Cases of
+severe dysentery, however, were also not very uncommon. Rheumatic pains
+were a common ailment, which, considering the dryness of the atmosphere,
+would hardly have been expected. Continued fever of a somewhat special
+type was not uncommon, and was sometimes spoken of under the name of the
+district, sometimes as veldt fever--of this I will say nothing, as
+others better fitted to point out its peculiarities will no doubt deal
+with it. Enteric fever, our chief scourge, I will pass over for the same
+reason. I might, however, remark from the point of view of one not very
+experienced in this disease, that in a large number of the fatal cases I
+happened to see, the actual cause of death seemed to me to be septicaemia
+from absorption from the mouth. The mouths were unusually bad, even
+allowing for the often insufficient cleansing that was able to be
+carried out, and I was inclined to attribute these in some degree to the
+dryness of the atmosphere, which very quickly and effectively dried up
+the mucous membrane of the mouth in patients not breathing through the
+nose, and encouraged the formation of large cracks. Pneumonia was rare,
+and this was rendered the more striking from the comparatively large
+number of men who contracted the disease on board ship on the voyage out
+from England.
+
+As will be gathered from the above, medical disease seldom called for
+the aid of the surgeon. Abdominal section was occasionally considered in
+cases of perforation in enteric fever, and was, I believe, a few times
+performed, but as far as I know without success. It was also proposed to
+treat some of the severe dysentery cases by colotomy, but I never saw
+the method tried. As far as I was concerned I never met with a case of
+either disease I thought suitable for the treatment. I saw one case in
+which an abscess of the liver had followed an attack of enteric, which
+had been successfully treated by incision, and a few cases of tropical
+abscess which probably came into the country were also subjected to
+operation. Some cases of appendicitis, as would be expected, also needed
+surgical treatment. In a few instances empyema followed influenza, and a
+few cases of mastoid suppuration had to be dealt with.
+
+Of surgical diseases the one most special to the campaign, although not
+of great importance, was the veldt sore. This was a small localised
+suppuration most common on the hands and neck, but sometimes invading
+the whole trunk, more particularly the lower extremities however, when
+the covered parts of the body were attacked. The sores were no doubt the
+result of local infections; they reminded me most of the sores seen on
+the hands of plasterers, and I think there is no doubt the dust was
+responsible for them. I think piles were somewhat more prevalent than
+they should have been among the men, but this was probably dependent on
+the strain involved in defaecation in the squatting position, since the
+soldiers were for the most part regularly attentive to the calls of
+nature.
+
+I saw a good many cases of lightning stroke, and some were fatal.
+Sunstroke was not common, and, considering the heat, it was very
+remarkable how little the men suffered from this condition. This was no
+doubt in part attributable to the absence of the possibility of getting
+alcoholic drinks, but it is not common for any one in South Africa to
+suffer in this way, probably as a result of the continuous nature of the
+sunshine.
+
+In spite of the labours of hospital surgeons at home, it was rather
+instructive to see the number of men who suffered with hernia,
+varicocele, and varicose veins to a sufficient degree to necessitate
+going to the base. The experience quite sufficed to explain the trouble
+which is taken to prevent men with these complaints entering the
+service.
+
+
+GENERAL CONSIDERATION OF THE NUMBER OF MEN KILLED AND WOUNDED
+
+I will now pass to the question of the proportionate frequency with
+which the men were killed or wounded during the present campaign. I
+propose to take only one series of battles, with which I was personally
+acquainted throughout, to illustrate this point. This seems the more
+satisfactory course to follow, since the number of casualties is still
+undergoing continuous gradual increase, and besides this the warfare has
+assumed a peculiar and irregular form, statistics from which scarcely
+possess general application.
+
+The battles included, those of the first Kimberley Relief Force, were
+fought under fair average conditions as to the nature of the ground. In
+the first two the defending enemy occupied heights, in the two following
+the ground advanced over by our men was comparatively even; thus at
+Modder River there was only a gradual slope upwards, and at
+Magersfontein the advanced trenches of the Boers were only slightly
+above the level of the ground over which the advance was made. At the
+same time, at the latter battle a great number of the Boers engaged were
+on the sides of the hill well above the advanced trenches. In no case
+were the Boers in such a position as to have to fire upwards, to them a
+considerable advantage. It must also be noted that throughout the Boers
+were able to rest their rifles; hence the fire should have been at any
+rate of an average degree of accuracy. In the advances of our own men,
+anthills and stones were practically the only cover to be obtained, and
+little or no help was given by variations in the general surface. All
+these points seem to favour a large proportional number of hits on the
+part of the riflemen. I very much regret that I am unable to say what
+was the proportional number of shell wounds among the men hit, but I can
+say with some confidence that among the wounded it was not as great as
+ten 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 bullets
+of large calibre such as the Martini-Henry, but this was certainly not
+large. I think if ten per cent. is deducted to represent the number of
+hits from either of these forms of projectile, that we may fairly assume
+the remaining 90 per cent. of the wounds to have been produced by
+bullets of small calibre. The numbers of the opposing forces were
+probably fairly even.
+
+Taking all these circumstances together, and bearing in mind that our
+army was always in the position of having to make frontal attacks on men
+well protected in strong positions, I think it must be allowed that a
+fair 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 the
+fact that the Boer rarely fights to the bitter end, hence the greater
+proportion 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 killed
+and wounded at each of four battles. Table III. shows for comparison the
+relative number of killed and wounded in some former campaigns while
+older forms of weapon were in use.
+
+With regard to the numbers in Tables I. and II. it should be at once
+said that they are only to be regarded as approximate, since they do not
+exactly tally with those officially reported in the 'Times' at a later
+date. Sources of error may, however, have crept into both, and as there
+is little difference in the gross numbers, I have preferred to retain
+the series compiled by Major Burtchaell, R.A.M.C., as Table II. contains
+interesting information as to the proportionate number of men who died
+during 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 the
+Franco-German war. It is mainly attributable to the circumstance that
+the officers, as leading, are always in the front and most exposed
+position. I much doubt whether at the end of the campaign the entire
+abandonment of distinctive badges will be found to have had any very
+important result in decreasing the relative number of casualties as
+between officers and men. At close quarters distinctive uniform is no
+doubt a danger, but at the common ranges of 1,000 yards and upwards the
+enemy's fire is rather directed to cover a zone than to pick out
+individuals.
+
+The especially high mortality among the officers at the battle of
+Graspan was attributable to the casualties among the naval officers, and
+the men of the brigade suffered most severely also.
+
+It will be noted that the most expensive battles were those of Belmont
+and Magersfontein.
+
+If the numbers of the men actually taking part in the fighting in these
+battles as given in Table I. are massed, we get an approximate total of
+12,420.[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, 1,512
+or 12.17 per cent.; missing, 132 or 1.06 per cent. Reference to Table
+III. shows that these percentages almost exactly correspond with those
+obtaining in the entire Crimean campaign, and are greater than those
+observed 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 the
+first 48 hours in the Field hospitals. From the surgical point of view
+these men all received mortal injury, and are therefore properly
+included among the fatalities. Their inclusion, moreover, makes an
+appreciable difference in the percentage proportion of mortal injuries
+to wounds. Thus, if the numbers are massed (omitting the 'missing'), we
+find that in the four battles 1,827 men were hit, of whom 315, or 17.24
+per 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: killed
+315, wounded 1,512, or 1 to 4.8. If we add to the men killed on the
+field of battle the 49 dying in the next 48 hours, the proportion of
+fatalities is increased to 1 to 4.15. The higher of these proportions is
+certainly the surgically correct one.
+
+With regard to the general accuracy of the numbers given above, a
+comparison of those published for the campaign up to September 15, 1900,
+is of value, as the two series substantially tally. Thus, up to that
+date, 17,072 men were hit, and of these 2,998 were killed. The
+proportion killed to wounded was therefore 1 to 4.69.
+
+If it be borne in mind that of the wounded men included in Table I., 1.5
+per cent. died later in the Base hospitals, the percentages are almost
+identical.
+
+Table III. is inserted with a view to instituting a comparison between
+the number of casualties in the present and earlier campaigns.
+
+For the purposes of this table it is necessary to take the approximate
+number of men at Lord Methuen's disposal, irrespective of their active
+participation in the fighting.
+
+The result of this addition to the total is to show that the percentage
+of men killed and wounded was slightly lower than in the Crimean war,
+and nearly corresponded with that observed in the Franco-German
+campaign.
+
+As it has been shown that our numbers correspond in general with those
+of the whole war up to September 15, 1900, there can be little doubt
+that the same ratios will be maintained to the close of the campaign.
+
+On the face of the numbers, therefore, there is little ground for
+assuming that the change in the nature of the weapons has materially
+influenced the deadliness of warfare at all. This is capable of
+explanation on the ground that in the Crimea the battles were fought at
+much closer quarters, and hence the weapons of the time were as
+effective, or more so, than the present ones. That this increased
+distance between the combatants will always counterbalance the increased
+deadliness of the weapons in the future is more than probable, since the
+range of effectiveness has been increased both in rifle and in artillery
+fire. In the present campaign the effect of the latter was very
+noticeable, since the Boers were, as a rule, quickly displaced by shell
+fire, unless they were in especially favourable positions, and this
+although no great number of men was hit by the projectiles. Under these
+circumstances, except on some occasions, neither side derived all the
+advantage from the increased shooting powers of their rifles which might
+have been expected. To a lesser degree this will probably always be the
+case in the future.
+
+In connection with these remarks, however, I would point to column 4 of
+Table III., as showing how difficult it is to draw definite deductions
+from any particular set of numbers alone. This column shows that in the
+Russo-Turkish War of 1877 all the percentages were practically doubled
+or more, and in the case of the number of men killed on the field of
+battle, the number was nearly five times as great as either in the
+Crimea or the present campaign. The explanation here depends on the race
+of men and their tenacity in resistance alone. In the case of either
+nation death in battle is little feared, and slight inclination to avoid
+it exists. When the theory of war held by the Boer--_i.e._ going out to
+shoot an enemy without incurring risk of being yourself shot--is borne
+in mind, the special circumstances attending the present campaign are
+sufficiently obvious to need little further remark. A future campaign in
+which the combatants are as equally well armed, but each side stands to
+the last, will probably give very different results.
+
+It is unfortunate that no details can be given as to the influence of
+range in altering the relative numbers of killed to wounded. It may be
+stated, however, that in no instance did the percentage of killed to
+wounded reach 25 per cent. At the battle of Magersfontein it amounted to
+19.26 per cent., at Colenso to 17.97 per cent., and at both these
+engagements there is little doubt that a considerable number of the men
+were hit within a distance of 1,000 yards. When the distances were very
+short the injuries were frequently multiple; and this character was a
+more common source of danger than increase of severity in the individual
+wounds received at a short range.
+
+A short consideration of the circumstances especially influencing the
+ultimate mortality amongst the wounded subsequent to the reception of
+the injury is here necessary, although I shall be obliged to make my
+remarks as short as possible. The subject is best treated of under the
+two headings of Transport and Hospital Accommodation.
+
+_Transport._--The importance of transport is felt from the moment of the
+injury till the time of arrival of the patient in the mother country. To
+the surgeon it is of the same vital importance as the carrying of food
+for the troops is to the combatant general.
+
+(_a_) Removal of the wounded from the field of battle. My experience was
+opposed to hurried action in this matter, although it is necessary to
+gather up the wounded before nightfall if possible. As a rule wounded
+men should not be removed from the field of battle under fire, at any
+rate when the troops are in open order at a range of 1,000 yards or
+more. I saw several instances in which mortal wounds were incurred by
+previously wounded men or their bearers during the process of removal,
+while it was astonishing how many scattered wounded men could lie out
+under a heavy fire and escape by the doctrine of chances. The erect
+position and small group necessary to bear off a wounded man at once
+draws a concentrated fire, if fighting is still proceeding.
+
+As to the best and quickest method of removing the patients to the first
+dressing station, there were few occasions when this was not more
+satisfactorily done by bearers with stretchers than by wagons. The
+movement was more easy to the wounded men, and, as a rule, time was
+saved. Over rough ground the wagons travel slowly, and patients with
+only provisional splints were shaken undesirably. A stretcher party in
+my experience easily outstripped the wagon unless a road or very smooth
+veldt existed. A larger number of men is of course required, but I take
+it that on the occasion of a great war men are both more easily obtained
+and fed than are transport animals. From what I have been able to learn,
+both the Indian dhoolie-bearers and the hastily recruited Colonial
+bearer companies were most successful in the removal of the large number
+of wounded men from the field of Colenso. I had several opportunities of
+comparing the two methods on a smaller scale during the fighting in
+Orange River Colony, and felt very strongly in favour of the stretcher
+parties.
+
+For removal of patients from one part of a hospital to another, or
+sometimes in loading trains, &c., great economy of men, and increased
+comfort to the patients, may be attained by the use of some form of
+ambulance trolly.
+
+I append an illustration of what seemed to me the simplest and best I
+came across among several in use in South Africa. The description
+beneath 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 men
+lying down, the same number as the big service wagon, and were drawn by
+two ponies only. Although somewhat highly springed, the vehicle is so
+well arranged and padded, that the occupants are seldom hurt by striking
+against the sides with rough jolting, unless quite helpless. I
+occasionally 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 steel
+spokes and rims with rubber tyres and ball bearings; on the axle are two
+light elliptic springs, to which is attached a transverse seat for the
+stretcher-carrier proper. This is securely bolted on to the seat, and
+consists of two pieces of hard wood, suitably worked, and forming an
+angle frame. On the bottom side the stretcher poles rest, and the sides
+of the L formed by the carrier proper prevent most effectually any
+jerking or turning of the stretcher when once it has been laid in the
+carrier. The carrier is about thirty inches long, but can be increased
+to any length desired. It has been found that this length is admirably
+suited for all purposes. To prevent the stretcher from any lateral or
+upward movement, two buttons with tightening screws are attached to the
+top of the carrier on each side. When the stretcher is laid on the
+carrier the screws are tightened and the stretcher is held rigid.
+
+Two iron supports are provided, one at each end and on opposite sides of
+the carrier. These are lowered when it is desired either to place the
+stretcher on the carriage or remove it therefrom, which can be effected
+in a second. The carriage meanwhile remains perfectly still. When the
+carriage is in motion the iron supports are turned up, and lie along the
+respective sides of the carrier, where each rests in a small clip. The
+great object of this stretcher carriage has been to obtain mobility,
+strength, and lightness combined with efficiency and a ready and easy
+means of transport for sick and wounded, no matter where a patient has
+to be transported from. The loaded stretcher and wheeled carriage can be
+readily handled by one man on good roads, and by two men in rough
+country. The springs prevent any jar being felt by the patient on the
+stretcher.]
+
+(_b_) For the longer journeys to the Field or Stationary hospitals, the
+service wagon and other transport vehicles came into use, particularly
+the 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 ten
+mules. The good construction of the wagon was amply proved by the manner
+in 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 small
+accommodation. Two lying-down patients and six sitting is its entire
+capacity. Some modified patterns were in use, notably those with the
+Irish and Imperial Yeomanry Field Hospitals, capable of carrying four
+lying-down cases, the men being arranged in two tiers. Major Hale,
+R.A.M.C., made a very successful trek from Rhenoster to Kroonstadt with
+some of these, carrying twice the regulation number of lying-down cases
+in his wagons. Some modification in the mode of fixation is, however,
+necessary to increase the security of the stretchers of the upper
+series.
+
+A really satisfactory wagon, combining both strength and comfort, still
+remains to be devised.
+
+[Illustration: FIG. 7.--Service Ambulance Wagon, the six front mules
+removed.
+
+(Photo by Mr. C. S. Wallace)]
+
+During the later stages of the campaign, a very large number of patients
+were transported by the South African ox- or mule- (buck) wagons.
+Although not of prepossessing appearance, and unprovided with any sort
+of springs, these vehicles were far from unsatisfactory. The ox-wagon
+consists 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 wheels
+for the posterior two-thirds. These bulwarks increase the actual width
+to 6 ft. 6 in., which corresponds with the gross width occupied by the
+wheels. One third is covered by a small hood 5 ft. 6 in. in height
+erected on wooden stave hoops. The latter was often absent in transport
+wagons. The two hind wheels are large, the fore somewhat smaller. They
+are attached to very heavy wooden cross-beams bearing the axles, and the
+two beams are connected by a longitudinal bar, continuous with the
+duessel boom or pole. This latter bar is in two sections, the connection
+of which allows considerable play in the long axis and serves to break
+the jolts occurring when either pair of wheels passes over uneven spots
+on the ground. When some sacks of oats or hay were spread over the
+floor the wounded men travelled comparatively comfortably in these
+wagons, the great distance between the fore and hind wheels tending to
+minimise the jolting. The principal objection to them was the slow pace
+of the oxen, and the fact that to obtain the greatest amount of work
+from these animals a major part of the journey must be performed during
+the night. The ox-wagon carries, with comfort, four lying-down cases on
+stretchers, or six without stretchers; or twenty sitting-up cases.
+
+[Illustration: FIG. 8.--South African Wagon, loaded with patients, and
+mule transport. (Photo by Mr. C. S. Wallace)]
+
+The mule- or buck-wagon, which is of the same class but smaller, can
+only accommodate two stretchers, four lying-down men without stretchers,
+or 12-14 sitting-up cases. As a rule, the wagons were loaded with
+recumbent cases in the centre, while more slightly wounded men sat
+around, and were able to give help to those lying down when needed. The
+wagons can be covered with canvas throughout.
+
+The steady even pace of the oxen is a great advantage, and I was often
+surprised to see how well men bore transport in these wagons, who seemed
+utterly unfit to be moved had it not been an absolute necessity. A very
+large number of the wounded from Paardeberg Drift were transported to
+Modder River in them.
+
+One other advantage of these wagons, the possibility of converting them
+into an excellent laager, is not to be underrated. Any one who saw the
+comfortable encampment which a naval contingent on the march made by
+massing the wagons with intervals covered by macintosh sheets, could at
+once appreciate their capabilities for a long trek.
+
+Traction engines were, as far as I know, never employed as a means of
+transporting the sick. The tendency of these heavy machines to stick in
+the mud and to break down bridges is so well known that it hardly needs
+mention. Putting these disadvantages on one side, with a supply of fuel
+ensured, and such roads as are afforded by a civilised country, a great
+future is probably before this means of transport for the wounded. A
+large number of patients might be carried at an even pace, and the camps
+would be saved all the trouble and worry of the transport animals.
+
+_Trains._--In many cases in Natal, and in a few instances on the western
+side, the wounded men were able to be transferred from the first
+dressing station directly into the trains. Space will not allow me to
+describe any of those in use, but the accompanying illustration shows
+the general arrangement of the beds in Nos. 2 and 3 trains (fig. 9). The
+carriages were converted from ordinary bogie wagons of the Cape
+Government 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 with
+accommodation for two medical officers, two nursing Sisters, orderlies,
+a kitchen, and a dispensary, and each carried some 120 patients. The
+trains 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 patients
+from all parts of the country to the Base and Station hospitals. They
+were most admirably worked, and seemed to offer little scope for
+improvement except in minor details. To them much of the success in the
+treatment of the wounded who had to traverse the immense distances
+incident to South Africa must be attributed. I made many pleasant
+journeys in each of them. Later, two additional trains, Nos. 4 and 5, of
+a similar nature, were added. Two trains, No. 1, and the Princess
+Christian train, which I was not fortunate enough to see, performed
+similar duties for Natal.
+
+[Illustration: FIG. 9.--Interior of one of the Wagons of No. 2 Hospital
+Train]
+
+_Hospital Ships._--These were numerous and some especially well
+arranged. Fig. 10 is of the 'Simla,' a P. & O. vessel which was
+admirably adapted to the requirements of a hospital ship. On her main
+deck some 250 patients were accommodated in a series of wards all on the
+same level, which much lightened the difficulties of service usually
+experienced. During the present campaign the abundance of transport
+vessels rendered the transhipment of patients to England a matter of
+comparative ease, and good vessels were always available. Considering
+the constant transhipment of invalids from India and our other colonial
+possessions, it would seem advisable that, in place of having to
+hurriedly improvise hospital ships, the Government should possess two or
+three hospital ships of the 'Simla' type. It is true this would deprive
+our naval transport officers of a duty which in this war was performed
+with extraordinary celerity and success; thus the 'Simla' was fitted in
+seven days, and sailed with a cargo of invalids ten days after her
+arrival at Durban; but on the other hand it would ensure that really
+suitable vessels were always provided.
+
+[Illustration: FIG. 10.--P. & O. Hospital Ship 'Simla' in Durban
+Harbour]
+
+To give some idea of the amount of work contingent on the transport of
+wounded men from an army of some 15,000, fighting its way against
+continued opposition, I will quote the approximate number of men moved
+during Lord Methuen's advance from Orange River to Magersfontein. (The
+number 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 Stationary
+Field hospitals at Orange River, then returned and loaded up with 130
+more. Some of the most severe cases in the latter were detrained at
+Orange River, and the remainder were taken direct to Wynberg (591-1/2
+miles).
+
+The division marched, and the battle of Graspan was fought during the
+day.
+
+_November 26._--A train of specially constructed trucks brought 90 of
+the less severe cases, including 20 Boers, to Orange River.
+
+_November 27._--The division marched, and in the morning No. 3 hospital
+train removed 80 severe cases from the Field hospitals direct to
+Wynberg.
+
+_November 28._--Battle of Modder River.
+
+_November 29._--339 patients, including a few sick, and some wounded
+Boers, were sent down to Orange River in open trucks with impromptu
+shelters made with rifles and blankets.
+
+Later, 97 severe cases were sent down in ordinary carriages, of which
+some had doors sawn out to admit lying-down patients.
+
+_December 10._--The division marched, and on the next day the battle of
+Magersfontein was fought.
+
+_December 11._--Nos. 2 and 3 trains were loaded up during the night and
+early morning of the 12th, in part from the Field hospitals, in part
+directly from the Ambulance wagons. During the day of the 12th, No. 3
+train made three journeys to Orange River, and No. 2 was sent direct to
+Wynberg.
+
+In all some 800 patients needed transport; they were picked up by 10
+ambulance wagons and 5 buck wagons for slighter cases and the two bearer
+companies sent out from Modder River. On the 12th Lord Methuen sent out
+a number of bearers with stretchers, and at 12 noon all the wounded were
+collected, but many had lain out through the night. The bearers had to
+retire under a shell fire kept up by the Boers as long as our army was
+within range of their position.
+
+Four Field hospitals were present, but only that of the IX. Brigade at
+Modder 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 of
+work most expeditiously and with great success.
+
+The nature of the advance on Kimberley necessitated the evacuation of
+the Field hospitals with extreme promptitude, as the troops were in
+constant action, and the arrangements for this were carried out with
+great success by Colonel Townsend, the P.M.O. of the First Division.
+
+The amount of fighting far exceeded anything that had been expected, and
+the Stationary hospitals on the lines of communication at Orange River
+and De Aar were unable to cope with the number of severe cases thrown on
+their hands, with the constant possibility of new arrivals. Hence a
+number of severe cases had to be sent direct to Wynberg.
+
+This experience strongly illustrated the necessity of possessing
+Stationary hospitals of greater mobility and a higher degree of
+equipment than the service at present possesses. In these a large number
+of severe cases could have been retained, and only the slighter ones
+exposed to the fatigue and general disadvantage of transport. In South
+Africa very special difficulties existed in the length of the line of
+communication, the single line of rails, and the absence of any source
+of supply within 500 to 600 miles; but in any other country mobile
+Stationary hospitals, although more easily equipped, would be equally
+valuable.
+
+The difficulties of transport experienced in the advance of the
+Kimberley Relief Force were many times multiplied in that upon
+Bloemfontein, since the whole of the severely wounded men had to be sent
+back thirty to forty miles to the railway. The ambulance accommodation
+on the occasion of this march, although, if untouched, proportionately
+smaller than that possessed by Lord Methuen, was reduced to one-fifth to
+meet the exigencies of warfare. Beyond this the equipment transport of
+the Field hospitals was reduced from four ox-wagons to two, and the
+Scotch cart was cut off, only two ox-wagons and the two water-carts
+being allowed. This greatly hampered the Field hospitals on the march,
+and when they arrived at Bloemfontein and had to undertake the work of
+Stationary hospitals, their efficiency was seriously impaired. Again, on
+the advance from Bloemfontein to Kroonstadt many of the Field hospitals
+were unable to accompany their respective divisions, not alone on
+account of the number of patients remaining in them, but also because
+the mule transport had been otherwise employed for military purposes.
+
+The transport of the ambulances and hospitals stands in a very special
+position. As far as my experience went, neither ambulances nor hospitals
+were ever taken or retained by the Boers, and consequently the transport
+animals originally devoted to this purpose should have been held sacred
+to it.
+
+_Hospitals._--Accommodation for the wounded was provided under canvas in
+the Field hospitals, also in the large General hospitals. Beyond this
+iron huts were erected in many of the Base and Station hospitals. At
+Capetown, Maritzburg, and Ladysmith barrack huts were modified and
+equipped as hospitals, and in towns such as Bloemfontein, Kimberley, and
+Johannesburg large civil hospitals were at our disposal. Beyond these
+sources of accommodation, churches, schools, public institutions, and
+private houses were made use of in the smaller towns.
+
+As to the broad question of canvas _v._ buildings, experience amply
+showed that in a climate such as is possessed by South Africa, canvas
+affords the greater advantages. The hospitals are more mobile, more
+readily extended, and the more healthy. Except under unusual conditions
+of rain and dust, the patients did excellently in the tents.
+
+Rain and dust were occasionally most troublesome, especially when
+combined with wind. I once saw a whole hospital, fortunately unoccupied,
+levelled to the ground in the course of some twenty minutes. Under such
+circumstances iron huts present advantages, and were on many occasions
+utilised with much success. They are readily erected, and it would have
+been a considerable improvement if a number of them had been ready for
+use at the earliest part of the campaign. Except in the matter of
+weight, they possess in a considerable degree the advantage of mobility
+possessed by canvas, and in addition they offer much more protection
+from the weather. On the other hand, they are more liable to become
+unhealthy from prolonged use.
+
+Churches and public institutions were mainly troublesome from the
+necessity of having to improvise sanitary arrangements, and sometimes
+the disadvantage of the collection of a large number of men in one
+chamber could not be avoided. None the less I cannot look back without
+admiration on the temporary hospitals established in the Raadzaal at
+Bloemfontein, and the Irish hospital in the Palace of Justice in
+Pretoria.
+
+The State schools in the smaller towns of the Orange River Colony also
+afforded excellent accommodation as small temporary hospitals.
+
+Private houses, possessing the disadvantages of ill-adapted construction
+and the necessity of a considerably increased staff to work them, were
+on the whole little used as hospitals. The scattered farmhouses
+occasionally afforded shelter to very severely wounded men. In most of
+the country I traversed, however, the farms were so wide apart as to be
+of little use in this respect; and again, under the special
+circumstances, patients left in them might have to be abandoned to the
+enemy.
+
+The chief interest during the campaign centred in the working of the
+Field and General hospitals.
+
+Two types of Field hospital were employed, one the Home, the other the
+Indian. The latter differs from the Home in that in it the bearer
+company is attached and consists of Indian natives, and that the
+hospital is separable into four sections in place of two only.
+
+The amalgamation of the Field hospital and bearer company into one unit
+is much to be desired in the Home service, both for economy of working
+and the more equal distribution of duties to the medical officers
+engaged. Again the divisibility of the hospital into four sections is
+also 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 of
+severely wounded men unfit to travel. As far as I could judge, it
+necessitates very small addition to the present equipment, and is in
+every way desirable.
+
+As to the working of the Field hospitals in the present campaign, it
+was universally acknowledged to possess a very high degree of
+excellence. The equipment, with small exceptions, proved equal to the
+demands made upon it. The mobility of the camps was proved again and
+again, and the rules governing their administration evidenced by their
+effectiveness the care and experience which have been bestowed on the
+organisation of the hospitals.
+
+It is difficult for any one who has not had an opportunity of observing
+the actual amount of work performed in the Field hospitals either to
+appreciate the storm and stress following an important engagement when
+the wounded men are first brought in, or the demands that are made on
+the powers of the medical officers in charge. To a civilian the first
+feeling is one of impotence, followed by an attempt to see no further
+than the case under immediate observation, and to nurture the conviction
+that the work is to be got through if it is only stuck to. I gathered
+that this first impression was absent in the minds of the officers in
+charge of the Field hospitals, as work commenced at once, and was
+carried on without intermission during the persistence of daylight, in
+the winter often by the aid of lanterns, and eventually the huge task
+was accomplished. In early days at Orange River work commenced at 4
+A.M., and was steadily continued until 6 P.M. or later, and this state
+of things persisted sometimes for many days together.
+
+The officers of the Field hospitals, the bearer companies, and those
+doing regimental duty carried out their duties with a calmness and
+efficiency which not only impressed observers like myself, but also
+excited the admiration of our German colleagues sent by their government
+to observe the working of the British system.
+
+I saw on several occasions the German and Dutch ambulances, and was much
+struck by the excellence of their equipment. In some details there was
+much to be learned from them, especially in the matter of appliances,
+dressings, and instruments. The Dutch ambulance I saw at Brandfort had a
+complete installation of acetylene gas, which was carried, gasometer and
+all, in one Scotch cart. They were, however, really designed to fill the
+combined position of our Field, Stationary, and General hospitals, and
+when it became necessary for them to move about frequently, the inferior
+mobility they possessed in comparison with our own Field hospitals was
+at once demonstrated.
+
+The large General hospitals of 500 beds were a great feature in the
+campaign. Although designed and organised some time since, the present
+was the first occasion on which they have come into general use, and
+they may be said to have actually been on trial. The organisation of
+these hospitals proved itself excellent, and in the case of the best of
+them left little to be desired.
+
+In some cases the accommodation was temporarily strained enormously, and
+the number of patients was extended beyond more than three times the
+regulation limit. The additional patients were then accommodated in
+marquees 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 were
+placed at a great disadvantage.
+
+My space does not allow me to give any description of the general
+arrangement of these hospitals, but I would suggest that a certain
+number of them should be so modified as to increase their mobility and
+allow 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 the
+Field hospitals were rapidly evacuated), were those in which some
+increased uniformity of organisation was most needed.
+
+It scarcely needs to be pointed out that this is the most difficult link
+of 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 is
+difficult to maintain a regular staff of officers ready for any
+emergency 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, which
+under ordinary circumstances is the minimum that may be necessary.
+
+Stationary hospitals as individual units are undesirable for the reasons
+above given.
+
+[Illustration: FIG. 11.--Type of a General Hospital (No. VIII.
+Bloemfontein) extended by use of bell tents in the distance. (Photo by
+Mr. C. S. Wallace)]
+
+The difficulty might be met by increasing the mobility of a certain
+number of the General hospitals, by making them divisible into five
+sections, each of which should be able to move independently, and to the
+last of which should be attached the heavy part of the equipment, such
+as the iron huts for operating and X-ray rooms, kitchens, store sheds,
+&c. The tents might also be lightened by the substitution of the
+tortoise tent for the service marquee. The tortoise tent is lighter (360
+as against 500 lbs.), easily pitched and moved, and holds at least two
+more patients with ease. The capabilities of this tent were amply proven
+during its use by the Portland, Irish, and other civil hospitals
+attached to the army. It withstood wind and weather, the former better
+than the service marquee. Figs. 11 and 12 show the appearance of camps
+composed of the two varieties. I must admit a warm preference for the
+appearance of the service pattern, but I think it is indubitable that
+the 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 to
+serve as Stationary hospitals at various points behind the advance of
+the troops, and on the cessation of active need, the sections could be
+reunited at any point to form an advanced Base hospital. The sections
+could be kept in touch throughout by visits from the officer of the
+lines of communication. This would appear a ready means of providing
+well-organised Stationary hospitals at short notice, and would save the
+disadvantage of a definitely separate series.
+
+[Illustration: FIG. 12.--Type of Tortoise Tent Hospital. Portland
+Hospital, Bloemfontein. (Photo by Mr. C. S. Wallace)]
+
+Such hospitals might have been used on many occasions when the transport
+of an entire General hospital was an impossibility. The service,
+moreover, has some experience in this direction, since at one time No. 3
+General Hospital was divided into two definite sections.
+
+Bearing in mind the extreme readiness and promptitude with which the
+officers during the present campaign extended the accommodation of
+either Field or General hospitals, one of such sections as are proposed
+might readily be made far more capacious than its regulation number
+would suggest.
+
+My duties being entirely in connection with the service hospitals, I did
+not become intimately acquainted with any of the volunteer hospitals
+which did such excellent service, except the Portland, to the staff of
+which I was indebted for much hospitality and kindness. This hospital
+was practically of about the capacity proposed for the above-mentioned
+sections, and the report of its work will no doubt furnish many points
+of detail as to equipment, &c., which may be useful.
+
+The general results of the surgical work done during the campaign were
+excellent, and taken as a whole the occurrence of any severe form of
+septic disease was unusual.
+
+Pure septicaemia, especially in connection with abdominal injuries,
+severe head injuries and secondary to acute traumatic osteo-myelitis,
+was the form most commonly seen. Pyaemia with secondary deposits was
+uncommon, and often of a somewhat subacute form; thus I saw several
+patients recover after secondary abscesses had been opened, or the
+primary focus of infection removed. The only really acute case of joint
+pyaemia I heard of, developed in connection with a blistered toe followed
+by cellulitis of the foot.
+
+Cutaneous erysipelas I never happened to see, and really acute
+phlegmonous 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; in
+one amputation was performed, and the process extended upwards on to the
+abdomen. The cases occurred with the army in the field in the
+neighbourhood 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 the
+patient developed the disease and died within ten days.
+
+To the civil surgeon the performance of operations, and the dressing of
+severe wounds at the front, proved on occasions a somewhat trying
+ordeal.
+
+When operations were necessary in the field, during the daytime, it was
+often possible to perform them in the open air, provided tolerable
+protection could be obtained from the sun. A number of cases were so
+operated upon during the march of the Highland Brigade from Wynberg to
+Heilbron, and gave excellent results, the patients deriving considerable
+benefit 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 were
+often much greater. The operations were necessarily performed under
+shelter for reasons of privacy. In the tents the draught carrying the
+dust from the camp was one of the commonest troubles. The exclusion of
+dust was impossible, and it not only found its way into open wounds, but
+permeated bandages with ease. Often when a bandage was removed, an even
+layer of dust moistened by perspiration covered the whole area included
+with a coating of mud. Again, in dust storms a similar layer of mud
+sometimes covered the whole of the exposed parts of the bodies of
+patients 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 River
+after the camp had been more than two months established, and discovered
+no pathogenic organisms in it. As a period of seven months had elapsed
+since this dust was collected, the fact is of no practical import,
+beyond showing that, if such organisms had existed, at any rate they
+were not of a resistent nature.
+
+Insects, particularly common house-flies, were an intolerable pest at
+times. In a fresh camp they were sometimes not abundant, but after two
+or three days they multiplied enormously. Not only hospital tents, but
+living and mess tents, swarmed with them, the canvas appearing
+positively black at night. Even when dressing a wound, without unceasing
+passage of the hand across the part, it was impossible to keep them from
+settling, and during operations the nuisance was much greater.
+
+Storms of rain were occasionally as troublesome as, though perhaps less
+harmful than, those of dust. On one occasion a whole Field hospital was
+flooded only a few hours after a number of important operations had been
+performed, and the patients were practically washed out of the tents. It
+was somewhat remarkable that none of the men suffered any serious ill as
+a result.
+
+At times the temperature was sufficiently high to make either dressing
+or operating a most exhausting process to the surgeon. The heat of the
+day was not on the whole so disadvantageous from the point of view of
+the operator, as the cold of the nights during the winter in Orange
+River Colony. On one or two occasions serious operations had to be left
+undone, as it was only possible to consider them in camp, where, as we
+arrived at night only, the temperature was too low to justify the
+necessary exposure.
+
+Water for use at operations was often a great difficulty. Even at Orange
+River, where, though muddy, the water was wholesome, it was impossible
+to get water suitable for operations unless it had previously gone
+through the complicated processes of precipitation by alum, boiling, and
+filtration. At Orange River a small room in the house of one of the
+railway servants was obtained and fitted as a rough operating room by
+the Royal Engineers. The necessary utensils were provided by Colonel
+Young, Commissioner of the Red Cross Societies. Here a stock of prepared
+water was kept for emergencies.
+
+The remaining difficulties mainly consisted in those we are familiar
+with in civil practice, such as the securing of suitable assistance in
+the handling of instruments and dressing, when the rush of work was very
+great.
+
+At the Base hospitals accommodation for operating in properly equipped
+rooms obviated many of the difficulties above referred to.
+
+In concluding this introduction I should sum up in a few words my
+experience of the general working of the hospital system during my stay
+in South Africa.
+
+The excellence of the Field hospitals for their purpose has been already
+alluded to, and, as far as I could ascertain, won the confidence and
+approval of patients, military commanders, and civilians such as myself.
+
+The Stationary hospitals (by which I intend to indicate those receiving
+the patients directly from the Field hospitals before the establishment
+of advanced Base hospitals), as already indicated, were not in my
+opinion so perfectly conceived or organised. The requirements of these
+are, however, far greater than those of the Field hospitals, and they of
+all others are dependent on the possession of facilities for rapid
+transport. In South Africa the difficulties of supplying them were
+enormous, and no doubt the conditions of the campaign in this, as so
+many other particulars, were novel and unusual. None the less the
+experience gained will no doubt be utilised in the future. With regard
+to the extravagant criticisms levelled at the Field hospitals serving as
+Stationary hospitals at the time of the early period of the occupation
+of Bloemfontein, it may be pointed out that the only proper ground for
+comparison was not between the patients at Bloemfontein and those in
+hospital at the base, but between the men in hospital and those in the
+field at that time, since the conditions were equally adverse to both.
+Besides, it must not be forgotten that a large proportion of the
+patients, at that time, were really comfortably housed in the Raadzaal
+and other buildings, the preparation of which entailed a very great
+amount of both labour and resource.
+
+The difficulties experienced at that time will, it is hoped, go far
+towards securing greater facilities and rights of transport to the Royal
+Army Medical Corps in the future. As a civilian, one cannot but
+recognise that the conditions of modern warfare are much altered from
+those of the past. Prisoners are well cared for and kindly treated, the
+sick and wounded are respected by both sides, and except in the actual
+horrors of fighting the condition of the soldier is a happier one. Under
+these circumstances the limitation of the transport facilities of a
+department so closely concerned with the well-being of all, and which
+has been organised on a most moderate scale, must soon become a
+tradition 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 personal
+equation of the officer in charge of them, but as a whole the service
+has every reason to be proud of their success. As far as surgical
+results are concerned, and with these I had special acquaintance, the
+success of the hospitals was amply demonstrated.
+
+Adverse criticism was not however wanting, and often expressed in the
+strongest terms by persons totally unacquainted with hospital methods,
+and apparently unconscious that such excellence as is exhibited in a
+London hospital is the result of continuous work and development for
+some centuries, and that such institutions are worked by committees and
+staffs of permanent constitution.
+
+The proportion of female nurses employed in these hospitals underwent
+steady increase from the commencement of the campaign, and the immense
+value of the nursing reserve was fully proved. There is no doubt that in
+Base hospitals the actual nursing should always be entrusted to women.
+
+The demands of the campaign necessitated the employment of a large
+number of civil surgeons in the various hospitals. These gentlemen
+accommodated themselves with true British aptitude to the conditions
+under which they were placed, and in all positions their sterling work
+contributed in no small degree to the success that was attained.
+
+One class of hospital still remains for mention. I refer to the
+improvised hospitals prepared in the Boer towns prior to the British
+occupation. They were met with in all the smaller towns, and also in the
+larger ones such as Johannesburg and Pretoria.
+
+The Burke hospital in Pretoria, started by a private citizen and his
+daughter, and the Victoria hospital in Johannesburg, presided over by
+Dr. and Mrs. Murray, were two of the largest, but each and all deserve
+due recognition.
+
+I am sure that many of our wounded officers and men who were cared for
+in these hospitals while prisoners in the hands of the Boers, will never
+lose their sense of gratitude to those inhabitants who spared no effort
+to render their position as happy as possible under the circumstances;
+and the existence of these hospitals was no small boon to the service
+when called upon to take charge of the sick and wounded therein
+contained.
+
+I cannot close this chapter without recognition of the immensity of the
+task which has fallen on the Royal Army Medical Corps in the treatment
+of the sick and wounded during the course of the campaign and full
+appreciation of the manner in which that task has been met. The strain
+thrown upon this department of the service, originally organised for the
+needs of an army less than half the magnitude of that eventually taking
+the field, was incalculably great, and the medical profession may well
+be proud of the efforts made by its military representatives to do the
+best possible work under the circumstances.
+
+FOOTNOTES:
+
+[1] 3,328 men of the IX. Brigade present are not included, as they never
+came into action.
+
+[2] The high mortality was due to deaths amongst the officers of the
+Naval Brigade.
+
+[3] To obtain this total the numbers of killed, wounded, and missing,
+after the three earlier battles, have been massed, and added to the
+total number of men known to have taken part in the battle of
+Magersfontein. The inaccuracy dependent on the fact that some of the men
+reported as wounded or missing in the earlier battles had already
+returned 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 INJURIES
+PRODUCED BY THEM ON THE HUMAN BODY
+
+
+Before proceeding to the actual description of the wounds inflicted by
+modern military rifles, it is necessary to prefix a few remarks on the
+mechanism and mode of production of these injuries.
+
+Recent tendency in the construction of military rifles has been in the
+direction of reduction of bore, and a corresponding one in the calibre
+of the bullet, the resulting loss of weight in the latter as an element
+in striking power being compensated for by the attainment of an
+augmentation of velocity in the flight of the projectile, and a
+comparatively flat trajectory.
+
+Changes in this direction have endowed the weapons with increase both in
+range and accuracy of fire; while the greater rapidity with which
+magazine rifles can be discharged and, in consequence of reduction in
+weight, the greater number of cartridges which can be carried by each
+man, also form important factors in the possible deadliness of warfare
+at the present day. None the less the experience of the present campaign
+has scarcely justified the early prognostications expressed as to a
+great increase in the number and severity of wounds amongst the
+combatants.[5] This comparative immunity is to be explained mainly on
+two grounds. The increased distance which for the most part separated
+the two bodies of men, a feature no doubt accentuated by the mode of
+warfare adopted by the Boer, and his strong sense of the folly of close
+combat on equal terms, tended to efface one of the chief characters,
+velocity of flight, on the part of the projectile. The want of
+effectiveness of the small-calibre bullet as an instrument of serious
+mischief also kept down the mortality.
+
+Since the year 1889 the calibre of the bullet in our own army has been
+reduced from that of the Martini-Henry (.450 in.) to one of .309 in. in
+the Lee-Metford, and a consequent reduction in weight from 480 to 215
+grains. To allow of the satisfactory assumption of the more complicated
+rifling by the more rapidly projected bullet, the lead core has been
+ensheathed in a mantle of denser metal. The bullet itself is of an
+original calibre (.309 in.) somewhat exceeding the bore of the rifle
+barrel (.303 in.), in which way a species of 'choke' is obtained and
+deep rifling of the surface ensured. Beyond this the comparative
+transverse and longitudinal measurements and shape have been altered in
+order to maintain weight, preserve a proper balance during flight, and
+increase the power of penetration. These alterations with slight
+differences in detail embody the general principles that underlie the
+construction of each of the weapons adopted by European nations. It will
+be well here to consider the influence of each alteration from the point
+of view of the surgeon.
+
+_Calibre._--The effect of the diminution of calibre is (_a_) to reduce
+the area of impact of the bullet on the part impinged upon, and hence to
+lower the degree of resistance offered by the tissues; this to a certain
+extent tends to neutralise the augmented striking force resulting from
+the increased velocity of flight. (_b_) To limit considerably the
+destructive powers of the bullet, as a smaller area of tissue is exposed
+to its action. (_c_) To allow of the production of very 'neat' injuries
+and the frequent escape of important structures, also the production of
+remarkably prolonged subcutaneous tracks in positions where such would
+be regarded as scarcely possible, and in point of fact were impossible
+with the older and larger projectiles.
+
+_Length._--The comparative increase in length of the bullet is, from the
+surgical point of view, only of material importance in increasing the
+weight and therefore the striking power, and in so far as it is a
+mechanical necessity for the flight of the projectile on an axis
+parallel to its long diameter, and so tends to ensure impact on the
+body by the tip of the bullet. This latter is, however, surgically
+favourable as ensuring a smaller wound.
+
+_Weight._--The decrease in weight must be regarded on the whole as
+altogether to the advantage of the wounded individual, since it cannot
+be considered to be entirely compensated for by the resulting increased
+velocity of flight, unless the range of fire is moderately close.
+
+_Shape._--The ogival tip and general wedge-like outline, while
+decreasing the aerial resistance to and increasing the power of
+penetration possessed by the bullet, at the same time allow the escape
+of some structures by displacement, while others are saved from complete
+destruction by undergoing perforation. Beyond this the sharper the tip,
+the smaller is the area of the body primarily impinged upon, the less
+the resistance offered to perforation, and to some degree the less the
+destruction of surrounding tissues.
+
+_Increased velocity of flight._--This multiplies the striking force, and
+compensates in part for decrease in volume and weight of the bullet. It
+is customary to speak of the velocity as 'initial' and 'remaining.'
+Initial velocity is the term employed to express the velocity at the
+time of the escape of the bullet from the barrel; this is also
+designated as 'muzzle velocity.' 'Remaining velocity' expresses that
+obtaining during any subsequent portion of the flight of the projectile.
+
+The greatest initial velocity is obtained with the use of bullets of the
+smallest calibre, but this is not of the practical importance which
+might be assumed, since the remaining velocity of flight of such
+projectiles falls more rapidly than that of those of slightly greater
+mass. Thus, although there may be a difference of a hundred metres per
+second in initial velocity between two rifles of calibres varying from
+6.5 to 8 millimetres (.303-.314 in.), at the end of 1,000 metres the
+discrepancy is greatly reduced, while at 2,000 metres it hardly exists.
+Under such circumstances the projectile of greater weight and volume, as
+possessing the greater striking force, is considerably the more
+formidable of the two. This is the more important if it be allowed, as I
+believe to be the case, that velocity _per se_ is of no practical import
+in the case of wounds of the soft parts of the body, which after all
+form the preponderating number of all gunshot injuries. The effect of
+the higher degrees of velocity differs, however, with the amount of
+resistance met with on the part of the body; hence its serious import is
+well exemplified when parts of the osseous skeleton are implicated,
+although even here considerable variations exist, dependent upon the
+structure of that part of the bone actually involved. The most obvious
+ill effect of injuries from bullets travelling at high rates is seen in
+the case of the various parts of the nervous system, and here it is
+undeniable. High velocity and striking force are also responsible for
+the prolonged course sometimes taken by bullets through the body.
+
+The actual degree of velocity, as judged by the range of fire at which
+an injury is received and the resulting injury, is very hard to estimate
+on account of the many and varying factors which enter into its
+determination. The mere recital of some of these will suffice to make
+this evident.
+
+1. Quality of the individual cartridge employed, as to loading, the
+materials employed, and their condition.
+
+2. The condition of the rifle as to cleanliness, heating, and the state
+of 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 man
+struck, or of an isolated limb.
+
+5. Special peculiarities of build in the individual struck, such as
+thickness and density of the integument and fasciae, strength and
+thickness of the bones, &c.
+
+6. State of tension of the muscles, fasciae, and ligaments at the moment
+of impact, and fixity or otherwise of the part of the body struck.
+
+7. The degree of wind, temperature, and hygroscopic conditions of the
+atmosphere.
+
+These form some of the more important points which have to be taken into
+consideration, in addition to a mere calculation of the actual distance
+from which a wound has been received from a particular rifle, and taken
+with the unsatisfactory nature of the evidence as to the latter, which
+is usually alone obtainable, it is clear that definite assumptions are
+scarcely possible. In a great number of cases I came to the conclusion
+that the only indisputable evidence of low velocity was the lodgment of
+an undeformed bullet. There is little doubt, moreover, that the general
+tendency of wounded men was to minimise the range of fire at which they
+were struck, and again that in the majority of cases in this campaign it
+was 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 some
+cases where there was no doubt of the short distance from which the
+bullet was fired, the wounds were due to 'ricochet' of portions of
+broken-up bullets. The following instance well illustrates this. A
+sentry fired five times at two men within a distance of six paces,
+knocking both down. One man received a severe direct fracture of the
+ilium, the bullet entering between the anterior superior and inferior
+iliac spines and emerging at the upper part of the buttock. The entry
+and exit apertures were large but hardly 'explosive,' as a subcutaneous
+track four to five inches long separated them. Besides this both men had
+other lesser injuries; thus in the second two perforating wounds of the
+arm existed. The latter were not unlike type Lee-Metford wounds, and
+were regarded as such until a few days afterwards when a hard body was
+felt in the distal portion of one track and removed. This proved to be a
+part of the leaden core only, and the similar wound had no doubt been
+produced by a like fragment, the bullet having broken up on striking the
+stony ground.
+
+_Trajectory._--The comparative flatness of this depends on the
+construction of the rifle and the propulsive force employed, and varies
+as does velocity with the nature, excellence, and amount of the
+explosive, the correctness of the principles upon which the bullet is
+devised, and the mechanical perfection of its manufacture. Its
+importance naturally consists in the manner in which it affects the
+possibility of covering objects on a wide area of ground and thus
+creating a broad 'dangerous zone.' A bullet fired on level ground from
+any one of three of the rifles referred to later (Lee-Metford, Mauser,
+Krag-Joergensen), sighted to 500 yards and fired from the shoulder in
+the standing position, will cover some part of an erect man of average
+height during the whole extent of its flight. A body of men within that
+distance is therefore in a position of extreme peril in the face of a
+good shooting enemy.
+
+The importance of a flat trajectory is progressively lost, however, with
+any rifle, as the weapon is gradually sighted to greater distances. Thus
+when sighted to 2,000 yards the bullet from the Lee-Metford rifle rises
+174 feet, and a whole army might comfortably be situated over a
+considerable area within that distance. The importance of flatness of
+trajectory is also influenced by the nature of the ground occupied by
+the combatants. Thus when the area to be covered consists in ground
+first rising then falling from the rifleman, the trajectory will become
+more or less parallel to the surface crossed, and the 'dangerous zone'
+will be correspondingly increased in extent. On the other hand, when the
+ground slopes away from the rifleman the rise of the projectile is
+exaggerated, and reaches its most limited capacity of covering an
+intervening space when the flight crosses a hollow.
+
+_Revolution of the bullet._--It only remains in this place to say a few
+words concerning the revolution imparted to the bullet by the rifling of
+the barrel. This ensures the flight of the projectile on a line parallel
+to 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 to
+a right angle with the skin, the more limited will be the area of
+contusion, even if it be of the most severe character, while to the
+twist of the bullet must be ascribed a not inconsiderable part in the
+explanation of the ready and neat perforations of narrow structures
+which are frequently produced.
+
+It has been pointed out that the Lee-Metford bullet turns on its own
+axis once in a distance of ten inches, while the Mauser revolves once in
+a distance of eight and eleven-sixteenths inches; hence not more than at
+most two revolutions are made in tracks crossing the trunk, and not more
+than half a full revolution in the perforation of a limb. None the
+less, no one can deny the influence of the one half turn of supination
+in entering a perforating tool of any description, both as preventing
+splintering, and in preserving the surrounding parts from damage.
+
+Beyond this, the spiral turn of the bullet, by diverting a part of the
+transmitted vibrations into a second direction, must, in the case of
+wounds of the body, help to throw off contiguous structures, and while
+those that are in actual contact are more severely contused, the
+surrounding ones suffer somewhat less direct injury. It must be borne in
+mind, also, that rapidity of revolution does not fall _pari passu_ with
+that of velocity of flight, but that the former undergoes a
+comparatively slighter diminution until the bullet is actually spent.
+Hence, the influence of revolution is felt, however low the velocity may
+be, provided sufficient striking force is retained to enter the body. A
+word must be added here as to the surface of a discharged bullet; this,
+in taking the rifling of the barrel, becomes permanently grooved. The
+depth of the groove differs with the variety of rifle. In the
+Lee-Metford the grooves are deep (.009), in the Mauser slightly less so
+(.007), but the surface of both bullets is comparatively roughened when
+revolving in the body, and this circumstance, since the projectile
+exactly fits its track, may influence the degree of the surface
+destruction of tissue, and somewhat aid in the clean perforation of
+bone, since a little bone dust is always found at the entrance aperture
+of a canal in cancellous bone.
+
+During the campaign many varieties of rifle projecting bullets of widely
+differing calibre were employed by the Boers, many of whom as sportsmen
+preferred the rifle to which they were accustomed to a regulation
+weapon, and an illustration of a large variety of bullets from
+cartridges which I collected from arsenals and camps is given below (p.
+96). The great majority of the men, however, were armed with
+small-calibre weapons of some sort, and as the wounds produced by these
+are of chief interest at the present day, I shall say little of any
+others, beyond an occasional reference to Martini-Henry rifle wounds
+which may be considered to represent approximately those made by large
+leaden 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-Joergensen]
+
+The most important, as the most frequently employed, rifles projecting
+small-calibre bullets were the Krag-Joergensen, Mauser, Lee-Metford, and
+Guedes, given in the order of increase of calibre (from 6.5 to 8
+millimetres, or .254-.314 in.) in the bullets. As to the seriousness of
+wounds produced by these there is little to choose, differences in
+character being only those of degree. Such differences depended on the
+area of tissue implicated, corresponding with the calibre of the
+particular bullet, the comparative weight of the bullet, and the degree
+of velocity of flight maintained at the moment of impact. When, however,
+any of these bullets have been exposed in their flight to influences
+capable of causing deformity of their outline and symmetry,
+peculiarities of construction and in the composition of the metals
+employed in their manufacture may materially alter the character of the
+wounds produced and revolutionise a classification founded purely on the
+relative weight, calibre, and degree of velocity with which each is
+endowed.
+
+
+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-     |
+|                   |               |                    |      Joergensen|
++-------------------+---------------+--------------------+---------------+
+|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 collated
+in Table I., to which is added the corresponding information regarding
+the Martini-Henry for the purposes of comparison.
+
+
+TABLE II.--PENETRATION
+
+The penetration of the Martini-Henry and the Lee-Metford or Lee-Enfield
+rifle 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 sand
+Lee-Enfield {bullet  }      1 in. apart                  containing 15 per
+                                                         cent. of moisture
+
+The penetration of bullets of .314 calibre differs little from that
+possessed by the Lee-Metford or Lee-Enfield, of which the muzzle
+velocities are very little lower, with Mark II. bullet. The Belgian
+Mauser perforates 55 inches of fir-wood at 12 metres distance. With
+regard to the penetration of bullets of smaller calibre that of the
+Roumanian Mannlicher (.256) may be taken as typical. When fired into a
+sand 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 particulars
+given in this table, but it will be noted that the Lee-Metford rifle is
+inferior to both the Krag-Joergensen and Mauser rifles in the initial
+velocity transmitted to its bullet. The tendency to equalisation, in
+this particular, when the remaining velocity is considered, has been
+mentioned; 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 of
+the three weapons.
+
+
+METRES PER SECOND
+
++---------------------+-------------+--------+----------------+
+|                     | Lee-Metford | Mauser | Krag-Joergensen |
++---------------------+-------------+--------+----------------+
+|                     |             |        |                |
+| 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 the
+severity of the injuries produced, when the large proportion of wounds
+received at distances above 1,000 yards is borne in mind, we see how
+rapidly the superiority of the smaller projectiles is lost. This loss,
+even in the early stages, is probably more than made up for in the case
+of the Lee-Metford, when the superiority in weight, calibre, and
+bluntness of extremity as contributing to striking force is taken into
+consideration.
+
+The striking force (kinetic energy) of a bullet is indicated by the
+following formula: F = 1/2 mv.^{2}; that is to say, the striking force
+is equal to half the weight of the bullet multiplied by the square of
+the velocity.
+
+In point of fact, with unaltered regulation bullets I was never able to
+determine any very material difference between the wounds produced,
+further than that the wounds of entry and exit in the soft parts tended
+to correspond with the calibre of the particular bullet concerned.
+Although the immense majority of the wounds which came under my notice
+were caused by the Mauser bullet, yet I saw some hundreds of wounded
+Boers and a good many of our own men wounded by Lee-Metford bullets, in
+the latter case no doubt by some of the sporting varieties. The only
+cases that I can call to mind or have noted as exhibiting a superior
+wounding power in the Lee-Metford bullet are some injuries to bone. Thus
+I saw a considerable number of clean perforations of the patella
+produced by Mauser bullets, while the only two Boers whom I saw with
+injured patellae had suffered transverse fractures. Again, I have a
+lively recollection of an old Boer who had suffered a fracture of the
+middle third of the femur, in the thigh of whom, with small apertures of
+entry and exit, a cavity of destroyed tissue, five inches across, was
+found beneath the fascia lata at the distal side of the fracture. I
+cannot however say that I did not observe many equally severe injuries
+to the femur produced by Mauser bullets in our own men, and as far as
+fractures of the skull went, a somewhat crucial test, among the men
+brought off the battlefield alive, I never saw any difference in
+severity whatever.
+
+[Illustration: FIG. 15.--Sections of four Bullets to show relative shape
+and thickness of mantles.
+
+From left to right: 1. Guedes; regular dome-shaped tip; mild steel
+mantle; 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, steel
+mantle plated with copper alloy; thickness at tip 0.8 mm.; gradual
+decrease at sides to 0.4 mm. 4. Krag-Joergensen; ogival tip as in
+Lee-Metford; steel mantle plated with cupro-nickel; thickness at tip 0.6
+mm.; gradual decrease at sides to 0.4 mm. The measurements of the sides
+are taken 2.5 cm. from the tip. Note the more gradual thinning in the
+Lee-Metford mantle.]
+
+These points of comparison having been made, it only remains to consider
+one other point, that of the relative stability of the bullets. This is
+a matter of the greatest importance as regards the regularity or
+otherwise of the wounding power of the projectile, and, as far as my
+experience went, I believe the Mauser to far exceed the Lee-Metford in
+instability of structure.
+
+The core of all four bullets is composed of lead hardened by a certain
+admixture of tin or antimony, but the mantle differs in composition,
+thickness both general and in different parts of the bullet, mode of
+fixation, and consequently in its power of resistance to violence.
+
+Fig. 15 gives an exact representation of the relative thickness of the
+mantles, and shows the general tendency to a thickening of the mantle at
+its upper extremity, designed to increase both the stability and
+striking power of the projectile. It will be noted that in general
+stoutness the Lee-Metford stands first, as the case increases gradually
+in thickness from base to apex.
+
+Beyond this it must be noted that the Lee-Metford is the only one of the
+four that is ensheathed with a mantle composed of a definite alloy, this
+consisting of 80 parts of nickel and 20 of copper. Two of the remaining
+bullets, the Mauser and Krag-Joergensen, are ensheathed with steel
+covered with a thin coating of an alloy of copper or cupro-nickel, to
+take the rifling of the barrel, while the third has a plain steel mantle
+which is covered with a layer of wax to take the place of the nickel
+used in the manufacture of the two others. It is interesting to mention
+here that the Boers evidently found the copper alloy coating
+insufficient for its purpose, or at any rate not satisfactory in
+preserving the weapon from the ill-effects consequent on the friction
+between the steel case and the rifling of the barrel, as at about the
+middle of the campaign they began to use their bullets waxed, as in the
+case of the Austrian Mannlicher; hence the legend of the poisoned
+bullets which caused such a sensation for a short period amongst the
+uninitiated. It is possible also that the additional layer of wax was
+necessitated 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 green
+colour depending on the formation of verdigris from the copper alloy
+with which the steel envelopes are plated. This completely corresponds
+with my own experience, since on the bullets in my possession the green
+colour, originally pale, has steadily increased in depth. Many old
+leaden bullets I found in the Boer arsenals were also waxed, but in this
+case no alteration in colour had taken place. The Guedes bullets, which
+are cased in mild steel, become somewhat brown with exposure from a
+similar oxidation or rusting of the surface.
+
+As far as my experience went, however, the steel casing has an important
+surgical bearing beyond the mere question of wear and tear on the rifle
+barrel. That it possesses elasticity and capability of bending is
+obvious, and in a later chapter, devoted to irregular wounds, several
+illustrations of such deformities are given; but when it strikes stone I
+believe it splits and tears with very much greater freedom than the
+cupro-nickel mantle of the Lee-Metford. At any rate, I never came across
+Lee-Metford bullets deformed to the same degree as Mauser bullets,
+either when removed from the body, or as ricochet projectiles on the
+field of battle. For this reason, therefore, provided the fighting takes
+place on stony ground, I believe the Mauser bullet and others ensheathed
+in steel to be much more dangerous surgically than those encased in
+cupro-nickel. I fancy this would be equally the case even if the mantles
+were of exactly the same thickness.
+
+The layer of copper alloy on the steel mantles is also a physical
+characteristic worthy of mention. This very readily chips off in a
+manner similar to that we are accustomed to see with nickel-plated
+instruments. This may be due to the compression into the grooving of the
+rifle, or as the result of passing impact of the bullet with an obstacle
+previous to entering the body or contact with a bone within it. Small
+scales of metal set free in one of these ways are seen in a very large
+proportion of Mauser wounds, and although they are so small as usually
+to be of little importance, the presence of such in, for instance, the
+substance of one of the peripheral nerves which has been perforated
+cannot be considered a desirable complication.
+
+To recapitulate, it would appear that at mean ranges, both in striking
+force and as regards the area of the tissues affected, the Lee-Metford
+is a superior projectile to the Mauser, in spite of the greater initial
+velocity possessed by the latter. On the other hand the comparative ease
+with which the Mauser bullet undergoes deformation either without or
+within the body, so ensuring more extensive injury and laceration,
+renders it the less desirable bullet to receive a wound from when not in
+its normal shape and condition.
+
+I can say little about the remaining two rifles. The Krag-Joergensen was
+little used, and beyond pointing out its capacity to inflict very neat
+individual injuries, in which it must surpass even the Mauser, I can
+only add that I had no opportunity of forming an opinion as to the
+danger dependent on the great initial velocity imparted to the bullet.
+The Guedes rifle has been included in the table because it approximates
+in bore to the other three. Its bullet is of the same calibre as the
+Austrian 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 of
+velocity and striking power of the bullets was indicated by the number
+of these which were retained in the body, and by the fact that I never
+saw one extracted that had undergone any more serious deformation than
+some flattening on one side of the tip. On the other hand wounds of the
+soft parts occasioned by it were only to be distinguished from Mauser
+wounds by their slightly greater size, and at a short range of fire the
+weight and volume of the bullet made it a dangerous projectile.
+
+The question of deformed bullets will be again referred to at length in
+the section on wounds of irregular type, and a number of type specimens
+are there figured and described (p. 76). In the same chapter will be
+found illustrations of a number of sporting bullets of small calibre, as
+well 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 connection
+with 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 powder
+was 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 discarded
+Portuguese regulation pattern, with which a copper-ensheathed soft-nosed
+bullet was originally employed. For the purposes of the present campaign
+a modified cartridge was constructed. Examination of some specimens in
+my 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 be
+divided into two classes:
+
+1. Direct or immediate destruction of tissue.
+
+2. Remote changes induced by the transmission of vibratory force from
+the passing projectile to neighbouring tissues or organs.
+
+Those of the first class will be mainly considered in this chapter; the
+remote effects will be dealt with under the headings devoted to special
+regions.
+
+In dealing with the wounds as a whole I shall first describe those of
+uncomplicated character as type injuries, and deal with those possessing
+special or irregular characters separately.
+
+
+TYPE WOUNDS
+
+1. _Nature of the external apertures._--The apertures of entry and exit
+in uncomplicated cases are very insignificant, but the size naturally
+varies slightly with that of the special form of bullet concerned. As
+will be shown moreover, the difference in size is the only real
+distinguishing characteristic in many cases between wounds produced by
+the modern bullet of small calibre and those resulting from the use of
+the older and larger projectiles of conical form. I have been very much
+struck on looking over my diagrams of entry, and especially exit, wounds
+to find that they reproduce in miniature most of those figured in the
+History of the War of the Rebellion; some of these diagrams are
+reproduced in this chapter.
+
+_Aperture of entry._--The typical wound of entry with a normal
+undeformed bullet varies in appearance according to whether the
+projectile has impinged at a right angle or at increasing degrees of
+obliquity, or again, to whether the skin is supported by soft tissues
+alone, or on those of a more resistent nature such as bone or cartilage.
+
+[Illustration: FIG. 16.--Mauser Entry and Exit Wounds. A, entry in
+buttock; circular opening filled with clot and crossed by a tag of
+tissue. B, exit in epigastrium near mid-line; irregular slit form, with
+well-marked prominence. Specimens hardened in formalin immediately after
+death; the resulting contraction has slightly exaggerated the
+irregularity 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. At
+the central part the gutter was 3/4 in. deep a few days after the
+injury]
+
+When the bullet impinges at a right angle the wound is circular, with
+more or less depressed margins, and of a diameter, corresponding to the
+size 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 it
+would be more correct to reverse the term to 'punched in,' since the
+appearance is really most nearly simulated by a hole resulting from the
+driving of a solid punch into a soft structure enveloped in a denser
+covering. The loss of substance, moreover, in the primary stage is not
+actually so great as appears to be the case, fragments of contused
+tissue 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 line
+differs somewhat according to the structure of the skin in the locality
+impinged upon. Thus the granular scalp and the comparatively homogeneous
+skin of the anterior abdominal wall will furnish good examples of the
+nature of the slight difference in appearance. From the first the margin
+is also often somewhat discoloured by a metallic stain, similar to that
+seen when a bullet is fired through a paper book. This ring is, however,
+narrow, and not likely to be noticeable when the bullet has passed
+through the clothing. In any case it is subsequently obscured by the
+development of a narrow ring of discoloration due to the contusion. This
+latter varies in width, and still later a halo of ecchymosis half an
+inch or more in diameter surrounds the original wound.
+
+[Illustration: FIG. 18.--Oblique Exit Gutter. Diagram enlarged to actual
+size from case shown in fig. 24, p. 64.]
+
+With increasing degrees of obliquity of impact more and more pronounced
+oval openings of entry result, culminating in an actual gutter such as
+is seen in fig. 17.
+
+In all oval openings the loss of substance is more pronounced at the
+proximal margin, while the wound is liable to undergo secondary
+enlargement at the distal margin, since in the former the epidermis is
+mainly affected, while in the latter the epidermis is spared as an
+ill-nourished bridge, the deeper layers of the skin suffering the more
+severely. When the wound occurs in regions, such as the chest-wall or
+over the sacrum, where the skin is firmly supported, the oval openings
+are often very considerable in size, reaching a diameter at least double
+that of the circular ones. In the case of the oval openings the
+depression of the margins is not such a well-marked feature as in wounds
+resulting from rectangular impact of the bullet, since the distal margin
+is really lifted.
+
+[Illustration: FIG. 19.--Oval Entry Wound over third sacral vertebra.
+Exit wound, anterior abdominal wall. Slightly starred variety. Diagram
+made on second day]
+
+_Aperture of exit._--The wound of exit in normal cases offers far more
+variation in appearance than that of entry, this variation depending on
+several circumstances: first, the want of support to the skin from
+without, and such other factors as the degree of velocity retained by
+the travelling bullet, the locality of the opening, and the density,
+tension, and resistance offered by the particular area of skin
+implicated.
+
+When the range has been short and the velocity high, it is often
+difficult to discriminate between the two apertures. Both may be
+circular and of approximately the same size, and the only distinguishing
+characteristic, the slight depression of the margin of the wound of
+entrance, may be absent if any time has elapsed between the infliction
+of the injury and examination by the surgeon. One very strong
+characteristic if present is the general tendency of the margins, and
+even the area surrounding the exit wound itself, to be somewhat
+prominent. Fig. 16 shows this point, although the wound from which it
+was drawn had been produced thirty-six hours before death. The specimen
+was then hardened in formalin and still preserves its original aspect.
+This character is, however, more frequently displayed in wounds received
+at mean, or longer, ranges. In wounds produced by bullets travelling at
+the highest degrees of velocity it is often absent.
+
+[Illustration: FIG. 20.--Circular Entry back of arm; exit (bird-like) in
+anterior elbow crease]
+
+[Illustration: FIG. 21.--Circular Entry over patella. Starred exit of
+elongated form in popliteal crease]
+
+When the range of fire has been greater and the velocity retained by the
+bullet lower, slit wounds are common, or some of the slighter degrees of
+starring. Actual starring I never saw, but reference to figs. 20 and 21
+will show a tendency in this direction, also a close resemblance to the
+starred wounds resulting from perforations by large leaden bullets.
+Such wounds, I believe, are usually the result of a somewhat low degree
+of 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 they
+are situated, the thickness, density, and tension of the skin, and the
+nature of the connection of the latter with the subcutaneous fascia in
+the locality. Thus in wounds of different parts of the hairy scalp, so
+little variation exists in the relative density and structure of the
+skin, that, in spite of the want of external support at the aperture of
+exit, it is often difficult to discriminate offhand the two apertures,
+if neither bone nor brain debris occupies that of exit.
+
+If, however, a wound crosses from side to side a region such as the
+thigh where well-marked differences exist in the subjacent support,
+thickness, and elasticity of the skin implicated in the apertures, the
+wound of entry, if in the thick skin of the outer aspect, was usually
+circular, while the exit in the thin elastic skin of the inner aspect
+was either slit-like or starred. The difficulty in laying down any
+general rule as to the occurrence of circular or slit apertures of exit
+in any definite region is, however, great, as may be seen by reference
+to the accompanying diagrams taken from two patients wounded at
+Paardeberg (figs. 22 and 23).
+
+In fig. 22 the bullet entered the outer and posterior aspect of the left
+buttock, crossed the limb behind the femur, and emerged at the inner
+aspect by a vertical slit: the bullet then entered the scrotum by a
+vertical slit, and emerged by a typical circular aperture; re-entered
+the right thigh by a transverse slit aperture, and, striking the femur
+in its further course, underwent deformation, and finally escaped by an
+irregular aperture 3/4 of an inch in diameter. The occurrence of exit
+slits in the adductor region is common, and to be explained by the
+tendency of the comparatively thin elastic skin to be carried before the
+bullet; the slit entry in this position must, I suppose, be explained by
+the comparatively slight support afforded by the underlying structures,
+which are often in a condition of hollow tension. The scrotal wounds are
+perhaps more difficult to account for, but in this case the fact of the
+distal aperture being directly supported by the right thigh is a ready
+explanation of the circular exit, while the skin corresponding to the
+slit entry was no doubt carried before the bullet, and finally gave way
+in the line of a normal crease.
+
+[Illustration: FIG. 22.--Entry and Exit Wounds in both thighs and
+scrotum. From right to left: 1. Circular entry in left buttock behind
+trochanter. 2. Vertical slit exit in adductor region. 3. Slit entry in
+scrotum (probably inverted before bullet broke the surface, and then a
+slit occurred in a normal crease). 4. Circular exit in scrotum (here
+supported by surface of right thigh). 5. Transverse slit entry in right
+adductor region. 6. Irregular 'explosive' exit, the bullet having set up
+on contact with the front surface of the femur, but without having
+caused solution of continuity of the bone.]
+
+In fig. 23 all the wounds are circular except the final exit, which was
+irregular as a result of the bullet in this case also having struck the
+femur in the second thigh. Considerable variation also exists in the
+size of the circular apertures; this illustrates the secondary
+enlargement often occurring in such wounds, and most marked at the
+apertures of entry, as the more contused. Both diagrams were made from
+patients eight days after the reception of the wounds.
+
+[Illustration: FIG. 23.--Wound of both Thighs. First and second entry
+typical circular wounds. First exit a small circular wound; the bullet
+'set up' on contact with the femur without causing solution of
+continuity of the bone, and second exit is irregular and large.
+
+This diagram is of considerable interest when compared with fig. 22. I
+believe the comparative regularity in the wounds to have been due to a
+higher degree of velocity of flight on the part of the bullet]
+
+Lastly, vertical or transverse slits may be looked for with considerable
+confidence in situations in which transverse oblique or vertical folds
+or creases normally exist in the skin, and depend on the lines of
+tension maintained by the connection of the skin in these situations to
+the underlying fascia. Thus I saw well-marked transverse and vertical
+slits in the forehead corresponding with the creases normally found
+there, and in this situation I noted some slit entries. Transverse
+slits 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 in
+creases like those stretching across from the anterior superior iliac
+spines. Again they were seen in the palms and soles, but here more
+readily tended to assume the stellate forms. Vertical slits are less
+common; they occurred with the greatest frequency in the posterior
+axillary folds.
+
+Oval apertures of exit are far less common than those of entry, since
+the most common factor for the production of an oval opening, bony
+support, is never present. In long subcutaneous tracks, or very
+superficial wounds, they are however sometimes met with and may
+terminate in a pointed gutter (see figs. 18 and 24).
+
+The greatest modifications in the appearance and nature of the apertures
+of entry are dependent on previous deformation of the bullet, when all
+special characteristics are lost, and it becomes impossible to form any
+opinion as to the type of bullet concerned. These modifications are
+naturally far more common in the aperture of exit, since the bullet so
+often acquires deformity in the body as the result of impact with the
+bones. Further remarks on this subject will be found with the
+description and comparison of the various bullets on p. 81.
+
+[Illustration: FIG. 24. Superficial Thoracico-abdominal Track. Small
+entry: discoloration of surface over costal margin from deep injury to
+skin; well-marked 'flame' gutter exit (see fig. 18)]
+
+2. _Direct course taken by the wound track._--This character primarily
+depends on the velocity with which bullets of small calibre are made to
+travel, and on the small area of the tissues upon which they operate. In
+this relation the degree of velocity retained by the bullet is often of
+minor importance, provided it be sufficient to penetrate the body. Fired
+within a distance of 2,500 yards there is little doubt that a bullet of
+the Lee-Metford, Mauser, or Krag-Joergensen types, passes straight
+between the apertures of entry and exit when these are of the type
+outline, even when the bones are implicated. By reason of the small size
+of the projectiles, their shape, and the spin and velocity transmitted
+to them, there is no reason why at a sufficiently short range they
+should not traverse the body from the crown of the head to the sole of
+the foot. The necessary conditions of position and distance for such an
+injury are obviously not often obtained, but it may be pointed out that
+the Belgian Mauser rifle at a distance of five yards is capable of
+driving 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 the
+following instances may be of interest in this relation. A bullet
+entering at the occipital protuberance traversed the muscles of the
+neck, passed through the thoracic cavity, fractured the bodies of the
+third and fourth and grooved the seventh and eighth dorsal vertebrae,
+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 the
+battle of Belmont a Mauser bullet entered the pelvis of a horse just
+below the anus, and traversed the entire trunk before emerging from the
+front of the chest: it may be of interest to mention that this animal
+was alive and moving about the next day, but I am sorry I can give no
+further 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 the
+chest or abdomen has therefore rarely to be considered, except in
+occasional instances where the bullet fired from a long range has
+impinged against a bone and is retained in the body. The small volume of
+the bullets, however, allows the production of very prolonged direct
+subcutaneous tracks in the body wall, in positions where they would be
+manifestly impossible with projectiles of larger calibre.
+
+Figs. 24 and 25 illustrate wounds of this nature. In the case figured in
+fig. 24 the bullet entered over the third rib in a vertical line above
+the right nipple; it then coursed obliquely down, crossing the seventh
+costal cartilage, and finally emerged 3 inches above the umbilicus.
+Where the track crossed the prominence of the thoracic margin the skin
+was so thinned as to undergo subsequent discoloration, while a distinct
+groove was evident there on palpation. In some similar cases I have seen
+the central part of the track secondarily laid open as a result of the
+thinning of the skin and consequent sloughing due to the interference
+with its vitality.
+
+Short of sloughing, the skin may show signs of alteration of vitality
+for a long period after the injury; thus fig. 25 depicts the condition
+seen in a superficial wound of the thigh five weeks after the injury.
+The line of passage of the bullet between the two openings was still
+clearly visible as a dark red coloured streak. Grooves in such cases are
+generally readily palpable in the early stages, while later the want of
+resistance is replaced by the readily felt firm cord representing the
+cicatrix. These points are of much importance in discriminating between
+perforating and non-perforating wounds of the abdomen, and are again
+referred to in that connection.
+
+The direction of the tracks obviously depends on the attitude assumed by
+the patient at the moment of impact of the bullet and the direction
+whence the firing has proceeded. The frequent assumption of the prone
+position during the campaign led to the occurrence of a large proportion
+of longitudinal tracks in the trunk, or trunk and head, which will be
+referred to later. Certain battles were in fact strongly characterised
+by the nature of the wounds sustained by the men. Thus at Belmont and
+Graspan, 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 prone
+position, glancing wounds of the uplifted head, of the occipital region,
+or longitudinal tracks in the trunk and limbs were particularly
+frequent. I very much regret that the material at my disposal does not
+allow me to add some remarks as to variation in the nature of the
+wounds according to whether they were received from an enemy firing from
+a height or from below, but it is possible that some information on this
+subject may be forthcoming when the returns of the Service are made up,
+since it is naturally of great importance as to the effect of trajectory
+in the proportionate occurrence of hits.
+
+3. _Multiple character of the wounds._--The same conditions responsible
+for the length and directness of the tracks, account for the frequently
+multiple character of the wounds implicating either the limbs or
+viscera--thus, lung, stomach, liver; neck, thorax, abdomen; abdomen,
+pelvis, thigh. Also for the frequent infliction of two or more separate
+tracks by the same bullet--thus, arm and forearm with the elbow in the
+flexed position; both lower extremities; both lower extremities, penis
+or scrotum; leg, thigh, and abdomen, with a flexed knee; upper extremity
+and trunk, and more rarely one upper and one lower extremity. Again, it
+was remarkable how often the same bullet would inflict injuries on two
+or more separate men, not unfrequently dealing lightly with the first
+and inflicting a fatal injury on the second, or vice versa. The small
+calibre of the bullet, moreover, allows of the neatest and most exact
+multiple injuries. Thus in a patient who was crawling up a kopje on all
+fours, the flexed middle digit of the hand was struck. The bullet
+entered at the base of the nail, first emerged at the distal
+interphalangeal flexor fold, re-entered the metacarpo-phalangeal fold,
+and finally emerged from the back of the hand between the third and
+fourth metacarpal bones.
+
+4. _Small 'bore' of the tracks, and tendency of the injury to be
+localised to individual structures of importance._--Here we meet with
+the most striking characteristic of the injuries, and evidence that
+reduction of calibre affects more strongly the nature of the lesion than
+does any other element in the structure of the modern rifle. The
+diameter of the track slightly exceeds that of the external apertures,
+probably as a result of the more ready separability of the elements of
+the structures perforated than exists in the skin. The calibre,
+moreover, tends to be fairly even throughout when soft structures only
+are implicated, though local enlargements result wherever increased
+resistance is met with. Thus a strong fascia may offer such resistance
+as to increase locally the bore of the track, and in this particular the
+state of tension of the fascia when struck will affect the degree of the
+enlargement. The most striking instances of local enlargement of the
+track 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--the
+propulsion of comminuted fragments together with the bullet itself. In
+cases of fracture the distal portion of the track is in consequence many
+times larger than the proximal. The most striking examples of small even
+tracks are seen, on the other hand, in punctures of the elastic and
+practically homogeneous lung tissue, where the wounds are extremely
+small.
+
+On transverse section of the track the gross amount of actual tissue
+destruction occupies a lesser area than that corresponding to the
+diameter of the bullet. The destructive action of the projectile is in
+fact exerted mainly on the tissues directly lying in its course, the
+track 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 the
+throwing off of the tissues forming the walls of the track by a
+diversion of a portion of the force in the form of spiral vibrations
+dependent on the revolution of the bullet. Again, the opening out of the
+tissues may be aided by the direction taken by the first and strongest
+as well as the simplest series of vibrations transmitted, which would
+assume the shape of a cone of which the point of impact forms the apex.
+
+The escape from actual destruction by structures lying in the immediate
+neighbourhood of the track is indeed often surprising, but not perhaps
+so astonishing as the perforation of long narrow structures such as the
+peripheral nerves and vessels, without irreparable damage to the parts
+remaining, and this although the structures themselves may be of a
+diameter not exceeding that of the bullet itself. The capacity of these
+projectiles to split such structures as tendons was already well known
+before our experience in this campaign, but the injuries to the nerves
+and vessels of the same character came as a surprise to most of us. The
+lateral displacement of tissues seems to bear a strong resemblance to
+what is seen on the passage of an express train, when solid bodies of
+considerable weight are displaced by the draught created without ever
+coming into contact with the train itself. The tendency to lateral
+displacement is still more strongly exhibited when dense hard structures
+such as bone are implicated. Here the fragments at the actual points of
+impact on the proximal and distal surfaces of a shaft are driven
+forwards, while the lateral walls of the track in the bone are simply
+comminuted and pushed on one side without loss of continuity with their
+covering periosteum.
+
+The extension of this form of displacement to a degree amounting to a
+so-called explosive character in the case of the soft tissues, even when
+the bullet passed at the highest degrees of velocity, was, however,
+never witnessed by me, and I very much doubt the existence of a
+so-called 'explosive zone' so far as wounds of the soft parts are
+concerned. On the contrary, I am inclined to believe that the highest
+degrees of velocity are favourable to clean-cut neat injuries of the
+soft tissues. I saw a large number of type wounds of entry and exit
+inflicted at a range of under fifty yards.
+
+5. _Clinical course of the wounds._--The tendency of simple wounds such
+as are above described to run an aseptic course was very marked, and,
+given satisfactory conditions, deep suppuration and cellulitis were
+distinctly rare. It may also be confidently affirmed that when
+suppuration did occur, with apertures of entry and exit of the normal
+small type, this was always the result of infection from the skin, or
+infection subsequent to the actual infliction of the wound. The
+infrequency of suppuration depended on the aseptic nature of the injury,
+the smallness of the openings, the small tendency of the track to weep
+and furnish serous discharge in any abundance, the comparative rarity of
+the inclusion of fragments of clothing or other foreign bodies, and
+possibly in some degree on the purity and dryness of the atmosphere,
+which favoured a firm dry clotting of the blood in the apertures of
+entry and exit, and consequent safe 'sealing of the wound.'
+
+As to the aseptic nature of the injury, it will be well to first
+consider the question of the sterility of the bullet. Putting laboratory
+experiments on one side, the large experience of this campaign seems to
+prove to absolute demonstration that, bearing in mind the very large
+proportion of instances of primary union in simple tracks, the surgeon
+has nothing to fear on the part of the bullet itself. This is the more
+striking when we remember that these bullets shortly before their
+employment were carried in a dirty bandolier, and freely handled by men
+whose opportunities of rendering either their hands or implements
+aseptic 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, except
+its tip and base, is practically renewed by passage through the barrel.
+Secondly, there is the question of the heat to which it is subjected. As
+far as cauterisation of the tissues is concerned, this question has been
+practically settled in the negative, since actual determinations of the
+heat immediately after the moment of impact have been made, and again it
+has been shown that butter is not melted, and that neither gunpowder nor
+dynamite is exploded, by firing bullets through small quantities of
+those materials. Again, the absence of any sign of scorching of the
+clothes of the wounded is strong evidence against the possibility of any
+considerable heat being applied to the tissues of the body; while
+another observation, although of less importance as affecting spent
+bullets only, that bullets, which have perforated the body but lie
+between the skin and the clothing, leave no sign of cauterising action
+on either, may be mentioned. None the less, the sources of heating while
+the bullet is passing from the barrel are many and obvious. Thus there
+is the heat consequent on explosion of the powder, the warm state of the
+barrel itself when the rifle has been fired a few times consecutively,
+and the heat resulting from the force and friction essential to the
+propulsion of the bullet through the barrel. Again, bullets covered with
+wax before their introduction into the barrel retain no trace of this
+when they have been fired, although at any rate the portion covering
+the tip is not exposed to friction on the part of the rifle, and lastly
+the base of the bullet has no other explicable reason for its
+innocuousness than subjection to a certain degree of heat. While not
+claiming any cauterising action on the tissues by the bullet, I should
+therefore still be inclined to allow the probability of the heat to
+which the surface of the bullet is exposed exerting a cleansing action
+on the projectile. In regard to this point it is interesting to bear in
+mind that shots from an ordinary gun seldom or never give rise to
+infection.
+
+Foreign bodies were rarely carried into the wounds with the bullet. I
+saw several instances in which portions of the metal of cigarette cases
+and of cartridge cases when the bullet had perforated cartridges in the
+wounded man's bandolier, and in one instance small pieces of glass from
+a pocket mirror, must have been carried in without any obvious ill
+effect. Fragments of clothing, on the other hand, in every case caused
+suppuration: clothing was not often carried in, the khaki linen was
+perforated with a clean aperture, most commonly a slit; but the thick
+woollen kilts of the Highlanders, and thick flannel shirts, occasionally
+furnished fragments. The introduction of large pieces of clothing is a
+sure proof of irregularity of impact on the part of the bullet. The
+frequency with which portions of cloth were introduced from the kilt was
+one of the strongest surgical objections to its retention as a part of
+the uniform on active service.
+
+Retained bullets themselves remained as foreign bodies in a certain
+number of cases. I cannot say that suppuration never followed the
+retention of a bullet, since in two of the instances where I saw such
+removed they lay in a small cavity containing at any rate a 'purulent
+fluid.' In one of these the bullet was a Martini-Henry, and in both the
+bullet had been imbedded for some weeks, and had certainly not
+occasioned a primary suppuration of the wound.
+
+The favourable influence of the pure and dry nature of the atmosphere in
+this campaign must certainly not be underrated, and in support of this
+influence I think I may say, from the experience of cases that I saw
+coming from Natal where the climate and surroundings were not so
+favourable as on the western side, that suppuration was more common and
+more severe in the moister atmosphere.
+
+Putting aside all the above remarks, however, I am inclined to think
+that a general tendency to primary union and the absence of suppuration
+will always be a feature of wounds from bullets of small calibre, and
+that this favourable tendency is attributable to certain inherent
+characters of the injuries. Of these the nature and small size of the
+openings, the dry character of the lining of the track due to
+superficial destruction and condensation of the tissue forming its wall,
+the small disposition to prolonged primary haemorrhage, and the absence
+of any great amount of serous exudation during the early stages of
+healing are the most important.
+
+A mechanical factor of great importance also exists in the spontaneous
+collapse and automatic apposition of the walls of the track. This
+closure is rendered additionally effective in many cases by the
+interruption of the continuous line in the wounded tissues consequent on
+alteration in the position of the parts traversed when an attitude of
+rest is assumed by the injured part. The indisposition to suppuration
+and the apparent unsuitability of the tissue lining the track for the
+development and spread of infecting organisms are well illustrated by
+several observations. Thus, even if the bullet be thoroughly aseptic,
+the fragments of destroyed skin driven into the track by the bullet can
+scarcely be free from organisms; yet these seldom give rise to trouble.
+Again, if for any reason a deep portion of a track becomes infected and
+suppurates, there is no tendency for the spread of infection along the
+line of wounded tissue, but rather for the development of a local
+abscess, 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 little
+over forty-eight hours after its infliction. Magnified twelve diameters.
+
+The margins of the opening are still sloping and depressed, indicating
+the originally 'punched-in' nature of the aperture. A thin stratified
+layer of epidermis completely closes it. No scab remains.
+
+The wound track is occluded by an effusion of lymph, commencing
+organisation of which is shown under a higher magnifying power by the
+presence of leucocytes near the margin of the bounding tissue, and some
+giant cells. The effusion of lymph occupies a slightly wider area
+immediately beneath the papillary layer of the skin, then narrows, and
+broadens again as the subcutaneous fascia is reached, indicating the
+effect of resistance in widening the area of damage.
+
+The subcutaneous connective tissue bounding the track shows little sign
+of alteration beyond a general slight tendency of the lines of structure
+to deviate in the direction of the passage of the bullet.
+
+No haemorrhage is apparent beyond a small collection of blood situated
+immediately beneath the new layer of epidermis at the left-hand corner
+of the opening.
+
+Range probably within 800 yards. Seat of wound, abdominal wall a highest
+point of iliac crest.]
+
+Fig. 25 (_a_), A (plate I.) represents a section carried across an
+aseptic aperture of entry. The specimen was removed by Mr. Cheatle from
+a patient who died forty-eight hours after reception of the injury. It
+shows well the small amount of gross destruction suffered by the
+subcutaneous tissue, and the rapid repair which follows, since
+macroscopically the track is scarcely discernible. Reference to plate I.
+shows the remarkable fact that even at this early date considerable
+progress towards definite healing has occurred, and a thin layer of
+stratified epidermis covers the original opening. The question may be
+raised whether the origin of this epidermal layer is not in part a
+floating up of the margins of the main aperture.
+
+During the course of healing some variation takes place in the
+appearance of the apertures, especially that of entry. This, at first
+contracted, later becomes somewhat relaxed, while in many cases a small
+halo of ecchymosis develops around it. The blood-clot occupying its
+centre now contracts, the margins rapidly become approximated
+centripetally, and a small circular dark spot only remains, which is
+later replaced by a small red cicatrix. The dark central spot under
+these circumstances consists of the contused margin of the wound in the
+skin, and a small proportion of blood-clot which finally comes away as a
+small dry scab. When slight local infection occurs in place of simple
+contraction and dry scabbing, the process is prolonged, the contused
+margin separates by granulation, the clot in the opening breaks down,
+and a small ulcer of somewhat larger proportions than the original wound
+remains and takes some days to heal.
+
+[Illustration: FIG. 25 (_a_).--_A._ Wound of entry 48 hours after
+reception. _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. (See
+plates I. and II.)]
+
+The aperture of exit in simple wounds of the soft parts sometimes heals
+even more rapidly than that of entry, and if of the slit form may be
+almost invisible at the end of ten days or a fortnight, actual primary
+union having taken place as after a simple small incision. Larger or
+irregular exit apertures, however, take a longer period to close than
+entry wounds, and this is most often observed when the bullet has
+undergone deformation within the body, or bone fragments have been
+driven out with the bullet.
+
+Fig. 25 (_a_), B (plate II.) represents a section of an infected exit
+aperture from a patient who died seven and a half days after its
+infliction. Two main points of interest are at once apparent: 1. The
+carrying forwards of the subcutaneous fat into the lips of the skin
+wound by the bullet. This illustrates the manner in which lightly
+supported structures are carried forward by the bullet, and throws some
+light on the mode by which vessels and nerves may escape by a process of
+displacement. This figure may be compared with fig. 25 (_b_) which shows
+a tag of omentum similarly carried forward by a bullet crossing the
+abdominal cavity and plugging the exit wound. 2. The second feature of
+interest is the amount of haemorrhage into the subcutaneous tissue. In
+this respect the contrast between the exit and entry apertures is
+marked, since in the latter haemorrhage is scarcely apparent. The
+presence of such haemorrhages is explained by the same dragging action as
+the extrusion of the fat, and is of course dependent on consequent
+rupture of small vessels. It is of importance as predisposing the exit
+wound to more easy infection, and it accounts for the persisting
+subcutaneous induration more often detected beneath healed exit than
+entry apertures. Again, it suggests that the presence of blood in the
+deeper parts of the tracks may be the determining cause of the indurated
+cords 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 by
+Infection. About 12/1.
+
+Section of the exit segment of a Mauser wound, removed seven and a half
+days 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 margins
+are 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 been
+carried forward by the bullet in its passage. A small wedge-shaped plug
+of lymph indicates the position of the actual track at its termination.
+
+Dragging on the surrounding tissue consequent on the extrusion of the
+plug of fat has ruptured some capillaries, and given rise to
+considerable extravasation of blood, which is seen as a darker layer in
+the 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 from
+the convex opening.
+
+Range 800 yards. Seat of wound, abdominal wall below 9th costal
+cartilage.]
+
+_Pari passu_ with the closure of the external openings, healing of the
+track takes place, but this is not always so rapid a process as is
+apparently the case. In many instances the closure, and even definite
+healing, of the external wounds is complete long before the track has
+actually healed, even though it be contracted up to complete closure as
+far as any cavity is concerned. This is well seen in many cases in which
+the exit opening is large as a result of deformation of the bullet, or
+the passage of bone splinters in conjunction with it; here, in spite of
+absence of all suppuration, the track may remain patent for many weeks.
+This may point to infection, but the tardiness in actual consolidation
+corresponds with what we are well acquainted with in the case of all
+aseptic wounds when a slough has to separate or become absorbed, and it
+is therefore only what might be reasonably expected when we remember
+that every such bullet track is lined by a thin layer of damaged tissue.
+
+[Illustration: FIG. 25 (_b_).--Great Omentum carried by the bullet into
+an exit track leading from the abdominal cavity. A. Outline of opening
+in the peritoneum]
+
+When fully healed, the points of entry and exit are so insignificant as
+to be less obvious than ordinary acne scars, and later are often hardly
+visible, but for a considerable period they are often more palpable than
+apparent. This depends upon the induration of the line of cicatrix
+corresponding to the course of the original track which is adherent to
+the two points. The induration is indeed so marked as to occasionally
+give rise to the suspicion that a foreign body such as a fragment of
+lead or of the mantle of the bullet has been enclosed during the healing
+of the wound.
+
+In the deeper portions of the tracks the extreme density of the cicatrix
+is a factor of great prognostic importance, since if it implicates
+muscles, tendons, vessels, or nerves, impairment of movement,
+circulatory disturbance, or signs of neuritis or nerve pressure are
+often witnessed. Thus, for instance, a track traversing the calf, will
+more or less tie the whole thickness of the structures perforated at one
+spot, and the apertures of entry and exit may be visibly retracted when
+the muscles are put in action with consequent pain and stiffness to the
+patient. Such pain and stiffness form some of the most troublesome
+after-consequences of many simple wounds. It is remarkable for how long
+a period after the healing of the wound and resumption of active duty
+the patients suffer from pain in and radiating from the locality of the
+wound, when fatigued or suffering from stiffness from the prolonged
+retention of one attitude or exposure to cold. The cords, however,
+eventually completely disappear, and the cicatrices become moveable. The
+effects of secondary pressure on the vessels and nerves are considered
+under the headings devoted to those structures.
+
+_Suppuration._--While the occurrence of deep suppuration or septic
+phlegmon was rare, local suppuration of the apertures of entry and exit
+was seen in a considerable proportion of the wounds. This was referable
+to infection from the skin itself, or to infection from without
+subsequent to the infliction of the injury. Infection from the skin,
+difficult to obviate at all times, is especially likely to occur in
+wounds the first dressing of which is often delayed, and which happen to
+men sweating freely into clothes the condition of which is at least
+undesirable for contact with a recent wound. Beyond this, the first
+dressing materials, removed from a soiled tunic by possibly a comrade or
+a stretcher-bearer, are scarcely above reproach of the probability of
+containing septic organisms themselves. Again, once applied, the
+exigencies of the situation often necessitate an amount of movement
+fatal to the retention of the dressing over the wound, and a second
+opportunity of infection arises before the patient comes into the hands
+of the surgeon in the Field hospital.
+
+The general tendency of such suppurations when they occurred in
+uncomplicated flesh wounds was to remain superficial, either involving
+the contused margin of the cutaneous opening and the plug of blood-clot
+occupying it, and resulting in a slight enlargement of the wound only,
+or at most involving the subcutaneous tissue and not extending into the
+deep planes of the trunk or limbs. In either case a slight delay in
+healing was the most serious result, while constitutional signs of
+infection were either absent or of the slightest nature. The same
+indisposition to spread by the track was equally noted when a deep
+portion became infected from, for instance, the intestine in a belly
+wound.
+
+Wounds of irregular type, however, such as those caused by ricochet
+bullets, or accompanying severe fractures, or those caused by fragments
+of larger projectiles, often suppurated freely in spite of exposure to
+no more unsatisfactory surrounding conditions than the wounds of small
+bore. This appears to show conclusively that the first element in the
+general slight consequences of small-bore wounds is their calibre, and,
+secondly, that increase of velocity on the part of the bullet, while it
+in some measure compensates for the loss of volume in the projectile, on
+the other hand reacts in favour of the wounded in so far as the injuries
+it effects on the soft tissues are ill suited to the development of
+septic organisms in the parts.
+
+_Retained bullets._--These were met with more frequently than might have
+been expected, but I can give no idea as to their proportional
+occurrence, since so many of the slighter injuries never came under my
+observation. Experience, however, showed that the bullets of large
+calibre and low velocity employed during the campaign were far more
+commonly lodged in proportion to the frequency of their use. Thus I saw
+a considerable number of Martini-Henry, Snider, large leaden sporting
+bullets, and shrapnel retained. Again, among the bullets of smaller
+calibre, the Guedes 8-mm. bullet, which travels at a comparatively low
+rate of velocity and with moderate spin, was far more frequently lodged
+than the Lee-Metford or Mauser in comparison with the number of Guedes
+rifles in use.
+
+Bullets of small calibre were, however, also retained with some degree
+of frequency, either as the result of striking at a long range, or in
+such a direction as to need to traverse a large segment of the body
+before escaping, or as striking large or several bones, or making some
+irregular form of impact: the last was a not infrequent explanation of
+lodgment, especially when a bone lay in the course of the track.
+Ricochet bullets naturally were especially likely to be retained, both
+on account of the low velocity with which they often travel and the
+irregularity of their surface with consequent loss of penetrating power.
+
+
+WOUNDS OF IRREGULAR TYPE
+
+Many of the wounds met with deviated so greatly in appearance and
+general characters from what has been described above as to afford
+little or no evidence of having been inflicted by small-calibre bullets,
+and before describing these it is necessary to give a short account of
+the circumstances which are responsible for such departures from the
+common type. In the case of the wound of entry, the simplest
+explanations are lateral impact on the part of the cylindro-conoidal
+projectile, due to the position of the part struck or the direction in
+which the bullet has been fired, wobbling on the part of the bullet due
+simply to loss of velocity and force in flight, or to turning of the
+bullet by impact with an obstacle to its course (ricochet) which may
+amount to actual reversal of the striking end. As a rule, in such cases
+the size of the aperture of entry exceeds that of exit, and in a large
+proportion the bullet is retained within the body.
+
+Of these explanations that of the 'wobble' needs some passing notice. In
+its simplest form it depends merely on loss of velocity of flight on the
+part of the bullet, the centre of gravity of which lies behind its
+middle; hence a tendency to turn over and over is acquired. As a result
+of this, either the side of the tip, the side of the bullet, the side of
+the base, or the base itself may form the portion of the projectile
+which comes into contact with the body. The tendency to wobble is
+naturally greatly increased in ricochet bullets, since the contact, if
+lateral, serves to check the spin on which the bullet depends for its
+flight on an axis parallel to its long diameter. The first effect of
+wobbling is to increase the size and interfere with the regularity of
+outline of the wound of entry; but it also acts in a more serious
+manner, since the increase of the area of impact augments the resistance
+offered by the body; therefore the degree of damage to the tissues is
+accentuated and becomes greater than it would be from a bullet
+travelling at the same rate on its normal axis. Hence the wounds are
+both large and severe, or if the velocity is very low, the projectile is
+especially likely to be retained.
+
+Actual reversal of the bullet usually only slightly enlarges the
+aperture of entry, but injuries to cancellous bone are apt to be more
+severe when the bullet enters in this manner, or again it is often
+retained. I saw several such cases during the campaign.
+
+Another form of wobble is suggested by Nimier and Laval,[9] of which I
+can offer no experience. They suggest that, as rotation slows, the
+bullet may on impact wobble like a top before it ceases to spin.
+Probably the power of penetration possessed by a bullet wobbling in this
+manner would not be very great, but its effect would mainly be altered
+in the direction of an abnormal increase in the size of the aperture of
+entry, or possibly in the degree of comminution in fractures.
+
+It is probable that some of the more serious wounds observed were merely
+the result of unusual forms of impact with normal flight on the part of
+the bullet. The majority, however, depended, in the case of the wound of
+exit, on deformation of the bullet within the body, or the propulsion of
+bone fragments with it, and, when both apertures were affected, to
+previous ricochet on the part of the projectile.
+
+It is here necessary to give a short account of the more common
+deformities met with, and to refer to the special characters possessed
+by different types of bullet of small calibre which may affect the ease
+with which deformity is produced, and the degree to which it is commonly
+carried. The effect of ricochet is to lower the velocity of flight, and
+at the same time to effect certain alterations of form in the bullet.
+These with rectangular impact in the case of bullets travelling at a low
+degree of velocity consist in a bending and deformation of the tip; in
+the higher degrees, of bending, shortening, extensive destruction, or
+complete fragmentation. If the bullet makes lateral impact, only
+widening and flattening result, often with the escape of the lead core
+from the mantle. That a ricochet bullet may travel a considerable
+distance is shown by the following observations quoted from Nimier and
+Laval.[10]
+
+[Illustration: FIG. 26.--Sections of four Bullets to show relative shape
+and thickness of mantles.
+
+From left to right: 1. Guedes; regular dome-shaped tip; mild steel
+mantle; 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, steel
+mantle plated with copper alloy; thickness at tip 0.8 mm.; gradual
+decrease at sides to 0.4 mm. 4. Krag-Joergensen; ogival tip as in
+Lee-Metford; steel mantle plated with cupro-nickel; thickness at tip 0.6
+mm.; gradual decrease at sides to 0.4 mm. The measurements of the sides
+are taken 2.5 cm. from the tip. Note the more gradual thinning in the
+Lee-Metford mantle.]
+
+Up to a distance of 1,700 to 1,800 metres the bullet may make several
+ricochet bounds. When the bullet strikes first at short distances (as
+600 metres), it may make several bounds of from 300 to 400 metres: at
+moderate distances (as from 600 to 1,200 metres), bounds of 200 to 300
+metres; and at distances above 1,200 metres, bounds of 100 to 200
+metres. The length of the ricochet bounds depends on the angle of impact
+of 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 are
+concerned with, I believe the most important variations as serious
+effects of ricochet depend on the relative thickness and the composition
+of the mantles. Fig. 26 illustrates the relative thickness of the
+mantles in the Krag-Joergensen, Mauser, Lee-Metford, and Guedes bullets.
+Given an equal degree of force and velocity on the part of the bullet at
+the moment of impact, the assumption is justifiable that the thinner
+mantles would tear or burst more readily in direct ratio to their
+relative thinness. I believe this assumption to be borne out by my own
+experience of the common deformities that occurred; but the great
+relative frequency with which Mauser bullets came under my observation,
+and the difficulty of forming any estimate of the velocity and force
+retained by any particular bullet at the moment of impact, make it
+impossible for me to express myself with the confidence which I should
+wish.
+
+[Illustration: FIG. 27.--Normal Mauser Bullet]
+
+The second condition which influences the nature and degree of the
+deformities depends on the relative tenacity or brittleness peculiar to
+the metal employed in the manufacture of the mantles. In the case of the
+Lee-Metford this consists of an alloy of 80 parts of nickel with 20 of
+copper. The Krag-Joergensen and Mauser are ensheathed in steel plated
+with cupro-nickel, and the Guedes has a plain steel envelope coated with
+wax.
+
+Both as a result of experience in the field gained from ricochet
+bullets, and in the hospitals from bullets which had undergone
+deformation within the body, I am under the firm impression that the
+thin nickel-plated steel envelope of the Mauser bullet splits more
+readily than the thicker and more tenacious cupro-nickel envelope of the
+Lee-Metford, that the direction of the ruptures is more purely
+longitudinal, and the fissuring itself more extensive and complete.
+
+I append below a series of deformities observed in Mauser bullets, some
+of which were collected on the field of battle, but all of which were
+familiar to me in bullets removed from the bodies of patients, except
+the complete disc shape shown in fig. 29. They correspond with specimens
+of which I made sketches at the time of removal from the body, but which
+I had not the heart to retain in view of the natural wish of the
+patients to keep them as mementoes of their wounds.
+
+[Illustration: FIG. 28.--Four common types of lateral Mauser Ricochet
+Bullets.
+
+From left to right: 1. Slipper form; slight broadening and turning of
+tip. 2. More pronounced degree of form 1, with laceration of the mantle
+opposite the shoulder of the bullet. This is the weakest spot, for two
+reasons: the alteration in curve at this position, and the junction of
+the thickened point of the mantle with the thinner sides. 3. Lateral
+ricochet involving nearly whole length of bullet. Rupture of mantle from
+broadening of core opposite shoulder. 4. Similar lateral ricochet with
+extensive longitudinal rupture of mantle, the latter being turned out
+and forming a cutting 'flange.']
+
+Slight indentations and deviations from strict symmetry of form of such
+degree as not seriously to influence the outline and nature of the
+apertures were very common. Beyond these one of the most frequent
+primary deformities was that we familiarly spoke of as the 'slipper
+form' (No. 1, fig. 28). This results from light glancing contact of the
+tip with a hard body: in it the mantle of the bullet is rarely
+fractured, and the deformity itself is of slight importance, except in
+so far as it may influence the direction of the wound track, which
+acquires a tendency to be curved. The tip of the bullet is slightly
+flattened and turned up, down, or to one side, according to the point
+struck. I saw this deformity frequently, both with Lee-Metford and
+Mauser bullets. Nos. 2, 3, and 4 are more pronounced degrees of the same
+type of deformity, accompanied by more or less extensive fissuring of
+the mantle. No. 4 illustrates the turning out of the longitudinally
+fissured mantle in such a way as to make a cutting flange. I have seen
+such bullets removed, and the variety is of some importance as
+materially increasing the cutting capabilities of the bullet, and
+augmenting its area of destructive action. No. 5, fig. 29, is the only
+form I have not seen removed, but such a bullet would account for some
+of the long irregular gutter wounds observed, if it retained sufficient
+velocity to strike with any force.
+
+[Illustration: FIG. 29.--'Disc'-shaped Lateral Ricochet. This form is of
+little practical importance, as the velocity retained by the bullet is
+low, and no perforating power would be retained. It is inserted
+separately in order to complete the series, shown in fig. 28.]
+
+Fig. 30 illustrates complete longitudinal fissuring of the mantle. Such
+mantles are common, and still more so are the opened-out sheets such as
+is shown still attached in fig. 29. Free mantles are often very numerous
+on stony ground, but are of little importance, since I never saw
+fragments of them removed or impacted. They probably travel a very short
+distance after their formation, and if they did strike would possess
+little power of penetration. The freed leaden cores do, however,
+sometimes enter the body, and some of the specimens removed have been
+referred to the use of expanding bullets. In all the Mauser specimens
+the longitudinal direction of the fissuring of the mantle is striking.
+
+[Illustration: FIG. 30.--Ruptured Mauser Mantle, to illustrate the
+tendency to complete longitudinal fissuring]
+
+Fig. 31 represents bullets removed from the body and illustrates types
+of deformity due to impact with the bones. The deformity resembles in
+some degree that of the mushroomed lead cores, and also indicates that
+the shoulder of the cased bullet is its weakest point. Each specimen
+exhibits shortening and widening without fracture of the mantle, the
+latter being simply thrown into folds; both bullets were lodged in the
+thigh after fracturing the femur. The localisation of injury to the fore
+part of the bullet, and the fact of expansion, allow us to infer that
+the degree of velocity retained on impact with the bone was
+comparatively low, and that neither bullet had been exposed to very
+severe strain.
+
+[Illustration: FIG. 31.--Two retained Mauser Bullets which had produced
+comminuted fractures of the femur of moderate severity. Each has given
+way at the shoulder, but the mantle has developed creases without
+rupture, and the bullets are correspondingly bent. Both bullets were
+travelling at a moderate if not low degree of velocity]
+
+Fig. 32 is also of a retained bullet in which the fore part of the
+mantle is very extensively fissured and the core set free. In this the
+mantle has suffered severely and the leaden core to a less extent. As an
+apical 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 the
+anterior part of the mantle very considerable]
+
+The deformity found in fig. 32 I met with both in retained bullets and
+also in those which had been fired into sand or anthills. The particular
+specimen figured was removed from the thigh of a patient wounded at the
+battle of Belmont. An irregular entry wound was situated over the
+internal tuberosity of the tibia, while a large fluctuating haematoma
+existed in the lower third of the thigh, at the upper part of which a
+hard elongated body was palpable. As was so often the case with internal
+haemorrhages, the patient's temperature rose high, and on the third day
+the haematoma was incised by Major Coutts, R.A.M.C. The core of the
+bullet was then found in the blood cavity near the surface, but on
+introduction of the finger a second body was discovered entangled in the
+quadriceps muscle, and this proved to be the tattered mantle. I saw
+similar deformity produced within the body by a bullet, which, entering
+by a small type aperture in the left ala of the nose, struck the margin
+of the right malar bone, and lodged beneath the latter. The similarity
+of this bullet to that seen in the ricochet in fig. 32 was exact. The
+form is of great importance both on account of the degree of laceration
+it effects in the track, the presence of two foreign bodies in the
+wound, and from the fact that it can be produced by making the bullet
+travel through sand or antheaps, since both the former in the shape of
+sandbags and the latter in their natural state so often formed the cover
+to men during the campaign. Bullets of 6.5 mm., such as the
+Krag-Joergensen, with steel envelopes apparently break up with great ease
+in sand.
+
+Fig. 33 shows a form not uncommon when the bullet comes into contact
+with the ribs. It is produced in bullets travelling at a low rate of
+velocity and striking by their side. I several times met with it when
+the bullet was retained, and also without fracture of the rib. In some
+variety it might occur after impact with any narrow margin of bone, and
+some importance attaches to the form, since it affords evidence as to
+the ease with which alterations in symmetry can be produced in Mauser
+bullets. Again its bent outline favours deviation in the further course
+of the bullet subsequent to impact with the bone, a result which I
+observed on more than one occasion.
+
+[Illustration: FIG. 33.--Grooved Mauser removed from anterior abdominal
+wall after crossing the ribs. I saw several such removed from the
+thoracic wall, and am inclined to attribute the grooving to impact with
+the margin of the ribs]
+
+Lastly, the question of actual spluttering or breaking up of the bullets
+must be considered. It is extraordinary into how many fragments either a
+Lee-Metford or a Mauser bullet may break up if it strike a hard body
+while travelling at a high rate of velocity. Fragmentation is exhibited
+in the skiagram forming the subject of plate XI. p. 194. It is somewhat
+remarkable how often this occurred when the short hard bones of the
+metacarpus were struck. With regard to the casing, the separation of
+small scales of the nickel plating has already been referred to;
+reference to the skiagrams, plates IX. and XVI., shows how readily the
+whole thickness of the mantle breaks up into small fragments, even when
+the bullet is travelling at moderately low degrees of velocity, and
+this I believe to be a special characteristic of the thin
+cupro-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. The
+leaden fragments occasionally show a simple fractured surface, such as
+is illustrated on a larger scale by the broken shrapnel bullets shown in
+fig. 96, p. 485. More commonly, however, the fragments, if of any size,
+appear torn, and if small, are mere spicules. These if of lancet shape
+often bury themselves in the skin only, while larger ones may penetrate
+deeply or even perforate. Thus, of a group of three officers standing
+near a stone on which a bullet struck, all were spattered about the
+face; most of the fragments lodged in the skin, but one perforated the
+concha of the ear and bruised the mastoid area, while others caused
+small jagged cuts. In another instance, both thighs of the patient were
+spattered after perforation of the clothes, and a large fragment lodged
+beneath the skin of the penis. A case in which larger fragments
+perforated 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 the
+Lee-Metford. The only deformed Lee-Metford bullets that I saw removed
+from the body were of the 'slipper' variety, exactly corresponding to
+the similarly altered Mausers, and with no fissuring of the mantle. I
+saw 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 to
+collect many forms of Lee-Metford ricochet, although I found many
+undeformed bullets. I insert here, therefore, some illustrations I
+obtained through the kindness of Colonel Hopton, Director of the School
+of Musketry at Hythe, which are of interest, and in some degree
+substantiate the impression I formed in South Africa as to the greater
+stability 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 not
+strictly comparable to the Mauser bullets forming the subjects of the
+preceding illustrations, which struck stones, and these mainly by their
+sides (if we except figs. 31 and 32), but they sufficiently exhibit the
+characters on which I wish to insist. That they support my opinion is
+the more probable as, with the exception of the type included above, I
+am under the impression that the large majority, if not all, of the
+Mauser bullets which struck stones fairly with their tips were broken to
+pieces, otherwise I must have met with some among the immense number
+which I saw. On the top of Tabanyama, for instance, the whole ground was
+littered at the time of my visit with shattered mantles and leaden
+cores, deformed almost past recognition.
+
+[Illustration: FIG. 35.--Apical Lee-Metford Ricochets. From Hythe
+targets. Tendency of cupro-nickel envelope to tear in transverse
+direction]
+
+The specimens depicted in figs. 35 and 36 indicate--(1) a greater
+malleability on the part of the mantle; thus in fig. 35 the cupro-nickel
+is obviously hammered and flattened out, while the fissures are neither
+numerous nor extensive. (2) Both bullets exhibit transverse tearing of
+the mantle, a common feature in Lee-Metford ricochets, of which I could
+offer other examples, but which I less often observed in Mauser
+bullets. (3) Tear is the term best expressing the nature of the
+fissures, while fracture more nearly expresses the nature of the
+fissures in the Mauser mantles. (4) Fig. 36 shows a mushroomed core and
+split mantle, which may be compared with the similarly deformed Mauser
+depicted in fig. 31. I think the variation in appearance is
+characteristic, the fissuring of the mantle being much less extreme,
+while the leaden core is normal at its base in consequence of the
+support afforded by the more tenacious cupro-nickel mantle. With regard
+to complete splitting of the mantles, however, I must add that free
+Lee-Metford mantles are often found from bullets fired at the target or
+elsewhere, 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 and
+limited extent. Compare with fig. 32]
+
+_Expanding bullets._--The wounds resulting from perforation with
+deformed regulation bullets, such as are described above, differ for the
+most part by deviation from the type appearances, and a tendency to take
+a less favourable course on account of their increased size and of the
+greater degree of laceration of the tissues accompanying them. I must
+now pass on to the consideration of the forms of bullet especially
+likely to occasion those wounds spoken of as 'explosive' in character,
+and my remarks on these must be prefaced by a short description of the
+varieties 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-Metford
+patterns, Tweedie and Jeffreys modifications of the Lee-Metford and
+Mauser, several soft-nosed bullets of a slightly larger calibre, mostly
+old Mauser or Mannlicher types, and a large variety of sporting leaden
+bullets of larger calibre and volume. Figs. 37 and 43.
+
+With regard to the various soft-nosed bullets of small calibre, I will
+first advert to a feature common to all, which consists in a solid base
+to the mantle. In the regulation whole-cased bullets the leaden core is
+inserted from the base, and the edge of the mantle is then so turned
+over for fixation purposes as to leave the central portion of the lead
+exposed. The position of the exposed portion of the core is therefore
+reversed in the two varieties. The small experience I had the
+opportunity of obtaining was all to the effect that the solid base
+considerably increases the stability of the mantle, and I never saw the
+latter seriously torn in any specimen either collected on the field or
+removed 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 it
+had perforated the scapula. In both the velocity retained was no doubt
+low, and neither encountered great resistance]
+
+Fig. 38, 1, represents a soft-nosed Lee-Metford removed from just below
+the lesser sigmoid cavity of the ulna, after it had perforated the
+elbow-joint. The soft nose appears to have been torn, and separated by
+impact with the bone, but the mantle is little altered. There can be
+little doubt, however, that the bullet was travelling at a comparatively
+low rate of velocity, since it was retained in the forearm, whence its
+various parts were removed by Major Lougheed, R.A.M.C. I picked up a
+number of similarly deformed bullets on the field. No. 2 represents a
+soft-nosed Lee-Metford which perforated the scapula from the front; the
+bullet was retained, hence again velocity cannot have been very high,
+and the comminution was slight. If it had passed out, a large exit wound
+would, however, have resulted.
+
+[Illustration: FIG. 39. Soft-nosed Lee-Metford Mantle. Lateral ricochet.
+Illustrating effect of solid base in maintaining the stability of the
+mantle]
+
+Fig. 39 represents a type of ricochet sometimes found on the field. In
+spite of a considerable amount of violence which has caused the escape
+of the core, the fissuring of the mantle is comparatively slight. In
+point of fact, the casing is, as a rule, preserved from the severe
+violence it suffers when complete, by the flattening and turning over of
+the soft nose. I am sorry I cannot append an illustration of a damaged
+soft-nosed Mauser, but I am of opinion that those used during the
+campaign were not of a very dangerous nature on account of the small
+amount of lead exposed. To gain the full advantage of the soft nose at
+least a third of the core should be exposed. No. 3, fig. 37, of a
+Lee-Metford, probably represents the most effective form of such
+bullets. I am inclined to think these bullets as a class, however, are
+not more dangerous to the wounded man than the regulation Mauser fired
+at short range, if the latter either comes into contact with bone or
+suffers ricochet.
+
+The Tweedie and Jeffreys bullets come under a somewhat different
+category. In the Tweedie the top of the bullet is sawn off in such a
+manner as to flatten the tip and widen the surface of direct impact, and
+to expose the leaden core over a small area. The general principle of
+the flat tip resembles that of the French Lebel bullet. In the Jeffreys
+modification the mantle is sawn down for about half the length of the
+whole mantle, the slits neither reaching tip nor base. I seldom saw
+these bullets removed, but they were used to a considerable extent. Fig.
+40 illustrates one of Mauser calibre in the possession of Mr. Cuthbert
+S. Wallace. It perforated the abdomen, producing fatal injuries, but the
+only alteration in outline consists in slight bulging and shortening.
+This specimen, however, manifestly suffered but slight resistance. A
+somewhat general impression existed that a number of severe injuries had
+been produced by the Jeffreys bullets, but it was a matter of
+conjecture, as few of them were removed. A weekly illustration appears
+in the advertisement sheet of the 'Field,' showing the deformity of some
+of them shot into animals, which bear a strong resemblance to the Mauser
+figured earlier (fig. 31), and which we have seen can be produced in the
+human body by contact of a regulation fully cased bullet with a bone
+like the malar. A tendency on the part of the longitudinal slits to
+become caught in the rifling of the barrel militates against the use of
+this bullet.
+
+[Illustration: FIG. 40.--Jeffreys modification of Mauser. The bullet is
+in the possession of Mr. C. S. Wallace. It perforated the abdomen and
+caused death. The bullet is only slightly shortened by bulging at the
+shoulder]
+
+[Illustration: FIG. 41.--1. Section of Mark IV. Lee-Metford. Note
+thickness of mantle and exposed core at base. 2. Soft-nosed Mauser. Note
+solid base. Short pattern]
+
+Fig. 41 represents sections of the soft-nosed Mauser, and the British
+Mark IV. bullet, and shows the different method of closure of the base.
+If the former remarks on the influence of the closed base in maintaining
+the stability of the bullet be correct, Mark IV. should be a very
+destructive bullet. I have no experience of its use, but I am inclined
+to think that here, as elsewhere, the thickness and resistance of the
+cupro-nickel mantle would endow it with considerable stability, unless
+it met with very great resistance.
+
+[Illustration: FIG. 42.--Types of Bullets tampered with by the Boers in
+the trenches. 1 and 3. Cross-cut tips, Martini-Henry and Lee-Metford. 2.
+Groove cut at base of exposed tip of Lee-Metford. Another modification
+of the Martini-Henry consisted in boring it longitudinally and inserting
+a wooden plug]
+
+In connection with the subject of soft-nosed bullets, I should mention
+that the Boers occasionally extemporised various modifications of them,
+such as are shown in fig. 42, with intent to increase the wounding power
+of the projectiles. I am unable, however, to give any information as to
+the effects produced by these, and I do not think they were often
+employed. The illustrations are from cartridges found in trenches which
+had been occupied for some time by the Boers, who had no doubt used
+their spare time in exercising their ingenuity on the bullets.
+
+'Explosive' bullets of small calibre were also said to have been
+employed; with regard to these I can only say that I never met with any
+example of a hollow bullet containing explosive material.
+
+One officer in a Colonial corps who spoke freely about them, told me he
+had 'sawn' them in half and found the cavities, but the method of
+investigation he had employed seemed against the presence of any
+fulminant in the body of the bullets. Others based their statements on
+the fact that they had frequently heard the bullets burst in the air;
+but this is probably to be explained by the breaking up of regulation
+bullets on impact with stones, which makes a smart crack like a small
+explosion.
+
+A clip of soft-nosed Mauser cartridges, in which a copper centre to the
+bullet suggested a percussion-cap, was sent home to the War Office.
+Colonel Montgomery has kindly furnished me with the following report on
+the bullet:
+
+'The bullet contains no explosive matter, it is fitted with a hollow
+copper tube in the nose, similar to the ordinary "Express" bullet. The
+envelope is made with a solid base, which is possible in this bullet
+owing to the core being inserted from the front.'
+
+One cannot help feeling some astonishment at the strong feeling that has
+been exhibited regarding the use of expanding bullets of small calibre,
+both at the Hague Conference and during this campaign, when the
+Martini-Henry, a far more dangerous and destructive missile in its
+effects 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 I
+append a photograph of some twenty out of thirty varieties which came
+into my possession during searches amongst captured ammunition. Some of
+these were provided with a copper core to facilitate 'setting up,'
+others were cupped at the top, and others flattened, to increase the
+resistance on impact. I can say little about them except that I believe
+some of the forms were responsible for a considerable proportion of the
+most severe injuries we met with, in some of which a large and regular
+entry made their use certain, while a considerable proportion of them
+were retained. In the case of the viscera their power of doing serious
+damage was very striking compared with that of the bullets of small
+calibre. As with the small sporting bullets I think their use was often
+due to the fact that the sporting Boer preferred to use the weapon he
+was 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 than
+with the larger commandos fighting regular engagements. The Transvaal
+Government, moreover, had Martini-Henry rifles made as late as 1898. The
+Martini-Henry bullet was responsible for some of the worst fractures
+that came under my notice, but it is of interest to remark that its
+capability to do damage did not satisfy some of the Boers, who cut them
+as is shown in fig. 43. I cannot say what the effect of this manoeuvre
+was, although it may have accounted for some of the wounds of the calf
+such 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 the
+Boers.
+
+_Anatomical characters of wounds of irregular type._--It will be seen
+from the above that in dealing with wounds of irregular type we have to
+consider those due to irregular impact of normal regulation bullets, to
+bullets deformed by contact with bone, to ricochet bullets, and lastly
+to bullets of the expanding type.
+
+No further mention of those due to irregular impact is needful beyond
+what has already been said under the heading of wobbling, except to
+point out that, given a fair degree of velocity, these injuries may
+assume an actual explosive character, especially in the case of skull
+fractures. The description of extensive wounds accompanying comminuted
+fractures finds its most appropriate place under the heading of injuries
+to the bones, and will be there considered (Chapter V. p. 155).
+
+'Explosive' exit apertures are, however, described as occasionally
+occurring in injuries involving the soft parts only. I saw no cases
+substantiating this belief, but several were described to me as having
+been met with in abdominal injuries, which terminated fatally at an
+early date.
+
+[Illustration: FIG. 43.--Four Soft-nosed Bullets of small calibre shown
+in fig. 37. Twenty large-calibre leaden carbine and rifle bullets from
+cartridges found in Boer arsenals. These were not very extensively used,
+but specimens of most varieties were at times removed from our wounded
+men. It will be noted that some are of great weight, and a large
+proportion either cupped or flattened at the apex to increase area of
+impact and consequent resistance. The 'express' bullet with a copper
+core is included in this series. It is worth remarking that all the
+bullets of this nature in the Pretoria Arsenal were waxed, and that the
+wax retained its white colour on the lead.]
+
+I still, however, incline to the opinion that the bullet in these cases
+had come into contact with some bone, or was one of the larger varieties
+of projectile. A few cases of wound of the calf did, however, come under
+my observation which presented fairly typical 'explosive' characters
+without evidence of solution of continuity of the bones. I will shortly
+recount two of them. In the first the exit opening was very large and on
+the outer aspect of the limb in the upper third. The bullet had
+apparently passed between the bones. Secondary haemorrhage from the
+anterior tibial artery necessitated exploration of the wound and
+ligature of the vessel (Mr. Carre). When the wound was thus laid open no
+injury to the bones could be detected, but I do not consider that it
+could be actually excluded. In the second case a wound traversed the
+calf transversely, just above the centre; the exit aperture was large
+and ragged. Deep suppuration occurred, and the wound had to be laid
+open, when a fracture of the tibia without solution of continuity was
+discovered. I also saw one or two wounds of the buttock in which very
+large exit apertures were present with small entry openings; in these
+again it was impossible to exclude passing contact of the bullet with a
+part of the pelvic wall. Unfortunately in all these cases it is
+impossible to obtain the bullet responsible for the injury. In this
+relation I append a diagrammatic illustration of a peculiar wound shown
+to me by Mr. Hanwell. In this case a typical small entry wound was
+situated at the outer margin of the left erector spinae muscle in the
+loin. The bullet had taken a subcutaneous course of not more than
+three-quarters of an inch, while the exit opening was a long shallow
+wound 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 fifty
+to a hundred yards. I think we can scarcely assume that impact with the
+margin of the erector spinae could have resulted in 'setting up' of the
+bullet, while an irregular tongue of skin at the point where the wound
+crossed the spines of the lumbar vertebrae did suggest possible bony
+contact. That the latter must have been of the slightest nature is
+evident, as no signs of concussion of the spinal cord were noted. I
+should rather be inclined to compare this case to one of gutter wound
+quoted on p. 56, and to assume that the bullet passed so closely
+beneath the surface as either to entirely sever the skin, or at any rate
+to allow it to give way on flexion of the back on movement.
+
+[Illustration: FIG. 44.--Small Circular Entry, large 'explosive' skin
+wound 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 be
+gathered that the opinion I formed was against either the very free use
+or the great wounding power of so-called expanding bullets of small
+calibre. I believe that a great number of the injuries which were
+attributed to the employment of these missiles were produced either by
+ricochet regulation bullets of small calibre, or by large leaden bullets
+of the Martini-Henry type.
+
+_Symptoms._--I very much doubt whether the general symptoms observed as
+the result of wounds from bullets of small calibre differ in more than
+slight degree from those described when larger bullets were regularly
+employed. Great variation was met with, but I do not think a diminution
+in serious results in this direction corresponding to the comparatively
+limited nature of the direct injury to the organs or tissues can be
+affirmed. It is true that the immediate symptoms in many patients were
+amazingly slight, but after all, this has always been a feature of
+gunshot injuries on the field of battle and cannot be assigned a
+position of distinctive importance.
+
+1. _Psychical disturbance and shock._--Some remarkable instances of
+psychical disturbance were observed, and although perhaps in no way
+influenced by the calibre of the projectile, they seem worthy of note in
+this place. Thus a patient wounded over the cervical spine and who
+suffered later with a slight degree of spinal concussion emitted an
+involuntary shriek like that of a wounded hare on being struck; another
+(Martini wound), after receiving a wound of the chest, lost all sense of
+his surroundings for a considerable period, and occupied himself in
+attempts to write on a white stone lying near him on the veldt; then
+suddenly realising his position he was greatly bewildered in trying to
+account for his own action. A similar instance of preoccupation is
+probably offered by the dead man in the accompanying photograph (fig.
+45), whose arms, forearms, and hands had evidently been in play until
+the actual moment of death. Again the influence of the psychical state
+on the actual occurrence of shock was often illustrated by the mental
+condition of the wounded after a battle; thus after the battles of
+Belmont and Graspan the patients came into hospital in excellent
+spirits, and minimised their injuries in the wish of rapidly regaining
+the front; while after the battle of Magersfontein the men were
+depressed and miserable, shock was more pronounced, and their sufferings
+were undoubtedly greater.
+
+On the whole, however, shock was by no means a prominent symptom in the
+small-bore injuries of soft parts, and was possibly less than when
+larger bullets were the rule, and again it was often remarkably slight
+after the infliction of serious visceral injury. Still shock was
+observed in a considerable proportion of the patients, and its
+occurrence appeared to vary under very much the same conditions as
+obtain in civil practice. Grades of severity depended on individual
+idiosyncrasy, on the degree of excitement or preoccupation at the moment
+of injury, and to a certain degree on the range of fire at which the
+injury was received.
+
+[Illustration: FIG. 45.--Note position of head, neck, and forearms in
+upper figure]
+
+The last is the only special factor, and as far as my observation went
+it was one of considerable importance. When the soft parts only were
+affected, even high velocity did not produce much effect; but when to a
+flesh wound a severe bone fracture or injury to any part of the nervous
+system was added, shock might be severe or profound. The question of
+shock dependent on visceral injury will be considered in succeeding
+chapters, but it may be well to state here that the most severe shock
+appeared to follow injuries to the central nervous system especially to
+the spinal cord, fracture of the larger bones, and wounds of the
+abdominal and thoracic viscera, the latter especially when the cardiac
+neighbourhood was encroached upon: hence the severity depended almost
+solely on the importance of the part injured and the degree of damage
+inflicted. I never observed instances of entire absence of shock in
+visceral injuries, unless the range of fire had been an especially long
+one.
+
+To these remarks on constitutional shock I should add a few on the
+'local shock' exhibited by the actual part of the body struck. The
+phenomena were of a severity I was quite unacquainted with in civil
+practice, and apparently were attributable to the local vibration
+transmitted to the whole structure of a limb or part of the trunk. In
+many fractures, and in some wounds of the soft parts alone, without the
+direct implication of any large nerve trunk, the loss of functional
+capacity of the limb was complete, and this condition persisted for
+hours or even days.
+
+2. _Pain._--As an initial symptom the occurrence of pain varied greatly
+with the idiosyncrasy of the patient, and according to the circumstances
+under which the wound was received. Some individuals are remarkably
+insensitive, and in these the fact of a wound being a gunshot injury in
+no way altered their habitual insensibility, but in persons of what may
+be termed the normal type in this particular great differences were
+observed.
+
+When a wound was received in the full excitement of battle during a
+rapid advance, pain was often slight, or so trifling in degree that it
+was almost unnoticed; many patients did not realise that they had been
+struck until a second wound, possibly implicating a bone or some
+specially sensitive structure, was superadded. In such instances the
+pain was often described as 'burning' in character, or even likened to a
+'sting from an insect.' Occasionally the pain was referred to a distant
+part; 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. Again
+in some multiple injuries, pain was only felt in the more sensitive of
+the regions implicated; thus a patient in whom a bullet (Martini)
+traversed the arm and chest emerging in the neck to again enter the chin
+and comminute the mandible, only felt pain in the chin and first
+realised that he had been wounded elsewhere when he undressed. A
+striking instance of the entire absence of initial pain was afforded by
+a man shot through the buttock, the bullet then traversing the abdomen:
+this patient remained unaware that he had been hit until on undressing
+he found blood in his trousers and exclaimed: 'Why I have got this
+bloody dysentery!' None the less his internal injuries were sufficiently
+severe to lead to death during the next thirty-six hours.
+
+Although initial pain might be slight or absent, practically all the
+patients complained of some of varying severity at the end of an hour
+after reception of the wound.
+
+In a large proportion of the wounded, however, pain was more or less
+severe from the first, and this was especially the case when the men had
+been exposed to fire for some hours behind inadequate 'cover.' The most
+common descriptions under these circumstances were that they felt as if
+they had been struck by 'a brick,' 'a ton of lead,' or 'a
+sledge-hammer.'
+
+3. _Haemorrhage._--This question is fully treated under the heading of
+injuries to the blood-vessels. It will suffice here to say that
+haemorrhage was rarely of a dangerous nature so far as life was
+concerned, unless the large visceral vessels or those in the walls of
+serous cavities were concerned, when death was often rapid. From limb
+wounds, even when the largest trunks were implicated, the general
+tendency was to spontaneous cessation of the haemorrhage. Consequently,
+except these patients were seen on the field, one seldom had to deal
+with serious bleeding. None the less, the condition of the patients'
+clothes bore testimony to a free rush immediately after the injury, and
+pools of blood were occasionally found where patients had lain. In
+nearly all cases the rush of the bullet determined the initial flow of
+the blood from the exit wound, and this aperture usually furnished any
+haemorrhage of importance.
+
+_Diagnosis._--The only diagnostic point which it is necessary to
+consider in this chapter is the determination of the nature of the
+bullet which has caused the particular injury under observation, and
+this is more a matter of interest than importance.
+
+The primary indication lies in the size of the aperture of entry, which
+naturally varies with the calibre of the bullet employed, and the
+difference, except in the case of large projectiles, is not always
+easily determined, unless we can be sure that the impact of the bullet
+was at right angles. In the latter case it is possible to distinguish
+even between, for instance, a Lee-Metford and a Mauser wound, if the
+resistance likely to be offered by the part struck is kept in mind. A
+ricochet bullet, on the other hand, may upset all our calculations, if
+size alone be taken as an indication; but here the irregularity of the
+wound often serves to exclude one of the larger varieties as the cause.
+The appearances of the exit wound are less useful in determining the
+nature of the bullet employed, as irregularities of outline are so much
+more common whatever projectile may have emerged; but examination of
+this wound often gives us useful information as to the existence of an
+injury to the bones not involving loss of continuity.
+
+[Illustration: FIG. 46.--Two flattened Leaden Cores to illustrate means
+of determination of nature of bullet. Note ring at base. The right-hand
+bullet is probably a 'man-stopping' revolver bullet; it flattened
+against bone]
+
+Other information beyond that furnished by the external wounds may be
+gleaned from the presence of fragments of lead in the wound; these, if
+unaccompanied by portions of casing, afford some presumptive evidence of
+the use of an unsheathen bullet, especially if found on the fractured
+surface of the bones; but it must be borne in mind that in the case of
+ricochet bullets the leaden core often perforates when entirely freed
+from its mantle. Pieces of the mantle again may give useful information
+both from examination of their thickness and composition. Lastly a naked
+core nearly always retains the marking on its base corresponding to the
+turning over of the mantle, this not being likely to suffer impact
+calculated to efface the groove. When this groove existed the employment
+of any of the soft-nosed bullets used in this campaign might be safely
+excluded (fig. 46).
+
+_Prognosis._--The question of general mortality amongst the wounded has
+already been considered (Chapter I. p. 11), and it has been shown,
+putting aside those dying at once on the field, or during the first
+twenty-four hours, that the mortality was a low one. Some other points
+specially dependent on the nature of the injury are, however, worthy of
+mention in this place. First, it has been shown, with a slight
+reservation as to when a wound can be considered definitely sound, that
+if suppuration did not occur, healing was rapid, and that many men with
+slight wounds were back with their regiments in the course of a very few
+days. Again, that suppuration when it did occur tended to be local in
+character; none the less, if it was at all extensive, it often proved
+very prolonged and difficult of treatment, while residual abscesses
+after apparent healing were not uncommon. In connection with this
+subject I may quote from Colonel Stevenson[12] an observation that limbs
+the subject of marked local shock are especially liable to furnish
+septic discharges. Parts the subject of local shock when infected show a
+lesser degree of vitality and power of resistance to the spread of
+infection than do normal ones, and if infected do badly. I think I
+convinced myself of this on many occasions, and also of the fact that
+cases of fracture in which this condition was marked were slow in
+consolidating. Again I am inclined to think that the bad results which
+sometimes followed the tying of the limb arteries were also consequent
+on lowered vitality, and possibly vaso-motor disturbance due to the
+effects of the exquisite vibratory force to which the nerves had been
+subjected. On this account I was never anxious to hurry operations in
+such cases, unless obviously necessary at the moment.
+
+The larger question of general nervous breakdown as the result of
+injuries from bullets of small calibre is at present hardly capable of
+an answer, and is so complicated by the co-existence of concurrent
+mental anxiety, exposure, &c., that a definite answer will always be
+difficult. I think there is already sufficient evidence, however, to
+suggest that the remote effects of many of these injuries may be far
+more serious than we expected at the moment, especially in the direction
+of sclerotic changes in the nervous system.
+
+_Treatment_.--In view of the remarks on the treatment of special
+injuries contained in succeeding chapters, I shall confine myself here
+to the question of the treatment of wounds of the soft parts alone.
+
+This consisted during the campaign in the primary application of the
+regulation first field dressing by one of the wounded man's comrades, an
+orderly, or less commonly an officer or a medical man. This dressing is
+composed of a piece of gauze, a pad of flax charpie between layers of
+gauze, a gauze bandage 4-1/2 yards long, a piece of mackintosh
+water-proof, and two safety pins, enclosed in an air-tight cover. Mr.
+Cheatle,[13] in insisting on the importance of an immediate antiseptic
+dressing in the field, recommends the following. A paste contained in a
+collapsible tube, made up in the following proportions: Mercury and zinc
+cyanide grs. 400, tragacanth in powder gr. 1, carbolic acid grs. 40,
+sterilised water grs. 800; sufficient bicyanide gauze and wool for the
+dressing of two wounds, a bandage, and four safety pins; the whole
+enclosed in a mackintosh bag. The paste possesses the advantage over any
+liquid or powder, that it can be applied in any position of the body to
+severe wounds, and its application in the open air is not interfered
+with by draughts of wind. Mr. Cheatle used a similar preparation with
+success during the campaign.
+
+On arrival at the Field hospital, or in some cases at the station of the
+bearer company, the wounds were then commonly dressed as follows: The
+parts around the wound were cleansed with an antiseptic lotion, either
+solution 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 a
+dressing of double cyanide of mercury and zinc applied. This was covered
+with a pad of wool and secured with a bandage. The gauze was usually
+wrung out in the lotion before application as a precaution against
+previous contamination, and the moistening was also useful as helping to
+ensure the dressing from subsequent displacement. It was early
+recognised that the drier the dressing the better, and hence anything
+like a mackintosh layer was carefully avoided. In some instances,
+antiseptic powders were employed, but they did not find much favour, and
+because they tended to favour slipping of the dressing, and to prevent
+the adhesion of the gauze dressing to the wound, they were certainly not
+desirable when there was any necessity for the patient to travel. In the
+absence 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 a
+considerable expenditure of time, which could only be obtained when the
+hospitals were fairly stationary. I very much preferred carbolic acid
+lotions.
+
+The wound having been once cleansed, or rather the surroundings of the
+wound, the drier the surface was kept the better; hence a too heavy or
+impervious dressing was not satisfactory; in point of fact, I think some
+of the slighter wounds in which all the dressings slipped off, and in
+which there was less consequent chance of the dressing being moistened
+with the sweat of the patient, did as well as any.
+
+I do not think the bicyanide gauze, absorbent wool, and common open-wove
+bandages, together with a good supply of nail brushes, soap, and
+carbolic acid for the primary disinfection of the skin and the external
+wound, are to be greatly bettered at the present day as materials for
+the first permanent dressing of cases in the field. The wound itself
+should be carefully shielded during the preliminary cleansing of the
+skin by a firmly applied antiseptic pad, and then the dressing applied
+as above described. The one desirable improvement is some mode of
+ensuring the dressing being kept in good position, and for this some
+form of adhesive covering for the gauze and wool should be devised. When
+the atmosphere is such as to allow of rapid drying, thin moistened
+book-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 some
+instances either the exit or entrance wounds may be in undesirable
+positions for purposes of asepsis, when a large opening may seem safer
+closed and actually sealed. I saw this method tried in a few cases, but
+without much success. It is one which might be of much use in Base
+hospitals if the patients were brought directly into them, but in the
+Field hospitals, in face of the rush with which the first dressings have
+to be done, I think it is seldom applicable, and consider the
+interference with the wound as rather likely to increase the danger of
+infection than to decrease it.
+
+Dressings should not be too frequent; two should suffice for simple
+wounds with type forms of entry and exit; there is little discharge and
+usually no bleeding: hence the more the dry scab form of healing can be
+simulated the better. When a dressing needs changing from fouling of its
+outer parts, it is preferable to cut round the adherent part of the deep
+layers and apply some fresh gauze over the central scab rather than to
+remove it. One point should be kept in mind: the first dressing in the
+Field hospital seals the fate of the wound as to the chances of primary
+union, and hence too much care is impossible with it.
+
+Operations in the Field hospitals were proportionately not numerous, and
+they should be kept down in number, as far as possible. At the same time
+such operations as are necessary are mostly of capital importance, such
+as the treatment of fractures of the skull, abdominal section, the
+ligature of arteries, and amputations. Of these only the first and last
+classes occur with any degree of frequency. In order to be prepared for
+these a stock of filtered water which has been boiled, and some special
+sterilised sponges, should be at hand if possible, also some small
+towels which can be wrung out in antiseptic lotion. If sterilised
+sponges are not to be had, wool pads wrung out in carbolic lotion must
+be substituted.
+
+Primary amputations bore transport badly. I saw few sent down from the
+front within a few days of their performance in which the flaps did not
+slough, or worse consequences ensue. On the other hand, if the first
+fortnight could be tided over at the front, they did well enough. The
+head cases on the other hand bore movement fairly well, provided only
+that asepsis was ensured.
+
+Retained bullets are rarely suitable for removal in the rush of the
+first work of a Field hospital after an engagement. A short delay is of
+no importance, and ensures their being removed safely if necessary. With
+regard to the broad question of the advisability of removing them at
+all, it may be laid down that they should not be interfered with unless
+some obvious reason exists. Those most commonly calling for removal are
+as follows: 1. Bullets lying immediately beneath the skin or quite
+superficially in any region, or those which, although they have produced
+an exit opening, yet lie within the body. 2. Those which lie at the
+bottom of an infected track, or cause secondary suppuration. 3. Those
+causing pressure on important structures, particularly nerves. 4. Those
+which interfere with the movements of joints when lodged in the bones or
+soft tissues in close proximity, or those which lie within the articular
+cavity itself. Bullets sunk in the great body cavities or in positions
+difficult of access should never be interfered with. Retained bullets
+sometimes give rise to unexpected surprises; thus in a man with a
+retained bullet in the pelvis no steps for its removal were taken.
+During the man's voyage home on a transport he had an attack of
+retention of urine. As a catheter would not pass, he was placed in a
+warm bath, and shortly after passed a Mauser bullet per urethram, and
+thus saved himself a cystotomy.
+
+One word may be added as to the treatment of shock when severe. Quiet in
+the supine position, and the administration of a small amount of
+stimulant, was usually all that was required. Hypodermic injections of
+strychnine sulph. grs. 1/30 to 1/10 were useful, and in some severe
+cases, especially where operations were needed, saline infusions with a
+small 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 haemorrhage is dealt with in Chapter IV.
+
+The after treatment of simple wounds needs little comment, but bearing
+in mind what has been said as to the definite healing of the internal
+portion of the tracks, it will be obvious that in parts such as the
+thigh or calf, care was needed as to not commencing active work at too
+early a date. On the other hand, a too long period of absolute rest is
+also to be deprecated. The best results were obtained by careful
+movement and massage, commenced after the first week or ten days,
+according to the appearance presented by the external wound, followed by
+a gradual resumption of active movement. It was a striking fact that
+some of the patients suffering from such wounds took longer to become
+apparently 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 a
+direct course, naturally favour the occurrence of more or less
+uncomplicated wounds of the large vascular trunks, and both the nature
+of these wounds and the results which follow them are in some respects
+most characteristic.
+
+
+NATURE OF THE LESIONS
+
+1. _Contusion or laceration without perforation._--(_a_)The vessel may
+be struck laterally, the injured portion then forming a part of the
+bounding wall of the wound track, or (_b_) one or more layers of the
+vessel wall may be destroyed over a limited area. Given primary union,
+these conditions are only of importance in so far as subsequent
+contraction of the lumen of the vessel may result from implication in
+the neighbouring cicatrix. One of the most striking features of the
+wounds as a whole was seen in the hair-breadth escapes of the large limb
+vessels with no subsequent ill effects, and such injuries were seen in
+every situation.
+
+In a certain proportion of wounds in close proximity to large vessels,
+however, a diminution of the normal calibre of the arteries was
+observed, either shortly after the injury or later in the advanced
+stages of cicatrisation. As an example of early obstruction, the
+following may be related. A Mauser bullet passed from the inner side of
+the thigh across the neck and great trochanter of the femur beneath the
+femoral vessels, and probably struck and grooved the bone, since the
+aperture of exit was large and irregular, some 3/4 of an inch in
+diameter. One week later no pulse was palpable in either anterior or
+posterior tibial arteries at the ankle, and pulsation which was strong
+in the common femoral artery was very weak in the superficial femoral.
+Slight fulness existed in the hollow of Scarpa's triangle, but not
+sufficient to make any serious difference in the contour of the two
+limbs. No thrill or abnormal murmur was discoverable. There was no
+oedema of the limb, which was also normal in temperature. The patient
+was kept at rest in the supine position for three weeks, during which
+time the tibial pulses gradually returned. Three weeks later he was
+invalided home, the pulses, however, still remaining considerably
+smaller than normal.
+
+In the advanced stages of cicatrisation narrowing of the lumen of the
+trunk vessels was far from uncommon, especially in cases of wounds of
+the arm crossing the course of the brachial artery; in many of these the
+radial pulse was diminished almost to imperceptibility. How far this
+condition may prove permanent there has been little opportunity of
+judging; nor as to the possible ultimate weakening of the vessel wall
+and the development of a secondary aneurism has time allowed the
+acquisition of experience. In the light of the observation of so many
+cases in which large vessels were wounded without the occurrence of
+severe haemorrhage, either primary or secondary, it is impossible to be
+certain whether some of the cases of arterial obstruction were not
+secondary to perforating lesions of the vessels.
+
+Pressure on, or minor lesion of the vessel was sometimes evidenced by
+the development of a murmur, as in the following case. A Mauser bullet
+entered immediately within and below the left coracoid process, and
+emerged at the back of the arm at its inner margin, 2-1/2 inches above
+the junction of the right posterior axillary fold. During the first week
+dysphagia and some pain and soreness in the episternal notch, with pain
+and difficulty of respiration, were noticed. Eight weeks later no
+trouble with the pharynx or oesophagus remained, but a short sharp
+systolic murmur was audible over the first part of the left axillary
+artery, which could be extinguished by pressure on the subclavian; the
+radial pulse was normal.[14]
+
+When primary union failed or was prevented by infection and
+suppuration, lesions, although incomplete, of the vessel coat naturally
+frequently gave rise to secondary haemorrhage.
+
+2. _Perforation of the vessels._--(_a_) This may be oblique or
+transverse to the long axis of a trunk; when the vessel is impinged upon
+laterally, 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 is
+maintained; (_c_) beyond these degrees a vessel may, of course, be
+completely divided. Cases of notching of the vessel will be referred to
+under the heading of traumatic aneurism; those of perforation under that
+of aneurismal varix and varicose aneurism, the perforations in these
+cases affecting a parallel artery and vein.
+
+
+RESULTS OF INJURY TO THE VESSELS
+
+1. _Haemorrhage._--The fact that haemorrhage was not a prominent feature
+in the wounds received during this campaign can scarcely be regarded as
+an experience confined to injuries caused by bullets of small calibre.
+The same observation was often made in the case of larger bullets in old
+days, and the absence of severe haemorrhage has previously been regarded
+as a special characteristic of gunshot wounds. None the less, as high a
+proportion as 50 per cent. of deaths occurring on the field in earlier
+days has been ascribed to this cause.
+
+Unfortunately no new facts can be furnished on this point, although a
+few cases of rapid death from primary haemorrhage will be found recounted
+under the heading of visceral injuries. Beyond these the general
+evidence offered by observations on men brought in from the field with
+vascular injuries, was opposed to the frequent occurrence of death from
+haemorrhage, at any rate of an external nature. This subject will be
+dealt with under the classical three headings of primary, recurrent, and
+secondary haemorrhage.
+
+_Primary haemorrhage._--A marked distinction needs to be drawn between
+external and internal haemorrhage. External haemorrhage from the great
+vessels of the limbs, or even of the neck, proved responsible for a
+remarkably small proportion of the deaths on the battlefield. This
+statement may be made with confidence, since it is not only my own
+experience, but coincides with what I was able to glean from many
+medical officers with the Field bearer companies. It is, moreover,
+supported by the facts that cases in which primary ligature had been
+resorted to were extremely rare at the Base hospitals, while, on the
+other hand, traumatic aneurisms and aneurismal varices of any one of the
+great trunks of the neck and limbs were comparatively common. Again,
+primary amputation for small-calibre bullet wounds, except when
+complicated by severe injury to the bones, was so rare as to render more
+than doubtful the frequent occurrence of severe primary haemorrhage on
+the field. Only one case of rapid death due to bleeding from a limb
+artery was recounted to me. In this a wound of the first part of the
+axillary artery proved fatal in the twenty minutes occupied by the
+removal of the patient to the dressing station. The amount of haemorrhage
+in many instances was no doubt checked by the application of pressure at
+the time of the first field dressing; but it can scarcely be argued that
+such dressings as were applied were of sufficient firmness to control
+bleeding from such trunks as the brachial, femoral, or carotid arteries.
+
+The spontaneous cessation of haemorrhage is rather to be ascribed to the
+special method of production and the consequent nature of the wound. The
+lesions were the result of immense force strictly localised in its
+application, which might well induce very complete and rapid contraction
+of the vessel wall; while the track in the soft parts was not only
+narrow, but also lined by a thin layer of tissue possibly so devitalised
+superficially as to specially favour rapid coagulation of the blood.
+Beyond this the tracks were often sinuous when the position of the limb
+at the time of reception of the injury was replaced by one of rest. The
+influence of mere narrowness of the track is illustrated by classical
+experience in the development of aneurismal varices after stabs by
+knives or bayonets; and in the injuries under consideration the frequent
+development of large interstitial haemorrhages into the tissues of the
+limbs indicated that blood does not readily travel along the wound
+track. It was noteworthy that when haemorrhage did occur it was most free
+from, or often limited to, the wound of exit. This is due to the
+direction of the active current set up by the rush of the bullet through
+the tissues. The mechanical factor is, no doubt, the most important.
+
+Control of primary haemorrhage from a wounded vessel by the impaction of
+a foreign body was of much less frequent occurrence than appears to have
+been the case with the older bullets. I saw a case in which, on removal
+of a fragment of shell (Mr. S. W. F. Richardson), very free haemorrhage
+occurred from a wound of one of the circumflex arteries of the thigh,
+but not a single one in which a similar result followed the extraction
+of a bullet of small calibre. The comparative infrequency of retention
+of modern bullets is probably one of the main elements in this relation.
+A very curious instance of provisional plugging of a wound in the upper
+part of the brachial artery by an inserted loop of the musculo-spiral
+nerve was related to me by Mr. Clinton Dent. This instance must, I
+think, be regarded as an accident definitely dependent on the size and
+outline of the bullet and on the nature of the force transmitted by it
+to neighbouring structures.
+
+While, however, deaths from external primary haemorrhage were rare, a
+considerable number resulted from primary internal haemorrhage. In some
+of these, injury to the largest trunks in the thorax or abdomen led to
+an immediately fatal issue; in others wounds of the large visceral
+arteries, as of the lungs, liver, or mesentery, were scarcely less rapid
+in their results. In such cases the potential space offered by the
+peritoneal or pleural cavities favours the ready escape of blood from
+the wounded vessel, while the tendency of the blood effused into serous
+cavities to rapid coagulation is notably slight. Beyond this the
+comparative deficiency in direct support afforded by surrounding
+structures to vessels running in the large body cavities is also an
+important 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 the
+abdomen, while the remarkable instances of escape from fatal haemorrhage
+from large vessels recorded below (cases 1-19) indicate that the mere
+size of a wounded vessel is not to be regarded as the sole factor in
+prognosis.
+
+_Recurrent haemorrhage_ was occasionally met with both in the case of the
+limb and trunk vessels. In the limbs it often necessitated ligature of
+the artery. I saw several cases in the lower extremity where recurrent
+haemorrhage on the second or third day was treated by ligature of the
+femoral or popliteal artery, and it also occurred during the course of
+development of one of the carotid aneurisms recounted below. On two
+occasions I saw rapid death follow recurrent abdominal haemorrhage; in
+one I was standing in a tent when a man who had been wounded the day
+before suddenly exclaimed: 'Why, I am going to die after all.' The
+appearance of the man was ghastly, and on examining the abdomen it was
+found greatly distended, and with dulness in the flanks; the patient
+expired a few minutes later. Another example of recurrent abdominal
+haemorrhage is related in case 169, p. 432.
+
+_Secondary haemorrhage._--In simple wounds of the soft parts by
+_small-calibre bullets_ this was decidedly rare. In wounds complicated
+by fractures of the bones, especially when they exhibited the so-called
+'explosive' character, secondary haemorrhage was not uncommon, and this
+not necessarily in conjunction with infection and suppuration.
+
+In the chapter on fracture some remarks will be found on the
+prolongation of healing often observed in the exit portion of the wound
+track, which is explained by the well-known fact that, given an aseptic
+condition of the wound, sloughs of tissue separate very slowly.
+Secondary haemorrhage in these cases is due to lesions of the vessel
+short of perforation, but severe enough to so lower the vitality that
+local gangrene of the wall occurs. In such instances haemorrhage most
+usually occurred on the tenth to the fourteenth day, but occasionally
+still later. In one instance of ligature of the anterior tibial artery
+for such haemorrhage three-quarters of the whole lumen of the vessel had
+been devitalised. The resemblance of some cases of secondary haemorrhage
+of this class to those occasionally observed after amputation, and due
+to accidental non-perforative injury of the artery at the time of
+operation above the point of ligature, was very striking.
+
+In other cases secondary haemorrhage was the result of perforation of the
+vessel by a sharp spicule of bone, but in the large majority sepsis and
+suppuration were the cause. Naturally therefore the accident was
+commoner in the more severe kinds of wound, and in those caused by
+_large_ bullets or fragments of shell. The symptoms in nearly all cases
+were the classical ones of repeated small haemorrhages followed by a
+sudden copious gush.
+
+The forms of secondary haemorrhage, however, which afforded most interest
+were the interstitial and the internal, mainly on account of the scope
+they allowed for diagnosis.
+
+Characteristic examples of internal secondary haemorrhage are furnished
+by cases of chest injury accompanied by haemothorax and fully dealt with
+under that heading (Chapter X.). Cases of interstitial secondary
+haemorrhage are also described under the heading of traumatic aneurism
+and abdominal injuries (No. 194, p. 445). It therefore suffices here
+merely to remark on the diagnostic difficulties the condition gave rise
+to. These mainly depended upon the elevation of general bodily
+temperature by which the haemorrhage was often accompanied. Further
+evidence of the condition was furnished by the development of local
+swellings, or physical signs indicative of the collection of fluid in a
+serous cavity. These signs developed rapidly, and the rise of
+temperature was sudden and decided enough to suggest commencing
+suppuration. In several cases incisions were made under the supposition
+that this had already occurred.
+
+The fever accompanying blood effusions was generally a somewhat special
+feature in the wounds of the campaign. At first bearing in mind that in
+every case a track, even if closed, led from the surface to the effused
+blood, one was disposed to suspect an infection of the clot of a
+somewhat innocuous nature. The absence of subsequent suppuration,
+however, was definitely opposed to this view, and suggested that the
+fever resulted from absorption of some element of the blood, possibly
+the fibrin ferment, or some form of albumose. A pronounced illustration
+was in fact afforded of the evanescent rise of temperature usually the
+accompaniment of simple fractures in the case of the limbs, and of the
+more marked rise not uncommon in cases of traumatic blood effusion into
+the peritoneal cavity, or when the pleurae or joints were the seats of
+the mischief. In the case of interstitial haemorrhages I only remember to
+have seen fever of such marked continued type in the subjects of
+haemophilia with recent effusions, although one is of course acquainted
+with it in a less pronounced form as a result of haemorrhage into
+operation wounds.
+
+In primary interstitial haemorrhages a similar continued rise of
+temperature was also common, and I cannot perhaps better illustrate its
+character than by the brief relation of two instances.
+
+In a patient wounded at Kamelfontein the bullet entered four inches
+below the acromion, pierced the deltoid, splintered the humerus, and
+crossed 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 radial
+artery, but the limb was warm. There was partial paralysis of the parts
+supplied by the ulnar and musculo-spiral nerves and complete loss of
+power and sensation in the area of distribution of the median nerve. Six
+months later the radial pulse was still absent in this patient, but
+there was no sign of the development of an aneurism.
+
+[Illustration: TEMPERATURE CHART 1.--Axillary Haematoma. Shows range of
+temperature during process of absorption and consolidation without
+suppuration]
+
+The accompanying temperature chart is characteristic. The blood
+effusion gradually gained in consistency and underwent steady diminution
+in size. No suppuration occurred.
+
+The median paralysis was found to be accompanied by the inclusion of the
+nerve in a sort of foramen of callus, when the patient was explored at a
+later date by Mr. Ballance.
+
+In a patient wounded at Paardeberg, a Mauser bullet entered by the left
+buttock, pierced the venter ilii, traversed the pelvis, and emerging at
+the brim of the latter, crossed the back, fractured the spine of the
+fourth lumbar vertebra, and escaped below the twelfth right rib. The
+track suppurated where it crossed the back, but the man did well until
+the twentieth day, when a swelling developed in the left iliac fossa and
+the general temperature rose to 102 deg.. An abscess was at once suspected
+and the swelling incised by Major Lougheed, R.A.M.C. A large
+subperitoneal haematoma only was discovered, and evacuated. The
+temperature at once fell and the after progress was uneventful, the
+wound healing by primary union.
+
+
+TREATMENT OF HAEMORRHAGE
+
+_Primary._--No deviation from the ordinary rules of surgery should be
+necessary in the majority of cases, but in a certain number the
+conditions are so unusual that the special considerations must be taken
+into account. The natural tendency to spontaneous cessation of primary
+haemorrhage in small-calibre wounds is the first of these. Experience has
+shown that often mere dressing, or at any rate slight pressure, suffices
+to efficiently stanch immediate bleeding. Although, however, immediate
+control is to be obtained by such means, the cases of traumatic aneurism
+of every variety related in the next section show that the ultimate
+result is in many such cases by no means satisfactory.
+
+Under these circumstances it may be said that the classical rule of
+ligation at the point of injury should never be disregarded. Against
+this, however, certain objections may be at once raised; thus in many
+cases both artery and vein need ligature, a consideration of much
+importance in the case of such vessels as the carotid and femoral
+arteries. Again in many of the injuries to the popliteal artery the
+wound directly communicated with the knee joint, a complication which,
+while it may be disregarded in civil practice, must take a much more
+important place in the circumstances under which many operations in
+military surgery are performed.
+
+On the whole, it seems clear that the military surgeon must be guided by
+circumstances, since it may be far better to risk the chances of
+recurrent haemorrhage, or the development of an aneurism or varix, all of
+which are amenable to successful treatment later, than those of gangrene
+of a limb or softening of the brain. As a general rule, therefore, on
+the field or in a Field hospital, primary ligature of the great vessels
+is best reserved for those cases only in which haemorrhage persists,
+while in those in which spontaneous cessation has occurred, or in which
+bleeding is readily controlled by pressure, rest and an expectant
+attitude are to be preferred.
+
+A word must be added as to the objections to distant proximal ligature
+for primary or recurrent haemorrhage. In some situations this may be
+unavoidable, and it is sometimes successful, but none the less it is
+opposed to all rules of good surgery and a most uncertain procedure. It
+leaves the patient exposed to all the risks attendant on the employment
+of simple pressure. In one case which I saw, the third part of the
+subclavian artery had been ligatured for axillary bleeding; secondary
+haemorrhage, as might have been expected, occurred, and that as late as
+five weeks after the operation. In another case ligature of the femoral
+artery for popliteal haemorrhage was followed by the development of a
+traumatic aneurism in the ham.
+
+_Secondary._--In secondary haemorrhage the treatment to be adopted
+depends upon the nature of the case. When the wound is aseptic, and
+bleeding the result of the separation of sloughs, local ligature is the
+proper treatment, and this was often successfully adopted, especially in
+the case of such arteries as the tibials. In septic cases, on the other
+hand, it is usually far better if possible to amputate, unless the
+general state of the patient and the local conditions are especially
+favourable.
+
+When neither amputation nor direct local ligature is practicable,
+proximal ligature may be of use. Sometimes this may be obligatory in
+consequence of the difficulties attendant on direct local treatment. I
+saw a few cases successfully treated in this manner: in one the common
+carotid was tied (Mr. Jameson) for haemorrhage from an arterial haematoma
+in connection with the internal maxillary artery. Although ligature of
+the external carotid would perhaps have been preferable, the result was
+excellent. When even this expedient is impracticable, local pressure is
+the only resort.
+
+Lastly, as to the treatment of secondary interstitial blood effusions, I
+believe the best initial treatment is the expectant. If interference is
+needed, it is much more likely to be satisfactory the more chronic the
+condition has become, since the source of the bleeding may be impossible
+to discover. I never saw a patient's life endangered by the amount of
+such haemorrhage, but if this should seem to be likely, local treatment
+is of course unavoidable. In several cases quoted below, incision and
+evacuation were followed by excellent results; in any such operation too
+much care to ensure asepsis is impossible.
+
+
+TRAUMATIC ANEURISMS
+
+The experience of the campaign fully bears out that of the past as to
+the steady increase of the number of aneurisms from gunshot wounds in
+direct ratio to diminution in the size of the projectiles employed.
+Every variety of traumatic aneurism was met with, and most frequently of
+all, perhaps, aneurismal varices and varicose aneurisms. While so
+experienced a military surgeon as Pirogoff could say, in 1864, that he
+had never seen a case of aneurismal varix, every young surgeon lately in
+South Africa has met with a series. Again, although the condition is a
+well-known one, it has been rather in connection with civil life; for
+the great majority of recorded cases were the result of stabs or
+punctured wounds such as are liable to be received in street brawls, or
+as a result of accidents with the tools of mechanics. Thus of ninety
+cases collected by K. Bardeleben in 1871, only 12 or 13.33 per cent.
+were the result of gunshot wound.
+
+_False traumatic aneurism or arterial haematoma._--This condition was met
+with comparatively frequently, and bears a very close relation to that
+already described under the heading of interstitial haemorrhages. The
+latter might almost have been included here, since the difference
+between the two conditions depended merely on the size of the vessels
+implicated. The exact correspondence in the period of development of
+some of the arterial haematomata, and of the occurrence of the aseptic
+form of secondary haemorrhage, also explains the pathology of the two
+conditions as identical; except that in the former the effused blood is
+retained in the tissues, while in the latter it escapes externally. The
+history of these cases was uniform and characteristic. A wound of the
+soft parts, or sometimes a fracture, was accompanied by a certain degree
+of primary interstitial haemorrhage, which might or might not have been
+associated with external bleeding. A haematoma resulted in connection
+with the wounded vessel, the general tendency in the effusion being to
+coagulation at the margins and subsequent contraction. Meanwhile the
+opening in the artery became more or less securely closed by the
+development of thrombus, and possibly by retraction of the inner and
+middle coats of the vessel. With the return of full circulatory force as
+shock passed off, or with the resumption of activity and consequent
+freer movement of the limb, the temporary thrombus became washed away.
+The newly formed wall of soft clot bounding the effusion proved
+insufficient to withstand the full force of the blood pressure, and
+extension of the cavity resulted. In the more rapidly developing
+haematomata, temporary pressure by the effused blood on the bleeding
+vessels was also, no doubt, a common explanation of temporary cessation
+of increase in size.
+
+A diffuse soft fluctuating swelling, sometimes accompanied by pulsation,
+but oftener without, developed, and not uncommonly diffusion was
+accompanied by some discoloration of the surface and elevation of the
+general temperature. Such arterial haematomata commonly developed from
+ten days to three weeks after the original wound. A few examples will
+suffice.
+
+     (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 haematoma 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
+     anaesthesia 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
+     anaesthesia 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
+     haemorrhage. 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 am
+glad to include them, as they illustrate one or two points of special
+importance. No. 3 shows the tendency to variation in the tension and
+firmness of the tumours, the tendency to primary contraction of the sac,
+followed by diffusion, and the rise of temperature often accompanying
+the latter occurrence. This is of great interest in relation to the
+similar rise of temperature seen with the increase of haemorrhage in
+cases of haemothorax. For purposes of comparison, the progress may well
+be considered alongside of that in the case related on p. 119, in which
+the wounded vessel was probably also the main trunk itself.
+
+No. 4 differs from any of the others in depending on a complete division
+of a large artery and vein. The development of the haematoma was
+consequently more rapid and continuous. Another point of interest was
+the maintenance of pulsation in the tibial vessels, in spite of complete
+solution of continuity in the parent trunk. That this was independent of
+the collateral circulation seems evident from its complete disappearance
+and slowness of return after ligation of the wounded vessels.
+
+_Prognosis and treatment._--The treatment in these cases is sufficiently
+obvious, and consists in direct incision and ligature of the wounded
+vessels. The cases related show the success with which this procedure
+was 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 during
+interference with axillary haematomata, combined with direct pressure on
+the bleeding spot after the clot has been removed. In the case of the
+arm, digital compression is always to be preferred, in view of the
+well-known danger of damage to the brachial nerves from the tourniquet.
+
+Proximal ligature is always to be avoided. It is inadequate, and proved
+more dangerous as far as the vitality of the limb was concerned, the
+latter point probably depending on the interference with the collateral
+circulation by pressure from the extravasated blood, which is unrelieved
+by the operation. I know of at least two cases of gangrene which
+occurred consecutively to proximal ligature of the femoral artery for
+this condition.
+
+_True traumatic aneurisms._--The cases met with differed so little from
+those seen in ordinary civil practice, that but slight notice of them is
+necessary. They differed from the last variety mainly in the more
+localised nature of the tumour, the greater firmness of its walls, and
+the more pronounced expansile pulsation. The development of this form of
+aneurism was probably influenced by several circumstances, such as the
+more complete rest secured for the patient, the locality in the limb as
+affecting movement of the spot in the vessel actually wounded, the size
+of the opening in the vessel, and the degree of support afforded by
+surrounding structures. (Examples are furnished by cases 6-9.)
+
+Under the influence of rest, all that I saw tended to contract and
+become firmer, and they so far resembled spontaneous aneurisms as to be
+readily cured by proximal ligature of the artery. The ideal treatment no
+doubt consists in local incision and ligature on either side of the
+wounded spot, with or without ablation of the sac. The choice of direct
+or proximal ligature in any case depends on the position of the
+aneurism, and the ease with which the former operation can be carried
+out. In all these cases a very great advantage in the localisation and
+diminution of the tumours was gained by postponing interference until
+they became stationary. I need scarcely add that any evidence of
+diffusion indicated immediate operation. The preference of direct or
+proximal ligation will probably, to a certain extent, always depend on
+the personal predilection of the surgeon, but while proximal ligature
+has often given good immediate results during this campaign, it cannot
+be with certainty decided whether the patients are definitely protected
+from the dangers of recurrence.
+
+Reference to cases 7 and 9 as illustrating the possible spontaneous cure
+of traumatic aneurisms is of great interest.
+
+I saw a number of cases successfully treated by proximal ligature; also
+a number where continuous improvement followed rest, and which were sent
+home for further treatment. None of these demand any special mention.
+
+One case of a very special nature, which terminated fatally, is of great
+interest:--
+
+     (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 haemoptysis and left
+     haemothorax. 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 haemorrhage 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 artery
+which can be wounded without leading to rapid death from primary
+haemorrhage, even when in communication with a serous sac, and still more
+as emphasising the importance of weakening of the radial pulse as a sign
+in connection with a wound of the upper part of the chest on the left
+side. It is somewhat surprising that this sign was not marked in two
+cases (Nos. 13 and 14, p. 140) recorded below, in which the innominate
+and 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
+     haemorrhage of any importance occurred from the wound, but there
+     was a typical haemarthrosis, 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 an
+incision in the line of the tendon of the adductor magnus. The aneurism
+then 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 haemorrhage, and so much
+     blood collected in the knee-joint that it was aspirated. On the
+     eighth day secondary haemorrhage occurred from the exit wound
+     and the femoral artery was tied in Hunter's canal. No further
+     haemorrhage 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 haematoma 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 be
+expected, were less common than those in which the arterio-venous
+communication was accompanied by the formation of a traumatic sac. The
+initial lesion accountable for each condition was, however, probably
+identical, and dependent on the passage of a bullet of small calibre
+across the line of large parallel arteries and veins. Thus, obliquely
+coursing antero-posterior wounds of the neck produced carotid and
+jugular varices; vertically coursing tracks laid the subclavian vessels
+in communication; antero-posterior tracks the brachial, popliteal, and
+lower part of the femoral; and transverse tracks, the vessels of the
+calf and forearm. Given an arterial wound, the mode of development of
+the aneurismal sac in no way differs from that of the ordinary
+traumatic variety; the main point of interest, therefore, is to seek an
+explanation of the causes which may restrict the ultimate result to the
+formation of a pure aneurismal varix. The explanation is possibly to be
+found in some of the following circumstances.
+
+_Size, position, and symmetry of the vascular wound._--It seems scarcely
+necessary to insist on the calibre of the projectile, since this alone
+determined the frequency of these conditions, but it must be borne in
+mind that in the diameter of the bullets, classed as of small calibre
+during this war, a range of from 6.5-8 mm. existed. In the case of both
+the Krag-Joergensen and Mauser, the shape of the bullet also was better
+adapted to pure perforation of the vessels. I saw no case of
+arterio-venous communication in which a larger bullet than one of the
+four types chosen had been responsible for the primary injury, but a
+difference of 1-1/2 mm. in calibre in the small projectile might well
+determine the division, the pure and symmetrical perforation of the two
+vessels, or the giving way of one side, so that they were deeply notched
+instead of perforated.
+
+Such positive evidence as was afforded by operation as to the exact
+condition of the vessels in two cases of femoral arterio-venous aneurism
+was, that in either case a clean perforation existed.
+
+It is improbable that notching of the two vessels can primarily produce
+a pure varix, although it may result in the formation of an
+arterio-venous aneurism, especially if the bullet should have passed
+between 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 secondary
+contraction of a sac produced in this manner may be in the determination
+of the ultimate relation of the vessels. In many of the cases clinically
+designated pure varix, the remains of such a sac may still actually
+persist. In the case also of pure perforation of the vessels, it is
+difficult to believe that a localised blood cavity has not originally
+existed. Given complete division of the vessels, as far as my experience
+went, arterial haematoma was the uniform result.
+
+Under these circumstances I am inclined to believe that a symmetrical
+perforation of both vessels is the most common precursor of either
+condition; that the pure varix is the rarer and less likely result, and
+that its formation is dependent mainly on certain anatomical conditions.
+The most important of these conditions are the proximity and degree of
+cohesion of the two vessels, the comparative spaciousness or the
+opposite of the vascular cleft, and the degree of support afforded by
+surrounding structures.
+
+Thus, the close proximity of the popliteal artery and vein, together
+with the particularly firm adhesion which exists between the vessels,
+probably favours the formation of a varix; again, a varix more readily
+forms if the femoral artery and vein are wounded in Hunter's canal than
+if the injury is situated high in Scarpa's triangle, where the vessels
+lie in a large areolar space. The passage of a bullet between an artery
+and vein may perhaps produce either condition, but wide separation of
+the two vessels, as for instance of the subclavian artery and vein,
+renders an aneurismal sac almost a certainty. These suggestions seem
+borne out by the cases recounted below, since the pure varices are one
+femoral, one popliteal, and one axillary. I cannot include the calf and
+forearm cases, as the existence of a small sac could not be disproved.
+
+To these anatomical factors certain others must be added. In most cases
+a false sac exists at first, which tends to undergo contraction and
+spontaneous cure, as is observed in some of the ordinary traumatic sacs.
+This history of development is moreover supported by the observation
+that proximal ligature of the artery usually converts an arterio-venous
+aneurism into an aneurismal varix. The process is no doubt favoured by
+cleanness and small size of the perforation, moderation in the amount of
+primary haemorrhage, the tone and resistance of the surrounding tissues,
+special points in the circulatory force and condition of the blood, and
+the possibility of maintaining the part at rest after the injury.
+
+Aneurismal varix, when pure, was evidenced by the presence of purring
+thrill and machinery murmur alone. In none of the cases I saw was pain
+or swelling of the limb present. In one popliteal varix, slight
+varicosity of the superficial veins of the leg was present, but it was
+not certain that the development of this was not antecedent to the
+injury, as the patient did not notice it until his attention was drawn
+to its existence. In none of the cases under observation in South Africa
+had enough time elapsed for sufficient dilatation of the artery above
+the point of communication to give rise to any confusion from this cause
+as to the presence of a sac.
+
+When an arterio-venous sac has once formed, clinical observation shows
+that the general tendency is towards extension in the direction of least
+resistance. This direction of course varies with the situation of the
+aneurism, and also with the nature of the wound track.
+
+Speaking generally the direction of least resistance in a typically pure
+perforation is towards the vein. Initial flow of blood from the wounded
+artery is naturally favoured towards the potential space afforded by a
+canal occupied by blood flowing at a lower degree of pressure. The
+partial collapse of the vein dependent on the wound in its wall also
+probably 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 cervical
+vascular cleft are those least likely to offer resistance to extension
+of the sac. In each the aneurisms mainly occupied the exit segment of
+the track; this is the general rule, as in the case of external
+haemorrhage, and is determined by the same cause.
+
+The latter rule however finds exceptions when the entry segment is so
+situated as to cross a region of lesser resistance, and case 12
+illustrates this point with regard to the cervical vascular cleft.
+Examples of the tendency to spread in the anatomical direction of least
+resistance are also offered by the cases of aneurism at the root of the
+neck, where extension was into the posterior triangle.
+
+The further clinical history and signs are as follows. A local swelling
+is found, usually at first diffuse, often commencing to develop with
+cessation of the external haemorrhage. It increases, for the first few
+days maintaining its diffuse character. If near the surface, it may be
+superficially ecchymosed. At the end of this time a tendency to
+localisation, as evidenced by increasing firmness and more definite
+margination, takes place, and this is followed by general contraction
+and rounding off of the tumour. The latter process may be continuous,
+and eventually the sac may become small and stationary or ultimately
+disappear and a pure varix be the result. The latter is only likely to
+be the case under the most satisfactory of the conditions enumerated
+above. Occasionally an opposite course may be followed, and fresh
+extension take place, as evidenced by enlargement of the tumour,
+disappearance of sharp definition, softening, and pain. The natural
+termination of such cases in the absence of interference would no doubt
+be rupture, and possibly death in some positions, loss of the limb in
+others. The former I never saw.
+
+_Purring thrill._--This, the pathognomonic sign of either condition, was
+always present in the fully developed stage, and is probably present
+from the first unless a temporary thrombosis obstructs the vascular
+openings. It was noted as early as the third day in case 13. In many of
+the other patients it was palpable only with the subsidence of the
+primary swelling attendant on the injury. In some of the forearm and
+calf aneurisms, and in some of the popliteal, it was only discovered by
+accident some weeks even after the injury, but this often because no
+serious vascular lesion had been suspected. The thrill was widely
+conducted, often apparently superficial on palpation, and much more
+pronounced with light than with forcible digital pressure.
+
+In case 10 the _visible_ vibration in consonance with the thrill when
+the vein was exposed during the operation of ligature of the carotid was
+a novel experience to me.
+
+_Murmur._--The typical 'bee in the bag,' or 'machinery' murmur was
+present in every case, and was often very widely distributed, especially
+over the thorax. (Cases 13, 14, and 20.)
+
+In all three carotid cases the murmur was troublesome, being audible to
+the patient at night when the head was rested on the side corresponding
+to the aneurism.
+
+_Expansile pulsation._--Pulsation in combination with the existence of a
+tumour is the main feature in the diagnosis between the conditions of
+pure varix and varicose aneurism. It was not always existent or
+prominent in the earliest stages, probably from temporary blocking of
+the artery, or from the diffuse and irregular nature of the cavity
+offering conditions unsuitable to the satisfactory transmission of the
+wave. 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 the
+remarkable effect of the disturbance to the even flow of the circulation
+on the heart. This first struck me in two of the cases of carotid
+arterio-venous aneurism recorded below (Nos. 10 and 11). In these I was
+inclined at first to attribute the rapid and irritable character of the
+pulse solely to injury to the vagus, as in each laryngeal paralysis
+pointed to concussion or contusion of the nerve. The pulse reached a
+rate of 120-140 to the minute. This disturbance was not of a transitory
+nature, for in the two cases referred to the rapid pulse persists, in
+spite of entire recovery of the laryngeal muscles, and the fact that in
+one case the aneurismal sac has been absolutely cured, and in the second
+only a small sac remains, in each as a result of proximal ligature of
+the carotid artery. In the former a varix still exists, and at the end
+of seven months the pulse is still over 100. In the latter, in which a
+sac is still present, the pulse rate varies from 110 to 130. In each
+case the condition has now existed twelve months. My attention once
+directed to this point, I noted a similar acceleration of the pulse in
+the case of these aneurisms elsewhere; thus in a femoral aneurism the
+rate was 120, and in an axillary varix of twenty years' standing which
+came under my observation the pulse rate varied from 110 to 120,
+according to the position of the patient. Unfortunately I had not
+directed my attention to this point in the early series of cases which
+came under observation.
+
+It will be remarked in cases 13 and 14 that at the expiration of a year
+the pulse rate was still high, but these again are cervical aneurisms
+each 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 rate
+was normal. In this instance great dilatation of the vessels had
+occurred.
+
+These observations raise the interesting question whether the irritable
+circulation which has been classically considered one of the
+predisposing causes of spontaneous aneurism should not rather be
+regarded as a result of the condition.
+
+(_b_) _Local._--In none of the cases of varix was the period of
+observation long enough to allow me to determine the development of
+dilatation of the arterial trunk above the point of obstruction. This,
+however, is the common sequence, and no doubt will occur in those
+patients who resume active occupation without operation.
+
+The effects of either condition on the distal circulation were
+remarkably slight. The distal pulses were little, if at all, modified in
+strength or volume, and signs of venous obstruction, if present at
+first, disappeared with much rapidity. In one case (No. 15) of a large
+arterio-venous popliteal aneurism there was considerable swelling of the
+leg, but in this case the sac was large and situated at the apex of the
+space, and no doubt exercised external pressure on the vein.
+
+In the case of the carotid aneurisms, especially that probably on the
+internal carotid, transient faintness was a symptom in the early stages
+of the case. All three of the cases recorded here, however, had been the
+subjects of very free haemorrhage, 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 haemorrhage at the time from
+     the exit wound, but no haemoptysis; 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 very
+slight. The condition gives rise to little or no trouble. Pulsation is
+strong in the external carotid artery, there is little in the common
+carotid. The voice is strong and good. This aneurism is either at the
+bifurcation of the common carotid, or on the immediate commencement of
+the internal carotid. Ligature of the external carotid will probably
+cure 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 haemorrhage 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 haemorrhage 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 deg.. 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 haemorrhage, 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 haemoptysis 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 palpebrae 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
+     haemorrhage 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 a
+lamplighter, and was able to do his work well, only complaining of
+attacks of shortness of breath on exertion. He said these were apt to
+come on each evening about 6 P.M. The pulse was 100 when the erect
+position was maintained, and 84 to 88 in the sitting posture. The right
+pupil 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 the
+normal left subclavian was more apparent in the posterior triangle of
+that side. The sterno-mastoid was prominent, also the sternal third of
+the clavicle. On firm pressure some pulsation was palpable beneath the
+sterno-mastoid, but no definite evidence of the presence of a sac could
+be detected. Purring thrill and machinery murmur were still present, but
+the former was slight, and palpable only with the lightest pressure. The
+machinery murmur had ceased to be audible to himself, and was by no
+means loud or very widely distributed.
+
+The condition had, in fact, steadily improved, and become far less
+obvious. The prominence of the sterno-mastoid and clavicle still present
+was difficult of explanation, except on the theory of an injury to the
+bone, 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 haemorrhage, but the injury was followed by some
+     difficulty in swallowing, and haemoptysis, 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
+     hyperaesthesia 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 as
+follows. He was living at home, and out of employment. He complained of
+shortness of breath on exertion, and said that when he mounted stairs he
+felt 'as if his heart were going to leave him.' The heart's apex beat in
+the sixth interspace in the nipple line, and the precordial dulness was
+somewhat increased. The pulse numbered 80 to 84. The muscles supplied by
+the ulnar nerve were very weak, but not much wasted, and ulnar sensation
+was imperfect.
+
+The aneurism had considerably altered in form and outline; its walls
+were dense and firm; it extended 2-1/2 inches upwards in the line of the
+carotid artery, beneath the sterno-mastoid, but projected beyond the
+posterior border of that muscle. The larynx was displaced 1/2 an inch to
+the left of the median line; the voice was still husky, although much
+stronger than it was; the anterior jugular vein was dilated. The purring
+thrill was very superficial, and chiefly palpable over the subclavian
+vessels. The machinery murmur was still loud, but much less widely
+distributed than before; it was still audible to the patient when he lay
+on his right side.
+
+This case was of much interest from the diagnostic point of view. When I
+first saw the patient I considered the injury to have implicated the
+innominate vessels. Later, from the facts that the thrill was
+imperceptible in the episternal notch, and that the main part of the
+tumour was situated in the posterior triangle, that the wound was of the
+root of the right subclavian vessels.
+
+It now appears that, at any rate, the root of the right carotid is the
+artery implicated.
+
+In spite of the continued existence of a large aneurism, the
+localisation of the sac, which had taken place, was very striking,
+considering that the man had been walking about freely, and living an
+ordinary 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 three
+other 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 haemarthrosis 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 the
+disinclination shown by the older surgeons to interference in cases of
+either aneurismal varix or varicose aneurism, even after the time that
+ligation of the vessels had become a favourite and successful operation.
+The objections lay in the technical difficulties of local treatment, and
+the danger of gangrene after proximal ligature. Modern surgery has
+lightened the difficulties under which our predecessors approached these
+operations, but none the less the experience in this campaign fully
+supports the objections to indiscriminate and ill-timed surgical
+interference, as accidents have followed both direct local and proximal
+ligature.
+
+In _pure varix_ no doubt can exist as to the advisability of
+non-interference in the early stage, in the absence of symptoms. This is
+the more evident when we bear in mind that a stage in which an
+aneurismal sac exists can seldom be absent. In many cases an expectant
+attitude may lead to the conviction that no interference is necessary,
+especially in certain situations where the danger of gangrene has been
+fully demonstrated. In connection with this subject I cannot help
+recalling the first case of femoral varix that ever came under my own
+observation. I discovered the condition accidentally in a man admitted
+into the hospital for other reasons. The patient remarked: 'For heaven's
+sake, sir, do not say anything about that. I have had it many years, and
+it has never given any trouble. If it is known, I shall be worried to
+death by people examining it.'
+
+None the less it must be borne in mind that beyond enlargement of the
+vein dilatation of the artery above the seat of obstruction does occur,
+and gives trouble in some situations. Again the disturbance of the
+general circulation already adverted to shows that the existence of this
+condition is sometimes of importance in its influence on the cardiac
+action.
+
+Under these circumstances the treatment varies with regard to the
+vessels affected, and the degree of disturbance the condition gives rise
+to.
+
+With regard to locality, experience appears to have shown clearly that
+communications between the carotid arteries and jugular veins usually
+give rise to so little serious trouble that, in view of the grave nature
+of the operation and its possible after consequences on the brain,
+interference is as a rule better avoided. I should, however, be
+inclined to draw a distinction between operations on the common and
+internal carotid arteries in this particular, and should regard varix of
+the latter vessel and the internal jugular vein as especially
+undesirable for interference.
+
+The vessels at the root of the neck are probably to be regarded from the
+same 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 most
+likely to be useful. In this relation it may be of interest to include
+here a case of a man who took part in the campaign when already the
+subject 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 interfered
+with, but in many instances an absence of any serious symptom renders
+operation 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 a
+certain amount of caution should be exercised in interfering with them.
+
+The same remarks in a lesser degree apply to the popliteal vessels. In
+the leg the tibials may readily and safely be attacked, but it may be
+mentioned that the widespread and diffused nature of the thrill may in
+some cases give rise to considerable difficulty in sharp localisation of
+the varix to either of the vessels, or to any particular spot in their
+course. In one case in my experience the posterior tibial was cut down
+upon, when the varix was probably peroneal in situation.
+
+The operation most in favour consists in ligation of the artery above
+and below the varix, the vein remaining untouched. Even this operation,
+however, in two cases of femoral varix failed to effect more than a
+temporary cessation of the symptoms, although the ligatures were placed
+but a short distance from the communication. Failure is due to the
+presence of collateral branches, which are not easy of detection. Even
+when the vessels lie exposed, the even distribution of the thrill
+renders determination of the exact point of communication difficult, and
+the difficulty is augmented by the temporary arrest of the thrill
+following the application of a proximal ligature to the artery. A
+successful 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 of
+communication.[16] Single ligation, or proximal ligature, is useless.
+
+If the vein cannot be spared, excision of a limited part of both vessels
+may be preferable, particularly in those of the upper extremity.
+
+Proximal ligation of the artery combined with double ligature of the
+vein, 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 treatment
+of this condition, as of the next, is preventive--_i.e._ primary
+ligation of the wounded artery. Many difficulties, however, lie in the
+way of this beyond mere unsatisfactory surroundings. It suffices to
+mention the two chief: uncertainty as to the vessel wounded, and the
+necessity of always ligaturing the vein as well as the artery in a limb
+often more or less dissected up by extravasated blood, to show that this
+will never be resorted to as routine treatment.
+
+_Arterio-venous aneurism._--Many of the remarks in the last section find
+equal application here, but in the presence of an aneurismal sac
+non-intervention is rarely possible or advisable. In the early stages
+the proper treatment in any case consists in placing the patient in as
+complete a condition of rest as possible, and affording local support to
+the limb by a splint, preferably a removable plaster-of-Paris case.
+Should no further extension, or, what is more likely, should contraction
+and diminution occur, it will be well to continue this treatment for
+some weeks at least.
+
+When the aneurism has reached a quiescent stage the question of further
+treatment arises, and whether this should consist in local interference
+or proximal ligature. The answer to this mainly depends on the size and
+situation of the vessels concerned. To take of the cases above described
+the five instances in which the cervical vessels were the seat of the
+aneurism. In No. 13 the symptoms appeared fairly conclusive of the
+injury being to the innominate artery and vein, or possibly innominate
+artery and jugular vein. Fortunately the aneurismal sac in this case was
+small and showed a tendency to decrease, but in any case no interference
+would have been justifiable. I think a similar opinion was unavoidable
+in No. 14, probably affecting the root of the right carotid. Here under
+any circumstances interference would have been most hazardous. The
+position of large aneurism made the route of approach to the wounded
+spot necessarily through the sac, exposing the patient to the double
+danger of immediate haemorrhage and of entrance of air into the great
+veins. Nos. 10, 11, and 12 fall into the same category, except that in
+No. 11 the immediate indication for interference was extension. In each,
+ligature of the artery above and below the point of communication would
+have necessitated so near an approach to the sac which must remain in
+communication with the vein as to have entailed injury to the latter,
+when both artery and vein must have been ligatured, probably risking
+serious cerebral trouble. In No. 11 I believe both the external and
+internal carotids were implicated; in No. 10 I believe the internal
+alone, close to its origin. The operation of proximal ligature ensured
+primary consolidation of the sac in both cases 10 and 11, but left the
+thrill unaltered, except in so far as it was temporarily weakened. It,
+in fact, converted these cases from arterio-venous aneurisms into pure
+aneurismal varices. In No. 10 a sac subsequently redeveloped. No. 12
+stood on a different basis. No operation was done for him in South
+Africa, but the first portion of the carotid might have been ligatured
+in 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 and
+below the communication would have been comparatively easy.
+
+As a general rule proximal ligature is to be reserved for those cases
+alone in which double ligature is either impracticable or inadvisable,
+and it can only be expected to convert a varicose aneurism into the less
+dangerous condition of aneurismal varix.
+
+In the case of arterio-venous aneurisms in the limbs the possibilities
+of treatment are enlarged, and here the alternatives of (_a_) local
+interference 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 treatment
+for aneurisms in the calf, forearm, and probably arm. Several cases in
+the two former situations were successfully treated by this method. On
+the other hand, the only case I saw in which a proximal ligature had
+been applied for an arterio-venous aneurism of the leg resulted most
+unsatisfactorily. The sac in the calf suppurated at a later date, and
+for many weeks the escape of small quantities of blood from the
+remaining sinus kept up the fear of a severe attack of secondary
+haemorrhage until the sinus closed.
+
+In the case of femoral and popliteal aneurisms the method of Antyllus is
+often unsuitable. A case of arterio-venous aneurism of the femoral
+artery quoted in the _Lancet_[17] will illustrate the difficulty which
+may be met with in determining the actual bleeding point in the
+irregular cavity laid open. In any case the necessary ligature of both
+artery and vein is a serious objection to the direct method either in
+the thigh or ham, and more particularly if adopted before the damage
+dependent on the dissection of the limb by extravasated blood has been
+repaired.
+
+Proximal ligature (Hunterian) even, offers dangers under these
+circumstances. In one case with which I became acquainted, it was
+followed by gangrene, necessitating amputation. The lesion in this
+instance was a perforating one of the femoral artery and vein.
+
+For either femoral or popliteal arterio-venous aneurisms ligature of the
+artery above and below the aneurism is the best and safest treatment. In
+view 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 as
+can be managed without interference with the sac is afforded. A number
+of popliteal cases treated in this way did perfectly. In the femoral
+cases a considerable period of rest to allow of consolidation of the
+sac, and readjustment of the circulation, should always be allowed to
+elapse.
+
+In the case of popliteal arterio-venous aneurisms a number were
+successfully treated by proximal (Hunterian) ligature, and by single
+ligature immediately above the sac. In a considerable proportion of the
+latter both artery and vein were tied. This was apparently the result of
+the difficulty of isolating the vessels in the tangled mass of clot and
+cicatricial tissue surrounding them, and is a strong argument against
+too early interference. The late Sir William Stokes expressed himself as
+in favour of ligature of the artery in Hunter's canal, combined with
+that of the great anastomotic branch, and quoted some successful cases
+to me. I have grave doubts, however, whether the varix can often be
+permanently cured by this operation.
+
+I can give no useful statistics on this subject, but with regard to the
+popliteal aneurisms I may state that in three instances gangrene of the
+leg followed early operative interference in the popliteal space.
+
+My own opinion on this subject is strong, and to the effect that none of
+these operations should be undertaken before a period of from two to
+three months after the injury, unless there is evidence of progressive
+enlargement. In every case which came under my own observation
+progressive contraction and consolidation took place up to a certain
+point under the influence of rest. When this process has become
+stationary, and the surrounding tissues have regained to a great extent
+their normal condition, the operations are far easier, and beyond this
+more likely to be followed by success.
+
+It appears to me that one argument only can be raised against the above
+opinion, viz. the possibility of healing of the recent wound in the
+vessels when the force of the circulation is lowered by proximal
+ligature. Such experience as that quoted from Sir W. Stokes and two of
+Mr. Ker's cases, mentioned below, support this possibility, but in all
+the reported results were recent. Against them I can only advance my
+knowledge of several mishaps following early operation.
+
+In concluding these observations on injuries to the arteries and
+aneurisms, a few general remarks as to the occurrence of gangrene after
+operation must be added. This was not uncommon, and in the main was no
+doubt attributable--(1) to the lowering of the vitality of the
+surrounding tissues by creeping blood extravasation, and sometimes to
+actual pressure by the extravasation on the vessels necessary for the
+establishment of the collateral circulation. (2) To the frequency with
+which both artery and vein required to be ligatured.
+
+Beyond these common causes, however, others must be advanced, dependent
+on the general and local condition of the nervous system in these cases.
+In general mental state many of the patients were much shaken, and in
+others the condition spoken of as local shock in a former chapter had
+been marked. In a third series obvious individual nerve lesions were
+co-existent with those to the vessels. Beyond this a fourth nervous
+element of unknown quantity, the effect of the form of injury on the
+vaso-motor nerves accompanying the great vessels, must be taken into
+consideration.
+
+I believe all these factors were of importance, since it appeared to me
+that gangrene occurred more often than I should have expected. In one
+case which I have heard of, gangrene followed a very slight injury to
+the foot in a patient who had apparently made an excellent recovery
+after ligature of the femoral artery.
+
+The nervous factor seems another element in favour of reasonable delay
+in active interference with traumatic aneurisms of the above varieties
+in the absence of threatening symptoms.
+
+It is worthy of remark that no case of gangrene due to aneurism came
+under my notice, except subsequently to operation.
+
+Since the above chapter was written, my friend, Mr. J. E. Ker, has sent
+me his experience in the treatment of four aneurisms, which is of such
+interest that I insert it as an addendum.
+
+_Arterial haematomata._--(1) Popliteal, treated by local incision. Both
+artery and vein completely divided. Ligature of the four ends. Cure.
+(2) Traumatic aneurism of upper third of forearm. Treated by rest and
+pressure by bandage. On the eighth day pulsation and bruit ceased
+spontaneously, and the remains of the sac steadily consolidated until
+the man's discharge on the twenty-sixth day.
+
+_Arterio-venous aneurisms._--(1) At junction of brachial and axillary
+arteries. Proximal ligature. Cure. (2) Arterio-venous aneurism at the
+bend of the elbow. Ligature of the brachial at the junction of the
+middle and lower thirds of the arm. Cure.
+
+FOOTNOTES:
+
+[14] The murmur is still present at the expiration of one year, but no
+other 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 the
+accidents we were called upon to treat, and afforded as much interest as
+any class, since they possessed many special features. I shall hope to
+show, however, as in some of the other injuries, that these features
+differed only in degree from those exhibited by injuries from the old
+leaden bullets of larger calibre, although with few exceptions they were
+of a distinctly more favourable character.
+
+It is of considerable interest to note that, taking the fractures as a
+whole, there was a somewhat striking change in their nature during the
+earlier and later portions of the campaign. In the earlier stages I
+think there is no doubt that punctured fractures were proportionately
+more common than in the later, when comminuted fractures were much more
+often seen. There was, I believe, a source of error in this opinion, as
+far as I myself was concerned, in that the first cases I saw were at
+Capetown and had come from Natal. There is no doubt that the punctured
+fractures were earlier fit to travel, and hence a larger number of them
+found their way to the Base hospitals at a period when the comminuted
+fractures were still in the Field or Stationary hospitals. I do not,
+however, rely on the cases seen at Capetown alone for my opinion, as
+while at the front I saw the same large proportion of clean punctures in
+the early engagements of the Kimberley relief force.
+
+I am inclined to attribute the change to two reasons: first, I believe
+that the use of regulation weapons was more universal in the earlier
+part of the war, while later, as more men were engaged, the
+Martini-Henry came more into evidence, and the Boers took more freely
+to the use of sporting rifles and ammunition. Another element also in
+the less clean punctures of the short and cancellous bones was probably
+the less accurate and hard shooting of the Mauser rifles as they became
+worn; the bullets seemed to evidence this by the comparative shallowness
+of their rifle grooves, which, I take it, would mean less velocity and
+accuracy in flight. This would be of importance, since the clean
+puncture of cancellous bone was no doubt favoured by a high rate of
+velocity.
+
+The special features of the fractures caused by the small-calibre
+bullets were: (1) The nature of the exit wound, which in a certain
+proportion of the cases exhibited the so-called 'explosive' character.
+(2) The presence, in a marked degree in the severe cases, of the
+condition spoken of in Chapter III. as 'local shock.' (3) The striking
+contrast of clean perforation and extreme comminution in different
+cases. (4) The occasional occurrence of fractures of a very high degree
+of longitudinal obliquity. (5) The rarity of any that could be termed
+transverse fractures. (6) The general tendency of longitudinal fissuring
+when it occurred to stop short of the articular extremities of the
+bones.
+
+It will perhaps be most convenient to consider first the explanation of
+the development of the so-called explosive apertures, and then to pass
+on to a general consideration of the types of fracture commonly met
+with, before proceeding to the description of the injuries to the
+separate bones.
+
+_Explosive wounds in connection with fractures._--The aperture of entry
+in these injuries presented little or no deviation from the normal,
+unless it was due to the passage of ricochet bullets, when it might be
+very irregular, but usually not of great size.
+
+[Illustration: FIG. 47--(21) 'Explosive' Exit Wound of Forearm over
+margin of ulna. Note creased tongue of skin originally covering whole
+wound. The entry wound was a small typical circular one]
+
+The aperture of exit offered special features beyond simple increase in
+size. First of all, as in the small type wounds, the actual extent of
+destruction of the skin was small, this having been projected outwards
+by the passing bullet and then either burst or torn by the bullet and
+accompanying bony fragments. Fig. 47 well illustrates this feature. A
+triangular tongue of skin was lifted by the passing bullet and probably
+by the lower end of the upper fragment of the fractured ulna; through
+the resulting opening a mass of soft tissues and bone fragments, bound
+together by an infiltration of coagulated blood, was extruded,
+separating the lateral lips of the aperture, while the original tongue
+has shortened and retracted up to the top of the wound.
+
+The small extent of skin actually destroyed is an important element in
+the rapid contraction often seen in these wounds when they progress
+favourably. Thus the large wound portrayed in fig. 48 contracted to
+one-fourth its original size ten days after the diagram and measurements
+were made. The large mass of protruded tissue was often most striking
+when a muscle such as the biceps in fig. 48 had been divided; but the
+herniae were more persistent when the mass projected in regions where
+tendons formed a large integral constituent, as at the wrist or lower
+third of the forearm. The protruding tissues naturally consisted of many
+varieties, according to what lay in the track of any particular wound.
+
+It should be added that for 'explosive' features to reach their
+strongest development, it is necessary that the bone affected should lie
+near the surface of the body; hence the most characteristic explosive
+wounds were met with in the forearm or leg, over the metacarpus or
+metatarsus, or in the arm. In the thigh, on the other hand, where the
+femur in a great part of its course not only lies deeply, but is also
+protected by particularly strong and resistent skin and fascia, another
+type of wound was met with. The explosive exit aperture, although large,
+was still only moderate in extent, sometimes, as in the front of the
+lower third, exposing a somewhat angular large track walled by the
+divided quadriceps extensor cruris. In other cases, on introducing the
+finger 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 of
+similar material. In either of these latter cases the fractured bone
+ends were situated too deeply to take part in the actual laceration of
+the skin, while the force transmitted to the bone fragments, although
+sufficient to cause them to widely destroy the first soft tissues met
+with, did not suffice to cause them to burst or lacerate the skin
+widely.
+
+[Illustration: FIG. 48.--(22) 'Explosive' Exit Wound of front of Arm.
+Wound actual size eight days after its infliction. The prominences in
+the upper and lower parts correspond with the lacerated biceps. The dark
+crater led down to the fracture. In another week the wound had
+contracted to half the size. The entry aperture was a normal circular
+one. The arm a year later was used in the patient's employment as a
+hammer-man.]
+
+With regard to the theories of the production of these phenomena, that
+of the transmission of a part of the force of the bullet to the
+comminuted fragments, which thus themselves acquire the characters of
+secondary projectiles, seems quite adequate.[18] Examination of any of
+the skiagrams in which considerable comminution has taken place, shows
+that the fragments are carried forward and perforate the tissues distal
+to the fracture.
+
+[Illustration: FIG. 49.--'Explosive' Wounds of Legs. Large irregular
+entry (1 x 3/4 in.). First exit (2 in.) roughly circular. Second entry
+wound, produced by bone fragments driven out of left leg, very large and
+irregular (5 x 3-1/2 in.). The measurements were taken eight days after
+infliction of the wounds. The right limb was amputated later for
+secondary haemorrhage]
+
+Fig. 49, although a poor delineation of the actual condition, shows well
+the possible action of projected fragments, even after they have been
+driven from the wound. In this case either a large or a ricochet bullet
+entered on the outer aspect of the upper third of the left tibia; it
+produced a severe comminuted fracture, the fragments from which,
+together with the deformed bullet, then struck and perforated the upper
+third of the right tibia. A large irregular entry wound 5 inches in
+transverse diameter was produced in the second limb together with a
+comminuted fracture of the bone. The right limb had eventually to be
+amputated for secondary haemorrhage, but I am unacquainted with the later
+history of the patient.
+
+The mode of displacement of the lateral fragments when a wide shaft such
+as that of the femur is struck, throws some light on that of the
+displacement of soft tissues such as the component parts of a perforated
+nerve or artery. The bullet, passing through, expends the chief part of
+its energy in driving before it the fragments produced in its direct
+course, while a minor part of the energy is expended on displacing the
+lateral fragments, which are pushed to either side without becoming
+separated from their periosteal attachment. The appearance, in fact,
+somewhat suggests what might be expected were a small charge of dynamite
+introduced into the centre of a small tunnel made across the shaft of
+the bone. Examination of some of the skiagrams also illustrates another
+point of interest, viz. that a certain degree of recoil on the part of
+the bone results from the blow, since in many of them portions of the
+mantle of the bullet and bone fragments are seen in that portion of the
+track proximal to the fractured bone.
+
+The importance of 'setting up' of the bullet is at once evident in
+relation to the production of wounds of an explosive type in connection
+with fractures of the bones. There can be no doubt that a considerable
+number of the most severe injuries we saw were produced by the various
+soft-nosed or expanding forms of bullet, also that others of an equally
+serious nature were produced by Martini-Henry or large leaden sporting
+bullets. Allowing for this, however, I think a considerable proportion
+were the result of deformation from bony impact, or ricochet deformities
+external to the body acquired by regulation Mauser bullets, and I think
+these bullets can be quite as formidable as any of the sporting
+varieties met with. The soft-nose varieties of small calibre may not set
+up enough to cause severe injury, while the large leaden bullets often
+flatten out so completely as to lose all penetrating power. As far as
+my impressions went, the small soft-nosed bullets needed to be
+travelling at a very considerable rate of velocity to be dangerous. In
+the form of soft-nose Mauser employed, the soft-nose was too short to
+allow of as successful a mushrooming of the bullet as often occurred
+with the regulation projectile, because, as already explained, the
+mantle 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 long
+bones are illustrated diagrammatically in fig. 50. Of the whole series
+comminuted fractures were by far the most frequently met with, while the
+various wedge-shaped forms were the most strongly characteristic of the
+special form of injury in which we are interested.
+
+[Illustration: FIG. 50.--Five Types of Fracture: A. Primary lines of
+stellate fracture; wedges driven out laterally and pointed extremities
+left to main fragments. B. Development of same lines by a bullet
+travelling at a low degree of velocity; suppression of two left-hand
+limbs and substitution of a transverse line of fracture; a spurious form
+of perforation. See plate XXIII. C. Typical complete wedge. See plate
+VII. D. Incomplete wedge; impact of bullet, lateral or oblique, and two
+left-hand lines seen in A are suppressed. E. Oblique single line, one
+right and one left hand line seen in A, suppressed. The influence of
+leverage 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 the
+acromial end of the clavicle with increasing depth, and eventually
+perforated the posterior margin of the bone, raising the compact tissue
+in an angular manner.
+
+The commencement of an incomplete groove extending from the anterior
+margin is seen, resembling the groove of the humerus, fig. 58.]
+
+1. _Stellate comminuted fractures._--A shows the primary nature of the
+lesion in all comminuted fractures of compact bone, consisting in the
+production of a number of radiating fissures, which assume a stellate
+form of which the point of impact corresponds to the centre. B shows an
+incomplete development of this form, the fragments being simply
+displaced laterally with slight loss of substance, so as to simulate a
+real punctured fracture. An illustration of this fracture produced by a
+bullet travelling at a low degree of velocity is seen in plate XXIII.,
+which also shows the unaltered bullet lying in close proximity to the
+injured fibula.
+
+The degree of comminution in these fractures depends first on the range
+of fire and consequent striking force retained by the bullet, a high
+degree of velocity producing extreme comminution of compact bone. The
+severity of the latter again may be influenced by the measure of
+resistance dependent on the density and brittleness of any individual
+bone, or on the possession of the same characters as a special property
+by the tissues of the man struck. Thus plate IV. shows a fracture of the
+humerus produced by a bullet shot from a short range, and the fragments
+are comparatively large and of even dimensions, while plate XIV. shows
+extreme comminution of the portion of the femur exposed to direct
+impact, with elongated large fragments at the sides of the track. Plate
+XIX. shows less extreme comminution and less separation of the
+fragments, and was probably produced by a bullet from a longer range of
+fire.
+
+The separation of elongated lateral fragments is a special feature, and
+best marked when the portion of bone struck is considerably wider than
+the bullet, as in the case of the shaft of the femur. These fragments
+correspond in the method of their production to those seen in the wedge
+fractures described below, while their separation leaves a pointed
+extremity to either segment of the shaft. This fracture in its purest
+type is, I believe, spoken of as the 'butterfly fracture.'
+
+With regard to the spread of the fissures in the long axis of the bone
+into neighbouring articulations I think fractures produced by bullets of
+small calibre differ considerably from those produced by larger
+projectiles, in that their general tendency is not to extend beyond the
+commencement of the cancellous bone forming the joint end. This is
+perhaps capable of explanation on several grounds: first, the smaller
+area of impact results in the assumption of a strongly marked stellate
+figure, the radiating fissures of which rapidly reach the lateral limits
+of the shaft, producing a solution of continuity in the bone which
+interrupts the continuance of the action of the wedge represented by the
+bullet. Secondly, the small size of the wedge itself is opposed to the
+wide separation of the parts directly implicated, which is necessary for
+the continued progress of the process of fissuring, and again the
+rapidity of passage minimises the period during which the force is
+exerted. It is in these points that I believe the chief differences
+between the modern and old gunshot fractures find their explanation,
+since with the larger bullets fractures extending from some distance
+into the joints were a somewhat special feature. In addition it is
+probable that the alteration in structure at the junction of the shafts
+with the cancellous ends also tends to check the regular extension of
+the fissures, as a similar limitation is illustrated even in some
+fractures by Snider bullets. Fig. 51 of the lower end of the femur
+illustrates a not uncommon lower limit to a comminuted injury in this
+region.
+
+[Illustration: FIG. 51.--Lower end of Femur. From Case needing
+amputation. It shows the usual tendency of the fissures to stop short of
+the articular ends of the long bones]
+
+The degree and nature of the comminution also vary with the directness
+of impact on the part of the bullet. The more nearly this approaches at
+a right angle, the more severe is the local comminution, but probably a
+lesser area of the shaft is implicated. Plate V. shows an example of
+this: all trace of continuity is lost, a wide gap separates the bone
+ends, while the fragments themselves have been for the most part driven
+altogether out of the wound. Oblique impact, on the other hand, may
+widen the comminuted area at the point of impact, while, if the bullet
+retains sufficient force and regularity of outline, it may then travel
+'cutting its way' through the remainder of the bone in an oblique
+direction. It will be of course recognised that the exact impact of the
+bullet depends not alone on the direction of the projectile, but also
+on the nature of the slope offered by the surface of bone struck.
+
+2. _Wedge fractures._--This form (C and D, fig. 50) is equally
+characteristic of gunshot injury with pure perforation; it is met with
+in two varieties. C illustrates the more strongly marked type; in it the
+bullet makes passing lateral impact with the shaft, and from the point
+struck radiating fissures extend to the opposite margin, so that a
+wedge-shaped piece of bone often secondarily comminuted is separated
+from the remainder of the shaft; see plate X. of the radius.
+
+The second variety, D, is an incomplete development of the stellate
+fracture in which the fissures pass to one margin of the bone only. The
+explanation of this variation is probably to be sought in the direction
+of impact on the part of the bullet, since the main fissure is often
+accompanied by secondary lines which run a somewhat parallel course to
+the main one, and suggest the dispersion of the force in the form of
+concentric waves. Such fractures were most strongly marked in the tibia,
+the breadth of the surfaces of this bone presenting especially
+favourable conditions for their production.
+
+3. _Notched fractures._--These may be a slight degree of the form of
+wedge 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 a
+passing bullet. Other notched fractures approximate themselves more
+nearly to perforations, the notch being a groove secondary to the
+opening up of such a track as is shown in the illustration of a
+perforation of the lower third of the shaft of the tibia (fig. 57 on p.
+219). Notching or grooving is naturally much more common in the
+cancellous portions of bones.
+
+4. _Oblique fractures._--These also occur in two varieties: the first
+has been already alluded to; in it the bullet actually cuts an oblique
+track in the bone; the main line of fracture is often considerably
+comminuted, usually at the proximal end of the track (see plates XV. and
+XIX.).
+
+The second variety (E, fig. 50) is less common; in it two of the main
+limbs of the simple stellate figure are suppressed, while the remaining
+two 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 of
+fracture. Such a fracture is illustrated by the skiagram of a femur in
+plate XVI. in which the bullet traversed the soft parts transversely at
+the 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 the
+femur, passing from the inner border of the shaft, the lower end of the
+upper fragment was formed by the compact tissue forming the outer wall
+of the external condyle. This latter perforated the vastus externus and
+lay beneath the skin; as it could not be disentangled, an incision was
+made over it, and the fragments when reduced were screwed together by
+Mr. S. W. F. Richardson. In neither fracture was there any comminution.
+Such fractures most nearly resemble the oblique or spiral ones met with
+in civil practice as the results of falls. In all the instances I
+observed the patients were supported on the lower extremities at the
+time of the accident, and one can only assume that a twist of the trunk
+consequent on the fall of the body diverts the most forcible vibrations
+resulting from the impact of the bullet into one line, and thus produces
+a solution of continuity of a simple oblique nature. In both the cases
+mentioned above the bullet was probably travelling at a low degree of
+velocity; in the first it was a ricochet and was retained. I never saw
+one of these fractures in the upper extremity.
+
+Plate XXI. affords an excellent example of this mechanism. The patient
+was standing when struck, and then fell backwards. An incomplete fissure
+7 inches in length is seen to extend from an otherwise pure perforation
+of the shaft of the tibia.
+
+5. _Transverse fractures._--Throughout these were of very rare
+occurrence. Plate XX. illustrates a pure transverse fracture produced by
+passing contact of a bullet probably fired at a distance not exceeding
+400 yards, and which subsequently struck the fibula plumb and produced
+considerable comminution. No fissure extended into the ankle-joint.
+Comminutions such as that illustrated by plate V. more or less simulated
+transverse fractures, but I saw no examples of transverse tracks
+comparable to the oblique ones described above 'cut through' the shaft
+of a bone.
+
+6. _Perforations._--Although these were common in cancellous bone, they
+were comparatively rare in the compact shafts. I saw, however, complete
+pure perforations of the shafts of the tibia, femur, clavicle, and other
+bones. These perforations were, I believe, always the result of low
+degrees of velocity, and they took the place of simple transverse
+fractures of the 'cut' variety. The apertures of entry and exit in the
+bones resembled in character those seen in the soft parts, or in the
+bones 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 plate
+of bone was raised, and either separated or turned back on a hinge by
+the bullet (fig. 52), (plate XVII.) Such a projecting hinged fragment
+was sometimes a source of some trouble; thus in a case of
+postero-anterior perforation of the lower third of the shaft of the
+femur, the long exit fragment projected into the substance of the
+quadriceps extensor muscle, and interfered with flexion of the
+knee-joint. Fig. 57 of a superficial tunnel of the lower third of the
+tibia is especially interesting as bringing such injuries of the long
+bones into line with fractures of the flat bones of the skull, such as
+are illustrated in fig. 68, p. 259.
+
+Plate XXI. affords an excellent example of perforation of the shaft of
+the 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 the
+shafts of bones, since comminution or loss of continuity accompanies all
+three.
+
+Subsequently to writing the above paragraphs, I took the opportunity of
+re-examining the magnificent series of gunshot fractures collected
+during the Franco-German campaign by Sir William MacCormac, and
+afterwards presented by him to the museum of St. Thomas's Hospital.
+
+The close approximation in type between the main features in these and
+those 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 coarser
+scale. 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 large
+Snider bullet by which they were produced. Thus the fragments generally
+are larger, and occupy a wider area of the shafts, the first character
+depending on the lesser degree of velocity of the bullet, the latter on
+its volume and weight. Fine comminution, however, the most striking
+feature of the modern injury, is throughout absent.
+
+The effect of the larger size of the wedge provided by the bullet in
+increasing the length of secondary longitudinal fissures is well marked,
+and for the same reason the perforations are usually accompanied by
+fissures of considerable extent. It is interesting to note, however,
+that even in the case of the large bullets, and the special tendency
+shown by them to cause the extension of fissures into the joints, one or
+two specimens still show that these fissures incline to stop short when
+the point of junction between the portion of the shaft occupied by the
+medullary canal and that built on a foundation of cancellous tissue is
+reached.
+
+
+LESIONS OF THE SHORT AND FLAT BONES
+
+The above types of fracture are those common to the shafts of the long
+bones, but the difference in structure of the articular ends and the
+short and flat bones endows lesions of these with somewhat different
+characters, the nature of which varies between grooving, perforation,
+and great comminution.
+
+The most typical injury consists in the production of a clean
+perforation of the cancellous bone; this was common both in the
+articular ends and in the short bones. The tunnel differed little in
+character from those already described, a tendency always existing to
+the 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 rates
+of velocity were distinctly favourable, although I am unable to maintain
+this statement by proof in the case of injuries received at the shortest
+ranges of fire. When the velocity was lower, yet with force still
+sufficient to produce a perforating injury, the separation of an
+extensive scale of bone at the exit aperture was a marked feature not
+seen in perforations produced by higher degrees of velocity. Fig. 52, of
+a 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 a
+pure one, both shaft and epiphysis taking part in the walls of the
+track, and the exit opening is in the former, where a thicker layer of
+compact bone exists than would cover any epiphysis, and hence the
+fragment is larger. I use the example, however, because it so forcibly
+illustrates the effect of increased resistance on the part of the bone
+struck in widening the area of the lesion. When the track was entirely
+limited to the articular ends the small amount of damage at either
+aperture was shown by clinical evidence in the rarity of subsequent
+limitation of joint movements due to bony deformity.
+
+[Illustration: FIG. 52.--Oblique perforation, implicating both epiphysis
+and diaphysis. Large fragment detached at exit aperture. Caused by a
+bullet travelling at a low rate of velocity. Compare with figs. 71 and
+72 of a skull fracture. The dotted lines indicate the course of the
+track]
+
+Again, it was rare for fissuring to extend from these tunnels to the
+articular surfaces; thus many instances could be given of perforation of
+the head of the humerus, the olecranon, or the femoral condyles, in
+which no evidence of joint fissure was discoverable. The slight amount
+of resistance offered by the cancellous ends was also clinically
+illustrated by the absence of severe synovial effusions when they were
+struck. When the joint cavity was not crossed, slight effusion only
+resulted, while in the case of fractures of the femoral shaft great
+effusion into the knee-joint, resulting from the forcible vibration
+transmitted to the limb, was a common feature, even when the point
+fractured was situated above the centre of the bone. Again, when the
+joint cavity was crossed a moderate degree only of haemarthrosis was the
+most common result.
+
+With regard to the implication of joints, either primary or secondary,
+in connection with fractures of the articular ends, I am inclined to
+place the lesions of the upper end of the tibia in a more important
+position than those of any other bone. Evidence of this implication was
+in my experience more frequent here than in any other situation. This
+may in part be attributable to the complexity of structure of this
+epiphysis, and perhaps more correctly to the influence of its irregular
+outline in favouring lateral forms of impact on the part of the bullet
+and consequent increase in the area of damage.
+
+Next to tunnelling, grooving was the most common form of injury to the
+short bones. In the case of superficial tracks the compact tissue might
+be considerably comminuted, but not, as a rule, over a width greatly
+exceeding the calibre of the bullet.
+
+Comminution and crushing of a single or several bones were rare in
+proportion to the occurrence of similar injuries produced by
+Martini-Henry or large leaden bullets. When the condition was produced
+by bullets of small calibre, I believe it was in the majority of cases
+the result of irregular impact on the part of the projectile. In support
+of this view it may be added that such injuries were most common in the
+bones of the tarsus, bones especially liable to be struck by ricochet
+bullets.
+
+It was generally believed that bullets travelling at a very high degree
+of velocity were liable to cause severe comminution of the short bones,
+but I never saw any cases supporting this opinion; in point of fact, all
+the short-range lesions of this nature that I saw were of the clean
+perforating variety. I believe that this is capable of satisfactory
+explanation on the ground of the thin character of the layer of compact
+tissue which for the most part ensheaths the short bones; this decreases
+the resistance offered to the bullet and so tends to localise the
+lesion. This statement may be supported by two observations with regard
+to the long and flat bones. First, if the shaft of a long bone be hit
+above the junction of diaphysis and epiphysis, the cancellous tissue in
+and extending from the medullary cavity is pulverised, and examination
+of fragments from such fractures gives the impression of the inner
+aspect having been scraped clean. Secondly, I saw one fracture of the
+ilium produced by a bullet taking a course between its compact layers
+for 3 inches from the notch between the anterior superior and anterior
+inferior spines; the bone to the extent of 2-1/2 square inches was
+pulverised, the cancellous tissue blown away as dust, and the compact
+tissue only represented by scales still adhering by their periosteum to
+the muscles attached to the two surfaces of the bone. This injury was
+produced from a rifle fired at five yards distance, and was an extreme
+example; but, on the other hand, it illustrates only what we are
+thoroughly well acquainted with in the case of flat bones, such as those
+of the cranium, where the compact element is abundant in comparison with
+the cancellous, and the resistance offered to the bullet is consequently
+great.
+
+Some remarks on transverse fractures of the patella will be found under
+the 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 are
+there described; some further remarks on these injuries will be found
+under the headings of the individual bones.
+
+_Special characters of the symptoms observed, and of the course of
+healing of the fractures._--Peculiarities in the initial signs may be
+rapidly passed over. The first depended on the large number of lesions
+of the bone which were unaccompanied by loss of continuity. In the case
+of perforations attention to the course of the track, external
+palpation, and possibly the detection of bone dust in the aperture of
+exit, were usually sufficient to indicate injury to the bones. When
+these did not suffice the introduction of a probe would usually set the
+question at rest; but this is always to be avoided if possible, as
+adding a fresh item of risk to the wound. The X rays were not always to
+hand, and are not always capable of giving reliable information in the
+matter of perforations, although very useful in detecting grooves or
+notching. The latter injuries are those in which information as to the
+condition of the bones is often of most interest in view of the
+characters of the external wounds.
+
+Fractures with solution of continuity were, as a rule, easy of
+detection, but the relative prominence of the classical signs varied
+somewhat from what we are accustomed to see in civil practice.
+
+The first striking peculiarity noted in comminuted fractures of the long
+bones was the degree of local shock; the limbs were often quite
+powerless, the muscles flaccid, and common sensation lowered. This was
+of importance in two ways; firstly, shortening of the limb was often
+absent as a sign, and, secondly, pain was sometimes not at all
+pronounced even when the patient was moved. The primary absence of
+shortening, even persisting for the first two or three days, was a
+phenomenon always important to bear in mind, as it affected the degree
+of extension needed in the treatment of the fracture, which, if
+sufficient at the moment, often proved quite inadequate with the return
+of tone in the muscles. Secondly, abnormal mobility was usually strongly
+marked, and this sometimes without very definite crepitus, as a result
+of the fine nature of the comminution and the displacement of the small
+fragments.
+
+During the course of healing some other peculiarities are worthy of
+mention. First of all, union was tardy and often not strong. On the
+other hand, an abundance of provisional callus was common, which formed
+large swellings apt to implicate neighbouring nerves, and sometimes to
+interfere with the movements of joints. The slowness of healing was
+particularly noticeable in those cases where the degree of local shock
+had been marked, and was probably to some extent dependent on
+disturbance of the general nutrition of the tissues of the affected
+limb. Beyond this, however, it was in many cases a direct result of the
+degree of comminution and displacement of the fragments, which
+necessitated the formation of a large amount of provisional callus, and
+time for the proper consolidation and contraction of the same. In many
+cases a large ball-like mass of callus surrounding the fragments was
+developed, into which the actual ends of the broken bone only dipped,
+and hence union was weak and insecure. As to those cases in which the
+wounds closed by primary union, we must bear in mind in this relation
+the tardy union often observed in civil practice, when the irritation of
+suppuration and consequent inflammation are absent.
+
+Another peculiarity of a similar nature was the occasional late necrosis
+of fragments; the wounds apparently healed well, only to break down
+weeks or months later for the discharge of a sequestrum. Such cases were
+quite distinct from those in which primary suppuration had occurred. I
+saw one or two instances in fractures of the humerus, the trouble
+arising with commencing use of the limb, and I suppose that fragments
+which suffered death at the time of the injury had been enclosed, and
+only caused irritation as foreign bodies when the muscles again came
+into action. In the absence both of evident necrosis and suppuration,
+however, in some cases the exit portion of the track in the soft parts
+was extremely slow in healing. Although no discharge beyond a small
+quantity of blood-tinged serum escaped, the wounds remained open for
+many weeks, even when the fracture consolidated well. I ascribed this to
+slow separation of aseptic sloughs, a point which has already been
+mentioned 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 was
+no doubt due to the infrequency of extension of the comminuted fractures
+beyond the junction of diaphysis and epiphysis.
+
+Lastly, with regard to suppuration, only a small proportion of the
+fractures, accompanied by the presence of large wounds, escaped
+infection. When infection did occur, the results offered some special
+features dependent on the small relative amount of damage to the soft
+tissues, compared with that suffered by the bone. In an ordinary
+compound fracture, such as we meet with in civil practice, whether the
+result of direct or indirect violence, a considerable amount of
+contusion or laceration, as the case may be, accompanies the injury to
+the bone. The result of this is a widespread effusion of blood into the
+limb, which tears and strips up the various layers of soft parts, and
+opens up the way to the spread of infection, often into the whole
+length of the segment of the limb affected. In fractures produced by
+bullets of small calibre, even when the exit portion of the track is
+large, the injury to the soft parts is far more localised, except in
+extreme cases, while the bone itself is the tissue which has suffered
+the most severe violence and contusion. When infection occurred, its
+spread corresponded with this anatomical feature of the lesion, and the
+bone itself and its immediate neighbourhood suffered the most severely.
+
+At the present day one is naturally not very familiar with a large
+series of suppurating compound fractures, but during my whole experience
+I have never seen so many cases of what might be regarded as fairly pure
+instances of acute osteo-myelitis. The symptoms corresponded with the
+main seat of the suppuration; only moderate swelling of the limbs
+occurred, this mainly consisting in soft superficial oedema; often
+there was no redness, and fluctuation was difficult to determine. At the
+same time symptoms of constitutional infection, such as continued fever,
+rapid pulse, restlessness, loss of strength, progressive anaemia, and
+emaciation, were marked. Pyaemia, as evidenced by secondary deposits,
+was, however, rare; I only saw two cases, both in fractures of the
+femur; in both recovery followed secondary amputation.
+
+_Prognosis._--This depended almost entirely on the nature of the injury
+to the soft parts; given moderate injury to these, and the preservation
+of the wound from infection, scarcely any degree of injury of the bones
+precluded recovery, even if this were slow and prolonged. The existence
+of perforations scarcely increased to an important extent the gravity of
+a wound of the soft parts alone; in fact, this injury could not be
+regarded as more severe than an ordinary surgical osteotomy, putting the
+risks of infection of the wound under the special circumstances on one
+side.
+
+With regard to the functional results, these depended on the degree of
+comminution; when this was extreme, union was slow and for a time weak,
+and shortening was often considerable, but a fair result was as a rule
+obtained.
+
+Suppuration and osteo-myelitis were the dangerous features when they
+occurred; still, even in the presence of these, I never saw a fatal
+result in an upper extremity fracture, although in the lower extremity
+a considerable mortality followed fractures both of the leg and thigh,
+the deaths being most commonly from septicaemia, or from a combination of
+this with secondary haemorrhage.
+
+_Treatment._--The general treatment was of a simple character. The
+perforations may be at once dismissed, since nothing more was needed
+than what has been already described under the heading of wounds of the
+soft parts. Again, with regard to the co-existence of vascular injury,
+or injury to the soft parts generally, the ordinary rules guiding us in
+civil practice were followed.
+
+The first point of importance, and needing consideration in the
+treatment of severely comminuted fractures, was as to whether in these
+it was better simply to try to obtain union of the wound with as little
+disturbance as possible, or to anaesthetise the patient and explore the
+wound, removing such fragments as were free or widely displaced. I think
+the answer to this question depends entirely on the nature of the
+external wounds. If these be of the small type forms, or if the exit
+aperture is, at any rate, of only moderate size, a strictly conservative
+attitude is the better when the risk of making an exploration under the
+circumstances is borne in mind, the more so as an exploration, to be
+safe and useful, ought to be done at once. If the exit wound is of the
+large or explosive type, on the other hand, there is no doubt that the
+best results are to be obtained by early exploration and the removal of
+all loose fragments. I saw several excellent results obtained in this
+way, even when the patients had to undergo the risk of transport
+shortly, in some cases the very next day, after the operation. The loose
+fragments are an immediate source of danger, and later may interfere
+with the healing of the fracture, even if suppuration does not occur. In
+all the cases that I saw the exit wound was dressed, but left freely
+open, and I do not think any attempt to close it should ever be made.
+
+The question of operative fixation rarely needs consideration; it
+occasionally happens, however, that oblique fractures, such as one
+mentioned on p. 166, are met with, in which screwing or wiring of the
+bone ends is advisable. What has been said above as to fractures,
+accompanied by loss of continuity, applies equally to cases of severe
+wedge-fracture, where many loose fragments exist.
+
+As to the disinfection of the limb, primary cleansing, mainly by soap
+and water, of course precedes the exploration, and when the latter has
+been carried out a second cleansing and disinfection, preferably with
+spirit and carbolic acid lotion, are imperative.
+
+Immobilisation is a more difficult problem. In practised hands
+plaster-of-Paris splints answer most requirements except in the case of
+the thigh; but the splints take time to apply and also to set firmly,
+and, as sometimes needing frequent removal, are not altogether suitable
+for Field hospital work. Of all the splints I saw in use, I think the
+best were wire splints, and the Dutch cane folding splints for the thigh
+and leg (figs. 56, 58); wire-gauze splints with steel at the margins
+(fig. 54), or strips of ordinary cardboard applied with some variety of
+adhesive bandage for the arm and forearm; and plain wooden of various
+lengths for any situation.
+
+A question of constant difficulty was that of frequency of dressing; in
+a Stationary or Base hospital this is not difficult, as the same surgeon
+has the patient continuously under his charge, and can readily decide as
+to the proper moment for the renewal of the dressing. When the patient
+is, however, being moved from the Field to the Stationary hospital, and
+thence to the Base, a constant succession of surgeons has the case in
+hand for short periods, the movements during transport disturb the
+fixity of the dressing, and, in consequence, dressings are apt to be far
+more frequent than is advisable. This question raises the larger one of
+the advisability of _any_ transport beyond what may be an actual
+necessity. There is only one answer to this. No fractures of the thigh
+or leg, and few of the arm, can be transported for any distance without
+material disadvantage. The risks attendant on disturbance of the
+fracture and tissue injury, septic infection as a result of slipping of
+the dressing and the impracticability of efficiently renewing it, far
+more than counterbalance any advantage to be gained from the superior
+comforts available at a Base hospital. For these reasons, if possible,
+all fractures of the arm, thigh, or leg should be kept at a Stationary
+hospital for a period of three or more weeks, and, as far as splints and
+appliances are concerned, these should be as numerous and complete as at
+a Base hospital. I have had a useful set made of aluminium. A word will
+be added later as to the splints suitable for different regions of the
+body.
+
+The necessity for _primary amputation_ chiefly depends on the nature of
+the injury to the soft parts, less commonly on the extent of the injury
+to the bones, and should be decided on exactly the same lines as in
+civil practice. So-called intermediate amputations are always to be
+avoided if possible; the results were consistently bad, and the
+operation should only be undertaken in cases of severe sepsis where
+little can be hoped from it, or for secondary haemorrhage. When the
+operation could be tided over until the septic process had settled down
+and localised itself, secondary amputation gave very fair results. In
+either intermediate or secondary amputation for suppurating fractures,
+it was necessary to bear in mind the special likelihood of the existence
+of extensive osteo-myelitis. If this condition affected the upper
+fragment, an amputation was of little use unless the whole bone was
+removed, as septic infection continued and brought about a fatal issue,
+or a fresh amputation was required in order to obtain a stump that would
+heal.
+
+
+SPECIAL FRACTURES
+
+_Upper Extremity._--Fractures of the _scapula_ were not uncommon, but
+were mostly of the perforative variety; thus perforations both of the
+spine in longitudinal wounds of the back, and of the ala in perforating
+wounds of the thorax, were tolerably frequent. They possessed little
+practical interest; as a rule, the openings were not large, and the most
+unexpected feature was the small interference with the movements of the
+bone on the chest wall that resulted. It might be assumed that
+comminuted fragments would project into the muscles and cause both pain
+and interference with movement; but neither was the case. I saw grooving
+of the crest of the spine, but never happened to meet with a fracture
+of the acromion process. Many axillary tracks passed in the closest
+proximity to the coracoid, but this again I never saw separated. One
+practical point of importance with regard to the scapula was the
+frequency with which bullets lodged in the venter, or the firmly
+bound-down muscles of the supra- and infra-spinous fossae. These retained
+bullets often gave rise to remarkably little trouble in this situation;
+thus I have a skiagram of a shrapnel bullet lying in the deepest part of
+the subscapular fossa, which did not inconvenience its possessor.
+
+[Illustration: FIG. 53. Head of Humerus, showing broken perforation. The
+roof forms a hinged covering to a groove.]
+
+Every variety of _fracture of the clavicle_ was met with, even
+perforation of the most compact portion of the shaft; comminuted, wedge,
+or notched fractures were, however, the more common, and were
+accompanied by the development of very large masses of provisional
+callus during the process of healing. An interesting skiagram is
+reproduced in plate III., which shows a compound form of injury to the
+clavicle. The bullet has passed obliquely beneath the acromial end,
+rising to perforate the posterior compact margin, and producing one of
+the diamond-shaped openings sometimes occurring in compact bone with the
+passage of bullets at a low rate of velocity. No case of perforation of
+the subclavian vein by comminuted fragments of the clavicle came under
+my notice.
+
+_Fractures of the humerus_ of every variety were common, and I think
+when the statistics of the campaign are published, it will be shown that
+the humerus was the most frequently injured individual bone in the whole
+body. I remember to have seen thirteen fractures of the shaft of the
+humerus in one pavilion alone at Wynberg after the battle of Paardeberg.
+
+Perforations of the upper articular extremity were common, and as a rule
+gave rise to wonderfully little trouble in the shoulder-joint. The outer
+aspect of the head of the humerus is a common situation for the
+production of a special form of broken canal or groove (fig. 53). The
+slope from the greater tuberosity to the shaft naturally favours the
+production of the injury in this position.
+
+I saw only one case in which a vertical fissure extended from a fracture
+of the shaft into the shoulder-joint; in this case the transverse
+solution of continuity was at the upper part of the middle third of the
+bone. Skiagram, plate IV., illustrates a well-marked stellate
+comminution of the shaft with large fragments. Plate V. shows extreme
+comminution with fragments blown out of the wound. Two plates, Nos. VI.
+and VIII., illustrate well the difference resulting from the oblique
+passage of a bullet at high and low rates of velocity respectively. In
+both cases good results were obtained; in the more severe the resultant
+mass of ensheathing callus was very large, temporarily interfered with
+flexion of the elbow-joint, and consolidation was very slow (see plate
+VII.). The patient was wounded at Belmont in November 1899, but he was
+able to row at the end of the summer of 1900, although very prolonged
+suppuration occurred, and the elbow movements became practically normal.
+Plate IX. illustrates a transverse track, the bullet having undergone
+considerable injury during its passage through the bone, as evidenced by
+the presence of fragments both of mantle and lead in the limb. This
+might be called an example of transverse fracture, and illustrates the
+nearest 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. Impact
+rectangular. 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 extremities
+to both main fragments, are shown.
+
+The fracture healed well, with the deposition of a large mass of
+provisional callus. The musculo-spiral nerve was united by suture some
+three months later.]
+
+Plate VIII. exhibits an oblique fracture of the lower part of the shaft
+produced by a bullet passing at a low rate of velocity. It does not
+widely differ from a perforation, and the illustration possesses some
+further interest as showing the deviation of a bullet likely to occur
+when a bone lies in its course. Although the velocity with which this
+bullet was travelling must have been very low, when the bone had been
+traversed the deviation in its course was slight. A few bony fragments
+from the compact tissue of the posterior surface of the humerus have
+been carried into the distal portion of the track.
+
+Fractures of the various prominences of the lower articular extremity
+were not uncommon, but deviated little from the types with which we are
+familiar in civil practice; the after results were good, both as to
+union and movement of the elbow.
+
+Explosive wounds of the soft parts were not infrequent in the arm, and
+fig. 48, p. 158, exhibits an extreme example. The humerus in respect of
+depth of covering, however, comes between the femur and the bones of the
+leg and forearm; hence such injuries were not so easily produced as in
+the latter segments of the limbs.
+
+In connection with the subject of fractures of this bone, one word must
+be added as to the occurrence of the most characteristic of its
+complications, musculo-spiral paralysis. This was frequent in every
+position of the fracture, and came on either immediately, or, at a
+subsequent period, as a result of callus irritation or pressure. Its
+frequency is only what would be expected when the nature of the fracture
+is considered, but the chief interest of the condition lay in the
+difficulty 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 the
+limb was so severe that the function of the whole of the muscles was
+lowered, or in some cases, although the musculo-spiral was the nerve
+chiefly affected, the other large trunks had also suffered concussion or
+contusion. In consequence of this difficulty the actual localised
+paralysis often only became evident at the end of a week, or even more,
+when there was difficulty in deciding as to whether the paralysis was
+primary or due to secondary trouble. In the fracture illustrated by
+skiagram, plate IV., the nerve suffered complete division, and was
+united some three months later, improvement in the symptoms being very
+slow. The latter was a common experience, and although not unusual in
+civil practice, I think it is more marked in these injuries as a result
+of 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 inches
+above the elbow crease. The wound of exit was on the inner aspect of the
+arm and explosive in character; it still measured 4 inches by 2 inches
+three weeks after the injury was received.
+
+The wounds suppurated locally, but at the end of six weeks fair union of
+the bone had taken place and the wound of exit had contracted to a
+sinus. 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 in
+free comminution of the bone, the sharper radiation of the stellate
+lines of fracture, and the propulsion of bone fragments.]
+
+The _bones of the forearm_ were also often fractured. The principal
+peculiarity of these fractures was the common localisation of the injury
+to one bone, which is readily seen to be probable.
+
+Each bone offered some special features dependent on its structural
+character and anatomical position. In the case of the _ulna_, pure
+perforation of the olecranon process, without obvious evidence of
+implication of the elbow, was seen on several occasions. The other
+important feature with regard to this bone depends on its subcutaneous
+position, which accounted for the frequency with which highly developed
+explosive exit wounds were met with. One is figured in the general
+section (fig. 47, p. 156). This, however, is a very slight instance
+compared with what was often seen in the upper and middle thirds of the
+bone, where the lateral soft parts often protruded as a much larger
+tumour, the particular illustration being mainly designed to show the
+nature of the injury to the skin. The _radius_, as more deeply placed in
+the upper part of its course, was less often the seat of such
+well-marked explosive injuries; but when the lower end was struck this
+character was sometimes very striking: thus in a track passing
+antero-posteriorly through this bone, the whole lower end appeared
+shattered, all the tendons at the back of the wrist being implicated in
+the protruding mass, while the bone itself seemed shortened, so that the
+hand took up the position common in Colles's fracture. It was found
+impossible to place the bone in good position; nevertheless the patient
+retained his hand, which is still of use in writing.
+
+Plate X. is a good example of a high-velocity injury in which lateral
+contact with the radius has produced local comminution, some slight
+injury 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 the
+chief troubles of such fractures of the forearm; the degree of
+splintering resulted in the formation of a large mass of callus, which
+for 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 the
+deltoid; exit, on inner aspect of arm at a slightly lower level. The
+bullet probably struck the bone laterally, and drove out the central
+fragment.
+
+Prolonged suppuration resulted, but the humerus healed well, and good
+movement of the elbow was preserved.
+
+The effect of oblique impact together with high velocity is well
+illustrated. Had the resistance been greater, as in the case of the
+femur, a nearer resemblance to the effect seen in plate XV. would have
+been 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 rendered
+injuries of an explosive character rare. I never saw one. Fractures of
+the _metacarpus_, on the other hand, presented exactly the opposite
+features. The density of these small bones was well illustrated by the
+frequency with which the bullet suffered injury, even amounting to
+fragmentation, and the great comminution they themselves suffered. The
+breaking up of the bullet in these fractures was a curious feature,
+which may perhaps be explained by the tendency of the distal part of the
+limb to be driven in the course of the bullet, with the result of
+somewhat lengthening the period of contact of the projectile, or more
+probably by somewhat frequently occurring irregular impact. Plate XI. is
+a good example of an injury of this nature of moderate severity. The
+soft parts suffered much in these injuries, the tendons were torn and
+lacerated at the moment, and were very apt to acquire more or less
+permanent adhesion. This latter condition was sometimes to be improved
+by the removal of bone fragments, and I have freed tendons from actual
+clefts in the bones where they had been carried in by the bullet. In
+some cases very great deformity of the digits, due to shortening,
+developed, even when no fragments were removed beyond those blown away
+by the bullet.
+
+One form of injury of some interest was multiple fracture of the
+phalanges produced by a bullet travelling in a course parallel to the
+length of the rifle when pointed by the patient. Occasionally several
+digits were lost.
+
+_Treatment of fractures of the upper extremity._--The general lines of
+this have already been foreshadowed in the general section, the remarks
+as to transport being applicable to all serious fractures of the shaft
+of the humerus, and this is the only one of the bones of the upper
+extremity on which anything special need be said, as the treatment of
+all the other fractures exactly coincides with that of ordinary civil
+practice.
+
+[Illustration: PLATE VII.
+
+Engraved and Printed by Bale and Danielsson, Ltd.
+
+(26_a_) CONDITION OF THE SAME FRACTURE SHOWN IN PLATE VI., A YEAR AFTER
+ITS PRODUCTION
+
+The ensheathing callus is still very abundant, but less so than at an
+earlier date. No trouble with the musculo-spiral nerve was noted, but
+residual abscesses occurred from time to time in connection with the
+fracture.]
+
+[Illustration: FIG. 54.--German Wire Gauze Splint on steel wire
+foundation.
+
+(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 comminuted
+fractures, however, the exit wound may be of very large size, and then
+frequent dressings are necessary. Loose fragments, by which those freed
+from their periosteal connections are meant, need removal. The question
+which most interested me was the best method of fixation. This needs to
+be sufficient to effect immobility, but on the other hand in many cases
+the weight of the arm as a means of extension is very valuable. Some of
+the most successfully treated cases that I saw were fixed by means of
+simple strips of pasteboard, applied moist, and fixed with an adhesive
+bandage. Ordinary book-muslin bandages are as good as anything for this
+purpose, as they can be reinforced by a stronger form outside them.
+Where necessary, an angular piece of cardboard can be applied on the
+inner aspect, or a wooden angular splint may be substituted, if it is at
+hand; but in this case most of the advantage of the weight of the arm as
+a means of extension is lost. The cardboard cases possess the great
+advantage of being readily cut off and reapplied much as is done with
+plaster of Paris. During the period in which dressing may be necessary I
+believe this form of splint is as good as can be got for use in Field
+hospitals, the only point needing care being to ensure that the
+bandaging is not too tight. It is much more reliable than are ordinary
+splints if transport is unavoidable, and is much lighter and less
+irksome to the patient. With such strips of cardboard, a few of the
+gauze splints (fig. 54), and a few angular and wooden splints, I believe
+a Field hospital is fully equipped for the treatment of any fractures of
+the 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 and
+undeformed, and the comminution of the bone was very slight. The wound
+of 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 bone
+without displacement]
+
+_Fractures of the pelvis._--These, as a rule, were of so slight a nature
+as to form a very insignificant part of the entire injury with which
+they were associated, or when uncomplicated they were of little more
+importance than simple wounds of the soft parts. The very great majority
+were of the simple perforating type. I had the opportunity of examining
+three at the brim of the pelvis, these all passing in a downward
+direction. 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 be
+found at the entry hole of a gimlet. It was these that made me consider
+the possibility of the rifle grooves having some part in the ease with
+which certain perforations are made. Of a large number of cases in which
+bullets traversed the ilium, the openings in the bone, as a rule, were
+with difficulty palpated. I must say that I was astonished that I never
+met with an instance of an extensive stellate fracture in the case of
+the ilium. Such may have occurred in some of the cases fatal on the
+field or shortly afterwards, but I never came across one in the
+hospital. It says much for the combined density and toughness of the
+human pelvis.
+
+Comminuted fractures were, however, occasionally met with when the
+bullet passed in a track parallel to the plane of the bone. One such of
+an unusual character has already been mentioned on p. 171. A still more
+interesting form, and one highly characteristic of flat bone injuries,
+is shown in fig. 55. The patient, a man wounded at Modder River, was
+struck at a range of 300 to 400 yards. The bullet entered over about the
+centre of the ilium and emerged in the anterior abdominal wall about 2
+inches above the anterior-superior spine. As there was some doubt as to
+penetration of the abdomen, and as the exit wound was of considerable
+size, the wound was explored, an anaesthetic having been given. A
+clean-cut track in the bone was discovered which allowed the middle
+finger to be placed in it. There was little splintering of either inner
+or outer table of the bone beyond the width of the track, but plates of
+each 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 widely
+separated from the venter ilii by effused blood. There was no
+perforation 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 noted
+that the fragments are lodged in both the proximal and distal segments
+of the track. This may indicate that the bullet was damaged prior to
+entry, or the recoil of fragments. I incline to the latter view. The
+skiagram was taken a fortnight after the injury.
+
+The large median fragment carried forwards, and the small degree of
+comminution, suggest the decrease of resistance and prolongation of
+impact by carriage back of the arm when struck.
+
+The fracture is one of the nearest approaches to a transverse cleft that
+I met with.
+
+The plate may well be compared with No. XII., where the effect of
+increased resistance in augmenting the degree of comminution is seen.]
+
+Lesser degrees of the same kind of injury amounting to grooving of the
+surface or notching of the crest of the ilium were not uncommon, and the
+occasional large character of exit openings in buttock wounds pointed to
+contact of travelling bullets with other parts of the external pelvic
+wall.
+
+[Illustration: FIG. 55.--Clean Gutter Fracture of the Ilium (range
+placed by patient at 300 yards. Highland Brigade, Magersfontein). The
+gutter was clean cut, and admitted the forefinger. The inner and outer
+tables of the bone were in part blown out of a large irregularly
+circular exit opening about 1-1/2 in. above the crest of the ilium. The
+cancellous tissue was probably entirely blown out. Plates of the outer
+and inner tables still remained connected by their periosteum to the
+deep aspects of the iliacus and gluteus medius muscles. The peritoneal
+cavity was not opened. The patient did well. Compare with the gutter
+fractures 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 much
+comminuted fracture of the horizontal ramus of the pubes was produced by
+a bullet which subsequently lodged in the thigh behind the femoral
+vessels. In this case the track was so oblique as to have necessitated
+almost pure lateral impact on the part of the bullet; hence the form of
+injury was nearly allied to the comminutions of the ilium already
+described.
+
+[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 entry
+wound was on the posterior aspect of the forearm at the junction of the
+middle and lower thirds. The exit wound was on the anterior aspect of
+the forearm, 1 inch below the elbow crease, and of moderate size.
+
+Some fine fragmentation of the mantle of the bullet is indicated, and
+very fine comminution of the bone. The fracture healed well, but the
+resulting mass of callus at the end of three months prevented any
+movements of pronation or supination.]
+
+I never observed a fracture of the floor of the acetabulum by a bullet
+which had entered from the back of the pelvis, although tracks entering
+by the great sciatic notch were not infrequent. I saw one case in which
+a bullet which traversed the upper part of the shoulder and emerged at
+the axilla entered a second time an inch behind and above the anterior
+superior spine, and split off a layer of the outer table of the ilium of
+the extent of two square inches, which involved the upper portion of the
+rim 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 no
+evidence of fluid in the hip-joint, the limb was adducted and slightly
+rotated outwards, and some movement in each direction could be made
+without causing any great amount of pain. I can say nothing of the
+further 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 is
+mentioned in the chapter on injuries to the abdomen, in which a central
+puncture at the level of the fourth vertebra was accompanied by
+temporary incontinence of faeces.
+
+Fractures of the _femur_ were fairly numerous and formed one of the most
+serious classes of case we had to treat, as well as one of the most
+fertile sources of mortality in the Base hospitals. In spite of the last
+observation, however, it is probable that the results in this campaign
+will be far better than in any previous war, both as to the smaller
+proportion 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 metacarpal
+bones were struck, also free comminution of a somewhat coarser variety
+than that seen when bones offering greater resistance were struck.
+
+This may be a result of the more frequent lateral impact of the bullet
+on these small bones.]
+
+In spite of a considerable experience, I never saw a case of perforation
+of either the head or neck of the thigh bone. I saw numerous tracks
+emerging at the side of the femoral vessels and entering at the buttock
+or vice versa, but never one accompanied either by effusion into the
+hip-joint or impairment of movement. Considering the regularity with
+which haemarthrosis occurred when the other joints were crossed, and also
+the nature of the compact tissue of the neck of the femur, which must
+have ensured some splintering, I do not think I can have overlooked an
+injury of this nature. No doubt also the escape of the neck of the bone
+was explained in some of the cases by the fact that the injuries were
+received while the hip-joint was in a position of flexion, the bullet
+passing over the neck of the femur. In two cases of extensive
+comminution of the upper third of the femur that I saw, the fissures
+stopped short at the inter-trochanteric line anteriorly, but in one of
+them a large angular fragment was torn out of the posterior surface of
+the neck.
+
+Excepting transverse fracture every form was met with in the shaft,
+although I saw only two instances of perforation. One has been already
+alluded to and was situated in the broadening portion of the lower
+third, the bullet taking an antero-posterior course. The second is seen
+in plate XVII.
+
+Plate XII. shows an instance of extreme comminution of the upper third
+accompanied by the presence of two typical elongated fragments. The
+course taken by the bullet was almost directly antero-posterior, and the
+wounds were of moderate size even in the case of the exit one. This
+seems to preclude the possibility of the injury having been produced by
+a ricochet bullet, while the fact of perforation and escape of the
+bullet in spite of the serious damage suffered by the mantle points to
+the injury having been produced at a short range of fire. The patient
+himself owns to being quite unable to give any estimate of the distance.
+Although no suppuration occurred, this fracture was very slow in
+consolidating, and the free comminution with consequent inaccurate
+apposition led to the development of four inches shortening of the limb.
+The skiagram was taken about six weeks after the occurrence of the
+injury, a few days after I first saw the patient; I have, however, had
+the opportunity of seeing a second skiagram taken some four months
+later. This is of considerable interest, as throwing light on the mode
+of union of such fractures. The two elongated fragments in the later
+skiagram are widened to three times their original breadth, and form
+buttresses on either side of the point of union, while the irregular
+ends of the shaft are rounded off, and the mass of fine fragments behind
+is consolidated. Beyond this the second skiagram shows that the upper
+fragment, apparently intact in the first, was really split
+longitudinally, and therefore was far less useful as a point of support
+than might have been assumed from the earlier skiagram, plate XIII. The
+case illustrates well the chief difficulty in the treatment of such
+fractures: that of maintaining the fragments in line, since absolutely
+no help is received from the apposition of the two ends, and artificial
+traction 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 THE
+FEMUR
+
+Range 'short.'
+
+Impact fairly direct. The wounds were of moderate size and at nearly the
+same 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 of
+the bone is very fine, suggesting high velocity, and great resistance by
+the bone. The skiagram was taken five weeks after the injury was
+received, and at that time no union had occurred.
+
+Reference to plate XIII. will explain more fully the difficulty
+experienced in maintaining this fracture in position. The upper fragment
+is seen to be split into fragments, beyond the separation of the long
+splinter on the inner side; hence no aid was to be obtained from the
+apposition of the ends. About 2 inches of the shaft were actually
+pulverised; the fine fragments seen in a mass to the inner side of the
+bone in the exit portion of the back, eventually formed a large mass of
+callus, and the fracture united, with considerable shortening.]
+
+Plate XIV. offers a good contrast; the fracture here presents a typical
+stellate form, and a good result without shortening was readily
+obtained. I assume that the difference in character of these two
+fractures depended mainly on the rate of velocity with which the bullet
+was travelling, since it passed fairly directly across the limb in each.
+I think it is clear, however, that the bullet struck the femur rather
+nearer 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. In
+spite of the great tendency to comminution of the shaft, these were rare
+in a severe form. This depended simply on the depth and thickness of the
+coverings of the bone, and, as already mentioned, although the skin
+openings were often comparatively small, a large cavity or area of
+destroyed soft tissues may be contained within the limb. I do not think
+I 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 referred
+to, and the influence of the weight and movement of the trunk on its
+production has been considered.
+
+Plate XV. illustrates an obliquely comminuted fracture of another
+character. The bullet has here been stripped of its mantle, which has
+undergone fragmentation, but the leaden core is little altered in shape.
+This is of much interest, since it shows that the bullet struck the bone
+by its side. The effect of such lateral impact on the part of the
+projectile is well shown: there is great bone comminution of a less
+regular character than usual, and the bullet is retained. Retention in
+this case was probably not a result of low velocity of flight, but of
+the increased resistance offered by the broad area of bone struck, and
+the check exerted on the axial rotation of the bullet by the lateral
+contact.
+
+[Illustration: PLATE XIII.
+
+Engraved and Printed by Bale and Danielsson, Ltd.
+
+(31_a_) THE FRACTURE SHOWN IN PLATE XII., SIX MONTHS AFTER RECEPTION OF
+THE INJURY
+
+The amount of callus furnished around the loose fragments is very
+striking.
+
+The upper end of the bone is shown to have been divided into at least
+two fragments, hence one of the difficulties of maintaining the ends in
+apposition. The stoppage of the fissuring short of the epiphysis is
+characteristic.]
+
+Slighter injuries to the femur in which the shaft was chipped or grooved
+without loss of continuity were not uncommon, and showed well the
+capacity of the bone to withstand the lateral shock transmitted by small
+bullets. 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 the
+wound of exit, the bullet probably underwent deformation, or was so
+deflected as to escape on a considerably altered axis. Beyond the nature
+of the exit wound in the case depicted in fig. 22, some thickening
+beneath the femoral vessels denoted bone injury, but unfortunately no
+skiagram was taken.
+
+I saw no case in which a transverse fracture of the shaft accompanied
+such injuries, but am under the impression that, if they had been
+produced by bullets of greater volume and weight, transverse solution of
+continuity would have been more common. In point of fact, no case of
+pure transverse fracture of the femur ever came under my notice.
+
+The diagram depicted in fig. 51, p. 164, is from a sketch made of the
+lower end of a femur in which a severely comminuted fracture followed by
+suppuration necessitated an amputation of the thigh, performed by Major
+Lougheed, R.A.M.C. It is inserted as an illustration of the tendency of
+the fissures to stop short above the actual articular extremities of the
+bones. In this case the comminution was extreme and accompanied by the
+usual long lateral fragments, one of which measured five inches in
+length and might well have extended into the knee-joint had that been an
+ordinary occurrence.
+
+Perforations of the lower extremity of the bone were very common. These
+were sometimes transverse and limited to the articular extremity itself,
+or the same limitation occurred to the antero-posterior tracks. These
+were the slightest forms of injury, putting on one side incomplete
+tunnels and grooves on the surface of the bone. With regard to the
+latter, however, when they invaded the joint cavity the injury was
+liable to be more severe than a complete perforation, in consequence of
+the projection of comminuted fragments into the joint cavity near the
+line of reflection of the synovial capsule and ulterior interference
+with 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 bone
+united without shortening of the limb.]
+
+Other tracks took a direction of longitudinal obliquity, and then
+implicated both epiphysis and diaphysis. Fig. 52, p. 169, shows an
+example, and also the peculiarity likely to be assumed by the exit
+aperture in the bone, especially if the bullet was travelling at a low
+rate of velocity, a considerable plate of the compact bone being driven
+out. In some cases these oblique tracks involved both femur and tibia.
+They will be referred to again under the heading of injuries to the
+joints, and some remarks will also be found there regarding the synovial
+effusion so often occurring into the knee-joint in cases of fracture of
+the shaft of the bone.
+
+It may be of interest to insert here a few remarks as to the clinical
+characteristics of fractures of the femur. First with regard to the
+primary signs and symptoms. A very considerable degree of general or
+constitutional shock usually accompanied them, and this was perhaps more
+constant than in the case of any other injury in the body. This was,
+moreover, no doubt increased by the unfavourable conditions in which
+patients on the field of battle are situated in regard to transport.
+When the patients were brought into hospital some delay in the primary
+treatment was often necessary until reaction took place. Local shock to
+the part was also a prominent feature. Abnormal mobility was very free
+in the badly comminuted cases. Crepitus was often loose, and of 'the bag
+of bone' variety. The result of local shock and consequent flaccidity of
+the muscles was to reduce the development of primary shortening; in some
+cases of severe comminution this was practically nil during the first
+day or two, when, with return of tone in the muscles, it sometimes
+became very considerable. Swelling of the limb was often very great, and
+vascular injury definitely far more common than in the fractures of
+civil practice, in consequence, no doubt, not only of the number and
+sharpness of the fragments, but also of the force with which they were
+driven into the surrounding tissues. The exit segment of the track was
+out of all proportion in size to the entry, as a result of the
+propulsion of bone fragments through it. This often made the closure of
+the exit wound a very protracted event, the track continuing to
+discharge a small quantity of bloody serum and fragments of necrosed
+tissue 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 which
+burst into numerous fragments. The bullet is seen to the inner side of
+the shaft, almost devoid of its mantle, and little deformed at the tip.
+The comminution of the upper portion of the fracture is very fine; the
+bullet has merely cut its way down the lower portion, and one or two
+long fragments are separated. The skiagram shows well the result of
+lateral impact by the side of the bullet.
+
+Compare this plate with No. VI. as illustrating lesser resistance, and
+No. VIII. as illustrating the effect of lower velocity.]
+
+In a large proportion of the cases which were transported for any
+distance suppuration occurred; this must have been the case in at least
+60 per cent. of the fractures. Suppuration was of the character already
+described in the general section, affecting particularly the bone
+itself, and accompanied by very marked signs of general infection.
+
+_Prognosis in fractures of the femur._--As regards mortality fractures
+in the upper third of the bone proved one of the most formidable
+injuries which came under treatment. Suppuration was common, at least 60
+per cent. of the wounds becoming infected. This depended on several
+reasons, often inseparable from the injuries, or from their treatment in
+Field hospitals: such as (1) the exit wound being situated in the
+dangerous region of the thigh; (2) ineffective dressing and fixation;
+(3) the impossibility of ensuring primary cleansing and removal of
+detached fragments of bone; (4) the necessity of the early transport of
+patients to the Stationary or Base hospitals, often for great distances;
+(5) the comparatively long period that often had to elapse before the
+opportunity of doing the first efficient dressing arrived.
+
+Fractures in the middle and lower thirds of the bone were more easy to
+treat successfully, but these also added to the list both of amputations
+and fatalities.
+
+Punctured fractures of the lower articular extremity were usually of
+little importance, as they progressed without exception, as far as my
+experience went, favourably.
+
+I can give no idea of the general results obtained during the whole
+campaign, but I am able to state the results of the fractures of the
+shaft treated at No. 1 General Hospital during my stay in South Africa.
+Thirty-two cases of fracture of the shaft of the bone came under
+treatment, and of these 6 or 18.7 per cent. needed amputation, and of
+the whole number 5 or 15.6 per cent. died. To emphasise the satisfactory
+nature of these figures I need only quote the results attained in the
+American 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 the
+thigh. Exit, about 2 inches lower, at the junction of the inner and
+posterior aspects. The bullet was retained just within the wound, and
+when removed the mantle fell off in two parts. The leaden core was
+mushroomed. The bullet had passed through another soldier previous to
+entering the patient's thigh. Only two small fragments of the mantle
+were retained, as seen in the skiagram. These were in the substance of
+the great sciatic nerve, and were subsequently removed by Sir Thomas
+Smith.
+
+It is difficult to determine how the bone was struck; reference to plate
+XXI. would suggest that the shaft may have been perforated, but no
+evidence of this remains in the skiagram taken, which was five months
+later.
+
+The patient was standing at the moment of reception of the injury, and
+the obliquity of the fracture no doubt depended on his fall and the
+resulting influence of the weight of the body. The length of the
+fracture cleft was 9 inches.]
+
+I need hardly dwell upon the difference between the nature of the
+injuries received in the American War of the Rebellion and in the
+present campaign, as in the former the old large bullets were employed,
+and shell injuries are possibly included; but I ought to add in this
+relation, 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, and
+opportunity for an efficient primary treatment of the same; the second
+the absence of necessity for transport of the patient. With regard to
+the second of these requirements, we were unfortunately situated in
+South Africa, and the majority of the cases which did badly were moved
+during the first few days and for a distance of between five and six
+hundred miles. On the other hand, as a rule, the external wounds were
+small.
+
+As to functional result, the fractures did well. I think an average of
+an inch and a half would well cover the shortening, and in many the
+length was little altered. Considering the serious nature of many of
+these fractures, this was good.
+
+_Treatment._--In all punctured fractures of the lower extremity,
+dressing of the wounds like uncomplicated ones and a short period of
+immobilisation were all that was necessary. In oblique fractures, and
+those with slight comminution, closure of the wound by dressings, after
+it had been carefully cleansed, was all that was necessary prior to
+applying the splints for immobilisation.
+
+[Illustration: PLATE XVII
+
+Skiagram by H. CATLING.
+
+Engraved and Printed by Bale and Danielsson, Ltd. (35) PERFORATION OF
+THE SHAFT OF THE FEMUR. FLAP OF BONE RAISED AT THE APERTURE OF EXIT IN
+THE 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 was
+indicated, especially if the exit wound was large. In these, after
+careful preliminary cleansing of the limb, the wounds, especially the
+exit aperture, needed exploration and, if necessary, enlargement, and
+all free splinters needed removal. If interference with the entry wound
+could be avoided, this was always preferable, as it was rare for this
+not to heal by primary union unless free suppuration occurred. Under
+Field hospital conditions I think the exit wound should never be
+sutured, whatever its situation; and in the present campaign, where
+carbolic acid lotion was freely used, this step was manifestly
+inadvisable, in view of the abundant serous discharge always to be
+expected when this disinfectant has been employed. Except in cases
+manifestly infected at the time of exploration, the use of drainage
+tubes or plugs is not to be recommended. I would point out also that in
+the majority of cases it is quite hopeless to attempt to make the entry
+wound the safety-valve for drainage, as its natural tendency, even if
+enlarged, is to heal, while the condition of the tissues in the exit
+segment of the track usually renders primary union an impossibility.
+
+The wound having been dealt with, the next indications were for the
+reduction of deformity, immobilisation of the limb, and the provision of
+a proper degree of extension. As to the reduction of the fracture, this
+was always a matter of ease, needing only slight axis traction. The
+provision of efficient means of extension and immobilisation was a very
+different matter. These questions had to be considered under two sets of
+conditions: (1) when it was possible to keep the patient at rest in the
+hospital he was first deposited in; (2) when it was necessary for him to
+be transported for a considerable distance, probably not less than 500
+miles.
+
+When transport is a necessity, the best method of immobilisation is the
+application of breeches of plaster of Paris, and a long outside splint.
+The latter we often had excellently made on emergency by the Ordnance
+Department or the Royal Engineers. A perineal band is the only form of
+extension possible under these circumstances. The Dutch ambulances were
+provided with a very excellent emergency splint for cases of fractured
+thigh, which is illustrated in fig. 56. I think something of this kind
+should be carried in one of the ambulances going on to every field of
+battle, as being far more suitable than a long outside splint for hasty
+and inaccurate application. This splint, fixed with some kind of firm
+bandage, 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 loss
+of substance of the bone was palpable superficial to the actual cleft of
+the fracture.]
+
+[Illustration: FIG. 56.--Dutch Cane Field Emergency Splint for Thigh or
+Lower Extremity. (Dutch Ambulance, Winberg)]
+
+In cases which can be treated at a Stationary hospital near at hand, a
+long outside splint supplemented by plaster breeches, and a well-applied
+American extension, is a very good method of treatment, the only point
+to bear in mind being frequent examination of the position of the limb
+to ensure the extension being efficient. As already mentioned, the
+shortening 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 found
+to have shortened considerably, principally as a result of recovery of
+tone by the muscles, and the absence of any help from the resting of the
+two fragments end to end. The weight, therefore, has often to be
+progressively increased and the fracture readjusted if necessary.
+Although this method of treatment is satisfactory in cases with a small
+wound, it is very troublesome to carry out, even when a bracket is
+inserted opposite the wound, when frequent dressing is necessary, as is
+generally at first the case when the wounds are large. For this purpose
+a much more satisfactory method is the use of Hodgen's splint. This
+allows of automatic adjustment of the degree of extension, and the
+dressing of the wound without interference with the position of the
+fracture. A continuous many-tailed bag is preferable to the strips
+usually employed for the suspension of the limb, as more easily
+adjustable 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 have
+been caused by a Mannlicher (8 mm.) soft-nosed bullet, or possibly a
+ricochet. The fragmentation is somewhat coarse at the periphery, but
+very fine in the track of the bullet. Several fragments of the mantle
+are visible.
+
+The fracture affords a good example of obliquity due to cutting by the
+bullet, and contrasts well with those due to rectangular impact such as
+are shown in plates IV. and XIV.]
+
+While at Orange River, in conjunction with Major Knaggs, R.A.M.C., and
+Mr. Langmore, we treated several cases of fracture of the shaft of the
+femur by this method. The splints were made for us by the Ordnance
+Department, while the Royal Engineers erected a kind of gallows for us
+down the centre of a commissariat marquee in order to avoid the risk of
+using the tent poles for suspension. The patients were then ranged on
+each side of the tent in two rows so that the pull of the two sets of
+limbs opposed each other on the gallows from which they were suspended.
+Although these patients had to lie on the ground, they were really
+comfortable compared with those treated with long outside splints, and
+the results obtained were very good: in three cases which I had the
+opportunity of measuring later the bones were in good position and the
+shortening was less than one inch.
+
+I have no doubt whatever that Hodgen's splint is by far the best method
+of treating all cases of fractured thigh in the Stationary field
+hospitals; and, more than this, I believe it is the only practicable and
+efficient one. It can be applied without the use of an anaesthetic
+without causing undue suffering to the patient, it allows of ready
+change of the dressing, it is comfortable and permits considerable range
+of movement on the part of the patient, it is as efficient with patients
+lying on the ground as in a bed, it keeps the limb in good position and
+allows of constant inspection on this point, and it is the only method
+which 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. The
+bullet crossed and grooved the posterior aspect of the tibia, but struck
+the fibula full. This is the only instance of a transverse cleft which
+came under my notice.
+
+The wound suppurated, and a number of fragments of the fibula needed
+removal; hence the amount of callus present.]
+
+Cases in which operative fixation is indicated are rare, but a few
+oblique fractures may be treated with advantage in this manner if the
+conditions surrounding the patient admit of it. Screwing is generally
+preferable to wiring.
+
+Lastly, we come to the cases in which primary amputation is necessary. I
+may say at once that I saw no case of wound from a bullet of small
+calibre in which this was indicated, and only one shell injury in which
+it was performed. I believe with small bullets that injury to the main
+blood-vessels is almost the only indication which is likely to be met
+with, and this by no means always indicates an amputation. First of all
+the question arises as to whether the wound in the vessel is caused by a
+bone fragment or by the bullet itself; reference to the chapter on
+blood-vessels would seem to prove that a bullet wound is by no means a
+necessary indication for amputation. Given favourable conditions, it
+might be treated locally by ligature at the time, while if haemorrhage is
+not proceeding, developments should be awaited before proceeding to
+amputation. In the case of bone fragment punctures, secondary haemorrhage
+is a more likely indication for amputation than primary.
+
+Broadly, it may be laid down that very extensive injury to the soft
+parts is the only indication for primary amputation beyond primary
+haemorrhage, and it may be added that the condition is rare with wounds
+from small-calibre bullets. If a primary amputation is necessary the
+observations as to the transport of fractured thighs are equally
+applicable. I never saw a primary amputation do well that was moved
+during the first week; sloughing of flaps or haemorrhage followed as a
+rule, and often death.
+
+Intermediate amputations were indicated in cases of septic infection and
+those of haemorrhage; they seldom did well, and should be avoided if
+possible. Secondary amputations for sepsis or haemorrhage were attended
+by fair results, but I can give no statistics. Unless extensive
+osteo-myelitis is evident, or very widespread cellulitis of the limb
+exists, I am strongly of opinion that the amputations when the fractures
+are above the middle of the thigh should be through the fracture, and
+not at the hip-joint, even if a subsequent secondary operation is
+risked.
+
+[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 OBLIQUE
+FISSURE EXTENDING FROM THE LOWER PART OF THE OPENING TO THE CREST OF THE
+BONE.
+
+Range medium. Entry and exit wounds at same level.
+
+The patient was standing when struck, and fell backwards, his rifle
+falling 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 of
+the fissure from above. The fissure comes to the surface at the seat of
+election, but its position may possibly have been determined by the blow
+from the falling rifle.
+
+The backward fall of the patient clearly explains the mechanism of
+production of the fissure, and throws light on the production of an
+oblique fracture such as shown in plate XVI.]
+
+_Fractures of the patella._--Punctured fractures of the patella were
+common with direct impact of the bullet; these were often difficult to
+palpate, and were only to be certainly diagnosed by attention to the
+direction of the track, and the development of haemarthrosis. I saw at
+least three or four in which the bullet, in addition to traversing the
+knee-joint, injured the popliteal vessels. I have notes of one case in
+which a bullet traversed the soft parts from above downwards and scored
+a vertical groove on the surface of the patella; this was readily
+palpable, but produced no solution of continuity. In several cases the
+margin of the patella was notched by a passing bullet.
+
+I never saw a case of stellate fracture, and by this my experience in
+the case of the ilium was confirmed.
+
+On two occasions I saw pure transverse fractures of the bone; in each
+the wound was produced by a Lee-Metford bullet. This is of some interest
+as denoting that the greater volume and weight, in conjunction with the
+blunter tip, of the Lee-Metford may produce more severe injury to the
+bones than the Mauser. I believe this to be the case, given an equal
+degree 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 the
+condyles of the femur when struck is of far greater importance in
+relation to the production of transverse fractures. The skiagram
+represented in plate XVIII. shows an obliquely transverse fracture,
+which in this instance resulted from a crossing bullet, which grooved
+the surface of the bone.
+
+With regard to the two cases of transverse fracture above referred to, I
+may add that one occurred in a youth under twenty, and a good result was
+obtained by treatment with splints, and later by massage. In the second
+the patient was a man over fifty, who had received other injuries. The
+wound over the patella healed and some union had occurred, when the
+patient fell and burst both the bone union and the skin cicatrix.
+Secondary suppuration of the knee-joint, necessitating an amputation of
+the thigh, followed, but the patient made a good recovery. The third
+case 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. Compare
+with figs. 51 and 57 in the text.]
+
+The treatment of these injuries differed in no way from that adopted in
+civil practice, given satisfactory surroundings. Suture might be
+indicated in some cases of transverse fracture, but this would only be
+necessary if the fragments were widely separated. The punctured
+fractures needed treatment as for simple wounds, combined with a short
+period of rest and pressure for the condition of haemarthrosis. It was
+important not to prolong the period of rest beyond a week or ten days if
+the effusion was slight, in view of possible ulterior interference with
+range of movement in the knee-joint.
+
+_Fractures of the tibia._--Some remarks have already been made regarding
+fractures of the head of the tibia, and the importance of the
+overhanging prominent margins in the production of somewhat irregular
+injuries (p. 170). Putting these peculiarities on one side, the
+cancellous ends are subject to the type forms of injury; thus
+perforations either of the head of the bone or the malleolus were common
+injuries. The fractures of the shaft also deviated from the type in so
+far as the broad flat surfaces in the upper two thirds of the bone
+rendered it especially liable to the results of lateral impact, and to
+the production of the extreme wedge-shaped types of fracture. Plate
+XXII. illustrates the different result of a bullet striking the dense
+and 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 the
+base corresponding to the posterior surface was the most common injury,
+the spine in many cases remaining intact and maintaining the continuity
+of the bone. Wedge-shaped fractures of this bone were apt to show
+multiple secondary wave fissures concentric with the main line, and
+consequently free comminution. I saw several examples, the loose
+fragments being remarkably numerous. Plate XIX. is an example of an
+oblique fracture produced by a bullet which has ploughed across the
+bone, displacing large fragments anteriorly, but finely comminuting the
+bone in its course, and leaving small fragments of the mantle on its
+way. Plate XX. is an example of the rare condition of transverse
+fracture.
+
+[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 foremost
+and lodged in the calf. The fracture is really an incomplete stellate
+form, two well-marked transverse fissures extending from the point
+struck. The position of the bullet suggests its entry into the limb base
+foremost, and as it is retained low velocity may be assumed.]
+
+This fracture was produced by a bullet travelling at a high rate of
+velocity, which struck the posterior surface of the tibia, and caused a
+grooving, accompanied by a horizontal fissure through the whole
+thickness of the bone; later it struck the fibula more directly, and
+produced an ordinary comminuted fracture two inches above the malleolus.
+Perforations of the shaft were far more common than in the case of the
+femur, and I saw them in every part of the length of the bone (plate
+XXI.). Fig. 57 illustrates a form of peculiar interest as showing the
+gradual transition of the tunnel to the groove, and also as bringing
+fractures of the long bones into line with such fractures of the flat
+bones 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. Compare
+with fig. 68, p. 259, of a fracture of the cranial vault.]
+
+_Fractures of the fibula_ offered no special features of importance. Any
+form might occur. The plate No. XXIII. is of interest as showing a
+spurious form of perforation, and also the primary form of displacement
+of the fragments in stellate fractures. It was produced by a reversed
+ricochet, but undeformed, bullet, still seen in position in the
+skiagram; the bullet only possessed sufficient force to perforate the
+bone, and then appears to have turned on its transverse axis. The
+following plate, No. XXIV., is inserted to show the depth at which the
+bullet lay, and its distance from the surface of the tibia, which
+appears in the first plate to be nil. It is also of interest as showing
+the ease with which a false impression may be obtained from a single
+picture, as, beyond a spot of transparency, no obvious injury to the
+fibula, 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 bullet
+lay from the surface. It is also interesting to note the insignificance
+of the fracture of the fibula from this aspect. Without the second
+skiagram the injury might have passed for a simple perforation or a
+transverse fracture.]
+
+Fractures of the bones of the leg possessed an unenviable degree of
+importance. First, on account of the very severe injuries to the soft
+parts that often accompanied them, without an apparently correspondingly
+serious damage to the bone. Secondly, on account of the frequency with
+which the vessels were implicated in these injuries to the soft parts,
+either by the bullet or bone fragments. Beyond this, fracture of either
+articular end of the tibia was certainly more frequently followed by
+troublesome joint complications than occurred in the case of any other
+bone.
+
+In the matter of 'explosive' injuries, I think more were seen in the
+calf of the leg than in any other part of the body, and this often
+without solution of continuity of the bones, and sometimes without
+evidence even of contact of the bullet with either tibia or fibula. Some
+remarks on this subject have already been made in the chapter on wounds
+in general, and some sources of fallacy exposed. I believe that in
+practically all these so-called explosive injuries the wound was either
+caused by a ricochet, or a bullet which deformed with great ease on bony
+contact during its progress through the limb. A considerable number of
+the wounds which were referred by the men to the use of expanding
+bullets were probably the result of the use of Martini-Henry or large
+leaden sporting bullets, and evidence of this was often forthcoming on
+examination of the entry wounds. In other cases the irregularity of the
+opening plainly pointed to ricochet of a small bullet as the explanation
+of the character of the injury. The greater frequency of ricochet
+injuries in the leg and foot when the men were standing is readily
+understood.
+
+Concurrent injury to the vessels of the leg was common, but primary
+haemorrhage, as was the case generally, usually ceased spontaneously. The
+importance of injury to the vessels was rather in view of secondary
+haemorrhage, which occurred with some frequency, and I think more
+commonly from the anterior than the posterior tibial vessels, usually
+occurring at the end of a week or ten days, and naturally most
+frequently in cases which suppurated.
+
+_Prognosis and treatment in fractures of the leg._--In fractures of the
+leg, except those of extreme severity, almost any form of splint
+sufficed to maintain the bones in position, but for field purposes the
+Dutch cane splint (fig. 58, p. 222) was certainly very convenient. For
+later use in cases that needed frequent dressing, a wooden back splint,
+with a foot-piece, or, if obtainable, a Neville's splint with a
+suspension cradle, was the best. Where the wounds were small and
+frequent dressing was not required, nothing was so good as plaster of
+Paris, 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 in
+connection with this secondary haemorrhage, or in the case of fractures
+near the articular ends, especially the upper, joint suppuration. The
+treatment of these cases varied: in many an amputation was the best or
+only treatment advisable; but I several times saw good results follow
+ligation of the anterior tibial artery for secondary haemorrhage, even
+when suppuration existed, and occasional good results after incision
+and drainage of joints if the infection was not of the most acute form.
+
+Primary amputation was rarely needed for any case of injury from a
+bullet of small calibre, since it was only necessary either in the case
+of injury to both main arteries, and this was rare, or in cases of very
+extensive injury to the soft parts. I saw many of the latter make fair
+results when treated conservatively, even though the condition seemed
+almost hopeless at first sight. All the primary amputations that I saw
+were either for shell or large bullet injuries. A word may be inserted
+here as to the weight that ought to attach to nerve injuries in this
+relation. From the experience gained elsewhere it is clear that we
+should attach little importance to these unless the divided nerves are
+actually in sight, as far as deciding on amputation is concerned. On the
+other hand, there is little doubt that the presence of concurrent nerve
+injury, be it only concussion or contusion, exerts an important ulterior
+influence on the healing of the wound, whether the part be amputated or
+not. Amputation flaps in such cases possess a very considerably lowered
+degree of vitality.
+
+Secondary amputations were often needed for sepsis, and on the whole did
+very well; both for the same cause and for haemorrhage intermediate
+amputations had occasionally to be performed; the results of these, as
+elsewhere, were bad.
+
+_Fractures of the tarsus._--Wounds of these short bones were as a rule
+of slight importance, given fairly direct impact on the part of the
+bullet. They then consisted of either simple perforations or surface
+grooving. A single bone might be implicated or several might be
+tunnelled; in the latter case the implication of the joints very
+considerably influenced the prognosis, since the addition of the joint
+injury caused much more prolonged weakening of the foot.
+
+Wounds of the foot were common from the fact that when the men lay out
+in the prone position, the foot was often the part least protected by
+the cover chosen, and particularly the heel. In these circumstances the
+os calcis was the bone most frequently implicated, and that by tracks
+taking an oblique course downwards from the leg to the sole. Again the
+foot was often struck by ricochet bullets, as a result of its position
+when the erect attitude was assumed. The latter fact was of much
+importance with regard to the nature of the injury sustained by the
+bones, 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. On
+the whole the prognosis in cases of injury to the os calcis was the
+best, since the injury was more often individual and did not implicate
+any joint, and also because of the comparatively regular architecture of
+the bone. In the smaller bones concurrent injury to a joint was more
+frequent. In the astragalus the central hard core extending upwards from
+the interosseous groove, as increasing resistance, I think accounted for
+the fact that comminution was more marked in this bone than in any
+other. The effect of wound of bones of the tarsus in producing a certain
+degree of laxity in the mediotarsal joint resulting in a slightly flexed
+position of the fore part of the foot and some projection of the head of
+the astragalus did not seem to me easy of explanation, but it occurred
+with some regularity.
+
+The injuries to the _metatarsus_ corresponded so nearly to those already
+spoken of in the case of the metacarpus that they need no further
+mention. They were less common, however, and I am under the impression
+that fragmentation of the bullet was not such a marked feature, probably
+on account of the lower degree of density of the bones, and their
+greater 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 class
+entailing the gravest anxiety to the surgeon, both in regard to the
+selection of primary measures of treatment and in the conduct of the
+after progress of the cases. The external wounds were severe,
+comminution of the bones was great, and retention of the bullet within
+the articulation was not uncommon. Operative surgery therefore found a
+large 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 injuries
+of much of the importance they possessed in earlier days and during the
+present campaign direct clean wounds of the joints were little more to
+be dreaded than uncomplicated wounds of the soft parts alone. No more
+striking evidence of the aseptic nature of the wounds, and the harmless
+character of the projectile as a possible infecting agent, than that
+offered by the general course of these injuries in this campaign, is to
+be found in the whole range of military surgery.
+
+The aseptic nature of the wounds, and the slight and localised character
+of the bone lesions, have in fact justified the opinion previously
+expressed by Von Coler, that these injuries in the future would be less
+feared than fractures of the diaphyses of the bones.
+
+Not less important than the localised character of the bone lesion
+itself is the fact that the accompanying wounds of the soft parts retain
+the small or type forms. Thus I occasionally observed more troublesome
+results from minor shell wounds in the neighbourhood of joints, but not
+implicating the synovial cavity, than in actual perforating injuries
+produced by bullets of small calibre.
+
+_Vibration synovitis._--Before proceeding to the consideration of wounds
+of the joints, a short account is necessary of a condition of some
+importance which is, I believe, more or less special to injuries from
+bullets of small calibre travelling at high rates of velocity. This
+condition, if not novel, at any rate excited little comment in the
+descriptions of the older forms of injury, although this may have
+depended on the more serious nature of the primary local lesions
+accompanying wounds from the larger bullets, among which it formed a
+comparatively unimportant element.
+
+The condition referred to was the occurrence of considerable synovial
+effusion into the joints of limbs in which the articulation itself was
+primarily untouched. These effusions sometimes occurred even when the
+soft parts alone were perforated, especially when the wounds were
+situated above or below the knee-joint. They were apparently the direct
+result of vibratory concussion of the entire limb dependent on the blow
+received from the bullet.
+
+The effusions were most strongly marked in cases of fractures of the
+diaphyses, although this was more noticeable in some situations than
+others. Thus with fractures of the shaft of the femur anywhere below the
+junction of the upper and middle thirds of the bone, and in some cases
+even higher, effusion into the knee-joint was very common, and sometimes
+extreme. On the other hand, similar effusions into the hip-joint were
+less marked, since I failed to determine their existence in the majority
+of cases. I am inclined to ascribe this to the different anatomical
+arrangement of the two joints, particularly to the fact that the head of
+the femur is included in a bony cup, into the hollow of which it is
+accurately fixed by the resilient cotyloid fibro-cartilage. The latter
+by its firm grasp of the head allows of little play in the joint; hence
+vibrations are conveyed directly to the acetabulum in continuous waves,
+and rocking of the articular surfaces is prevented. Beyond this no doubt
+the difficulty of detecting small effusions in this joint is an element
+which must be taken into consideration.
+
+I do not think that wrenches of the knee-joint in the act of falling
+can be suggested as an explanation of the frequency of effusions into
+that articulation, since the fractures of the femur were not always
+received while the erect position was maintained, and effusion was most
+marked when the diaphysis was the part affected, the latter point
+illustrating the greater resistance offered by compact bone. Again, when
+fracture had taken place, the solution of continuity rendered the
+directly injured point the most mobile, and tended to prevent lateral
+strain from falling on the joints.
+
+Effusion into the knee or ankle, or sometimes both joints, was common in
+fractures of the shaft of the tibia.
+
+In the articulations of the upper extremity the condition was also
+common, but somewhat less marked than in the lower limb. Effusions into
+the shoulder or elbow occurred. In the former these were less striking;
+again, perhaps, as a result of the difficulty of detecting small
+effusions in this situation. The elbow was to a certain extent protected
+by the possession of a degree of fixity somewhat resembling that already
+mentioned in the case of the hip-joint, although here depending on the
+conformation of the bones alone. I think this explained the absence of
+free effusion in many cases of fracture of the humeral shaft, but when
+the latter affected the lower third effusion into the elbow was usually
+abundant.
+
+The lighter weight and greater mobility of the upper extremity as a
+whole, as decreasing the resistance to the bullet, were also probably an
+element in the fact that these effusions were less severe than those in
+the joints of the lower limb.
+
+The nature of the effusions was apparently simple, since they were
+rapidly reabsorbed, and little thickening of the synovial membrane
+remained to suggest either a marked degree of inflammation, or the
+deposition of blood-clot on the inner aspect of the same.
+
+The only treatment indicated was a short period of rest, accompanied in
+the early stages by pressure and slight fixation, followed later by
+massage and movement if necessary.
+
+Before dismissing this subject, I should like to particularly emphasise
+the fact, that in the cases described there was no reason to suspect the
+extension of fissures from the point of fracture in the shafts into the
+articular ends of the bones. This was as far as possible excluded by
+clinical examination, and in the cases where wounds of the soft parts
+only were present, the rapid return of the patients to active duty, with
+absence of remaining joint trouble, negatived the possibility of such
+fractures.
+
+I only saw one case in which a longitudinal fracture actually extended
+for any considerable distance into a neighbouring joint. In this a
+comminuted fracture occurred just above the centre of the shaft of the
+humerus. At the time of examination and putting up of the fracture there
+was considerable swelling of the whole arm, and nothing special was
+noticed about the shoulder-joint. Three weeks later, however, when the
+fracture was consolidating, difficulty in abduction of the shoulder was
+noted, and the arm could not be placed closely in contact with the
+trunk. There was no evident displacement of the head of the humerus
+forwards. A skiagram, which I much regret I have not been able to
+insert, showed that a longitudinal fissure extended from the seat of
+fracture upwards in such a manner as to divide the upper fragment into
+two parts, of which the outer bore the greater tuberosity, the inner the
+articular surface of the head. The latter fragment had become somewhat
+displaced downwards, and had united in such a manner that the head
+rested on the lower part of the glenoid cavity. Abduction of the limb
+therefore brought the greater tuberosity into contact with the acromion
+process, and movement was checked. This case passed out of my
+observation shortly afterwards, and I have no knowledge of the final
+result as to movement.
+
+Fractures of the bony processes surrounding the elbow-joint, and of the
+malleoli of the tibia and fibula, were not infrequent, but offered no
+special features.
+
+One other form of injury indirectly affecting the joints is perhaps
+worthy of mention, but I observed it only once, and that in the case of
+the shoulder, the only joint where it is likely to be marked. I refer to
+the displacement of the head of the humerus by the force of gravity,
+when the circumflex nerve is injured. In the instance I refer to, a
+fracture of the surgical neck of the humerus was accompanied by
+complete motor paralysis of the deltoid and very rapid wasting of the
+muscle. Circumflex sensation was impaired, but not absent at the time
+the condition of the muscle was noted--a favourable prognostic sign of
+much importance. At the end of five weeks, when the fracture of the bone
+was consolidated, the head of the humerus had dropped vertically at
+least an inch, but could be replaced with ease. Shortly afterwards an
+improvement in the condition of the muscle commenced, and with this the
+head of the humerus was gradually raised. This patient later recovered
+his power in great part, but not completely.
+
+In a few cases bullets lodged in the neighbourhood of joints in such
+positions as to limit movement by mechanical impact with the bones. Thus
+I saw one case in which a bullet lay between the radius and ulna just
+below the lesser sigmoid cavity; in another the bullet lay in front of
+the ankle-joint, and limited the possibility of flexion; and in a case
+related to me by Mr. Bowlby, a bullet was removed by him from the wall
+of the acetabulum where it was tightly fixed in the substance of the
+bone. In two other cases I saw bullets lying deeply on the anterior
+surface of the hip capsule and so limiting flexion. In all such cases
+the indication for removal of the bullet was sufficiently strongly
+marked.
+
+
+WOUNDS OF THE JOINTS
+
+These may be divided into several classes, varying much in comparative
+severity, and in prognostic importance.
+
+1. The comparatively rare instances in which a wound implicated a joint
+cavity, without accompanying lesion of any bone.
+
+2. Perforating wounds in which the bullet was retained within the
+articular cavity. These were also rare.
+
+3. Wounds of the joints accompanied by grooving of the articular
+extremities 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 extending
+into joints.
+
+Of these several classes, the first was of the least prognostic
+importance. In the absence of bone injury the wounds usually healed
+without any obvious ill effect beyond the transient effusion into the
+joints of a mixture of blood and synovial fluid. When suppuration of the
+wound in the soft parts occurred, however, the remarks made as to the
+injuries classed under the third heading also apply here in a lesser
+degree.
+
+With regard to the retention of the bullet, in the case of bullets of
+small calibre this was a distinctly rare occurrence. I never happened to
+see an instance of retention of either a Mauser or Lee-Metford bullet in
+an articulation. It is only possible with bullets practically spent, or
+travelling at a very low rate of velocity and making irregular impact.
+
+The influence of both volume and velocity of flight was well illustrated
+by my own small experience of retained bullets. In one case a
+Martini-Henry was found impacted between the femoral condyles, having
+slipped in beneath the margin of the patella. It caused a semiflexed
+position 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 Portland
+Hospital at Bloemfontein in a patient of Mr. Bowlby's. The bullet was a
+Guedes, a form which has been already described as possessing low
+velocity and deficient power of penetration; beyond this, in the
+particular instance irregular impact was evidenced by the presence of a
+large irregular contused wound of entry over the tuberosity of the
+tibia.
+
+The presence of the bullet in the knee-joint was later determined by the
+X-rays, and Mr. Bowlby removed it successfully. Seven months later the
+range of movement was nearly normal.
+
+I may add that I saw several instances of large leaden bullets lodging
+in the popliteal space, and a comparatively insignificant number of
+bullets 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 the
+neighbourhood of joints, unless at the distal end of a long track. To
+take the extreme example of large bullets, those employed as shrapnel,
+in comparison with the frequency with which wounds were produced by
+them, bullets lying at the bottom of short tracks in the neighbourhood
+of 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 superficially
+grooved, were in some respects the most serious. This was especially so
+in the knee and ankle joints, and some cases will be quoted later under
+the heading of the special joints to illustrate this point. Danger only
+arose in the event of suppuration; and here the presence of the long
+oblique superficial track in a neighbourhood liable to comparatively
+free movement was the important element. Such tracks usually opened the
+synovial sac more extensively than direct perforating wounds, and if
+suppuration occurred in any portion of the track, the pus was very
+liable to be sucked into the joint on any free movement. The presence of
+fine splinters of the bone displaced in the production of the groove was
+also a special character of wounds of this class. Another point worthy
+of mention is that in these cases it was not always easy to be quite
+certain whether the joint cavity had been implicated or not, since cases
+often occurred in which, although the bones had been grooved, the joint
+cavity escaped. The indication, however, was to consider any wound in
+the immediate proximity of a joint as perforating until it was healed.
+This course was the more easy to take, since a large proportion of such
+wounds were accompanied by some degree of synovial effusion, even when
+the neighbouring joint had escaped puncture.
+
+Wounds of the fourth class, although the most highly characteristic of
+the form of accident, were in many instances the most favourable in
+regard to their course. The tracks might course directly across the
+joint in any direction, or they might course obliquely, traversing
+either one or both the component bones. In the latter case the exit
+might be in the diaphysis, and be accompanied by the separation of an
+exit fragment such as is illustrated in fig. 52, p. 169. The
+particularly favourable character of the direct transverse and
+antero-posterior wounds depended on the slight amount of splintering of
+the bones, the limited nature of the opening into the joint, and the
+shortness of the tracks in the soft parts, which ensured that, even if
+infection did occur, the resulting pus was near the surface, and
+generally spread in that direction and escaped.
+
+Wounds of the fifth class were the most dangerous, but the danger was
+entirely a secondary one, dependent on the occurrence of infection.
+These injuries were liable to be accompanied by the presence of
+extensive irregular wounds of the soft parts, in which suppuration was
+frequent, and the suppuration of the joint frequently meant subsequent
+amputation, if not a worse result.
+
+_Course and symptoms of wounds of the joints._--The immediate result of
+any perforation of a joint was the development of intra-articular
+effusion. This consisted of synovial fluid admixed with a varying
+proportion of blood. The degree of synovitis was apt to vary with the
+amount of force expended in the production of the injury; for this
+reason both high velocity and irregular impact were of importance in
+this relation.
+
+The constant feature, however, depended on the effusion of blood; this
+was not rapid, or, as a rule, very abundant, but tended to increase
+during the first twenty-four hours. It resulted in a swelling of the
+joint, which possessed some peculiar features. At first elastic and
+resilient, it slowly decreased in volume with the assumption of a soft
+doughy character on palpation. In the case of the knee, where readily
+palpated, it very much resembled a tubercular synovial membrane, except
+for its extreme regularity of surface; still more closely the condition
+noted in a haemophilic knee of some duration. Absorption took place with
+some rapidity, and except for slight thickening, the joints might appear
+almost normal, in a period of from two to four weeks. With the
+development of the effusion there was local rise in temperature of the
+surface, and in a considerable number of the cases a general rise of
+temperature.
+
+This latter was sometimes very marked, as in the case of all the other
+traumatic blood effusions, but not quite so regular in occurrence. It
+was important, as I have seen it give rise to the suspicion of
+suppuration, when tapping resulted in nothing more than the evacuation
+of turbid synovia mixed with blood. Pain was rarely a prominent symptom
+in consequence of the generally moderate degree of distension.
+
+As a rule, these injuries were characterised by the small tendency to
+the development of adhesions; but this in great part depended on the
+care expended on their treatment. If kept too long quiet, either from
+necessity when the effusion was followed by much thickening, or when the
+external wound was large and so situated as to be harmfully influenced
+by movement, or in the ordinary course of treatment, troublesome
+stiffness, even amounting to firm anchylosis, sometimes followed. I saw
+several such cases, some of the most confirmed being wounds of the
+knee-joint complicated by injury to the popliteal vessels or nerves. The
+latter complication I saw altogether six times, but only once with a
+thoroughly bad knee, and in this case the injury had affected both the
+vessels and the internal popliteal nerve. The joint in that case was
+straightened out by continuous extension by Major Lougheed, when it came
+under his charge some six weeks after the primary injury, but I hear has
+again relapsed, and the popliteal paralysis is not much improved.
+
+The small tendency to formation of adhesions in uncomplicated cases
+probably depended on the coagulation of a layer of blood over the whole
+internal lining of the joint. This kept the synovial surfaces apart at
+the lines of reflection of the membrane, and, given sufficiently active
+treatment, mobility was restored before any firm union could take place.
+
+The primary escape of synovial fluid was rarely observed, as the wounds
+of the soft parts were too small and valvular to permit of it. Synovia
+in some abundance, mixed with pus, sometimes escaped in considerable
+quantity when infection had opened up the tracks.
+
+Primary suppuration in any joint as a result of small and direct wounds
+was very rare. I observed it only on one occasion. On the other hand, a
+considerable number of cases in which secondary suppuration occurred
+came under my notice. In some of these the suppuration was secondary to
+comminuted fractures of the shaft of the tibia, in which the articular
+extremity was implicated. These offered no special peculiarity. In
+others infection of the joint was secondary to infection and suppuration
+in the deep part of long oblique wound tracks, and these were of
+sufficient 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 haemorrhage 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 anaesthetised, 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, how
+quietly a small amount of deep suppuration may sometimes take place;
+and, secondly, the importance of keeping the joints quiet on a splint
+when there is any reason to suspect their implication by wounds of this
+character.
+
+_The general treatment_ of the wounded joints was simple. The old
+difficulties of deciding on partial as against full excision, or
+amputation, were never met with by us. We had merely to do our first
+dressings with care, fix the joint for a short period, and be careful to
+commence passive movement as soon as the wounds were properly healed, to
+obtain in the great majority of cases perfect results. Careful light
+massage, if available, was used to promote absorption of blood.
+
+If suppuration occurred, the choice between incision and amputation had
+to be considered. In the early stages this choice depended entirely on
+the nature of the injury to the bones. If this were slight, incision was
+the best plan to adopt. I saw several cases so treated which did well,
+although convalescence was often prolonged, and only a small amount of
+movement was regained. Amputation was sometimes indicated in cases of
+severe bone-splintering, when the shafts were implicated, but was as a
+rule only performed after an ineffectual trial to cut short general
+infection of the septicaemic type by incision.
+
+I have dwelt at such length on the subject of suppuration on account of
+its importance, but I should add that, on the whole, suppuration of the
+joints was uncommon, except in the case of injuries far exceeding the
+average in primary severity.
+
+_Special joints._--Such deviations from the general type of injury as
+above described depended entirely on peculiarities of anatomical
+arrangement, and peculiarities in the situation of the joint clefts in
+the different parts of the body. A few words as to these are perhaps
+necessary.
+
+_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 joint
+needed to come with great exactitude from the immediate front; secondly,
+wounds received from a purely lateral direction calculated to pierce the
+head of the humerus and the glenoid cavity were naturally of very rare
+occurrence. Wounds of the prominent tip of the shoulder received while
+the men were in the prone position were not uncommon, but it was
+remarkable how rarely the shoulder-joint was implicated in these. The
+question of the narrow nature of the cleft exposed also comes up in this
+position. As far as my experience went, injuries to the lower portion of
+the capsule accompanying wounds of the axilla were those most often met
+with. The ease and neatness with which pure perforations of the head of
+the humerus can be produced was also an important element in the
+frequent escape of this joint. No case of fracture of the glenoid cavity
+happened to come under my notice.
+
+I saw few instances in which the joint needed incision, and cannot
+recall or find in my notes any case in which serious trouble arose.
+
+_Elbow-joint._--Injuries to this joint came second in frequency in my
+experience to those of the knee. They were, in fact, comparatively
+common, especially in conjunction with fractures of the various bony
+prominences surrounding the articulation. Fractures of the lower end of
+the humerus were of worse prognostic significance than those of the
+ulna, on account of the greater tendency to splintering of the bone. I
+saw several cases of pure perforation of the olecranon without any signs
+of implication of the elbow-joint. In a case which has been utilised for
+the illustration of some of the types of aperture (fig. 20, p. 59), at
+the end of a week there was no sign of any joint lesion, although the
+bullet had obviously perforated the articulation.
+
+Several cases of suppuration which came under my notice did well. I saw
+one of them a few days ago, six months after the injury, with perfect
+movement. In another of which I took notes, the bullet entered over the
+outer aspect of the head of the radius, to emerge just above the
+internal condyle anteriorly. A considerable amount of comminution of the
+olecranon resulted, and when the man came into hospital some ten days
+later the joint was suppurating. The joint was opened up from behind,
+and some fragments of bone removed by Mr. Hanwell. On the 26th day this
+joint was doing well, and considerable flexion and extension were
+possible without pain. There was a somewhat abundant discharge of bloody
+synovia during the first few days after the operation.
+
+[Illustration: FIG. 59.--Illustrates the very neat and limited injury to
+the Phalanges over the dorsal aspect of the first inter-phalangeal joint
+of the Middle Finger, accompanying a gutter wound received by the
+patient 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 extreme
+neatness 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 have
+already said as to the injuries to the head of the femur. I had
+practically no experience of small-calibre bullet injuries to the
+femoral constituent, and beyond the single case of injury to the
+acetabular margin mentioned on p. 193 I saw no obvious wounds of the
+joint at all.
+
+_The knee_, as usual, proved itself _par excellence_ the joint most
+commonly injured, no doubt as a result of its size, the extent of its
+capsule anteriorly, and its exposed position. In spite, however, of the
+frequency with which it suffered injury, and the opportunities it
+afforded for observation of the progress of the effusions towards
+absorption, the injuries to the joint gave less anxiety and attained a
+more favourable prognostic character than is the case in civil practice.
+This depended on the very favourable course observed in the frequent
+pure perforations following a direct line. These occurred in every
+direction, the accompanying haemarthrosis usually disappearing completely
+in an average period of little over a month. The extremes can be fairly
+placed at a fortnight and six weeks. Limitation of movement was slight
+or non-existent in many cases; in others it was of a very moderate
+character, and I only remember to have seen one case in which a really
+serious anchylosis developed. In this the man was struck from a distance
+of 300 yards, and a considerable amount of bone dust from the femur was
+found in the lips of the exit aperture. The wounds healed _per primam_,
+but when I saw the man two months later anchylosis in the straight
+position was apparently complete.
+
+The comparatively frequent association of popliteal aneurisms with
+wounds of the knee-joint has already been spoken of in relation to
+anchylosis. Wounds of the popliteal space from larger bullets sometimes
+caused more troublesome after-stiffness than wounds of the articulation
+itself. Again I remember a small pom-pom wound at the inner margin of
+the ligamentum patellae without obvious wound of the joint, which was
+accompanied by synovitis from contusion, and was followed by very
+considerable limitation of movement. This had only been partially
+improved when the patient returned home, in spite of prolonged massage
+and passive movement.
+
+The general remarks on the joints cover all that need be said as to
+suppuration of the knee-joint.
+
+_The ankle-joint_ maintained the undesirable character which it has
+always held as a subject for gunshot injuries. This is entirely a
+question of sepsis, and in great measure depends on the fact that the
+foot, as enclosed in a boot, is invested with skin particularly
+difficult to thoroughly cleanse; while the socks are an additional
+source of infection to the wounds before the patients come under proper
+treatment.
+
+Of seven cases of suppurating ankle-joint, of which I have notes, only
+two retained the foot, and one of these after a very dangerous illness.
+This case was one of special interest as exemplifying the results
+dependent on variations in velocity on the part of the bullet. The
+patient was struck at a distance of twenty yards. The bullet entered the
+front of the right ankle-joint and emerged through the internal
+malleolus, just behind its centre, causing no comminution of the latter.
+It then entered the left foot by a type wound one inch behind and below
+the tip of the internal malleolus, traversed and comminuted the
+astragalus, and emerged one inch below the tip of the external
+malleolus. The first joint healed _per primam_. The second produced by
+the bullet when passing at a lower rate of velocity was accompanied by
+considerable comminution of the bone. It suppurated, and gave rise to
+great anxiety both for the fate of the foot and the life of the patient.
+It is probable that the more abundant haemorrhage which took place from
+the second wound was in part responsible for the occurrence of
+infection.
+
+The second of the two cases is of some interest in relation to the
+doctrine 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 passing
+transversely through his leg immediately behind the bones and about half
+an inch above the level of the ankle-joint. He recovered, and rejoined
+his regiment, only to receive at Paardeberg a second wound, about an
+inch lower, which traversed the ankle-joint. On his return to Wynberg he
+happened to be sent to the same pavilion, and occupied the same bed he
+had left on returning to the front.
+
+The subject of the result of wounds of the joints of the _foot_ has
+received sufficient consideration under the heading of wounds of the
+tarsus.
+
+The repetition of the fact that, among the whole series of cases on
+which this chapter is founded, not a single instance of primary or
+secondary 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 been
+suggested that the mere fact of wounds of the head being readily visible
+ensured all such being at once distinguished and correctly reported,
+while wounds hidden by the clothing often escaped detection. When the
+external insignificance of many of the fatal wounds of the trunk is
+taken into consideration this is possible; but, on the other hand, it
+must be borne in mind that the head is in any attitude the most
+advanced, and often the most exposed, part of the body, and even when
+the soldier had taken 'cover,' it was frequently raised for purposes of
+observation. For the latter reasons I believe injury to the head fully
+deserved the comparative importance as a fatal accident with which it
+was credited.
+
+A number of somewhat sensational immediate recoveries from serious
+wounds of the head have been placed upon record. Observation, however,
+shows that these, with but few exceptions, belonged either to certain
+groups of cases the relatively favourable prognosis in which is familiar
+to us in civil practice, or that the wounds were received from a very
+long range of fire, and hence the injuries were strictly localised in
+character.
+
+
+ANATOMICAL LESIONS
+
+_Wounds of the scalp._--Nothing very special is to be recorded with
+regard to these; they either formed the terminals of perforating wounds,
+or were the result of superficial glancing shots. The glancing wounds
+were of the nature of furrows, varying in depth from mere grazes to
+wounds laying bare the bone. Their peculiarity was centred in the fact
+that a definite loss of substance accompanied them, the skin being
+actually carried away by the bullet; hence gaping was the rule. Every
+gradation in depth was met with, but the only situations in which wounds
+of considerable length could occur were the frontal region in tranverse
+shots, or, when the bullet passed sagitally, the sides of the head, or
+the flat area of the vertex.
+
+The danger of overlooking injuries to the bone was of special importance
+in the short subcutaneous tracks occasionally met with at the points at
+which the surface of the skull makes sharp bends. In all such wounds it
+was a safe rule to assume a fracture of the skull until this was
+excluded by direct examination. In some of the gutter wounds and
+subcutaneous tracks crossing the forehead and sides of the head, signs
+of intracranial disturbance were occasionally observed in the absence of
+external fracture, such as transient muscular weakness, unsteadiness in
+movements, giddiness, diplopia, or loss of memory and intellectual
+clearness. In connection with such symptoms the classical injury of
+splintering of the internal table of the skull, the external remaining
+intact, had to be borne in mind, but I observed no proven instance of
+this accident. I am of opinion, moreover, that its occurrence with small
+bullets travelling at a high degree of velocity must be very rare, since
+little deflection is probable unless the contact has been sufficiently
+decided to fracture the external table; while in the cases of spent
+bullets the injury is unlikely, as requiring a considerable degree of
+force.
+
+_Injuries to the cranial bones, without evidence of gross lesion to the
+brain._--It may be premised that these were of the rarest occurrence,
+and they may be most readily described by shortly recounting the
+conditions observed in a few cases I noted at the time. The injuries
+resulted from blows with spent bullets, from bullets barely striking the
+skull directly, or those striking over the region of the frontal
+sinuses. Wounds of the mastoid process will not be considered in this
+connection as being of a special nature (see p. 299).
+
+I saw only one case of escape of the internal, with depressed fracture
+of 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 deg. 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 fossae, 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 was
+the commonest form of head injury, and possessed two main peculiarities;
+firstly, the large amount of brain destruction compared with the extent
+of the bone lesion; secondly, the fact that any region of the skull was
+equally open to damage. In consequence of the second peculiarity, the
+position and direction of secondary fissures are not so dependent on
+anatomical structure as in the corresponding injuries of civil practice.
+Thus, fractures of the base, for instance, were less constant in their
+course and position. The cases as a whole are best divided into four
+classes.
+
+[Illustration: FIG. 60.--Mauser Bullet in Nasal Fossa. (Skiagram by H.
+Catling.) Case No. 47]
+
+1. Extensive sagittal tracks passing _deeply_ through the brain, and
+vertical wounds passing from base to vertex or _vice versa_, in the
+posterior two thirds of the skull. These will be referred to as general
+injuries.
+
+2. Vertical or coronal wounds in the frontal region.
+
+3. Glancing or obliquely perforating wounds of varying depth in any part
+of the head.
+
+4. Fractures of the base.
+
+Of these classes the first was nearly uniformly fatal; the second
+relatively favourable, and with low degrees of velocity often
+accompanied by surprisingly slight immediate effects; while the third
+had perhaps the best prognosis of all, but this varied as to the defects
+that might be left, and with the region of the head affected.
+
+1. _General injuries._--Fractures of this class may be treated of almost
+apart. For their production the retention of a considerable degree of
+velocity on the part of the bullet was always necessary, and the results
+were consequently both extensive and severe.
+
+The aperture of entry was comparatively small, since to take so direct
+and lengthy a course through the skull the impact of the bullet needed
+to be at nearly an exact right angle to the surface of the bone. Any
+disposition to assume the oval form, therefore, depended mainly upon the
+degree of slope of the actual area of the skull implicated. In size the
+aperture of entry did not greatly exceed the calibre of the bullet; in
+outline it was seldom exactly circular, but rather roughly four-sided,
+with rounded angles, slightly oval, or pear-shaped. The margin of the
+opening consisted of outer table alone, the inner being always
+considerably comminuted. Fragments of the latter, together with the
+majority of those corresponding to the loss of substance of the outer
+table, were driven through the dura mater and embedded in the brain.
+These bony fragments were more or less widely distributed over an area
+of 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 region
+was of typical explosive character. Range '100 yards'.]
+
+The amount of fissuring at the aperture of entry was often not so
+extensive as I had been led to expect. Fig. 61 is a diagram illustrating
+a fairly typical instance; in some cases no fissuring existed. As a rule
+the nearer to the base, the greater was the amount of fissuring
+observed. The fissures were sometimes very extensive in this position,
+probably as a result of the lesser degree of elasticity in this region
+of the skull. Again, when the aperture of entry was near the parts of
+the vertex where sudden bends take place, considerable fissuring of the
+same nature as that seen in the superficial tracks (fig. 68) was
+produced in the flat portion of the skull above the point of entrance.
+
+Radial fissuring around the aperture of entry in the skull scarcely
+corresponds in degree with that seen when the shafts of the long bones
+are struck, and is far less marked and regular than when one of these
+small bullets strikes a thick sheet of glass set in a frame. I saw
+several apertures in the thick glass of the windows of the waterworks
+building at Bloemfontein produced by Mauser bullets. They differed
+little from the opening seen in an ordinary plate-glass window resulting
+from a blow from a stone, except perhaps in the regularity and
+multiplicity of the radial fissures. As in the skull, the opening was a
+little larger than the calibre of the bullet, and the loss of substance
+on the inner aspect considerably exceeded that on the outer.
+
+The degree of fissuring is probably affected by the resistance offered
+by the particular skull, or the special region struck, but as a rule the
+elasticity and capacity for alteration in shape possessed by the bony
+capsule, is opposed to the production of the extreme radial starring
+observed in the long bones or a fixed sheet of glass. Corroborative
+evidence of the influence of elasticity in the prevention of starring is
+seen in the limited nature of the comminution of the ribs in cases of
+perforating wounds of the thorax.
+
+In the most severe cases we can only speak of the 'aperture' of exit in
+a limited sense in so far as the opening in the scalp is concerned; this
+was often comparatively small, not exceeding 3/4 of an inch in diameter.
+Beneath this limited opening in the soft parts, the bone of the skull
+was smashed in a most extensive manner. The portion exactly
+corresponding to the point of exit of the bullet was carried altogether
+away, but around this point a number of large irregularly shaped
+fragments of bone, from 3/4 to 1 inch in diameter, were found loose, and
+often so displaced as to expose a considerable area of the dura-mater.
+Beyond the area of these loose fragments, fissures extended into the
+base and vertex, in the latter case often being limited in their extent
+by the nearest suture.
+
+Over extensive fractures of this nature general oedema and
+infiltration of the scalp, due to extravasation of blood, were present.
+When the exit was situated in the frontal region ecchymosis often
+extended to the eyelids and down the face, while in the occipital region
+similar ecchymosis was often seen at the back of the neck.
+
+The opening in the dura mater at the aperture of entry was either
+slitlike, or more often irregular from laceration by the fragments of
+bone driven in by the bullet. At the point of exit a similar limited
+opening corresponded with the spot at which the bullet had passed, while
+separate rents of larger size were often seen at some little distance.
+The latter were the result of laceration of the outer surface of the
+membrane by the margins of the large loose fragments of bone above
+described.
+
+Injury to the brain more than corresponded in extent to the fractures of
+the bone. Pulping of its tissue existed over a wide area both at the
+points of entrance and of exit. In the former position the amount of
+damage was the less, the gross changes roughly corresponding with the
+tissue directly implicated by the bullet itself, and the fragments of
+bone carried forward by it. The degree of splintering of the skull
+therefore in great part determined the severity of the lesion. At the
+exit aperture much more widespread destruction existed, while masses of
+brain tissue, small shreds of the membranes, fragments of bone, and
+_debris_ from the scalp were found occasionally bound together by
+coagulated blood and protruding from an exit opening of some size. The
+largest masses of such _debris_ were most often seen in instances in
+which the bullet had entered by the base to escape at the vertex of the
+skull.
+
+The brain in the line of injury suffered comparatively slightly, but
+small parenchymatous haemorrhages into its tissue indicated in lesser
+degree the same type of injury undergone by the mass of brain pulp and
+small blood-clots found at the external limits of the wound. Beyond this
+extensive haemorrhages at the base of the skull were common.
+
+With regard to the extensive character of the brain destruction in the
+region of the aperture of exit, it must be borne in mind that this
+lesion corresponds in position with one which would exist even if the
+injury were of a non-penetrating degree. A large proportion of the
+contusion and destruction is therefore explained by violent impact of
+the 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 lesions
+to which the term 'explosive' has been applied, and as such have an
+important bearing on the theories held as to the mode of production of
+explosive effect. The increased area of tissue damage at the aperture of
+exit favours the theory of direct transmission of a part of the force
+with which the bullet is endowed, to the molecules of tissue bounding
+the track made by the projectile. Thus the area of destruction
+corresponds with the cone-like figure which one would expect to be built
+up by the vibrations spreading from the primary point of impact. The
+exit region of the skull is subjected not alone to the force of the
+travelling bullet, but also to that exerted over a much wider area by
+the tissue to which secondary vibrations have been communicated. The
+brain itself is, in fact, dashed with such violence against the bone as
+to cause a great part of the injury.
+
+No doubt the brain in its reaction to the bullet forms as near an
+approach to a fluid as any solid tissue in the human body, and
+experimental observation has shown how greatly its presence or absence
+in the skull affects the degree of comminution on the exit side; hence
+the fondness for the so-called hydraulic theory that has been always
+exhibited in the case of these injuries. The localisation of the injury
+in its highest degree to the neighbourhood of the exit aperture,
+however, shows that in any case the main wave takes a definite direction
+in a course corresponding to that of the bullet.
+
+The real importance of the presence of the brain within the skull in
+increasing the amount of damage at the exit end of the track, is as a
+medium for the ready transmission of forcible vibrations. That the
+latter are to some extent conveyed as by a fluid is evidenced by the
+occasional presence of brain matter and fragments of bone in the
+aperture of entry, which suggests recoil or splash such as would be
+expected from a fluid wave.
+
+Experience of the character of the lesions observed after severe
+concussion by the ordinarily somewhat coarser forms of violence common
+to civil life, fully explains the severity of the damage to the brain
+tissue met with in injuries due to bullets of small calibre. Viewing the
+elaborate arrangements which exist for the preservation of the central
+nervous system from the moderate vibration incidental to ordinary
+existence, it is easy to appreciate the harmfulness of such exquisite
+vibratory force as that transmitted by a bullet of small calibre
+travelling at a high rate of velocity.
+
+_Effect of ricochet in the production of severe forms of injury._--In
+connection with the lesions above described mention must be made of
+cases in which the aperture of entry reaches a large size, or a portion
+of the skull is actually blown away.
+
+Examples of the former class were not uncommon; I will briefly relate
+one.
+
+     (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 faeces 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 septicaemia, 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 portions
+of the skull and scalp were actually blown away. I never witnessed one
+of these myself, but I recall two instances described to me by officers
+who lay near the wounded men on the field. In one the frontal region was
+carried away so extensively that, to repeat the familiar description
+given by the officer, 'he could see down into the man's stomach through
+his head.' In a second case the greater part of the occipital region was
+blown away in a similar manner, and this was of especial interest as the
+wounded man was seen to sit up on the buttocks and turn rapidly round
+three or four times before falling apparently dead. The observation
+offers interesting evidence of the result of an extensive gross lesion
+of the cerebellum.
+
+In the absence of exact information, it may well be that such injuries
+as the two latter were produced by some special form of bullet, but as
+both were produced while the patients were lying on the ground, and
+therefore especially liable to blows from ricochet bullets, I am
+inclined to attribute both to this cause.
+
+In considering injuries of the above nature, one cannot help speculating
+on the possible influence of a head-over-heels ricochet turn on the part
+of the bullet while traversing the long sagittal axis of the skull. It
+is not uncommon for apical target ricochets to present evidence of
+damage to the apex and base of the mantle alone. This must depend on a
+rapid turn on impact, which might well be imitated in the case of the
+skull, and would then go far to explain the production of some of the
+most severe forms of explosive exit wounds met with. See cases 48, 54,
+68.
+
+Short of ricochet, the influence of simple wobbling must also be
+considered in shots from a long range. The entry wound may be large as a
+result of this condition, but as the velocity possessed by the bullet is
+low, the injuries would probably not be of a very severe nature.
+
+In connection with the subject of wobbling, reference should be made to
+the form suggested by Nimier and Laval, in which the wobble, as the
+result of resistance to the apex of the revolving bullet, assumes the
+form of movement seen when the spin of a top is failing. This would
+explain a peculiarity in some wounds of entry over the skull first
+pointed out to me by Mr. J. J. Day. When such wounds were explored, as
+well as the presence of brain in the entry aperture, a number of
+fragments of the external table of the skull were found everted and
+fixed in the tissues of the scalp. As already suggested, this may be
+mere evidence of splash, but it may be equally well explained by a
+process of wobble around the axis of revolution of the bullet. This
+might, no doubt, also be invoked to explain the displacement of some of
+the fragments in fractures of the long bones, where considerable
+resistance to the passage of the bullet is offered.
+
+II. _Vertical or coronal wounds in the frontal region._--These injuries
+were common, and offered some of the most interesting illustrations of
+the variations in symptoms and effects following apparently exactly
+identical lesions, judging from the condition of the external soft parts
+alone; 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 the
+skull resulted, without extensive lesion of the frontal lobes as
+evidenced by immediate symptoms. The nature of the fractures differed in
+no way from the punctured fractures we are familiar with in civil
+practice. 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 was
+either considerably comminuted, or a large piece was depressed, wounding
+the dura-mater and projecting into the brain substance (see fig. 63).
+The aperture of exit presented exactly the opposite characters, the
+splintering comminution or separation of a large fragment affecting the
+outer table, while the inner presented a simple perforation. The latter
+condition is represented in figs. 71 and 72, and I will here give short
+notes of four illustrative cases, as being the shortest and most
+satisfactory method of conveying a correct idea of the nature of such
+injuries.
+
+[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 anaesthesia 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 deg. 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 _debris_. 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 any
+portion of the cranium._--These injuries were the most common, the most
+highly characteristic of small-calibre bullet wounds, the most
+interesting from the point of view of diagnosis, prognosis, and
+treatment, and beyond this they formed the variety most unlike any that
+we meet with in civil practice.
+
+They were met with in every region of the cranium, and in every degree
+of depth and severity. The lesser are best designated as gutter
+fractures, the deeper are perforating and gradually approximate
+themselves to the type of injury described as class 1.
+
+When the bullet struck a prominent or angular spot on the skull a
+considerable oval-shaped fragment was occasionally carried away, leaving
+an exposed surface of the diploe (case 60, p. 274). Under these
+circumstances the apparent lesion on raising a flap was slight, but
+exploration often showed extensive intra-cranial mischief. Thus in the
+case referred to both dura and brain were wounded, and continuing
+haemorrhage led to the development of progressive paralysis, relieved
+only by operation.
+
+From the more deeply passing bullets a more or less oval opening
+resulted, in which both tables were freely comminuted and displaced.
+These cases differed from the typical gutter fracture only in length and
+outline, and the nature of the accompanying intra-cranial lesion was
+identical, while in the latter particular they differed much from
+fractures in which the impact of the bullet was direct, in spite of a
+near resemblance in the appearances in the osseous defect.
+
+I saw one instance in which a circular fissure about 1-1/2 inch from
+the actual opening of entry surrounded the latter, the area of bone
+within the circle being somewhat depressed, though radial fissures were
+absent.
+
+In several of these cases fragments of lead were either found on the
+fractured surface of the bone or within the cranial cavity, showing that
+the bullets had undergone fissuring of the mantle, or had actually
+broken up on impact.
+
+_Gutter fractures._--The nature of the injury to the bones in these is
+best illustrated by a series of diagrams of sections such as are shown
+below.
+
+[Illustration: FIG. 64.--Gutter Fracture of first degree. The drawing
+does not show well the small fragments of bone usually carried from the
+margins of the depression by the bullet.]
+
+In the most superficial injuries the outer table was grooved and
+depressed, usually with loss of substance from small fragments directly
+shot away: these latter had either been driven through the wound in the
+soft parts, or remained embedded on the deep aspect of the enveloping
+scalp (fig. 64). In the less common variety the scalp was slit to a
+length corresponding with the injury to the bone, but more often oval
+openings in the skin existed at either end of the track. The inner table
+was practically never intact, but the amount of comminution naturally
+varied 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 also
+emphasises the consequences which may follow primary non-interference.
+
+[Illustration: FIG. 65.--Diagrammatic transverse sections of varying
+condition of bones in Gutter Fractures of the first degree. _A._ With no
+loss 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 alone
+carried away at either end.]
+
+Bevelling at the expense of the outer table at both entry and exit ends
+of the course existed, but in either case a portion of the inner table
+was also detached and depressed. Sometimes the depressed portion of the
+inner table was mainly composed of one elongated fragment; this was
+either when the bullet had not implicated a great thickness of the outer
+table, or had passed with great obliquity through especially dense bone
+(see fig. 70). When the bullet had passed more deeply the inner table
+was comminuted into numberless fragments. I have frequently seen 50 or
+60 removed. Where such tracks crossed convex surfaces of the skull, the
+two conditions were often combined; thus at one portion of the track,
+usually the centre, the comminution was extreme, while at either end a
+considerable elongated fragment of inner table was often found, the
+latter perhaps more commonly at the distal or exit extremity (fig. 67).
+
+[Illustration: FIG. 67.--Diagrammatic transverse sections of complete
+Gutter Fracture. _A._ External table destroyed, large fragment of
+internal table depressed. (Low velocity or dense bone.) _B._ Comminution
+and pulverisation of both tables centre of track. _C._ Depression of
+inner table (low velocity)]
+
+The nature of the injury to the bone when the flight of the bullet
+actually involved the whole thickness of the calvarium was comparable to
+that seen in the case of the long bones when struck by a bullet
+travelling at a moderate rate (see plate XIX. of the tibia, or what is
+illustrated in the case of the pelvis in fig. 55). In point of fact, a
+clean longitudinal track appeared to have been cut out. The length of
+these tracks naturally depended upon the region of the skull struck.
+When a point corresponding to a sharp convexity, or a sudden bend in
+the surface, was implicated, an oval opening of varying length in its
+long axis was the result; when a flat area, as exists in the frontal or
+lateral portions of the skull, was the seat of injury, a long track was
+cut.
+
+_Superficial perforating fractures._--These formed the next degree; the
+chief peculiarity in them was the lifting of nearly the whole thickness
+of the skull at the distal margin of the entry, and the proximal edge of
+the exit, openings; the flatter the area of skull under which the bullet
+travelled the more extensive was the comminution. In some cases nearly
+the whole length of the bone superficial to the track would be raised;
+in fact, the bullet having once entered, the force is applied from
+within in exactly the same way that it operates on the inner table in
+the gutter fractures. A corresponding injury is met with in the case of
+the bones of the extremities (see fig. 57 of the tibia), and again the
+resemblance between these injuries of the skull and such perforations of
+the long bones as are illustrated by skiagrams Nos. III. and XXIII. of
+the clavicle and fibula is a close one.
+
+[Illustration: FIG. 68.--Superficial Perforating Fracture. Illustrating
+lifting of roof at both entry and exit openings]
+
+I will add here a case of coexistent gutter fracture and perforating
+wound of the skull, the conditions of the bone in which will illustrate
+the behaviour of the outer and inner tables respectively, when struck
+with moderate force.
+
+[Illustration: FIG. 69.--Diagrammatic longitudinal section of Fracture
+shown in fig. 68]
+
+[Illustration: FIG. 70.--Fragment forming the main part of the floor of
+Gutter Fracture in the squamous portion of the temporal bone. (Low
+velocity, 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 haematoma, 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 deg.. 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 deg., 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 deg. to 103 deg., 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 haemorrhage
+     extending over the whole base of the brain.
+
+[Illustration: FIG. 71.--Scale of outer table of Frontal Bone and
+Diploe. Exact size, from fracture shown in fig. 72]
+
+[Illustration: FIG. 72.--Perforating Fracture of Frontal Bone from
+within Separation of plate outer table. (Low velocity.) 1/2]
+
+The injury to the _cranial contents_ varied with the degree of bone
+injury. Haemorrhage on the surface of the dura may in rare instances have
+been the sole gross lesion; I never met with such a condition, however.
+In all the cases in which comminution had occurred, some laceration of
+the dura, even if not more than surface damage or a punctiform opening,
+had resulted. In the more serious gutter fractures an elongated rent of
+some extent usually existed. In the perforating fractures two more or
+less irregular openings were the rule. The amount of haemorrhage, even if
+the venous sinuses were implicated, was on the whole surprisingly small,
+when the cases were such as to survive the injury long enough to be
+brought to the Field hospital. I never saw a typical case of middle
+meningeal haemorrhage, although many fractures crossing the line of
+distribution of the large branches came under observation. Case 60, p.
+274, illustrated the fact that the osseous lesions of lesser apparent
+degree are sometimes the more to be feared in the matter of haemorrhage,
+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 weight
+of the patient, but chiefly on the degree of velocity retained by the
+bullet. It was sometimes slight and local as far as symptoms would guide
+us; but in the majority of cases out of all proportion to the apparent
+bone lesion, if the range was at all a short one. Cases illustrative of
+these injuries are included under the heading of symptoms.
+
+It will be, of course, appreciated that the coarse brain lesions under
+the third heading differed in localisation and in extent alone, and in
+no wise in nature, from those observed in the two preceding classes. The
+damage consisted in direct superficial laceration and contusion, and
+beyond the limits of the area of actual destruction, abundant
+parenchymatous haemorrhages more or less broke up the structure of the
+brain, such haemorrhages decreasing both in size and number as
+macroscopically uninjured tissue was reached. No opportunity was ever
+afforded of examining a simple wound track in a case in which no obvious
+cerebral symptoms had been present.
+
+IV. _Fractures of the base._--In addition to the above classes, a few
+words ought to be added regarding the gunshot fractures of the base of
+the skull. These possessed some striking peculiarities; first in the
+fact that they might occur in any position, and hence differed from the
+typically coursing 'bursting' fractures we are accustomed to in civil
+life as the consequence of blows and falls, and consequently were often
+present without any of the classical symptoms by which we are accustomed
+to locate such fissures. Secondly, the peculiar form was not uncommon in
+which extensive mischief was produced from within by direct contact of a
+passing bullet.
+
+As far as could be judged from clinical symptoms, indirect fractures of
+the base such as we are accustomed to meet in civil practice in
+connection with fractures of the vault were decidedly rare, and, as has
+already been mentioned, ocular evidence of extensive fissures extending
+from perforating wounds of the vertex was wanting, except in the extreme
+cases classed under heading I. For these reasons I am inclined to regard
+them as uncommon.
+
+Direct fractures of the base, on the other hand, were of common
+occurrence, especially in the anterior fossa of the skull. These might
+be produced either from within, the most characteristic form of gunshot
+injury, or from without. The fractures from within were often simple
+punctures of the roof of the orbit or nose.
+
+Punctured fractures of the roof of the orbit caused little trouble as
+far as the cranium was concerned, but the orbital structures often
+suffered severely. I saw one or two very severe comminutions of the roof
+of the orbit caused by bullets which had crossed the interior of the
+skull; in one case the whole roof was in small fragments, while the
+damage in others was not greater than chipping off some portion of the
+lesser wing of the sphenoid. The roof of the orbit again was sometimes
+very severely damaged by bullets which first traversed that cavity
+itself; thus in one case which recovered, the bullet passed
+transversely, smashing both globes, and fracturing the roof of both
+orbits and the cribriform plate so severely as to lacerate both
+dura-mater and brain, portions of the latter being found in the orbit on
+removal of the damaged eyes.
+
+Fractures of the middle and posterior fossae were met with far less
+frequently, partly I think because vertical wounds passing from the
+vertex to the base in these regions were with few exceptions rapidly
+fatal, and partly from the fact that the occipital region, being
+ordinarily sheltered from the line of fire, was rarely exposed to the
+danger of direct fracture from without. As an odd coincidence I may
+mention that in my whole experience during the war I only once saw
+bleeding from the ear as a sign of fracture of the base, apart from
+direct injuries to the tympanum or external auditory meatus.
+
+_Symptoms of fracture of the skull, with concurrent injury to the
+brain._--These consisted in various combinations of the groups of signs
+indicative of the conditions of concussion, compression, cerebral
+irritation, or destruction. Although the symptoms possessed no inherent
+peculiarities, yet certain characteristics exhibited served to
+illustrate the fact that, as a result of the special mechanism of
+causation of the injuries, the type deviated in many ways from that
+accompanying the corresponding injuries of civil practice.
+
+The characters of the external wounds will be first considered, followed
+by some remarks concerning the symptoms attendant on the different
+degrees and types of lesion, the symptoms special to injuries to
+different regions of the head, and on the subsequent complications
+observed.
+
+In the simplest injuries the type forms of entry and exit wound were
+found, and it has already been observed that in these, if symmetrical,
+considerable difficulty existed in discriminating between the two
+apertures. This is to be explained by the fact that the arrangement and
+structure of the scalp are identical in corresponding regions; hence the
+only difference in the conditions of production of the entry and exit
+wounds exists in the absence of support to the skin in the latter. The
+granular structure of the hairy scalp is opposed to the occurrence of
+the slit forms of exit, hence the openings were usually irregularly
+rounded. Any increase of size in the exit wound in the soft parts due to
+the passage of bone fragments with the bullet, was equalised in that of
+entry by the fact that the latter, as supported by a hard substratum,
+was usually larger than those met with in situations where the skin
+covers soft parts alone.
+
+In some cases of gutter fracture the wounds of entry were large and
+irregular, as a result of upward splintering of the bone at the distal
+margin of the aperture of entry in the skull, and consequent laceration
+of the scalp. Again, on the forehead very pure types of slit exit wound
+were often met with in the position of the vertical or horizontal
+creases. With higher degrees of velocity on the part of the bullet and
+consequent comminution at the aperture of exit in the bone, the scalp
+was more extensively lacerated, and large irregular openings in the soft
+parts, often occupied by fragments of bone and brain pulp, were met
+with. It is well to repeat here, however, that the presence of brain
+pulp 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 exit
+wound often possessed in the highest degree the so-called 'explosive'
+character. From an opening in the skin with everted margins two or more
+inches in diameter a mass of brain debris, bone fragments and particles
+of dura-mater, skin, and hair, bound together by coagulated blood,
+protruded as a primary hernia cerebri if the patient survived the first
+few hours after the injury. In other cases of the same class the actual
+opening was smaller, but the whole scalp was swollen and oedematous,
+sometimes crackling when touched from the presence of extravasated blood
+in the cellular tissue, while firm palpation often gave the impression
+that the head consisted of a bag of bones over a considerable area.
+
+Gutter fractures of the scalp were sometimes situated beneath an open
+furrow, gaping from loss of substance, or beneath a bridge of skin; in
+the latter case they were usually palpable. Simple punctures were also
+usually palpable, but the smallness of the openings sometimes rendered
+their detection more difficult than might be assumed.
+
+I never saw a case in which the skull escaped injury when the bullet
+struck the scalp at right angles, but the frequency with which Mauser
+bullets were found within the helmets of men would suggest that this
+must have sometimes occurred. A case of injury to the external table
+alone has been described (p. 243). An illustration of the next degree of
+injury is afforded by the following:--A bullet lodged in the centre of
+the forehead, the point lying within the cranial cavity, while the base
+projected from the surface: this patient suffered but slight immediate
+trouble, so little, indeed, that he merely asked his officer to remove
+the bullet for him, as it was inconvenient. The bullet was subsequently
+removed in the Field hospital.
+
+In a few cases the bullet entered the skull and was retained, when only
+a single wound was found. Such cases are described in Nos. 54 and 68,
+where the position of the bullet was determined by palpable fractures
+beneath the skin. With regard to the retention of bullets, however, in
+small-calibre wounds, it was always necessary to examine the other parts
+of the body with great care, and to ascertain, if possible, the
+direction from which the wound was received, as an exit was often found
+some distance down the neck or trunk. Again the possibility of the
+opening having been produced by glancing contact had to be considered.
+
+In cases which survived the injury on the field, free haemorrhage, as in
+wounds of other regions, was rare, and although general evidence of loss
+of blood was often noted in patients brought in, progressive bleeding
+was seldom observed. Again, when the wounds were explored, the amount of
+blood, although considerable, was usually not more than sufficed to fill
+up the space consequent on the loss of brain tissue. This was especially
+striking when large venous sinuses, as the superior longitudinal, were
+involved in the injury. None the less, haemorrhage at the base of the
+brain was, I believe, responsible for early death in many of the severe
+cases, especially when the wounds were near the lower regions of the
+skull.
+
+Escape of cerebro-spinal fluid was not so prominent a feature as might
+have been expected, considering how freely the arachnoid space was
+opened up in many cases. I think this was usually checked by early
+coagulation of the blood, and later by adhesions. It must be remembered
+also that extensive wounds were most common on the vertex, or at any
+rate over the convex surface of the brain, while fractures of the middle
+fossa were usually rapidly fatal.
+
+_Concussion._--Cases exhibiting symptoms of pure uncomplicated
+concussion were distinctly rare, as would be expected from the
+mechanism of the injuries. On the other hand, symptoms of concussion
+formed the dominant feature of all severe cases.
+
+The symptoms in many instances consisted in great part in transitory
+signs of the so-called 'radiation' type, such as are seen in destructive
+lesions where the signs of nervous damage rapidly tend to diminish and
+localise themselves.
+
+As to the causation of the 'radiation' symptoms, it is difficult to
+discriminate the effects of neighbouring parenchymatous haemorrhages from
+those of local vibratory concussion of the nervous tissue. The local
+character of the signs seems, however, to point to causation by
+molecular disturbance, resulting from the conduction of forcible
+mechanical vibration to the brain tissue rather than to upset in the
+intra-cranial pressure. Again the limited nature of the paralysis
+observed, sharply defines it from the general loss of power accompanying
+ordinary cases of concussion of the brain. The similarity of the
+phenomena to those described in other parts of the body under the
+heading 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 to
+be exhibited. This depended on two circumstances: first, the rarity of
+injuries giving rise to meningeal haemorrhage; secondly, the fact that in
+nearly every case a more or less extensive destructive lesion was
+present, at the margins of which less completely destroyed tissue
+remained, capable of giving rise to symptoms of irritation. Again, as we
+have seen, free haemorrhage into, or from the walls of, the cavities
+produced in the brain was not a marked feature, and beyond this the
+large defect in the cranial parietes was calculated to render a high
+degree of compression impossible.
+
+As the most serious head injuries presented a remarkable similarity in
+their symptoms, I will shortly summarise their common features.
+
+Every degree of mental stupor up to complete unconsciousness was met
+with, but in some instances where the pulse, respiration, and general
+bodily condition pointed to speedy dissolution, the patients answered
+rationally often between moans or cries indicative of pain.
+
+Widespread paralysis often existed, but this was seldom completely
+general; more commonly it was combined with extreme restlessness of the
+unparalysed parts, or sometimes, even when the whole of one hemisphere
+was tunnelled, and in all probability widely destroyed, restlessness was
+the only symptom. In some cases twitching of the features or the limbs
+or severe convulsions were superadded.
+
+The pupils were rarely unequal, and at the stage in which these patients
+were first seen were usually moderately contracted. Wide dilatation was
+uncommon throughout.
+
+The pulse was with very few exceptions slow, sometimes irregular. In
+some instances, when the wounds had been thought suitable for
+exploration, 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 of
+the Cheyne-Stokes type; actual stertor was exceptional, but the
+respiration was often noisy.
+
+The temperature was often raised from an early stage to 99 deg. or 100 deg., and
+if the patient survived a day or two, it often rose to 103 deg. or 104 deg.. How
+far the secondary rise depended on sepsis it was not always easy to
+determine. The urine was usually retained.
+
+Cases presenting the above characters were usually those suffering from
+lesions such as are described in class I., and mostly died in
+twenty-four to forty-eight hours. The correspondence of the train of
+symptoms with those due to combined brain destruction and severe
+concussion is at once apparent.
+
+To illustrate the nature of the symptoms in patients suffering from the
+less extensive forms of injury, such as those included in classes II.
+and III. under the heading of anatomical lesion, the relation of a short
+series of histories will be advisable. I may first premise, however,
+that the special characteristics of these were in some instances the
+almost entire absence of primary symptoms of gravity; in others general
+symptoms of a severity out of apparent proportion to the external
+lesion; while in all destructive lesions, very widely distributed
+radiation symptoms developed, often disappearing with great rapidity.
+
+The symptoms consisted in those of concussion, irritation, local
+pressure, and actual destruction.
+
+The symptoms of concussion were either general, and then usually
+transient, or local paralysis of the radiation variety, which also
+rapidly improved.
+
+Signs of irritation consisted in irritability of temper, drowsiness,
+closure of the eyes and objection to light, contracted pupils sometimes
+unequal, a tendency to the assumption of the flexed position at all the
+joints, twitchings, and sometimes convulsions. Sometimes these appeared
+early as a direct result of mechanical irritation from bone fragments or
+blood-clot; sometimes only in the course of a few days, as a result of
+irritation of parts recovering from the radiation effects which had
+prevented earlier nervous reaction. Possibly in some cases the symptoms
+of irritation depended upon an increase in the amount of haemorrhage, and
+in others upon the development of local inflammatory changes.
+
+Local pressure, or actual destruction of brain tissue, was evidenced by
+temporary paralysis in the former, permanent loss of function in the
+latter, condition.
+
+Fractures of the anterior fossa of the skull were attended by very
+marked evidence of orbital haemorrhage, as subconjunctival ecchymosis
+(rarely pure), increased tension, and proptosis.
+
+Injuries to the cranial nerves at the base, with the single exception of
+lesion of the optic nerves, which was not rare, were in my experience
+uncommon in the hospitals--a fact pointing to the very fatal nature of
+direct basal injuries, except in the anterior fossa of the skull. Signs
+indicative of injury to the olfactory lobe were occasionally observed.
+
+I should, perhaps, again insist here on the rarity with which acute
+diffuse septic infection occurred in cases of these degrees of severity,
+also on the fact that interference with the wounds in the way of
+secondary exploration, even when they were manifestly the seat of local
+infection, was followed almost without exception by good immediate
+results; and, lastly, that when suppuration did occur, it was usually
+strictly local in character. The influence of the climate of South
+Africa and our surroundings has already been discussed, but whether
+climate, condition of the patients, or peculiarity in the nature of
+causation of the wounds was responsible, in no series of cases was the
+absence of acute inflammatory troubles more striking than in this one of
+brain injuries.
+
+Frontal injuries were those most frequently unaccompanied by primary
+symptoms of severity; slowing of the pulse--this often fell to 40--and
+occasional irregularity, were almost the only constant signs of cerebral
+damage. Some patients temporarily lost consciousness, others rose at
+once and walked to the dressing station, and in few cases was any
+psychical disturbance noted in the early stages.
+
+I think, however, it may be affirmed that frontal injuries, accompanied
+by trivial signs, resulted without exception from the passage of bullets
+travelling at a low rate of velocity. Thus in several of the instances
+here related the patients at the time of reception of the wound were
+under the impression that they were entirely beyond the range of fire,
+and in one, in which well-marked signs of concussion followed, the
+bullet, which had traversed the head, retained only sufficient force to
+perforate the skin of the neck and bury itself in the posterior
+triangle without even fracturing the clavicle, against which it
+impinged. In men struck at a shorter range, signs of concussion, often
+followed by transient radiation signs of injury to the parietal lobe,
+were common. These signs were, I think, not as a rule due to surface
+haemorrhage, since they were of a purely paralytic nature and not
+irritative. 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 deg.. 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 the
+cortical motor area were seldom absent, sometimes evanescent, at others
+prolonged. In some cases the signs were permanent and followed by
+evidence of local sclerosis.
+
+The motor area on both sides of the brain was sometimes implicated; thus
+in a child shot at Kimberley the bullet entered in the right frontal
+region, and emerged to the left of the line connecting bregma and inion
+a little behind its centre. Paralysis of both lower extremities
+resulted, power rapidly returning in the right, while incomplete
+paralysis persisted in the left.
+
+In only one instance (see case 73, p. 292) was any permanent sensory
+defect observed, and the mental condition of this patient would have
+certainly suggested a functional explanation for its presence, had it
+not been for the accompanying inequality in the axillary surface
+temperatures.
+
+In a second case (No. 67) blunting of sensation followed a definite
+lesion of the inferior parietal lobule. In this instance an occipital
+lesion 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 diploe
+     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 deg., 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 superficial
+injuries were comparatively favourable; those near the base, especially
+if perforating, were very dangerous. Two such cases are referred to
+elsewhere. Case 69 is included as the only example of cerebellar injury
+I happened to see who lived any appreciable time after the accident.
+
+The main interest in these cases centres in the defects produced in the
+area 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 the
+following cases. It will be noted that in two instances the injury was
+to the left occipital lobe. In these the resulting hemianopsia was of
+the pure lateral homonymous character, and in both the visual symptoms
+were accompanied by a certain degree of amnesic aphasia (65 and 68).
+
+In 65 the injury was definitely unilateral, and at the time of the
+operation I decided that at least an inch and a half of the posterior
+extremity of the left occipital lobe was totally destroyed.
+
+In 68 the lesion was probably confined to the left lobe, but it is
+impossible to exclude slight injury to the right lobe also. In this
+instance amnesic aphasia was a far more marked symptom than in 65, and
+the position of the lesion suggested damage both to the visual and
+auditory 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 so
+near the median line, and accompanied by such severe damage to the bone,
+that a symmetrical lesion of the cuneate and precuneate lobules of both
+right and left sides is to be inferred. In 67 the great longitudinal
+fissure was traversed by the bullet obliquely. It is of great interest
+to observe that in each of these cases the lesion of the visual field
+was a horizontal one and affected the lower half in place of assuming a
+lateral distribution.
+
+In all four cases the primary effect of the occipital injury was the
+same--viz. absolute blindness--while the return of vision in each was of
+the nature of the dawning of light. I regret that I am unable to furnish
+any detail as to increase of the field of vision in the progress of the
+cases, but circumstances rendered continuous observation of the patients
+impossible.
+
+In each case deafness was apparently the direct result of concussion of
+the ear on the side corresponding to the wound. Deafness of the opposite
+ear was never noted.
+
+In case 67 some general blunting of sensation was noted in the paralysed
+upper extremity, and in this patient, no doubt, injury to the inferior
+parietal 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 deg.. 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 haemorrhage (nor did the
+     history suggest that haemorrhage 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 left
+occipital lobe. Field for white. Test spot 10 mm. Good daylight. Right
+homonymous 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
+     haemorrhage.
+
+     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 deg.. 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 both
+occipital lobes. Field for white. Test spot 10 mm. Good artificial
+light. Defect in field complicated by functional symptoms]
+
+[Illustration: FIG. 76.--Left Visual Field, in case 66. Defect in lower
+half 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 haemorrhage 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 both
+occipital lobes. Field for white. Test spot 10 mm. Good artificial
+light. 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 to
+me, 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 notes
+of 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 vertebrae, 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 been
+mentioned as one of the peculiarities of some explosive wounds. In the
+later stages of the cases in which primary union did not take place the
+development of granulation tumours was often seen, sometimes in
+connection with slight local suppuration, sometimes over a cerebral
+abscess. In some cases a wound which had once closed reopened and a
+hernia developed. This sequence was chiefly of prognostic significance
+as an indication of intra-cranial inflammation, usually of a chronic
+character, and affecting rather the lowly organised granulation tissue
+formed in the cavity than the brain itself. When primary union of the
+skin flap and wound failed, the process of definitive closure of the
+subjacent cavity was always a very prolonged one, and it was in such
+cases that a great proportion of the so-called herniae developed.
+
+_Abscess of the brain._--Local abscesses formed in a considerable
+proportion of the cases where serious damage to the brain had occurred,
+in whatever region this happened to be. I never saw one develop in cases
+where primary union had taken place, even when bone fragments had not
+been removed; neither did I ever see an abscess situated at a distance
+from the original injury. I take it that the latter is to be explained
+by the early date of the suppuration, and the fact that in the great
+majority of small-calibre wounds the exit opening exists in the
+situation of the contre-coup damages of civil practice.
+
+The main feature in the symptoms when abscesses developed was the
+insidious mode of their appearance, usually at the end of fourteen to
+twenty-one days, and their comparative mildness.
+
+Very slight evidences of compression were observed; thus, varying
+degrees of headache, drowsiness, irritability of temper or depression,
+twitchings, or in some cases Jacksonian seizures, combined with slow
+pulse and slight rises of temperature. I never happened to see complete
+unconsciousness. The slight evidence of compression was perhaps
+explained in most cases by the large bony defect in the skull, which
+acted as a kind of safety-valve. Again the firm nature of the
+cicatricial tissue which formed at the periphery of the injury and
+extended up to the skull and there formed a more or less firm
+attachment, also preserved the actual brain tissue to some degree from
+either pressure or direct irritation. After evacuation of the pus, the
+usual difficulty was experienced in ensuring free drainage, and
+definitive healing and closure of the cavities was very slow. The
+following two cases will illustrate the character of the cases of
+cerebral 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 to
+determine the condition of the bone has already been insisted upon. The
+localisation of the position and extent of the injury to the cranial
+contents depended simply on attention to the symptoms, and needs no
+further mention here.
+
+_Prognosis._--This subject can only be very imperfectly considered at
+the present time, since only the more or less immediate results of the
+injuries are known to us, while the more important after consequences
+remain to be followed up.
+
+As to life the immediate prognosis has been already foreshadowed in the
+section on the anatomical lesions. It is there shown that the first
+point of general importance is the range of fire at which the injury has
+been received. At short ranges, as evidenced by the history, the
+characters of the wounds, and the severity of the symptoms, the
+immediate prognosis was uniformly bad, a very great majority of the
+patients dying, and that at the end of a few hours or days.
+
+The rapidity with which death followed depended in part on the actual
+severity of the wound, and still more on the region it affected; the
+nearer the base and the longer the track the more rapidly the patients
+died, and this always with signs of failure of the functions of the
+heart and lungs due to general concussion, pressure from basal
+haemorrhage, or rapid intracranial oedema. In my experience no patients
+survived direct fracture of the base in any region but the frontal,
+although many, no doubt, got well in whom fissures merely spread into
+the middle or posterior fossa. Patients with very extensive injuries at
+a 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 idea
+of, 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 at
+Paardeberg Drift, no less than 8 died; while of 61 cases from various
+battles who survived to be sent down to the Base during a period of some
+months, only 4 or 6.55 per cent. died. Many of the latter, as is seen
+from the cases here recorded which were among the number, were none the
+less of a very serious nature. The early causes of death in patients
+dying 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 to
+the frontal lobes, and after these in injuries to the occipital region.
+In the latter permanent lesions of vision were, however, common. The
+above injuries apart, the prognosis depended on the severity and depth
+of the lesion. The frequency and extent of radiation symptoms often made
+it possible to give a more hopeful prognosis than the immediate
+conditions seemed to warrant, if the exact situation of the lesion, and
+the probable velocity at which the bullet was travelling, were taken
+into account; since the actual destructive lesion, when the velocity had
+been insufficient to cause damage of a general nature, was often very
+strictly localised.
+
+Another very important point in the immediate prognosis was the primary
+union of the scalp wound; if this could only be ensured, few cases went
+wrong afterwards. Such remote effects as I witnessed were mainly the
+results of the actual destructive lesion, such as paralyses and
+contraction. I know of only one case in which early maniacal symptoms
+closely followed on a frontal injury, and here the symptoms accompanied
+the development of an abscess. Some patients were depressed and
+irritable, and some were blind or deaf, probably from gross lesion; in
+one patient the mental faculties generally were lowered.
+
+In spite of the surprising immediate recoveries which occurred, and the
+small amount of experience I am able to record as to remote ill effects
+of these injuries, I feel certain that a long roll of secondary troubles
+from the contraction of cicatricial tissue, irritation from distant
+remaining bone fragments, as well as mental troubles from actual brain
+destruction, await record in the near future.
+
+Since my return to England I have heard of four cases of injury to the
+head, which died on their return, as the result of the formation of
+secondary residual abscesses; and of one who died suddenly, soon after
+his return to active service in South Africa apparently well. These
+occurrences are sufficiently suggestive.
+
+It may be of interest to add here two cases of secondary traumatic
+epilepsy 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 deg. 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 degree
+of surgical interest that attaches to no other class of gunshot injury,
+since operative interference is necessary in every case in which
+recovery is judged possible. The injuries are, without exception, of the
+nature of punctured wounds of the skull, and the ordinary rule of
+surgery should under no circumstances be deviated from. An expectant
+attitude, although it often appears immediately satisfactory, exposes
+the patient to future risks which are incalculable, but none the less
+serious. Happily the operations needed may be included amongst the most
+simple as well as the most successful, and expose the patient with
+ordinary precautions to no increase of risk beyond that dependent on the
+original injury.
+
+Cases of a general character, or in which the base has been directly
+fractured other than in the frontal region, are seldom suitable for
+operation, since surgical skill is in these of no avail; but in all
+others an exploration is indicated. I use the word 'exploration'
+advisedly, since what may be called the formal operation of trephining
+is seldom necessary except in the case of the small openings due to
+wounds received from a very long range of fire; in all others there is
+no difficulty, but very great advantage, in making such enlargement of
+the bone opening as is necessary with Hoffman's forceps.
+
+The scalp should be first shaved and cleansed; if for any reason an
+operation is impossible, this procedure at least should be carried out,
+with a view to ensuring, as far as possible, future asepsis, infection
+in head injuries being almost the only danger to be feared. The shaving
+may need to be complete, but local clearance of the hair suffices in
+many cases. The hair having been removed, the scalp is cleansed with all
+care, a flap is raised of which the bullet opening forms the central
+point, and the wound explored. In slight cases the entry opening is the
+one of chief importance, and the exit may be simply cleansed and
+dressed. In some instances, as in direct fracture of the roof of the
+orbit from above, the exit should not be touched.
+
+The flap having been raised, if the wound be a small perforation, a
+1/2-inch trephine crown may be taken from one side; but it is rare for
+the opening to be so small that the tip of a pair of Hoffman's forceps
+cannot be inserted. The trephine is more often useful in cases of
+non-penetrating gutter fractures where space is needed for exploration,
+and the elevation or removal of fragments of the inner-table. Loose
+fragments may need to be removed from beneath the scalp, but the
+important ones are those within the cranium. These may either be of some
+size, or fine comminuted splinters of either table, often at as great a
+distance as 2 inches or more from the surface. The cavity must be
+thoroughly explored and all splinters removed. I have seen more than
+fifty extracted in one case of open gutter fracture. The brain pulp and
+clot should then be gently removed or washed away, and the wound closed
+without drainage. Fragments of bone, as a rule, are better not replaced,
+but complete suture of the skin flap is always advisable in view of the
+great importance of primary union, and the fact that a drainage opening
+exists at the original wound of entry, and that the wound is readily
+re-opened to its whole extent, should such a step be advisable.
+
+The detection of fragments is easiest and most satisfactorily done with
+the finger, and in all but simple punctures the opening should be large
+enough to allow thoroughly effective digital exploration; the remarks
+already made as to the factors determining the size of fragments are of
+interest in this connection. The determination of the amount of brain
+pulp which should be removed is somewhat more difficult; one can only
+say that all that washes readily away should be removed, and its place
+is usually taken up by blood.
+
+Few fractures of the base are suitable for treatment; the only ones I
+saw were those of direct fracture of the roof of the orbit or nose,
+produced by bullets passing across the orbits; here the advisability of
+interference with the injured eye led to opening of the orbit, and
+sometimes exposed the fracture. Some patients recovered, even when the
+damage had been sufficient to cause escape of pulped brain into the
+orbit.
+
+The after treatment simply consisted in keeping the patients as quiet as
+circumstances would permit, and the administration of a fluid diet. In
+some cases recurring symptoms pointed to the continued presence of bone
+fragments; these were usually indicated by signs of irritation, or often
+of local inflammation, in the latter case infection taking the greater
+share in the causation. Such cases needed secondary exploration, and the
+wonderful success of this operation, even when the wound was evidently
+infected, was perhaps one of the most striking experiences of the
+surgery in general.
+
+I should add a word here as to the most satisfactory time for the
+performance of these operations; as in all cases the earlier they could
+be undertaken the better, but in the head injuries the advantages of
+early interference were more evident than in any other region. This
+depended on the fact that, as in civil practice, the scalp is one of the
+most dangerous regions as far as auto-infection of the wound is
+concerned, and one of the most difficult to cleanse, except by thorough
+shaving. Beyond this the extreme simplicity of the operative procedure
+needed, called for few precautions beyond those for asepsis, and very
+little armament in the way of instruments, &c.
+
+When on the march from Winberg to Heilbron with the Highland Brigade we
+had some five days' continuous fighting, and on this occasion several
+perforating fractures of the skull were brought in. The coldness of the
+nights at that time made evening operations an impossibility; hence the
+operations on these men were performed at the first dressing station, in
+the open air, at the side of the ambulance wagons, often during the
+progress of fighting around. Of several cases so operated on, all healed
+by primary union without a bad symptom of any kind, except one (see p.
+249), in whom a very large entrance opening over the right cortical
+motor 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 at
+the end of fourteen days. As the whole cortical motor area was
+destroyed, death was, perhaps, the end most to be desired; but the fight
+that 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 the
+injury, very strongly impressed me with the possibility of recovery,
+even in such extensive cases, if only an aseptic condition can be
+maintained. I saw many other cases of the same nature, particularly in
+men who, as a result of unfortunate circumstances, were necessarily left
+out on the field for more than twenty-four hours. In some of these
+maggots were found in the wounds only thirty-six hours after the
+infliction of the injury.
+
+I have said nothing as to the treatment of the large primary herniae
+cerebri in wounds of an explosive nature, since these were rarely
+subjects suitable for operation; but in the instances of minor severity
+they were treated as the other cases where the pulped brain lay mostly
+within the skull.
+
+In cases where the wounds were in the frontal or fronto-parietal
+regions, and hemiplegia existed, the rapid improvement in the paralytic
+symptoms, after operation, was very marked, showing that the signs were
+mainly, or entirely, due to 'radiation' injury. I am inclined to think
+that temporary injury of this kind from vibratory disturbance and small
+parenchymatous haemorrhages, were far more often the cause of the
+paralysis than surface haemorrhage, since the latter was rarely found in
+large quantity. Large clots, however, no doubt growing in both size and
+firmness, occasionally occupied the area of destroyed brain, and these
+sometimes manifestly exercised pressure that was at once relieved by
+their evacuation.
+
+In cases where inflammatory hernia cerebri developed, a secondary
+exploration was often indicated for the removal of fragments of bone or
+the evacuation of pus, otherwise the condition was best treated by dry
+dressings and gentle support.
+
+Abscess of the brain was treated by simple evacuation and drainage by
+metal or rubber tubes: the operations were always of extreme simplicity,
+since the abscess in every case I saw was in the direct line of the
+wound track, and was readily opened by the insertion of a director or
+blunt knife. The only trouble in the after treatment was that already
+referred to, of preventing premature closure of the drainage opening.
+
+I have made no special reference to the method of dressing, since it was
+of the ordinary routine kind. The most important factor in success was
+the efficient primary disinfection of the scalp; a piece of antiseptic
+gauze and some absorbent wool, efficiently secured, was all that was
+needed later.
+
+As usual the consideration of the treatment of cases in which the bullet
+was retained may be considered last. Such accidents were distinctly
+rare. I operated in only one (No. 54, p. 260) in whom the indications
+both for localisation and interference were obvious, since the bullet
+had palpably fractured the bone, although it had not retained sufficient
+force to enable it to leave the skull. In two other cases that I saw, in
+one the bullet was lodged in the zygomatic fossa, in the second just
+below the mastoid process. The former patient died; the latter exhibited
+symptoms indicative of injury to the occipital lobe (No. 68), and was
+successfully treated by Mr. J. E. Ker. I never happened to see a case in
+which a retained bullet in the skull was localised by the X rays, but
+such might have been possible in case No. 64, p. 275. In no case is
+primary interference indicated, unless a fracture exists where the
+bullet has tried to escape, or secondary symptoms develop pointing to
+irritation.
+
+Under ordinary circumstances, moreover, the indications for removal of a
+bullet are not likely to be sufficiently imperative to necessitate the
+operation being undertaken until the patient can be placed under the
+best conditions that can be secured. This is the more advisable since
+such operations need the infliction of an additional wound, require
+great delicacy, and may be very prolonged in performance. The experience
+of civil practice has already sufficiently proved the small amount of
+inconvenience likely to follow the retention of a bullet in the skull.
+
+I may again mention the fact that in explorations for the removal of
+bone fragments, fragments of lead, from breaking or setting up of the
+bullet, are sometimes found.
+
+Taken as a whole, the operations on the head were extremely satisfactory
+from a technical point of view; the large depressed pulsating cicatrix
+so often left was the chief defect observed. The circumstances under
+which 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 the
+scope of these experiences. In case 73, p. 292, it is of interest to
+note the manner in which the cavity due to loss of brain substance was
+filled up. No doubt a similar vicarious arachnoid space develops in all
+cases in which a soft pulsating swelling fills an aperture in the bones
+of the skull.
+
+
+WOUNDS OF THE HEAD NOT INVOLVING THE BRAIN
+
+_Mastoid process._--The most important wound of the cranium not already
+mentioned was that involving the mastoid process and the bony capsule of
+the ear. Wounds of the mastoid process obtained their chief interest in
+connection with paralysis of the seventh nerve. This nerve rarely or
+never escaped, and, as far as my experience went, the facial paralysis
+was permanent (see cases 111-114, p. 355). I think the same prognosis
+holds good with regard to the deafness resulting from these injuries,
+and it is difficult to believe, with our experience of the effect of
+vibration on other nerve centres and organs, that the internal ear could
+ever escape permanent damage.
+
+In a number of cases the tympanum itself, or the external auditory
+meatus, was directly implicated in tracks; in these, also, loss of
+hearing was the rule.
+
+Wounds of the pinna when produced by undeformed bullets were usually of
+the same slitlike nature remarked in perforations of the cartilages of
+the nose, and healed with equal rapidity.
+
+_Wounds of the orbit._--Injuries to the orbit were very numerous and
+serious in their results, both to the globe of the eye and the
+surrounding structures.
+
+_Anatomical lesions._--The wound tracks, with regard to the injuries
+produced, 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 this
+mainly from the fact of limitation of the injury to one orbital cavity.
+They were usually produced by bullets passing from above downwards
+through the frontal region of the cranium, and were received by the
+patients while in the prone position.
+
+Transverse and oblique wounds owed their greater importance to the fact
+that both eyes were more likely to be implicated.
+
+Besides these tracks, which actually crossed the cavities, a number
+involved the bony boundaries, producing almost as severe lesions in the
+globe of the eye, many of the patients being rendered permanently blind.
+The only difference in nature of such cases was the escape of orbital
+structures, and this was of minor importance in the presence of the
+graver 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 haemorrhage (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 I
+saw were two in which lateral impact by a bullet crossing the cranial
+cavity caused general comminution of the whole orbital roof. Fissures of
+the roof were common in connection with 'explosive' exit apertures in
+the frontal region of the skull. Pure perforations usually accompanied
+the vertical or transverse wounds of the cavity, fragments at the
+aperture of entry then being projected into the orbit, sometimes
+penetrating the muscles.
+
+Occasionally the margin of the cavity was merely notched.
+
+The ocular muscles were often divided more or less completely, and
+occasionally some difficulty arose in determining whether loss of
+movement of the globe in any definite direction depended on injury to
+the muscle itself, or to the nerve supplying the muscle. The following
+case 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 haemorrhage with proptosis and
+ecchymosis of the lids were usually well marked. The latter was
+sometimes extreme.
+
+Injury to the nerves was naturally of a very mixed character. In many
+instances the branches of the first two divisions of the fifth nerve
+were obviously implicated and regional anaesthesia was common. This was
+often transitory when the result of vibratory concussion, contusion, or
+pressure from haemorrhage. In other cases it was more prolonged as a
+result of actual division of the nerve. As is usually the case, when a
+small area of distribution only was affected, sensation was rapidly
+regained from vicarious sources, even when section had been complete.
+
+As individual injuries, those to the optic nerve were the most
+frequently diagnosed. I am sorry to be unable to attempt a
+discrimination of injuries to the nerve alone from those in which both
+nerve and globe suffered, but the globe can rarely have escaped injury,
+either direct or indirect, when the bullet actually traversed the
+orbital cavity. (A few further remarks concerning injuries to the optic
+nerve will be found in Chapter IX.)
+
+Injuries to the globe of the eye, either direct or indirect, accompanied
+most of the orbital wounds.
+
+In some the lesion was of the nature of concussion. In such the bone
+injury was usually at the periphery of the orbit, or to the bones of the
+face in the neighbourhood. The loss of vision might then be temporary,
+persisting from two to ten days, then returning, often with some
+deficiencies.
+
+In other similar external injuries, the lesion of the globe was more
+severe, and permanent blindness followed.
+
+In variability of degree of completeness, these lesions of the globe
+corresponded exactly with those produced in other parts of the nervous
+system by bullets striking the bones in their vicinity, and they were no
+doubt the result of a similar transmission of vibratory force.
+
+In a third series of cases the globe suffered direct contusion, and in a
+fourth was perforated and destroyed.
+
+In cases in which permanent blindness was produced without solution of
+continuity of the sclerotic coat, the nature of the lesion was probably
+in most cases vibratory concussion and the development of multiple
+haemorrhages from choroidal ruptures of a similar nature to those seen in
+the brain and spinal cord. The actual haemorrhagic areae varied in size;
+but, as far as my experience went, gross haemorrhages into the anterior
+chamber did not occur without severe direct contact of the bullet.
+
+In the vast majority of the cases blindness, whether transitory or
+permanent, developed immediately on the reception of the injury, and was
+possibly in its initial stage the result of primary concussion.
+
+Cases were, however, seen occasionally in which the symptoms were less
+sudden, of which the following is an example. I did not think that the
+mode of progress seen here could be referred to simple orbital
+haemorrhage, although this existed, but rather to intravaginal haemorrhage
+into the sheath of the optic nerve. On external inspection the globes
+appeared 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 palpebrae superioris acted very slightly;
+     the right, however, better than the left.
+
+     There were marked right proptosis, less left proptosis, and
+     slight patchy subconjunctival haemorrhage 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, kindly
+furnishes me with the following note as to the condition. There was
+extensive damage to both eyes, haemorrhage, and probably retinal
+detachment as well as choroidal changes.
+
+The quotation of a few illustrative examples typical of the ordinary
+orbital 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. Anaesthesia 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
+     haemorrhage 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 palpebrae
+     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 haemorrhage, 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 haemorrhage, 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 cases
+in which return of vision was rapid, the prognosis was consistently bad
+in 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 I
+saw secondary suppuration.
+
+With regard to active treatment, the majority of the cases were
+complicated by fracture of the roof of the orbit, and in many instances
+concurrent 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 roof
+prior to removal of the injured eye, if that was considered necessary.
+The only exception to this rule was offered by instances in which the
+bullet passed from the orbit into the cranium; in these primary removal
+of fragments projecting into the frontal lobe was preferable. As already
+indicated, such wounds were comparatively rare except in the case of
+bullets coursing transversely or obliquely.
+
+The wounds were, as a rule, followed by considerable matting of the
+orbital structures.
+
+_Wounds of the nose._--I will pass by the external parts, with the
+remark that perforating wounds of the cartilages were remarkable for
+their sharp limitation and simple nature. I remember one case shown to
+me in the Irish Hospital in Bloemfontein by Sir W. Thomson, in which at
+the end of the third day small symmetrical vertical slits in each ala
+already healed were scarcely visible. This case very strongly impressed
+one with the doctrine of chances, since on the same morning I was asked
+to see a patient in whom a similar transverse shot had crossed both
+orbits, destroying both globes and injuring the brain.
+
+A retained bullet in the upper portion of the nasal cavity has already
+been referred to (fig. 60). This accident was naturally a rare one; in
+that instance the bullet had only retained sufficient force to insert
+itself neatly between the bones.
+
+Wounds crossing the nasal fossae were comparatively common. The
+interference with the sense of smell often resulting is discussed in
+Chapter IX.
+
+_Wounds of the malar bone_ were not infrequent. The small amount of
+splintering was somewhat remarkable considering the density of structure
+of the bone. In this particular the behaviour of the malar corresponded
+with what was observed in the flat bones in general. A case quoted in
+Chapter III. p. 87, illustrates the capacity of the hard edge of the
+bone to check the course of a bullet, and cause considerable deformity
+and fissuring of the mantle.
+
+_Wounds of the jaws. Upper jaw._--A large number of tracks crossing the
+antrum transversely, obliquely, or vertically were observed. In the
+first case the nasal cavity, in the others the orbital or buccal cavity,
+were generally concurrently involved. It was somewhat striking that I
+never observed any trouble, immediate or remote, from these perforations
+of the antrum. If haemorrhage into the cavity occurred, it gave rise to
+no ultimate trouble. I never saw an instance of secondary suppuration
+even in cases where the bullet entered or escaped through the alveolar
+process with considerable local comminution. The branches of the second
+division of the fifth nerve were sometimes implicated. In one instance a
+bullet traversed and cut away a longitudinal groove in the bones,
+extending from the posterior margin of the hard palate, and terminating
+by a wide notch in the alveolar process.
+
+A good example of a troublesome transverse wound of the bones of the
+face 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 some
+peculiarities, the chief of which were the liability of any part of the
+bone to be damaged, and the absence of the obliquity between the cleft
+in the outer and inner tables so common in the fractures seen in civil
+practice.
+
+The neck of the condyle I three times saw fractured; in each instance
+permanent stiffness and inability to open the mouth resulted. This
+stiffness was of a degree sufficient to raise the question whether the
+best course in such cases would not be to cut down primarily and remove
+a considerable number of loose fragments, and thus diminish the amount
+of callus likely to be thrown out.
+
+Fractures of the ascending ramus and body were more frequent. They were
+accompanied by considerable comminution, but all that I observed healed
+remarkably well, and in good position, in spite of the fact that many of
+the 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 these
+fractures were at the lower margin of the bone, the buccal cavity
+occasionally escaped in spite of considerable comminution, the latter
+confining itself to the basal portion of the bone.
+
+When the base of the teeth, or the alveolus, was struck, a wedge was
+often broken away, and from the apex of the resulting gap a fracture
+extended to the lower margin of the bone.
+
+When fractures of the latter nature resulted from vertically coursing
+bullets, much trouble often ensued. I will quote two cases in
+illustration:--
+
+     (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 haemorrhage 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 from
+the bullet to the teeth, and bears on the theory of explosive action.
+
+In the treatment of fractures of the upper jaw, interference was rarely
+needed. In the case of the mandible, a remark has already been made as
+to the advisability of removing fragments when the neck of the condyle
+has suffered comminution. The removal of loose fragments is necessary in
+all cases in which the buccal cavity is involved. Experience in fracture
+of the limbs has shown a tendency to quiet necrosis when comminution was
+severe, in spite of primary union. This is no doubt dependent on the
+very free separation of fragments on the entry and exit aspects from
+their enveloping periosteum. In the case of the mandible, considerable
+necrosis is inevitable, and much time is saved by the primary removal of
+all actually loose fragments.
+
+A splint of the ordinary chin-cap type with a four-tailed bandage meets
+all further requirements, but the patients often object to them. Cases
+in which the fragments could be fixed by wiring the teeth were not
+common, as the latter had so frequently been carried away. The usual
+precautions as to maintaining oral asepsis were especially necessary.
+
+The results of fractures of the mandible were, in so far as my
+experience went, remarkably good, as deformity was seldom considerable.
+The absence of obliquity and the effect of primary local shock were no
+doubt favourable elements, little primary displacement from muscular
+action occurring.
+
+Wounds of the _cheek_ healed readily, and the same was noticeable of the
+lips. Wounds of the _tongue_ healed with remarkable rapidity when of the
+simple perforating type, often with little or no swelling or evidence of
+contusion. At the end of a few days it was often difficult to localise
+them.
+
+In connection with this subject a remarkable case which occurred at the
+fighting at Koodoosberg Drift is worthy of mention, although the
+projectile 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 septicaemia 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 septicaemia secondary to wound of the
+     tongue.
+
+
+WOUNDS OF THE NECK
+
+Wounds of the neck were not unfrequent and were of the gravest
+importance; there can be little doubt that they accounted for a
+considerable proportion of the deaths on the field. On the other hand,
+the neck as a region offered some of the most striking examples of
+hairbreadth escape of important structures. Consideration of a number of
+the vascular lesions (see cervical aneurisms, p. 135) also shows
+conclusively that in no region did the small size of the bullet more
+materially influence the result, since no doubt can exist that all these
+wounds would have proved immediately fatal if produced by projectiles of
+larger calibre.
+
+In this place only a few general considerations will be entered into, as
+most of the important cases are dealt with under the general headings of
+vessels, nerves, and spine; but it is convenient to include here the few
+remarks that have to be made concerning the cervical viscera.
+
+The wounds of the soft parts might course in any direction, but vertical
+tracks from above downwards were rare. In point of fact, these occurred
+only in connection with perforations of the head, and as vertical wounds
+of the latter were received in the prone position, usually when the head
+was raised, the necessary conditions for longitudinal tracks were seldom
+offered. One case of a complete vertical track in the muscles of the
+back of the neck has been already quoted (No. 69, p. 286).
+
+Tracks coursing upwards from the trunk were somewhat more frequent in
+occurrence; thus a considerable number traversing the thorax were seen.
+In such instances the aperture of exit was generally situated in the
+posterior triangle, and some of the brachial nerves often suffered.
+
+The commonest forms of wound were the transverse or the oblique. A large
+number of cases with such tracks will be found among the cases of injury
+to the cervical vessels and nerves. In some instances the course was
+restricted to the neck alone, in others the trunk or upper extremity was
+also implicated.
+
+The favourable influence of the arrangement of the structures of the
+neck, which allows of the ordinary displacement excursions necessary for
+deglutition, respiration, and their cognate movements, was very strongly
+marked. Thus in several cases the bullet traversed the neck behind the
+pharynx and oesophagus without injuring either viscus, and the escape
+of the main vessels and nerves was equally striking. In such wounds the
+wedge-like bullet without doubt separated and displaced all these
+structures, causing mere superficial contusion.
+
+In connection with the latter statement, the rarity of direct sagittal
+wounds in the hospitals should be mentioned. This is probably to be
+explained by the facts that wounds in the mid-line of the neck
+implicated the cervical spinal cord, and that sagittal wounds
+implicating the vessels were apt to lead more directly to the surface,
+and thus external haemorrhage was favoured. A few examples of cervical
+tracks will suffice to illustrate these remarks:--
+
+     (85) _Entry_ (Lee-Metford), below angle of scapula; _exit_,
+     centre of posterior triangle. Injury to the lung, and
+     haemothorax. 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 the
+pharynx; in each the injury was in the nasal or buccal segment of the
+cavity, and in each the soft palate was injured, in two instances the
+wound 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. The
+second was under the charge of Mr. Bowlby, and will no doubt be more
+fully recounted by him, as interesting signs of injury to the cervical
+cord were present. In the third the occipital neuralgia was the only
+troublesome symptom.
+
+In both cases 90 and 91 the high position of the wound in the fixed
+portion of the pharynx no doubt accounted for the absence of any
+infective 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 haemorrhage.
+
+     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. Haemorrhage
+     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 either
+side at the level of the Pomum Adami. Transitory haemorrhage and signs of
+oedema were the only signs referable to the wound, but in addition the
+bullet contused the left vagus and gave rise to temporary laryngeal
+paralysis. The same course was observed in a second case of perforation
+of the larynx of which I was told.
+
+_Wounds of the trachea._--The two cases recounted below are the only
+tracheal injuries I met with; in one the oesophagus was also
+implicated. This patient died from mediastinal emphysema. In the second
+case the wide development of emphysema was prevented by the early
+introduction 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 haemorrhage 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 vertebrae and the
+contents of the spinal canal was met with considerable frequency. Pure
+uncomplicated fractures of the bones were of minor importance, except in
+so far as they exemplified the general tendency to localised injury in
+small-calibre bullet wounds. Injuries implicating the spinal medulla, on
+the other hand, were proportionately the most fatal of any in the whole
+body to the wounded who left the field of battle or Field hospital
+alive, and these cases formed one of the most painful and distressing
+features of the surgery of the campaign.
+
+The prognostic gravity of any spinal injury depended upon two factors:
+first, the obvious one of relative contiguity or direct implication of
+the cord or nerves in the wound track; secondly, the degree of velocity
+retained by the bullet at the moment of impact with the spine.
+Observation of the serious ill effects produced by bullets passing in
+the immediate proximity of large strongly ensheathed peripheral nerves
+surrounded by soft tissue, such as those of the arm or thigh, would lead
+one to expect that a comparatively thin-clad bundle of delicate nerve
+tissue like the spinal cord, enclosed in a bony canal so well disposed
+for the conveyance of vibrations, would suffer severely, and such proved
+to 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 determination
+of the injury to anyone being naturally dependent on the position and
+direction taken by the wound track.
+
+For implication of the _transverse processes_ sagittal wounds coursing
+in varying degrees of obliquity were mainly responsible. Such injuries
+might be unaccompanied by any nerve lesion. Thus a Boer received a
+Lee-Metford wound at Belmont which passed from just below the tip of the
+right 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 persisted
+was opened up later, a number of small comminuted fragments were found
+detached from the transverse process of the axis. In other cases more or
+less severe symptoms of nerve lesion were observed, varying from
+transient hyperaesthesia, due to implication of the issuing nerves, to
+symptoms of spinal haemorrhage, 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 faeces,
+     complete motor and sensory paralysis of the right lower
+     extremity, and total absence of all reflexes. Anaesthesia
+     existed over the whole area of skin supplied by the nerves of
+     the sacral plexus, hyperaesthesia over that supplied by the
+     lumbar nerves.
+
+     On the tenth day subsequent to the injury, the hyperaesthesia 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 hyperaesthesia
+     developed, but on the twenty-eighth day the patient developed
+     secondary peritonitis from other causes and died on the
+     thirty-first. A fracture of the transverse process existed, but
+     unfortunately the spinal canal was not opened for examination
+     and no details can be given as to the condition of the cord.
+     (See case 201, p. 463.)
+
+Fractures of the _spinous processes_, or those involving both the
+process and laminae, were not uncommon. Isolated separation of the
+spinous process was usually the result of wounds crossing the back
+obliquely or transversely. Examples of this injury were numerous,
+especially in the dorsal region, as being the most prominent,
+particularly when the patients assumed the prone position when advancing
+on the enemy.
+
+Cervical injuries, owing to the comparatively sheltered position of the
+more deeply sunk spines, and from the fact that the head was usually
+under cover of a stone or ant-heap, were less common; in one instance
+hyperaesthesia was noted in one upper extremity as the result of a
+crossing bullet having struck the fourth cervical spine. In a man
+wounded at Paardeberg Drift the bullet entered at the centre of the
+buttock, traversed the bones of the pelvis, and, leaving that cavity
+above the crest of the ilium, crossed the spine to emerge in the
+opposite loin. Suppuration occurred, and when the wound was laid open
+the third and fourth lumbar spinous processes were found to be loosened,
+but still connected to the surrounding soft parts. There were no nerve
+symptoms in this case; these would not have been expected, since by the
+time that the bullet had traversed the bones of the pelvis its velocity
+must have been considerably lessened, even if high at the moment of
+primary impact. In another case a dorsal spine, together with its
+lamina, was separated and moveable; the only nerve symptoms were slight
+pain and a crop of herpes on the line of distribution of the
+corresponding intercostal nerve, the bullet having probably struck the
+nerve in passing across the intercostal space. In one instance of a
+retained bullet lying beneath the skin of the back, its passage between
+two contiguous dorsal spines without fracture of either was determined
+during an extraction operation.
+
+When the prone position was assumed by the men, more or less
+longitudinal wounds in the course of the spine were naturally liable to
+occur. These tracks assumed somewhat greater importance than the
+transverse ones, because the injury to bone was more often multiple, and
+the laminae were frequently implicated. The relative importance of such
+injuries was dependent on the velocity of the bullet and the depth at
+which it travelled. As an instance of a more serious character the
+following may be given:--
+
+     (95) In a Highlander wounded at Magersfontein, probably at a
+     range within 1,000 yards, the bullet entered at the right side
+     of the sixth cervical vertebra; tracking downwards, it loosened
+     the laminae of the fifth and sixth dorsal vertebrae from the
+     pedicles, and separated the tip of the seventh spine. The
+     bullet was extracted from beneath the skin at the latter spot,
+     its force having been no doubt exhausted by the resistance of
+     the firm neural arches supported by the weight of the man's
+     body. Symptoms of total transverse lesion of the cord followed,
+     and the patient died at the end of fifty-four days. The bone
+     had not apparently been sufficiently depressed to exert
+     continuous pressure, but the cord was diffluent and actually
+     destroyed over an area corresponding with the fourth, fifth,
+     sixth, and seventh dorsal segments.
+
+I saw no instance of wound of the _neural arch_ from a direct shot in
+the back in any of our men, neither was I ever able to detect an injury
+to the articular processes as a localised lesion.
+
+Injuries to the _centra_ were very frequent, but differed
+extraordinarily in their importance. Perforation by bullets travelling
+at a relatively low grade of velocity, but still one sufficient to allow
+them to pass through the body, produced in many instances no symptoms
+whatever when the track did not lie in immediate contiguity to the
+spinal canal or perforate it.
+
+In all the wounds which I had the opportunity of examining post mortem,
+the fracture was of the nature of a pure perforation of the cancellous
+tissue of the centrum, with no comminution beyond slight splintering of
+the compact tissue at the aperture of exit. In one instance the bullet
+passed in a coronal direction so close to the back of the centrum as to
+leave a septum of only the thickness of stout paper between the track
+and the spinal canal. In this case signs of total transverse lesion were
+present. I never happened to meet with a case in which the canal was
+encroached upon from the front by displaced bone. In some cases at the
+end of six weeks there was difficulty in determining the position of the
+openings, and section of the bone was necessary in order to assure
+oneself as to the direction of the track.
+
+In some instances the centra were pierced in the coronal direction with
+varying degrees of obliquity; in others the direction was more sagittal;
+in two of the latter the bullet was retained in the spinal canal. The
+tracks were sometimes confined to one vertebra, but often implicated
+two. In others the bullet passed longitudinally through the thorax,
+grooving or perforating one or more centra.
+
+The accompanying evidences of nerve injury varied from nil to those of
+pressure or irritation of the nerve roots, transient signs of spinal
+concussion, signs of contusion and haemorrhage, or to evidence of total
+transverse lesion. Instances of all these conditions will be quoted
+under the heading of injuries to the cord or nerves.
+
+_Signs of injury to the vertebrae._--Separation of the spinous processes
+was often indicated by slight deformity, either evident or palpable,
+local pain, tenderness, mobility, and crepitus. In some cases these
+local signs were reinforced by evidence of cord injury. Fractures
+involving the laminae differed merely in the degree to which the above
+signs were developed. Fractures of the transverse processes were
+generally only to be assumed from the position and direction of the
+wounds, the assumption being sometimes strengthened in probability by
+evidence of injury to the cord and nerves.
+
+Fractures of the centra were also frequently only to be assumed from the
+direction of the wound tracks, and possibly from evidence of nerve
+injury. When no paralysis supervened, interference with the movements of
+the back, or pain, was so slight as to be inappreciable, especially in
+the presence of concurrent injury to other parts, which was seldom
+absent. I only once saw any angular deformity from this injury, and that
+slight, and not apparent before the end of three weeks. In this
+particular a very striking difference exists between injuries from
+small-calibre bullets and larger ones such as the Martini-Henry. In the
+only instance of Martini-Henry fracture of the spine that came under my
+notice, 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 been
+observed to be slight in nature compared with what is met with in the
+compression fractures of civil life.
+
+A few words will suffice to dismiss the questions of diagnosis,
+prognosis, and treatment of the above injuries. The diagnosis depended
+on attention to the signs above indicated, the prognosis almost entirely
+on the concurrent injury to the nervous system, which will be considered
+later, and the treatment consisted in enforcing rest alone.
+
+
+INJURIES TO THE SPINAL CORD ACCOMPANYING SMALL-CALIBRE BULLET WOUNDS OF
+THE VERTEBRAE
+
+_Anatomical lesions._--In introducing the subject of the nature of the
+lesions of the spinal cord and membranes, I should again enforce the
+statement that their character and degree, in comparison with the slight
+accompanying bone damage, are pathognomonic of gunshot wounds, and that
+these characters find their completest exemplification in injuries
+produced by bullets of small calibre, endowed with a high grade of
+velocity. Again, that the varying degrees of damage depend comparatively
+slightly on the position of the bone lesion, apart from actual
+encroachment on the canal, while the degree of velocity retained by the
+bullet at the moment of impact is all-important. In no other way are the
+divergent results to be explained which follow an apparently identical
+injury, in so far as extent, position, and external evidence of damage
+to 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 a
+better standpoint in the case of small-calibre bullet injuries than in
+any others, since in many instances it is, I think, possible to exclude
+any complications such as wrenches and strains of the vertebral column,
+and ascribe the symptoms to the pure effect of extreme vibratory force
+communicated to the cord by its enveloping bony canal. The condition
+must be considered under the two headings of slight and severe.
+
+In _slight concussion_ the usually transient effects of the injury, and
+its happy tendency not to destroy life, place us in a state of
+uncertainty as to the occurrence of anatomical changes, since no
+opportunity of post-mortem examination occurred. The clinical condition
+included under this term corresponds with that implied in 'spinal
+concussion' in civil practice. One point of extreme interest, whether
+the subjects of small-calibre bullet spinal concussion will in the
+future suffer from the remote effects common to similar sufferers in
+civil life from other causes such as railway collisions, still remains
+for future determination. An ample field for such observations has at
+any 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 haemorrhages into its
+substance. Either or both of these pathological conditions are produced
+by the impact of the bullet with the spine, given a sufficiently high
+degree of velocity, and it is difficult to separate clinically the
+resulting symptoms. This is a matter perhaps of less importance, since
+it stands to reason that a vibratory force, capable of rupturing the
+spinal capillaries, would at the same time damage the nervous tissue.
+
+In speaking of concussion of this degree, it should be clearly
+recognised that a general condition, such as is indicated by the use of
+the term 'concussion of the brain,' is in no wise implied. The condition
+is really far more nearly allied to one of contusion, a strictly
+localised portion of the spinal cord undergoing the destructive process
+which affects the segments below only in so far as it interrupts the
+normal channels of communication with the higher centres.
+
+Case 102 is an instance of such a lesion, the post-mortem examination
+showing clearly that the spinal canal was not encroached upon by the
+bullet. The cord in this instance appeared little changed
+macroscopically, and this fact was observed in other instances, both
+during operations and post mortem.
+
+_Contusion._--This condition is very closely allied to the last. In
+cases 101 and 103 the spinal canal was as little encroached upon as in
+102, but the bullet struck the somewhat elastic neural arch in each
+case, and post mortem an adhesion between the cord and the enveloping
+dura opposite the point at which impact of the bullet was closest
+suggests that, in spite of the escape of the bone from fracture, it may
+have been momentarily depressed to a sufficient degree to contuse the
+cord, or the latter may have suffered a _contre-coup_ injury. For these
+reasons the inclusion of the cases as instances of pure concussion is
+not warranted. In both Nos. 99 and 100 the neural arch had actually
+suffered fracture, and although the bone was not depressed or exercising
+pressure at the time of the autopsies, it was no doubt driven in
+temporarily at the moment of impact of the bullet.
+
+At the post-mortem examinations of injuries of this nature it was common
+to find one to four segments of the spinal cord completely disorganised.
+At the end of some five weeks, the common duration of life, the
+structure of the cord was represented by a semi-diffluent yellowish
+material, the consistence of which was so deficient in firmness as to
+allow the partial collapse of the membranes covering the affected
+portion, so as to exhibit a definite narrowing when the whole was held
+up (see fig. 79). In such cases traces of extra- or intra-dural
+haemorrhage sometimes still persisted.
+
+_Haemorrhage._--This occurred as surface extravasation and in the form of
+parenchymatous haemorrhages. I saw the former both in the extra-dural and
+peri-pial forms, but never in sufficient quantity to exert a degree of
+pressure calculated to produce symptoms of total transverse lesion. Here
+again, however, it is difficult to speak with confidence since the
+conditions which regulate the tension within the normal spinal canal are
+so complicated and liable to variation, that it is very difficult to
+estimate the effect of any given haemorrhage discovered.
+
+My friend Mr. R. H. Mills-Roberts described to me one fatal case under
+his care in the Welsh Hospital in which extra-dural haemorrhage was so
+abundant as, in his opinion, to have taken a prominent part in the
+production of the paralytic symptoms.
+
+Examples of both extra- and intra-dural (peri-pial) haemorrhage are
+afforded by cases 99, 102, and 103; in none was it large in amount or
+widely distributed. The condition was probably also frequently
+associated in varying degree with that to be immediately described
+below.
+
+_Intra-medullary haemorrhage_ (_haemato-myelia_).--The importance of this
+condition is lessened in small-calibre bullet injuries by the fact
+already alluded to, that it is almost invariably accompanied by
+concussion changes. In one instance in which death took place at the end
+of eight days, partly as the result of concurrent injury, in a man in
+whom signs of total transverse lesion of the cord were present, the
+substance of the cord was found to be closely scattered over with
+haemorrhages of various sizes and extending for a longitudinal area of
+some three inches.
+
+As to the frequency with which haemorrhage into the substance of the cord
+occurred, I regret to be unable to give an opinion. In the late
+post-mortem examinations I witnessed, a yellow discoloration of the
+softened cord was the only macroscopic evidence of haemorrhage.
+
+Haemorrhages of this nature may, however, account for the grave paralytic
+symptoms in some cases of partial or total transverse lesion not due to
+direct compression or laceration.
+
+The conditions of concussion, contusion, or haematomyelia were, I
+believe, responsible for at least nine-tenths of the cases in which a
+total transverse lesion was indicated by the symptoms. The extreme
+importance of realising this fact and the rarity of the production of
+symptoms by continuing compression both from the prognostic and the
+therapeutic point of view is obvious.
+
+The analogous injuries termed generally in Chapter IX. nerve contusion,
+although frequently accompanied by tissue destruction, may be followed
+by reparative change, and are capable of complete or almost complete
+spontaneous recovery; while the lesions in the spinal cord are
+permanent, and complete recovery is only witnessed in the parts affected
+by the remote pressure or irritation from blood extravasation, or in
+those influenced by concussion.
+
+I include below short abstracts of all the cases of lesion of the spinal
+cord which terminated fatally, in which I had the opportunity of
+witnessing the post-mortem conditions. In a considerable proportion of
+the cases at the end of six weeks the spinal cord was softened over an
+area of from two to four segments in such degree as to have practically
+lost all continuity. Although the autopsies were made on patients who
+had died slowly and in summer weather, often twelve to sixteen hours
+after death, I think it can be but fair to assume, when the consistency
+of the remaining portion of the spinal cord is considered, that the
+softening was only in slight degree if at all exaggerated by post-mortem
+change. Again symptoms of secondary myelitis and meningitis had been
+observed in some of the fatal cases prior to death.
+
+I had but one opportunity of observing a case in which a retained bullet
+exercised compression, and none in which this was due to displaced bone
+fragments. I also only once came across a case of complete section, but
+no doubt both bone pressure and section may have occurred with greater
+frequency amongst patients dying on the field or shortly after. The case
+of section is illustrated in fig. 80. It will be noted that, although
+the section is complete, the bullet lies to one side of the canal, and
+hence 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 in
+the neighbourhood of the spot of division. This well illustrates the
+comparatively slight vibratory effect of a bullet travelling with a
+degree of velocity insufficient to completely perforate the vertebral
+column.
+
+_Symptoms of injury to the spinal cord._--In _slight spinal concussion_
+these exactly resembled those of the more severe lesions, except in
+their transitory nature. They consisted in loss of cutaneous
+sensibility, motor paralysis, and vesical and rectal incompetence. The
+phenomena persisted from periods of a few hours to two or three days,
+return of function being first noticeable in the sensory nerves, and
+often with modification in the way of lowered acuteness, or minor signs
+of irritation, such as formication, slight hyperaesthesia or pain,
+pointing to a combination with the least extensive degrees of
+haemorrhage; later, motor power was rapidly regained. The subjects of
+such symptoms often suffered from weakness and unsteadiness in movement
+for some days or weeks; a sharp line of discrimination between such
+cases and those described in the next paragraphs is manifestly
+impossible.
+
+_Spinal haemorrhage._--The symptoms of this condition developed
+differently according to whether concurrent concussion existed.
+Occasionally very typical instances of pure haemorrhage were observed
+with 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 was
+very much more common to meet with an admixture of signs of primary
+concussion, or at any rate symptoms of radiation. The following is an
+extreme 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 faeces, 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 hyperaesthesia 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 hyperaesthesia on the left side. The patient left for
+     home shortly after the last note.
+
+In both these cases the absence of marked hyperaesthesia or pain points
+to medullary haemorrhage (haemato-myelia) as the pathological condition
+produced by the injury. In this particular they contrast well with case
+94 quoted on page 315, where the degree of both hyperaesthesia and pain
+indicated a combination of pressure and irritation of the nerve roots by
+surface haemorrhage on the affected side. In case 97 the persistence for
+four weeks of paralysis of the bladder and rectum suggested medullary
+haemorrhage in addition, while the return of patellar reflex in the
+paralysed limb negatived the occurrence of an extensive destructive
+lesion.
+
+In view of the extreme interest of these cases I will shortly detail one
+other in which the cauda equina alone was affected.
+
+I must confess my inability to place the case definitely in the
+category either of concussion or medullary haemorrhage. As so often
+happened, both conditions probably took part in the lesion. The
+immediate development of the primary symptoms is no doubt to be referred
+to concussion, while the patchy nature of the prolonged lesion and
+gradual recession of the symptoms point to the presence of haemorrhages.
+We find here the link most nearly connecting the spinal cord and the
+peripheral systemic nerves. Such a case goes far to show that the
+condition which I have in the next chapter often referred to as nerve
+contusion may in fact be produced by an injury far short of actual
+contact.
+
+     (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 deg. or at times to
+     102 deg.; 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, anaesthesia 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
+     hyperaesthesia 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 haemorrhage
+     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 haemorrhage 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 hyperaesthetic zone at the lower limit
+     of sensation usually existed.
+
+     In the majority of the cases pain must have depended on
+     meningeal haemorrhage. 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 deg. 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 haemorrhage, 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. Hyperaesthesia
+     was present in both upper extremities, with a zone of
+     hyperaesthesia around the chest. The patient suffered greatly
+     for some weeks from pain in the hyperaesthetic 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 septicaemia, 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 laminae of the fifth, sixth, and
+     seventh vertebrae were separated from the pedicles, and somewhat
+     depressed on the left side. These laminae were adherent to the
+     dura, as were also a few small separated bony spiculae. There
+     was no sign of old haemorrhage. The spinal cord was practically
+     gone between the levels of the fourth and seventh dorsal
+     vertebrae, 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 laminae 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 haemorrhage.
+
+     (102) _Dorsal region; total transverse lesion; slight
+     extra-dural haemorrhage._--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 haemorrhage 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 haemorrhage._--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 hyperaesthetic zone around trunk. All reflexes
+     absent. Retention of urine. Incontinence of faeces. 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 deg.. 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 vertebrae, and opposite the seventh
+     the cord was soft and of the consistence of butter. A small
+     intra-dural haemorrhage 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 membranes
+in case 103 after removal from the canal. When the membranes were opened
+a white custard-like substance took the place of the cord. Slight
+evidence of extra-dural haemorrhage 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 faeces.
+     Large sacral bed-sore developed rapidly. Right haemothorax.
+
+     The patient emaciated rapidly, and for the last fourteen days
+     the temperature ranged to 104 deg., 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 haemorrhage was detectible.
+
+[Illustration: FIG. 80.--Complete division of Spinal Cord. The bullet is
+retained, and from its position can be seen to have struck the right
+half of the cord only. The nickel plating of half of the tip of the
+bullet 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 haemorrhage 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 faeces.
+     The mucous lining elsewhere was slaty grey, with small
+     haemorrhages. 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 deg., 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, the
+patients dying on the third day; pain and high temperature were
+prominent symptoms in both. In one patient early delirium was present.
+
+     (106) _Dorsal region; Martini-Henry wound._--Wound of _entry_,
+     oval, 1 inch x 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 bullae.
+
+     General hyperaesthesia 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 deg., while on the last two days the
+     temperature was normal in the mornings, rising to 105 deg. in the
+     evenings. No alteration resulted in the trunk symptoms.
+
+_Diagnosis._--The pure question of the fact of injury of the spinal cord
+needs no discussion; but it is necessary to make some remarks on the
+discrimination between concussion, contusion and haemorrhage, meningeal
+and medullary haemorrhage, the latter condition and compression, and on
+partial and complete severance of the cord.
+
+The sharp discrimination of cases of concussion from those of slight
+medullary haemorrhage was necessarily impossible. I think the only points
+of any importance in diagnosing pure concussion were the transitory
+nature of the symptoms, and the uniformity of recovery, without
+persistence of any signs of minor destructive lesion. In medullary
+haemorrhage the tendency for a certain period was towards increase in
+gravity in the signs. It goes almost without saying that the latter
+point was seldom accurately determined in patients struck on the field
+of 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 not
+usually allow the careful observation necessary to clear up this
+difference in the development of the symptoms. Nevertheless it is
+preferable to consider the cases in which transitory symptoms persist
+for a period of hours, or even a couple of days, as instances of pure
+concussion, unless the existence of this condition can be disproved by
+actual observation.
+
+Extra-medullary haemorrhage, accompanied by only slight encroachment on
+the spinal canal, certainly results with some frequency from
+small-calibre wounds. Some of the quoted cases show this decisively by
+_post-mortem_ evidence, others by such clinical signs of irritation as
+pain and hyperaesthesia. I think its presence may also be assumed in
+cases of total transverse lesion due to medullary haemorrhage or severe
+concussion, accompanied by well-marked pain and hyperaesthesia above the
+level of paralysis. As affecting treatment, however, determination of
+its presence is of small importance.
+
+The important conditions for discriminative diagnosis are those of local
+compression, actual destructive lesion, whether from concussion changes,
+contusion, or medullary haemorrhage, and partial and total section of the
+cord.
+
+First, with regard to compression of the cord, the possible sources are
+three; (i) extra-dural haemorrhage, which may, I think, be dismissed with
+mention as rarely capable of producing severe symptoms. (ii) The
+displacement of bone fragments. This is of less importance than in civil
+practice, because an injury by a bullet of small calibre, capable of
+seriously displacing fragments, has probably at the same time produced
+grave changes in the cord. In the presence of severe immediate symptoms
+we may tentatively assume that a simultaneous destructive lesion has
+been produced. In such injuries pain, combined with a tendency to
+improvement in the paralytic symptoms and return of reflexes, is the
+only point in favour of bone pressure, unless considerable deformity of
+the spinal column can be detected by palpation or examination with the
+X-rays.
+
+(iii) Pressure from the bullet. This is the most important form of
+compression, because the mere fact of retention of the bullet is
+evidence of a low degree of velocity, and therefore opposed to the
+existence of the most severe form of intramedullary lesion. In a case of
+apparent transverse lesion with retained bullet, shown to me at No. 3
+General Hospital by Mr. J. E. Ker, the pain was very severe, and so
+greatly aggravated by movement that an anaesthetic had to be administered
+prior to the renewal of some necessary dressings. The general condition
+of this patient precluded a projected operation, and after death the
+bullet was found to be pressing laterally upon a cord not materially
+altered on macroscopic inspection. In the case of retained bullet
+recorded (No. 104), the slight degree to which the severed ends of the
+cord appeared altered has been already remarked upon.
+
+Beyond this we are helped by the position of the aperture of entry, and
+its shape, as evidence of the direction in which the bullet passed, the
+presence of pain, and positive proof may be obtained by examination with
+the X-rays.
+
+Lastly, we come to the discrimination of total or partial section,
+destruction by vibratory concussion or contusion, and severe
+intramedullary haemorrhage. Except in the case of partial section with
+localised symptoms, which must be rare, I believe this to be impossible
+from the primary symptoms, although some indication of possible
+encroachment on the canal may be obtained from careful consideration of
+the course of the wound, as evidenced by the position and shape of the
+openings, the position of the patient's body at the time of reception of
+the injury being taken into consideration. Later we may get some aid
+from the possible improvement in the symptoms in the case of haemorrhage.
+In cases with signs of total transverse lesion, however, the
+discrimination of the conditions is of little practical importance,
+since either is equally unfavourable and unsuitable for surgical
+treatment.
+
+In closing these remarks reference must be made to the occasional
+occurrence of paraplegic symptoms of an apparently purely functional
+nature. I saw these on one or two occasions, of which the following is
+a fair example. A man was wounded in the lower extremity and fell. When
+brought into the hospital he complained of loss of power in the legs and
+inability to straighten his back. No very definite evidence was present
+of serious impairment either of motor or sensory nerves, and the man was
+got up and walked with crutches. While moving about the hospital camp,
+another man pushed him down, and the patient then became completely
+paraplegic. He was placed in bed, and the next day moved his limbs
+without any difficulty, and gave rise to no further anxiety.
+
+_Prognosis._--In slight concussion the importance of prognosis is as to
+remote effects, and upon this no opinion can be given at the present
+time. The same may be said concerning cases in which transient symptoms
+followed the slighter degrees of surface and medullary haemorrhage. In
+the case of the latter, however, I think it would be rash to give a too
+confident opinion as to the future non-occurrence of secondary changes.
+
+Severe concussion is probably irrecoverable.
+
+Meningeal haemorrhage of either form is one of the slighter lesions, and
+less dangerous, both as an immediate condition and as to the
+probabilities of after trouble. None the less the possibilities of
+secondary chronic meningitis, or chronic trouble from adhesions, must be
+kept in mind.
+
+Cases of medullary haemorrhage with incomplete signs are favourable in
+prognosis, as far as life is concerned; as to complete recovery,
+however, this is hardly possible; in many cases serious functional
+deficiency at any rate will remain, while in others the healing of the
+lacerated tissue and subsequent contraction can scarcely fail to
+influence unfavourably an already imperfect recovery.
+
+I think it must be a rare occurrence for pressure from bone fragments to
+be able to be regarded as a favourable prognostic condition, since in
+the very large majority of cases the velocity of the bullet causing the
+injury will have been such as to inflict irreparable damage on the cord.
+Still, cases may occasionally be met with where the velocity has been
+sufficiently low, or contact with the bone slight enough, to allow of
+the comparative escape of the cord. In this relation cases in which the
+bullet is retained, especially if the symptoms of transverse lesion are
+incomplete, may be regarded as relatively favourable.
+
+Cervical and high dorsal injuries, as in civil practice, offered the
+worst prognosis. In cases in which symptoms of total transverse lesion
+were present, as far as my experience went, it was, however, only a
+matter of importance as to the prolongation of a miserable existence.
+All the patients eventually died; those with higher lesions at the end
+of a few days; the lower ones, at the completion on an average of six
+weeks of suffering.
+
+The actual causes of death resembled exactly those met with in civil
+practice, except in so far as it was more often influenced or determined
+by concurrent injuries, a complication so characteristic of modern
+gunshot wounds. Thus exhaustion, septicaemia from absorption from
+suppurating bed-sores or from severe cystitis, secondary myelitis, and
+pulmonary complications, carried off most of the patients.
+
+_Treatment._--The general treatment of the cases demanded nothing
+special to military surgery, except in so far as it was modified by the
+disadvantage to the patient of necessarily having to be transported,
+often for some distance. The ill effects of this, particularly in cases
+of haemorrhage, are obvious, but in so far as fracture was concerned the
+question of transport did not acquire the importance that it does in
+civil practice, since the nature of the fractures and their strict
+localisation did not render movement either painful or particularly
+hurtful. It was indeed striking how little pain movement, made for the
+purposes of examination, caused these patients. The treatment of
+bed-sores, cystitis, or other secondary complications possessed no
+special features.
+
+The importance of insuring rest in the early stages of the cases of
+haemorrhage is self-evident; hence, if the possibility exists of not
+moving the patient, its advantage cannot be too strongly insisted upon.
+Again, if transport is inevitable, the shorter distance that can be
+arranged for the better. It should be borne in mind, also, that from the
+peculiar nature of causation of the injuries, stretcher or wagon
+transport for short distances is preferable to the vibratory movements
+of a long railway journey. Beyond this the administration of opium, and
+in some cases the assumption of the prone position, are both useful in
+the recent or possibly progressive stage of haemorrhage.
+
+Lastly, as to active surgical treatment by operation. In no form of
+spinal injury is this less often indicated, or less likely to be useful.
+It is useless in the cases of severe concussion, contusion, or medullary
+haemorrhage which form such a very large proportion of those exhibiting
+total tranverse lesion, and equally unsuited to cases of partial lesion
+of the same character. Extra-medullary haemorrhage can rarely be
+extensive enough to produce signs calling for the mechanical relief of
+pressure; the section of the cord cannot be remedied. In one case with
+signs of total transverse lesion, in which a laminectomy was performed,
+no apparent lesion was discovered, and this would frequently be the
+case, since the damage is parenchymatous. The experience was indeed
+exactly comparable to that which followed early exposure of the
+peripheral nerves.
+
+Only three indications for operation exist. 1. Excessive pain in the
+area of the body above the paralysed segment; operation is here of
+doubtful practical use, except in so far as it relieves the immediate
+sufferings of the patient.
+
+2. An incomplete or recovering lesion, when such is accompanied by
+evidence furnished by the position of the wounds, pain, and signs of
+irritation of pressure from without, or possibly palpable displacement
+of parts of the vertebra, that the spinal canal is encroached upon by
+fragments of bone.
+
+3. Retention of the bullet, accompanied by similar signs to those
+detailed under 2.
+
+In both the latter cases the aid of the X-rays should be invoked before
+resorting 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 the
+actual source of trouble, it is obvious that the more promptly operation
+is undertaken the better for early relief and ulterior prognostic
+chances.
+
+In only one case of the whole series I observed did it seem possible to
+regret the omission of an exploration.
+
+
+
+
+CHAPTER IX
+
+INJURIES TO THE PERIPHERAL NERVE TRUNKS
+
+
+The occurrence of these injuries has undoubtedly increased in frequency
+with the employment of bullets of small calibre, and no other class of
+case more strikingly illustrates the localised nature of the lesions
+produced by small projectiles of high velocity. Again, no other series
+of injuries affords such obvious indications of the firm and resistent
+nature of the cicatricial tissue formed in the process of repair of
+small-calibre wounds, and in none is the advantage of a conservative and
+expectant attitude so forcibly impressed upon the surgeon. Implication
+of the nerves may be primary, or secondary to an injury which left them
+originally unscathed.
+
+_Nature of the anatomical lesions._--In degree these vary in
+mathematical progression, but the extent of the lesion is not always
+readily differentiated by the early clinical manifestations, and again
+the actual damage is not to be estimated by the gross apparent
+anatomical lesion alone; but, in addition, consists in part in changes
+of a less easily demonstrable nature, varying with the velocity with
+which the bullet was travelling and the consequent comparative degree of
+vibratory force to which the nerve has been subjected. In these
+injuries, as in those of every part of the nervous system, the degree of
+velocity appears to gain especial importance both in regard to the
+general symptoms and the local effect on the functional capacity of the
+nerve.
+
+This is perhaps a fitting place for the introduction of a few further
+remarks as to the significance of the term 'concussion' in connection
+with the injuries produced by bullets of small calibre, since the most
+striking exemplification of the results following the transmission of
+the vibratory force of the projectile is afforded by the behaviour of
+the comparatively densely ensheathed and supported peripheral nerves.
+
+As already pointed out in Chapters VII. and VIII. the chief concussion
+effects on the nervous tissue of the brain and spinal cord are of a
+destructive nature, far exceeding those accompanying the injuries
+designated by the same term seen in the ordinary accidents met with in
+civil 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 and
+clinical phenomena, but any sharp distinction between the two conditions
+on a morbid anatomical basis is impossible. The results of severe
+vibratory concussion may, in fact, be more generally destructive than
+those of contusion, and the subsequent effects more prolonged. A certain
+length of the affected nerve is apparently completely destroyed as a
+conductor of impulses, the connective-tissue element alone remaining
+intact. Under these circumstances a nerve, the subject of the most
+serious degree of vibratory concussion, which, if cut down upon, may
+exhibit no macroscopic change, may take a longer period to recover than
+one in which the presence of considerable local thickening points to
+direct contact with the bullet, with resulting haemorrhage into the nerve
+sheath and perhaps partial gross rupture of nerve fibres.
+
+The therapeutic and prognostic importance of the above remarks, if
+correct, is obvious. The course of the nerve is preserved by its intact
+connective-tissue framework, and ultimate recovery by a regeneration of
+the nerve fibres is more likely to be complete, and will be just as
+rapid, if nature be relied on and the nerve be left untouched by the
+hand of the surgeon.
+
+It is, I think, undeniable that nerve trunks may escape severe or
+irrecoverable injury by lateral displacement. The mere fact that the
+trunk itself may be perforated by a slit in its long axis would suggest
+the possibility of displacement of the whole structure, and this no
+doubt occurred with some frequency. Displacement would naturally be most
+frequent in the case of nerves, such as those of the arm, which run long
+courses in comparatively loose tissue. In a remarkable case already
+narrated, an exploratory operation showed the musculo-spiral nerve in
+the upper part of the arm to have been driven into a loop which
+projected into, and provisionally closed, an opening in the brachial
+artery.
+
+I. _Simple concussion._--Anatomically, or histologically, no information
+exists as to the changes which give rise to the often transitory
+symptoms dependent on this condition. We are reduced to the same
+theories of molecular disturbance and change which have been invoked to
+account for similar affections of the central nervous system. The
+causation of concussion is, however, materially influenced in its degree
+by the velocity of flight of the bullet and consequent severity of the
+vibratory force exerted. Hence actual contact of the bullet with the
+nerves is not necessary for its production, as is seen in the temporary
+complete loss of functional capacity in the limbs in many cases of
+fracture, where the vibrations are rendered still more far-reaching and
+effective as the result of their wider distribution from the larger
+solid resistance afforded by the bone. The relative density and
+resistance offered by the different parts of the bone acquire great
+significance in this relation, since local shock due to nerve concussion
+is far more profound when the shafts are struck than when the cancellous
+ends furnish the point of impact.
+
+The form of concussion which most nearly interests us in this chapter is
+that 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 the
+nerve that there is difficulty in drawing a strict line of demarcation
+between such cases and those dealt with in the next paragraph.
+
+II. _Contusion._--Clinically this was the form of nerve injury both of
+greatest comparative frequency and of interest from the points of view
+both of diagnosis and prognosis.
+
+The seriousness of a contusion depends on two factors: first, the
+relative degree of violence exerted upon the nerve, which is dependent
+on the force still retained by the travelling bullet; and, secondly, on
+the extent of tissue actually implicated. The range of fire at which the
+injury was received determines the importance of the first factor; the
+second varies with the degree of exactness with which the nerve is
+struck, and on the direction taken by the bullet. Naturally transverse
+wounds affect a small area; while an oblique or longitudinal direction
+of the track may indefinitely increase the extent of injury to the nerve
+trunk, and hence acquire prognostic significance in direct ratio to the
+amount of tissue which needs to be regenerated.
+
+As to the actual anatomical lesion resulting in the cases which we
+designated clinically as contusion I can give no information. On many
+occasions when the symptoms were considered of such a nature as to
+render an exploration advisable, no macroscopic evidence of gross injury
+was obtained. It was therefore impossible to draw a definite line of
+demarcation between such cases and those which we considered merely
+concussion. It could only be assumed that the vibration transmitted to
+the nerve had occasioned such changes as to destroy its capacity as a
+conductor of impressions.
+
+In some cases the presence of a certain amount of interstitial blood
+extravasation was suggested clinically by early hyperaesthesia and signs
+of irritation; in others the paralysis was of such a degree as to lead
+to the inference that a complete regeneration of the existing nerve
+would be necessary prior to the restitution of functional capacity.
+
+In a certain proportion of the injuries the development of a distinct
+fusiform swelling in the course of the nerve pointed to the existence of
+considerable tissue damage, while in others this was evidenced
+clinically by early signs of neuritis.
+
+III. _Division or laceration._--The varying mechanical conditions
+affecting the last class of injury play a similar role here. Thus the
+degree of laceration depends on the direction of the wound track, and as
+all lacerations are accompanied by contusion, the relative velocity
+retained by the travelling bullet assumes the same importance.
+
+I saw every degree of injury to the trunks, from notching to complete
+solution of continuity, and in some cases destruction and disappearance
+of pieces from one to two or more inches in length. Such lesions as the
+latter were most common in the forearm. In this segment of the limbs
+tracks of varying degrees of longitudinal obliquity are readily
+produced, whether the patient be in the upright or prone position,
+since the upper extremities are commonly in forward action whichever
+position is assumed.
+
+The most peculiar form of injury consisted in perforation of the trunk
+without gross destruction of its fibres, and without in many cases
+prolonged or permanent loss of functional capacity. I cannot speak with
+any confidence as to the comparative frequency of occurrence of this
+form of injury, but judging by the analogous perforations of the
+vessels, it is probably not uncommon in trunks large enough to allow of
+its production. The trunk nerves of the arm, and the great sciatic
+nerve, were probably the most frequent seats of such wounds. As,
+however, a very short experience of the futility of early interference
+in the case of nerve lesions warned me against exploration before a date
+at which observations of this nature were unsatisfactory, I gained less
+experience on this point than I could have wished.
+
+In the case of completely divided nerves the development of a bulbous
+enlargement on the proximal end was constant, and very marked in degree.
+I saw few cases in which primary effects could be certainly referred to
+pressure or laceration by bone spicules, excepting in some fractures of
+the humerus, and perhaps some injuries of the seventh nerve accompanying
+perforating wounds of the mastoid process.
+
+IV. _Secondary implication of the nerves._--This was a striking
+characteristic in many at first apparently simple wounds of the soft
+parts. In such cases it was due to implication of the contiguous trunk
+in the process of cicatrisation, and its importance varied with the size
+of the nerve in question. In the smaller sensory trunks it was often
+evidenced by the occurrence of neuralgic pain, especially liable to be
+influenced by climatic changes; in the larger, by signs of more or less
+severe motor, sensory, and trophic disturbance. Musculo-spiral paralysis
+from implication in, or pressure from, callus in cases of fracture of
+the humerus was very frequent. This would naturally be expected from the
+extreme degree the comminution of the bone often reached, and the
+consequently large amount of callus developed.
+
+The effect of cicatrisation of the tissues surrounding the nerves
+varied somewhat according to the degree of fixation of the individual
+nerve implicated. Thus if a nerve lay in a fixed bed some form of
+circular constriction resulted; if, on the other hand, the nerve was
+readily displaceable, the cicatrix often drew it considerably out of its
+course; in either case symptoms corresponding with those of pressure
+resulted.
+
+_Symptoms of nerve lesion_.--These differed little in character from
+those common to such injuries in civil practice, except in the relative
+frequency with which they assumed a serious aspect. After all in civil
+practice nerve concussion is most familiar to us in the degree common
+after knocking the elbow against a hard object, and the same may be said
+in regard to the allied injury of contusion. It is in small-calibre
+bullet wounds alone that the occurrence of such severe and sharply
+localised injury to deep parts as was observed is possible.
+
+_Concussion_.--Temporary loss of function was often observed in the
+limbs, corresponding to the distribution of one or more nerve trunks
+when wound tracks had passed in their vicinity. Interference with
+function sometimes amounted to loss of sensation alone: in others to
+loss of both sensation and motor power. Such symptoms were of a
+transitory character, lasting for a few days or a week; if both
+sensation and motion were impaired, sensation was usually the first to
+be regained. In these cases secondary trouble was not uncommon, since
+the near proximity of the track to the originally affected nerve offered
+every chance for implication of the latter in the resulting cicatrix.
+This sequence was often observed, and its symptoms are described under
+the heading of secondary implication below. Equally striking were the
+instances of concussion in the case of the nerves of special sense and
+their end organs, temporary loss of smell, vision, or hearing being not
+uncommon, often passing off in the course of a few days with no apparent
+ulterior ill-effect.
+
+One of the most interesting illustrations of the occurrence of
+concussion was furnished by cases in which complete paralysis of a limb
+rapidly cleared up with the exception of that corresponding to a single
+individual nerve of the complex apparently originally implicated.
+Instances of severe contusion or division of one nerve of the arm, for
+instance, accompanied by transient signs of concussion of varying
+degrees 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 irritation
+were often observed. In the slighter cases irritation was often a marked
+feature, as was evidenced by hyperaesthesia and pain combined with loss
+of power. In cases in which pain and hyperaesthesia were primary
+symptoms, these were often transitory. I will quote an illustrative case
+which, though affecting the nerve roots, is characteristic of the
+effects of slight contusion in the case of the nerve trunks in any part
+of 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
+     hyperaesthesia 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 hyperaesthesia 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 many
+similar instances in injuries of the nerve trunks of the limbs in which
+the course was exactly parallel. In the more severe, pain was often
+added to hyperaesthesia.
+
+In the most severe cases the signs corresponded in all particulars,
+except in the early entire loss of reaction of the muscles to
+electricity, with those of complete section. Loss of sensation and
+motion was immediate, complete, and prolonged, the limbs being lowered
+in temperature, flaccid, and powerless. General systemic shock was also
+severe. In the case either of plexus or multiple contusions, or where
+the injury was more local, correspondingly complete signs were present
+in the area supplied by the affected nerves.
+
+In the cases in which the contusion was not of extreme degree,
+hyperaesthesia often developed as a later sign, and was probably due to
+the irritation of haemorrhage, when the sensory portion of the nerve
+began to regain functional capacity. The date of appearance of the
+hyperaesthesia varied from a few days to a week or later. It might then
+persist for weeks or many months.
+
+In a few instances large blebs rose on the back of the hand, or patches
+of vesicles appeared over the terminal distribution of the nerve,
+pointing to early trophic changes.
+
+The period of recovery varied greatly; in some instances of very
+complete paralysis, function was regained and became apparently normal
+at the end of three or four weeks; in others, even after severe wasting
+of muscles for weeks, rapid improvement occurred often suddenly, while
+in some there was no apparent recovery at the end of months. In cases of
+long-deferred improvement, wasting of the muscles became a very
+prominent feature; but this without complete loss of reaction of the
+muscles to electrical stimulation.
+
+Recovery of sensation usually preceded by some time that of motion, the
+former often reappearing in some degree at an early date, and, even if
+very modified in character, it formed a most useful and valuable aid
+both in diagnosis and prognosis.
+
+When in a position allowing of direct examination, the contused portion
+of the nerve sometimes developed a palpable fusiform thickening,
+manipulation of which might give rise to formication in the area of
+distribution--a favourable prognostic sign.
+
+Many of the cases bore a very marked resemblance in character to those
+in which paralysis results from tight constriction of the limb, as in
+the arm after the application of an Esmarch's tourniquet.
+
+_Laceration._--If incomplete, the signs corresponded very nearly to
+those of severe contusion, since partial section is impossible without
+the occurrence of the latter. The condition indeed was only to be
+distinguished by the partial nature of the recovery, and even this
+latter might be only more prolonged.
+
+The same remarks hold good with regard to perforation of the nerve
+trunks; but, as regards function, these injuries are not so serious in
+prognosis as very much more limited transverse divisions or mere
+notching, and in some cases the disturbance of function was by no means
+profound or prolonged.
+
+Absolute loss of reaction to electrical stimulus from above was the only
+pathognomonic sign of actual section, unless the position of the nerve
+was such as to allow of palpation, when the presence of a bulbous end at
+once settled the difficulty. In many cases of superficial tracks with
+division of such nerves as the long or short saphenous, the early
+development of bulbs in the course of the trunks gave positive
+information, and these were often observed.
+
+_Traumatic neuritis._--This was a common sequence of contusion of the
+nerve itself, or of its subsequent inclusion in a cicatrix or callus. It
+was evidenced by hyperaesthesia both superficial and deep, pain,
+contracture, wasting of the muscles, local sweating, and the development
+of glossy skin.
+
+Examples of this condition were seen in the case of nearly every nerve
+in the body. In frequency of occurrence, degree of severity, and in its
+selection of individual nerves considerable variation was met with. With
+regard to the two former points, personal idiosyncrasy, and degree of or
+peculiarity in the nature of the injury, are the only explanations I can
+suggest. Perhaps in some instances exposure to wet or cold in the early
+stages of the injury was of some import. Thus, I saw several severe
+cases of musculo-spiral neuritis in men who were wounded during the
+trying and wet march on Bloemfontein. I did not observe that suppuration
+or wound complications seemed important explanatory moments, as most of
+the cases occurred in wounds that healed rapidly.
+
+With regard to the question of selection; the same nerves that appear
+particularly liable to suffer from idiopathic inflammations, toxic
+influences, or to be the seat of ascending changes (e.g. ulnar,
+musculo-spiral, and external popliteal), were those most often affected
+by secondary neuritis. Many of the most severe cases I saw were in the
+musculo-spiral nerve.
+
+_Scar implication._--The signs of this most commonly commenced with
+neuralgia, or painful sensations when such movements were made as to put
+the cicatrix on the stretch. Although such neuralgia might not be
+constant, it was often observed to be troublesome when the patients were
+exposed to cold in sleeping out at night, or to extra fatigue, as in
+long marches. The results in many cases stopped at this point, but the
+size and wide distribution of certain nerves rendered even such slight
+symptoms of importance; while in others well-marked signs of neuritis
+declared themselves, such as glossy skin, pain, muscular wasting, and
+paralysis.
+
+_Ascending neuritis._--In a few cases I observed very remarkable
+instances of ascending neuritis, after comparatively slight wounds. I
+will quote three of these as illustrations and make no further remarks
+as 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
+     hyperaesthesia 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, mention
+must be made of the fact that the functional element was often somewhat
+prominent. The influence of this factor was not to be neglected in case
+108; again, its presence was a feature in cases 132 and 134, of injury
+to the sciatic nerve and of peripheral injury to the seventh nerve (p.
+355). A remark has been made as to the occurrence of functional
+paraplegia 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 of
+organic and functional phenomena might be a source of error, even in the
+determination of the visual field in the subject of an undoubted
+destructive lesion. On more than one occasion an injury was accompanied
+by loss of the power of speech; thus a patient who received a slight
+wound of the neck did not speak again until the application of a battery
+by my colleague, Mr. H. B. Robinson. A patient was also for a short time
+an inmate of No. 1 General Hospital, Wynberg, who had become deaf and
+dumb 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 the
+mother-country.
+
+In many other cases of nerve concussion or contusion, the recovery of
+power and sensation, or the disappearance of neuralgia or contractures,
+was so sudden and rapid after prolonged continuance of the symptoms, as
+to suggest a very strong functional element in their origin. The
+influence of the general shock to the nervous system received by the
+patients had an important bearing on these phenomena, and their interest
+from a prognostic point of view was very great.
+
+
+INJURIES TO SPECIAL NERVES
+
+_Cranial nerves._--It will be convenient first to make a few remarks
+concerning the nerves of special sense.
+
+_Olfactory._--I observed temporary loss of smell on three occasions. In
+two instances this accompanied transverse wounds of the bones of the
+face in which the upper third of the nasal cavities was crossed; in the
+third a track passing obliquely downwards from the frontal region passed
+through the inner wall of the orbit, and crossed the nose at a lower
+level. In view of the small area of the olfactory distribution which was
+directly implicated, I was at first inclined to regard the loss of smell
+as dependent on the presence of dried blood on the surface of the mucous
+membrane, or on obstruction of the cavities from the same cause. Further
+observation, however, appeared to show that it was due to concussion of
+the branches of the olfactory nerve, since the loss of function
+persisted when the cavities were manifestly clear.
+
+In all these cases we were confronted with the same difficulty which was
+experienced both in lesions of sight and hearing, the determination as
+to 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 the
+orbit, the possibility of concussion of the olfactory lobe was manifest.
+In all, again, it was difficult to say what part the accompanying
+concussion of the branches of the fifth nerve took in the production of
+the symptom. In all three cases mentioned the return of function was
+gradual, but apparently fairly complete at the end of three weeks. In
+one it was noted that at first the patient was conscious of an odour
+before he was able to discriminate its actual nature; later he could
+determine the latter readily.
+
+_Optic._--Some remarks concerning lesions of the optic nerve have
+already been made under the heading of wounds of the orbit. Concussion
+and contusion of the nerve both occurred, but I was unable to
+differentiate between the effects of these on the nerve itself, apart
+from the effects on the globe of the eye, which usually accompanied
+wounds of the orbit.
+
+In some cases the nerve was directly divided in orbital wounds, and
+either pressure on or division of the nerve in the intra-cranial portion
+of its course, or as it traversed the optic foramen, was not uncommon.
+
+_Auditory._--Loss of hearing was also not infrequent; thus it
+accompanied all three wounds of the mastoid process quoted under the
+heading of the seventh nerve, also two cases of fracture of the
+occipital bone near the ear quoted on p. 278. In all these instances it
+was impossible to attribute the deafness to lesion of the nerve alone,
+as the causative injury equally affected the internal ear, and in at
+least two the bullet implicated the tympanum as well in its course. The
+deafness was absolute in each case, and in none had any improvement
+occurred at the end of nine months. Deafness was a symptom in a certain
+number of the more severe cerebral injuries in which the course of the
+bullet was not so near to the internal ear: probably some of these were
+central 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 was
+occasionally seen in wounds of the skull involving the roof of the
+orbit, but the relative parts taken by injury to nerve and laceration or
+fixation of muscle respectively, were usually hard to determine. Again,
+the fourth and sixth nerves may have been damaged in some of the more
+extensive orbital wounds, especially those in which the globe suffered
+injury, but the signs under such circumstances were difficult to
+discriminate, and the injury was of slight practical importance, in view
+of the major injury to the globe itself.
+
+_Fifth nerve._--Concussion, contusion, or laceration of the different
+branches of the three divisions of the fifth nerve were common in wounds
+of the head, but most frequent in fractures of the upper or lower jaws.
+Localised anaesthesia was common from one or other of these causes, but
+for the most part transitory in the cases of contusion or concussion. I
+saw no case of entire loss of function in any one division, symptoms
+being mostly confined to certain branches, as the supra-orbital, the
+temporo-malar, the dental branches of the second division, the
+auriculo-temporal nerve, and the lingual, dental, and mental branches of
+the third division. I did not observe any cases in which modification of
+the special senses accompanied these injuries beyond those mentioned in
+the remarks already made on the subject of anosmia, and one case in
+which some modification of the sense of taste accompanied an injury to
+the floor of the mouth. It was a matter of surprise, considering the
+frequency with which subsequent neuritis was met with in the nerves
+generally, that trifacial neuralgia in some form was not more often met
+with. I never observed any serious case. Perhaps this is one of the
+fields in which a longer after-period may increase our knowledge.
+Lastly, I never observed motor paralysis in the case of the third
+division, 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 cases
+of wound of the mastoid process, apart from central cortical facial
+paralyses, of which several are quoted in the chapter on injuries of the
+head. All the wounds of the mastoid process were, in addition,
+accompanied by absolute deafness. I am sorry to be unable to give any
+details as to the electrical condition of the muscles in these cases,
+but I believe that in the great majority the paralysis was mainly the
+result of nerve concussion, since the perforations were clean in
+character and not obviously accompanied by comminution. Pressure from
+haemorrhage into the Fallopian canal may, of course, have been present,
+and in some instances, particularly those in which the bullet traversed
+the tympanic cavity, spicules of bone may have caused laceration. In
+every case, however, all the branches were equally affected; the
+paralysis was absolute, and in none did any improvement occur while the
+cases 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 haemorrhage from
+     the left ear. The injury was followed by complete deafness, and
+     facial paralysis, which showed no sign of improvement.
+
+     There was complete anaesthesia 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 haemorrhage from ear. Complete facial
+     paralysis and deafness. Anaesthesia 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 seventh
+nerve secondary to wound of peripheral branches. In one a patient was
+struck by several fragments of lead from a bullet which broke up against
+a neighbouring stone. These for the most part lodged in the skin over
+the left orbicularis muscle, but one also lodged in the conjunctiva and
+was removed. Some ten days later the patient complained that he could
+not lift the upper lid. The levator palpebrae was normal, but spasm of
+the orbicularis held the eye firmly closed. The condition did not
+improve, and the patient was invalided home. He recovered later.
+
+In another patient a bullet entered above the right zygoma and traversed
+the orbits, without wounding the globes. At the time no want of power of
+the muscles of the face was noted, but a year later there was evident
+weakness of the whole of the muscles of the right side of the face, with
+loss of symmetry.
+
+In the former case the functional element was strong, but in both an
+ascending neuritis was probably present.
+
+_Tenth nerve._--The pneumogastric was implicated in many wounds of the
+neck. I never observed an uncomplicated case, but laryngeal paralysis
+was temporarily present in two of the cases of cervical aneurism in
+which the wound crossed above the level of origin of the recurrent
+laryngeal branch, while in two others the recurrent branch itself was in
+close contact with the wall of the aneurism (p. 135). In all such cases
+signs of concussion or contusion of the nerve would be expected, judging
+from the similar results observed in the brachial nerves when the
+neighbouring artery was implicated. The only obvious symptoms occurring,
+however, were laryngeal paralysis and acceleration of the pulse. As the
+latter symptom was often observed in the cases of arterio-venous
+communication, wherever situated, and as the sympathetic nerve also lay
+in close contiguity to the wound track, it was difficult to ascribe it
+with certainty solely to the vagus lesion. In the two cases of high
+vagus injury the laryngeal paralysis steadily improved, and at the end
+of six months was apparently well; in the two others it persisted at the
+end 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 the
+death of some of the patients with cervical wounds upon the field.
+
+_Eleventh nerve._--I append the only case of localised spinal accessory
+paralysis I observed. This was one of my earliest experiences, and when
+I examined the neck, in the Field hospital, I assumed from the
+completeness of the sterno-mastoid and trapezius paralysis that the
+nerve was severed. The patient, however, made such a rapid recovery
+that it became evident that the nerve had been contused only, and that
+the recovery of function was not due, as is so often the case, to
+vicarious 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
+     hyperaesthesia of the whole left upper extremity, most severe in
+     the circumflex area. The hyperaesthesia 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 of
+the mouth. I saw no case of permanent paralysis.
+
+_Injury to the systemic nerves._ _Cervical plexus._--Evidence of injury
+to the superficial branches of the cervical plexus was not rare; thus I
+saw cases of small occipital anaesthesia, 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 supply
+possessed by many of the muscles of the neck, would both take part in
+rendering certain evidence of the injury of an individual motor nerve
+rare.
+
+_Brachial plexus._--Injury to this plexus in the neck was common; the
+main peculiarity observed was the partial nature of the damage
+inflicted.
+
+Thus injury to a single nerve, or to a complex of two or more, was far
+more common than one implicating the whole plexus. Again, while complete
+paralysis might affect one set of nerves, another might simply exhibit
+signs of irritation in the form of hyperaesthesia or pain.
+
+The wounds producing these injuries varied much in direction; thus some
+crossed the neck transversely, some were obliquely transverse, while
+others took a more or less vertical course.
+
+These same remarks hold good in the case of the nerves of the arm. In
+the upper half, especially, complex injury was not rare, while in the
+lower third affection of individual nerves was more common. Another
+important difference must be mentioned in regard to the upper and lower
+segments of the course of the brachial nerves; they are not only more
+widely distributed below, but also more fixed in position, a fact
+antagonistic to the escape of the nerve by displacement and liable to
+expose it to more severe contusion.
+
+The latter point holds good in the forearm also; here, individual
+injuries often occurred.
+
+While at work in the Field hospital alone I gained the impression that
+the musculo-spiral nerve would not retain the unenviable character of
+being the most vulnerable nerve of the upper extremity, since the
+chances of each individual nerve seemed about equal, putting the
+question of the long course of the musculo-spiral nerve against the
+humerus out of question. This expectation was, however, not confirmed,
+since the musculo-spiral itself, if not primarily affected, was so often
+the seat of secondary mischief in fractures of the humerus. The
+posterior interosseous branch seemed to exhibit a similar vulnerability
+to slight injuries, to be referred to later under the external popliteal
+of the lower extremity. Again, in complex injuries of the brachial
+plexus, or nerve trunks, the musculo-spiral branch rarely escaped being
+a member, if not individually singled out.
+
+Of the _thoracic nerves_ I have little to say. They must have been often
+injured in the thoracic wounds, yet, as far as my experience went,
+intercostal neuralgia was uncommon, or at any rate not a special
+feature. One observation of interest, however, does exist; in the cases
+in which the ribs were fractured by bullets travelling across them
+within the thorax, pain was distinctly a prominent feature. This was no
+doubt referable to the facts that in such instances the intercostal
+nerves were especially liable to direct injury, and that this was often
+multiple. On one occasion a crop of herpetic vesicles developed along
+the course of a dorsal nerve in an injury implicating a single
+intercostal space posteriorly.
+
+_Lumbar plexus._--Although not quite so well arranged to escape bullet
+wounds as the thoracic nerves, the lumbar, by reason of their deep
+position and the comparatively wide area they cover, together with the
+rarity of wounds taking a sufficiently longitudinal direction to cross
+the course of more than one or two branches, were also comparatively
+rarely damaged. I never saw an uncomplicated case of anterior crural
+paralysis, and rarely cruralgia. I think this is to be explained in two
+ways: first, that the trunk course of the nerve is short; secondly, that
+it lies in the inguinal fossa. The second fact is of importance, since
+wounds in this region were in my experience responsible for a
+considerable percentage of the deaths on the field or shortly
+afterwards. Such deaths probably occurred from internal haemorrhage from
+the iliac arteries, and it was in such cases that the anterior crural
+nerve stood in greatest danger of injury. I also never saw a case of
+localised obturator paralysis. On the other hand, anaesthesia or
+hyperaesthesia in the area of distribution of the lumbar nerves in the
+groin, the external cutaneous and the long saphenous in the thigh, were
+not uncommon. Hyperaesthesia developed in more than one case in which
+injury to the psoas had led to haemorrhage into the muscle sheath.
+
+_Sacral plexus._--The sacral plexus is far more liable to extensive
+direct injury than either of the two preceding. Its cords are larger,
+gathered up into a much smaller space, and more liable to injury, from
+the fact that the slope in which they lie is more readily followed by a
+bullet track. Again, the cords rest for a considerable portion of their
+course on a bony bed, a particularly dangerous position in gunshot
+wounds, since the nerves are not only exposed to the danger of direct
+wound, or pressure from bony spicules, but also readily receive
+transmitted vibrations secondary to impact of the bullet with the bone.
+
+None the less I had few occasions to observe extensive injuries of the
+plexus. In one instance damage particularly affecting the lumbo-sacral
+cord occurred, but this was complicated by signs of irritation of the
+anterior crural and obturator nerves, as the result of retro-peritoneal
+haemorrhage and injury to the psoas muscle. Two cases in which the
+sacro-coccygeal plexus suffered isolated injury on account of their
+characteristic 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
+     faeces 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 faeces, 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 sacral
+plexus that has been already given in the case of the anterior crural
+nerve holds good--viz. that in a great many of the pelvic wounds
+involving the plexus early death followed from the severity of the
+concurrent injuries.
+
+Injuries to the great sciatic nerve outside the pelvis, or to one of its
+constituent elements, on the other hand, formed one of the most familiar
+of the nerve lesions. The wounds giving rise to these were of the most
+diverse character; some crossed the buttock in a vertical, transverse,
+or oblique direction; others travelled through the thigh in
+corresponding directions, while a third series involved both buttock and
+thigh.
+
+The size of the great sciatic nerve renders complete laceration by a
+bullet of small calibre a matter almost of impossibility; hence complete
+division may almost be left out of consideration in the case of this
+nerve. On the other hand, partial division, perforation, and severe
+contusion are each and all favoured by the same factor.
+
+With an extended thigh the nerve is in a state of comparatively slight
+tension, and this may be still lessened if the knee be flexed. This
+factor, together with the density of the sheath of the nerve, favours
+the possibility of displacement, and this occurrence is more likely in
+the lower segment than in the upper, which is comparatively fixed in
+position.
+
+Clinical experience appeared to illustrate the importance of these
+anatomical factors, as the worst cases of sciatic injury that I saw were
+in connection with wounds of the buttock or the junction of that segment
+of the trunk with the thigh.
+
+The most striking observation with regard to the injuries of the great
+sciatic nerve was the comparatively frequent escape of the popliteal
+element and the severe lesion of the peroneal. This was so pronounced as
+to amount to as high a proportion of peroneal symptoms as 90 per cent.,
+and often when the whole nerve was implicated the popliteal signs were
+of the irritative, the peroneal of the paralytic type. When bullets
+crossed the popliteal space, given wounds of equal severity in
+corresponding degrees of contiguity to the respective nerves, the
+peroneal element always suffered in greater degree. Again, the peroneal
+nerve symptoms were more obstinate and prolonged, and instances of
+ascending neuritis were more common than in the case of any other nerve
+of the lower extremity, and the trophic wasting of muscles was more
+marked.
+
+The peroneal nerve, therefore, acquires the same unenviable degree of
+importance in the lower extremity enjoyed by the musculo-spiral in the
+upper. Here, again, we are confronted with the fact that the peroneal
+element of the great sciatic nerve is the more prone to idiopathic
+inflammations or toxic influences, and hence we can only assume it to
+possess a special vulnerability. The peroneal element is of course
+somewhat the more exposed, as lying posterior; but it seems unreasonable
+to assume that so large a proportion of the injuries can implicate the
+posterior segment of the nerve as to make the startling difference in
+the incidence of degeneration explicable. In this relation we may bear
+in mind that the muscles supplied by this nerve suffer most in the
+degeneration subsequent to anterior polio-myelitis, and again that in
+cerebral hemiplegia or spinal-cord injuries they are the last to
+recover. Unfortunately no explanation of these remarkable facts, so
+forcibly impressed by the large series of cases with peroneal symptoms
+seen 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 latter
+was injured, it was surprising how sharply the imperfections in the
+anaesthesia corresponded with the composite character of the nerve.
+
+
+CASES OF NERVE INJURY
+
+The following cases are added mainly to give some idea of the
+comparative frequency with which the individual nerves were injured, and
+also to exemplify the more common forms of complex injury met with.
+Circumstances, unfortunately, did not always allow of extended
+observation at the time, and I have not been very fortunate in my
+attempts to obtain subsequent information on this series since my
+return. A certain amount of prognostic information is, however,
+furnished by some of the records, and I am very much indebted to my
+colleague, 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 anaesthesia. 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. Hyperaesthesia 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 hyperaesthesia 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; haemothorax. 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; hyperaesthesia 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 hyperaesthesia.
+     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, anaesthesia 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 anaesthesia, 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 anaesthetic.
+
+     (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
+     anaesthetic median area became hyperaesthetic 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
+     hyperaesthesia 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 hyperaesthesia 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.). Hyperaesthesia 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
+     anaesthesia 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 anaesthesia 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 anaesthesia, except in the hinder
+     part of the region supplied by the mixed external saphenous.
+     Slight hyperaesthesia 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 anaesthesia_.--_Shell_
+     wounds of the right popliteal space. Wounded at Belmont.
+     Anaesthesia of the outer side of the calf, the leg and sole of
+     foot. No motor paralysis. As cicatrisation progressed, the
+     anaesthesia 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. Hyperaesthesia 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 anaesthesia
+     was less apparent, but a feeling of numbness persisted, which
+     soon disappeared.
+
+_Prognosis and treatment._--In considering the prognosis in cases of
+nerve injury, several of the points already raised as to the nature of
+the lesion are of importance. Short of actual section, it may be broadly
+stated that no lesion is too serious to render ultimate recovery
+impossible.
+
+In cases in which the injury has been produced by a bullet fired at a
+short range, or in which contact with the nerve has been close, the
+return of functional activity is very slow. In such instances the
+condition probably resembles that in which a divided nerve has been
+sutured, with the additional disadvantage that a considerable portion of
+the nerve, both above and below the point actually struck, has been
+destroyed as far as the conduction of nervous impulses is concerned.
+This may reasonably be concluded in the light of the evidence offered by
+the injuries of the spinal cord, in which several segments usually
+suffered if the velocity of the bullet was great, and also if the fact
+is remembered that, when thickening takes place, a considerable length
+of 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 of
+extreme severity. Again, these same nerves are apparently more seriously
+affected by moderate degrees of damage than are others.
+
+As favourable prognostic elements we may bear in mind: low velocity on
+the part of the travelling bullet, and with this a lesser degree of
+contiguity of the track to the nerve. The early return of sensation is a
+favourable sign, and in this relation the development of hyperaesthesia,
+whether preceded by anaesthesia or no, points to the maintenance of
+continuity of, and a moderate degree of damage to, the nerve. The early
+return of sensation, even if modified in acuteness, was always a very
+hopeful sign; also the production of formication in the area of
+distribution of the nerve on manipulation of the injured spot. As in the
+case of nerve injuries of every nature, the disposition and temperament
+of the patient exerted considerable influence on the course of the
+cases.
+
+Complete section of the nerves in these bullet wounds only obtained
+special importance in two ways: first, in that a considerable portion of
+the trunk might be shot away in oblique tracks, and, secondly, in that
+very severe contusion might affect the nerve for a considerable
+distance beyond the point actually implicated. In point of fact,
+complete section when treated by suture was often more rapidly recovered
+from than an injury in which only a portion of the width of a trunk was
+divided. This was no doubt to be explained on the theory that the
+contiguous portion of the nerve suffered less when tension and
+resistance were lessened by complete severance of the cord.
+
+_The treatment_ of slight nerve contusion was simple; rest alone was
+necessary, and in the course of hours or days paralysis was recovered
+from. The symptoms were most troublesome in patients of a neurotic
+temperament, or those who had suffered from severe systemic shock.
+
+In severe concussions and contusions the first care had to be devoted to
+the discrimination of the lesion from that of division. A period of rest
+then needed to be followed by one of massage and movement, to maintain
+the nutrition of the muscles. In a considerable portion of the cases a
+stage of neuritis had to be expected. In all cases, either of severe
+concussion, contusion, or complete section, accompanied by the fracture
+of a bone, especial care was necessary that the bandaging and fixation
+of the limb were not sufficiently tight to add the dangers of muscular
+ischaemia 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 same
+treatment: rest, preservation of the limb from cold or damp, and the
+local application of anodynes, as belladonna, or hot laudanum
+fomentations. In some cases a general anodyne, as morphia, was
+preferable; then always to be used with caution, as the patients soon
+craved inordinately for it, and were unwilling to give it up. Later,
+local blisters in the line of the nerve trunk, careful massage and
+exercise when muscular and cutaneous tenderness had subsided, the
+application of the continuous current to the nerves, and perhaps
+faradisation of the muscles, were all useful.
+
+Splints were often temporarily required to resist contracture, or the
+assumption of false positions; in either case they needed to be
+frequently removed, and movement &c. made, in order to avoid any chance
+of troublesome stiffness.
+
+_Operative treatment._--Early interference was only warranted by
+positive knowledge that some source of irritation or pressure could be
+removed; thus a bone spicule, or a bullet, or part of one, particularly
+portions of mantles.
+
+In case of contusion the expiration of three months is the earliest date
+at which any operation should be taken into consideration, and
+interference is only then advisable if there is good prospect of freeing
+the nerve from compressing adhesions. The two strongest indications for
+operation are (1) signs pointing to the secondary implication of the
+nerve in a cicatrix, especially when these are of such a nature as to
+indicate local tension, fixation, or pressure; (2) the possibility of
+the irritation being the result of the presence of some foreign body,
+such as a bone spicule, or portions of a bullet mantle; in such cases
+the X rays will often give useful help.
+
+With regard to the early exploration of cases of traumatic neuralgia, it
+may be pointed out that when this was undertaken the results were as a
+rule very temporary. In many cases in which the measure was resorted to,
+either no macroscopic evidence of injury to the nerve was discovered, or
+a bulbous thickening was met with of such extent as to make excision
+inadvisable, even if it were considered otherwise the most suitable
+treatment.
+
+Even when complete section of the nerve was assured by the absence of
+any power of reaction to stimulation by electricity from above on the
+part of the muscles, operation was better not undertaken until
+cicatrisation had reached a certain stage. If done earlier than at the
+end of three weeks, the sutured spot became implicated in a hard
+cicatrix, and any advantage to be obtained by early interference was
+lost. When partial division of a trunk was determined, the same date was
+the most favourable one for exploration, the gap in the nerve being
+freshened and closed by suture. There is little doubt, however, that in
+some cases such injuries were recovered from spontaneously.
+
+In view of the uniformly bad results observed in the case of the seventh
+nerve, I am inclined to think that the above rules might be tentatively
+relaxed, and the nerve primarily explored by an operation resembling
+that for mastoid suppuration. It is of course doubtful whether the
+trouble does not generally result from the vibratory concussion alone;
+but as this is not certain, and the operation would only have to be
+performed on patients already permanently deaf, it might be worth while
+at any rate opening the Fallopian canal with the object of relieving
+tension. It is not probable that in any of the cases quoted much
+splintering of the bone had occurred, as the wounds appeared to be of
+the nature of pure perforations.
+
+
+
+
+CHAPTER X
+
+INJURIES TO THE CHEST
+
+
+In regard to Prognosis wounds of the chest furnished the most hopeful
+class of the whole series of trunk or visceral injuries. Cases of wound
+of the heart and great vessels afforded the only exceptions to an almost
+universally favourable course, both as regards life and the
+non-occurrence of serious after-effects.
+
+This was mainly explicable on two grounds: first, the sharply localised
+character of the lesion produced by the bullet of small calibre; and,
+secondly, the fact that the lung, the most frequently injured organ, is
+not materially affected by the grade of velocity with which the bullet
+strikes. In point of fact, wounds of this organ probably afford an
+instance in which high grades of velocity are distinctly favourable to
+the nature of the injury, and this is possibly true in the case of
+wounds of the chest-wall also.
+
+The significance of the calibre of the bullet in wounds of the chest is
+evident. The late Mr. Archibald Forbes, in one of his letters from the
+seat of the Franco-German war, remarked that in crossing a battlefield
+it was easy to recognise the patients who had suffered a wound of the
+lung from the fact that the whistle of the air entering and leaving the
+chest was plainly audible. This was, indeed, not uncommonly the case in
+wounds produced by the older bullets of large calibre, but with the
+employment of the smaller projectile it has become an experience of the
+past. Some evidence as to the comparative severity of wounds produced by
+the larger forms of bullet was, moreover, afforded by the present
+campaign, since Martini-Henry wounds were occasionally met with. Of some
+instances observed by myself, in one, external haemorrhage was a
+prominent symptom; in another, a piece of lung was prolapsed from a
+wound in the back, and twice I observed pneumothorax, an uncommon
+sequela to wounds from bullets of small calibre.
+
+It may be remarked, however, that all these more serious injuries were
+recovered from, also that when we consider that the patients were
+comparatively young and healthy subjects, the favourable prognosis was
+what might have reasonably been expected. When, as occasionally
+happened, a patient of more mature years, with enlarged facial
+capillaries, received a wound of the lung, the course was in no way so
+favourable as that witnessed in the case of the younger men.
+
+In support of this opinion I may add that wounds from shrapnel and
+fragments of shell also did remarkably well, although they sometimes
+gave rise to more troublesome symptoms than did wounds produced by
+bullets of the Mauser type. Again, these injuries as a whole were of
+nothing like so serious a nature as the lacerations of the lung produced
+by fractured ribs, which we commonly have to treat in civil practice,
+and are not accustomed to regard as especially dangerous.
+
+It is also a striking fact that the most common and troublesome
+complication of wounds of the chest, haemothorax, was usually the result
+of the wound of the chest-wall and not of the lung. I preface these
+remarks to the detailed account of the thoracic injuries, because I
+think the favourable course usually taken by patients with wounds of the
+lung has been accorded somewhat greater prominence than the
+circumstances warranted.
+
+_Non-penetrating wounds of the chest-wall._--Surface wounds were not
+very common, and were chiefly of interest in so far as they illustrated
+the very superficial course that may be occasionally taken by a bullet
+without breach of the integument, and as sometimes affording opportunity
+for the exercise of diagnostic skill when the track traversed the
+axilla.
+
+The most common situation for tracks taking a long course on the surface
+of the thoracic skeleton was the back. Such wounds were usually received
+while the patients were prone on the ground; thus I might instance a
+case in which the bullet entered the posterior aspect of the shoulder 3
+inches above the spine of the scapula, passed downwards, pierced that
+process, and emerged 2 inches below the inferior angle of the bone.
+Wounds of a similar nature coursing in transverse and oblique
+directions, and not implicating bone, were also seen. Those implicating
+the vertebrae have been already dealt with. The scapular region was also
+a favourite one for the lodgment of retained bullets, some resting in
+the supra- and infra-spinatus muscles, others lying beneath the bone
+itself.
+
+On the anterior aspect of the chest, bullets coming from the front
+sometimes traversed and fractured the clavicle, and then took a short
+course downwards, emerging over the ribs or sternum. Figure 81
+represents a particularly long track in this region. In other cases the
+precordial region was crossed, but I never witnessed any serious effect
+on the heart's action in any such injury at the time the patients came
+under my notice.
+
+Wounds received with the arm outstretched and traversing the axilla
+sometimes gave considerable trouble in excluding with certainty a
+perforation of the thoracic cavity. Thus a bullet entered below the
+centre of the right clavicle and emerged 2-1/2 inches below, above the
+angle of the scapula, at its axillary margin. The arm was outstretched
+at the moment of the reception of the injury; but when the wound was
+viewed with the limb placed alongside the trunk, it seemed almost
+impossible that the chest cavity could have escaped. In some cases of
+this kind the difficulty was at once cleared up by noting evidence of
+injury to the axillary nerves.
+
+A word will suffice as to the treatment of these wounds. The only
+special indication was to keep the scapula at rest for a sufficient
+period. I have dealt with the anatomy of them at such length only
+because in their extreme form they are so highly characteristic of the
+nature of the injuries which may be produced by bullets of small
+calibre.
+
+_Penetrating wounds of the chest._--Tracks crossing the thoracic cavity
+in every direction were common. When the erect attitude was maintained,
+frontal and sagittal wounds, pure or oblique, were received; when the
+prone position was assumed, longitudinal tracks, either purely or
+obliquely vertical, were the rule. Experience of wounds of the latter
+class was extensive in the present campaign, from the fact that so many
+of the advances were made in prone or crawling attitudes. The vertical
+and transverse tracks each possessed the special characteristic of
+frequently implicating both the thoracic and abdominal cavities, but the
+vertical were often prolonged into the neck, or even downwards through
+the pelvis. The vertical wounds in addition sometimes exhibited one very
+important feature, the fracture of several ribs from within, often at a
+very 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 been
+mentioned, the chest-wall was one of the situations in which the
+aperture of entry was often large, and the oval form due to obliquity of
+impact on the part of the bullet was particularly well marked. The exit
+wounds were often smaller than those of entry, especially if the bullet
+emerged by an intercostal space; even when the ribs were comminuted, the
+fragments were, as a rule, too small to occasion more than a slightly
+enlarged and irregular aperture. Taken as a class, however, and putting
+aside explosive exit wounds, wounds of the chest afforded more numerous
+examples of irregular outline and variation in size than were met with
+in any other region of the body.
+
+When the tracks penetrated the broad upper intercostal spaces, an
+interesting feature, due to the tense and rigid nature of the muscles
+closing the intervals, and their large admixture of fibrous tissue, was
+sometimes noticed. The bullet, especially if passing obliquely, was apt
+to cut a slit in the muscles far exceeding in size the opening in the
+overlying integument, with the result of leaving a palpable subcutaneous
+defect. Under these circumstances the yielding spot was often noticed to
+rise and fall with the movements of respiration, external palpation met
+with an absence of normal resistance, and there was impulse on coughing.
+
+_Fractures of the ribs._--These injuries were produced in either
+transverse or longitudinal coursing tracks, their special feature being
+a sharp localisation of the lesion of the bone.
+
+In tracks crossing the chest transversely the injury to the ribs might
+consist in notching, perforation, or complete solution of continuity,
+sometimes with fine comminution. In the incomplete injuries some
+importance attached to the localisation of the lesion to the upper or
+lower border of the rib, in so far as the intercostal artery was
+concerned. Comminution at the wound of entry was, as a rule, not so
+extensive as at the aperture of exit, and in any case was less apparent,
+since the fragments were driven inward. The wider comminution at the
+exit aperture depends on the lesser degree of support afforded by the
+thoracic coverings to the convex outer surface of the rib, and on the
+fact that the velocity of the bullet has been lowered by its passage
+through the opposite rib and the chest cavity.
+
+The splinters of comminuted ribs are small, and wide-reaching fissures
+rare. These characters depend on the elastic nature of the resistance
+offered by the curved rib to the passage of the bullet, which is
+calculated to preserve the bone from the full force of impact, except at
+the point actually impinged upon.
+
+Fractures of the ribs, produced from within by bullets taking a
+longitudinal course through the thorax, were still more special in
+character. They were also more important, as giving rise to troublesome
+symptoms.
+
+In these, again, the degree of injury to the bones varied considerably.
+In some cases the bones were merely grooved internally, without any
+external deformity; in other cases a sort of green-stick fracture was
+produced, accompanied by the projection of a tender salient angle
+externally; in others complete solution of continuity was effected.
+
+Another feature of importance was the occasional implication of several
+ribs. In this case the symptoms accompanying the injury were very much
+more like those observed in the corresponding injuries resulting from
+indirect 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 comminution
+were observed. The latter condition differed from the similar one seen
+in the case of the ribs only in so far as the tougher consistence of the
+cartilage did not lend itself to such free comminution, and the
+splinters 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 pure
+perforation; these were not uncommon in the hospitals, either in the
+upper or the extreme lower portions of the bone. Fractures in other
+portions were no doubt usually associated with fatal injuries to the
+heart. The openings were usually so small as to be difficult of
+palpation, and I never had the opportunity of examining one _post
+mortem_.
+
+Perforations of the body of the _scapula_ were common, but they were of
+little importance in symptoms or prognosis.
+
+_Symptoms of fracture of the ribs._--Fractures accompanying transverse
+wounds of the chest were characterised by the insignificance of the
+symptoms produced. Every common sign of fracture of the rib was in fact
+absent. Neither pain, stitch on inspiration, nor crepitus, either
+audible or palpable, was, as a rule, present. This absence of signs was
+accounted for by the nature of the lesion: thus in perforations or
+notchings there was no loss of continuity, while in the freely
+comminuted fractures the loss of continuity was so absolute as to allow
+no possibility of the main fragments rubbing together. Again, part of
+the symptoms attending these injuries, as seen in civil practice,
+depends upon contusion and laceration of the surrounding structures--a
+condition precluded by the localised nature of the application of the
+violence by a bullet of small calibre. In order to establish a
+diagnosis, therefore, we were in many cases reduced to palpation, and
+occasionally to direct examination of the wound.
+
+Fractures accompanying longitudinal tracks formed a class rather apart
+in the matter of symptoms. In these mere groovings might also be
+accompanied by no signs, or at the most by slight local pain and
+tenderness. When, however, the grooving was sufficiently deep to be
+accompanied by deformity, or a complete solution of continuity was
+effected, the signs were often severe. The tender salient angle, or, in
+the absence of this, a highly tender localised spot, often pointed to
+the less severe injuries, and when the fractures were complete or
+multiple, pain was a very prominent symptom, both constant and in the
+form of inspiratory stitch. The severity of the pain was probably to be
+in part ascribed to implication of the intercostal nerves, which in
+these injuries was direct and often multiple. Again, severe contusion or
+actual laceration of the nerves, with resulting anaesthesia, was less
+common than when the bullet directly implicated the nerves in transverse
+wounds. Free comminution and absolute solution of continuity were also
+less common than in the fractures accompanying transverse wounds; hence
+pain from rubbing of the fragments on inspiratory movement or palpation
+was more common, and crepitus, either on auscultation or palpation, was
+more often met with. Patients with this class of fracture often suffered
+greatly from painful dyspnoea, and were unable to assume the supine
+position.
+
+_External haemorrhage_ of severity was rare from these thoracic wounds;
+in many cases it did not amount to more than local staining of the
+shirt; altogether I saw only one or two cases where any serious bleeding
+occurred. Internal haemorrhage into the pleura, in consequence of the
+position of the intercostal arteries, was common, and often abundant;
+this will be treated of under the heading of haemothorax.
+
+_Treatment of fractured ribs._--Transverse wounds of the thorax, with no
+symptoms of fractured ribs, needed to be dealt with as wounds of the
+soft parts alone.
+
+In multiple fractures accompanying longitudinal tracks, bandaging or
+strapping for the purpose of fixation was necessary to relieve pain. A
+few fragments of bone sometimes needed primary removal, and occasionally
+small 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 such
+cases the last remaining energy of the bullet often seemed to have been
+spent in diving under the margin of a rib and turning longitudinally up
+or down. Removal was sometimes necessary, either from the prominence
+produced, the presence of pain, or the continuance of suppuration. Some
+of the specimens removed offered interesting evidence of the capacity of
+the ribs to withstand considerable violence from a bullet. These were
+slightly bent, and marked by a half-spiral groove. I saw such bullets
+removed from the thoracic and the abdominal wall, and the evidence
+seemed rather against the groove having been produced prior to their
+entrance into the body.
+
+[Illustration: FIG. 82.--Spirally grooved Mauser Bullet]
+
+_Wounds of the diaphragm._--Perforations of the diaphragm were very
+frequent, and as a rule of small significance. When, however, the course
+taken by the bullet was parallel with that of the slope of the
+diaphragm, a more or less extensive slit was the result. I saw such a
+wound still gaping, and 2 inches in length, in the body of a patient
+who died three weeks after the infliction of a fatal abdominal injury.
+
+In several other obliquely transverse thoracic wounds there was reason
+to assume the existence of similar slits. Certain signs were more or
+less constant under these circumstances. These consisted in shallow
+respiration, often accompanied by a groan or the slightest degree of
+hiccough on inspiration, and considerable increase in respiratory
+frequency. In one patient the respirations were at first 48, only
+dropping to 36 some seventy hours after the reception of the injury. In
+some of the cases in which the abdominal cavity was implicated, wound to
+the diaphragm seemed a more likely explanation of early, frequent, and
+painful vomiting than did visceral injury. The possibility of the later
+development of diaphragmatic herniae in some of these patients will have
+to be borne in mind in the future.
+
+_Visceral injuries._--The frequent escape of the thoracic viscera from
+injury, putting aside the lungs which fill so great a part of the
+cavity, was very remarkable. I never saw a case in which I could assume
+injury to any of the posterior mediastinal viscera, although such may
+have occurred on the field of battle. An injury to the oesophagus, for
+instance, would almost of necessity be accompanied by wound of either
+one of the large vessels, even the thoracic aorta, or the spinal column.
+I was somewhat surprised, however, to learn on enquiry from surgeons who
+had seen a large number of the dead and dying on the field, that
+thoracic 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, and
+the heart, is, I believe, to be explained by the fact that all are
+supported and held in position by the loose meshed mediastinal tissue,
+which allows for their displacement after the manner observed in the
+case of the vessels and nerves lying in the loose tissue of the great
+vascular clefts.
+
+_Wounds of the heart._--Perforating wounds of the heart were probably
+fatal in all instances, in spite of the fact that, in some patients who
+survived, the position of wound apertures on the surface of the body
+made 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 variations
+in bulk, its elastic compressibility, and its variations in position in
+systole and diastole. The variations in bulk and position would be
+capable of explaining the escape of the organ from injury at some
+particular moment, when a second shot apparently through the same wound
+track might implicate it. Beyond this, reasoning from the case of
+analogous hollow viscera, as the arteries or the intestine, a bullet
+might readily score the surface of the heart without perforating its
+cavity.
+
+Such accidents were observed. Thus, in a case examined by Mr. Cheatle,
+the patient died of suppurative pericarditis, secondary to a wound of
+which the external apertures had closed. In this patient both auricle
+and ventricle were scored externally by the passage of the bullet.
+
+I am, however, disinclined to allow that many patients survived direct
+blows on the heart, since I believe that in the majority if not in all
+cardiac wounds the actual cause of death was not haemorrhage, but sudden
+stoppage of the heart's action. This is to be inferred from the fact
+that severe external haemorrhage did not occur; in some cases the shirt
+was hardly stained, and in all death occurred in the course of a very
+few minutes. Again, in none of the patients whom I saw who had received
+possible wounds of the heart-wall were there evident signs of
+haemo-pericardium. In view of the difficulty of detecting this condition
+from physical signs, this argument is naturally not of great weight, but
+must be allowed.
+
+One or two death scenes from cardiac wound were described to me. In one
+the patient muttered 'They have got me this time,' and died quietly; in
+a second the patient's face became ghastly pale, he lay on his back with
+the knees flexed, clutching the ground, gasping for breath, and died
+only after some minutes of evident great agony. The absence of any
+_post-mortem_ details as to the condition of the heart in these injuries
+is 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 pleurae, 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-haemo-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 haemoptysis.
+
+Some remarks regarding wounds of the thoracic vessels have already been
+made in Chapter IV., where instances of injury to the innominate and
+left subclavian arteries are recounted. The escape of the large trunks
+was 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 haemorrhage from the wound
+     of entry caused great anxiety; this ceased spontaneously,
+     however, and, beyond transient haemoptysis 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
+     haemorrhage 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 most
+important series of visceral injuries met with in the thorax, the
+frequency of incidence corresponding with the proportionate sectional
+area occupied by the organs. Although these injuries did well, and
+needed little interference on the part of the surgeon, many points of
+interest were raised by them.
+
+Thus the comparative importance of the wound in the chest-wall to that
+in the lung itself, was scarcely what, without actual experience, would
+have been expected, the former proving so very much the more important
+element of the two.
+
+The question of velocity on the part of the bullet took a very secondary
+position in these injuries. I saw a number of cases in which the
+patients estimated the range at which they received their wounds as from
+30 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-wall
+than 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 any
+importance, further than from the fact that a sufficiently low degree to
+allow of lodgment of the bullet was distinctly unfavourable.
+
+In view of the general lack of significance in these injuries it was
+interesting to note how very definite was the ill effect of early
+transport on the after course. This depended on the frequent development
+of parietal haemothorax in patients who were not kept absolutely at rest.
+
+The tracks produced in the lungs by the bullets were very minute, and in
+the few cases in which opportunity arose for their examination _post
+mortem_ some little time after the infliction of the wound, there was
+great difficulty in localising them. The slight damage incurred by the
+pulmonary tissue is due to its elasticity and non-resistent character.
+
+Pulmonary haemothorax was distinctly rare. Reasoning from the analogous
+wounds of the liver, tracks scoring the surface of these organs might be
+much more to be feared than clean perforations. The elasticity of the
+lung tissue, however, must make such lesions rare. In point of fact,
+there is no reason why a perforation by a bullet of small calibre should
+be much more feared than a puncture from an exploring trocar, and the
+danger of the two wounds is probably very nearly the same.
+
+The only points of importance as to the particular region of the lung
+traversed were the distance from the periphery as affecting the probable
+size of the vessels injured, and perhaps the implication of the base or
+apex of the organ respectively. I am under the impression that wounds in
+the apical region were somewhat more liable to be followed by the
+development of pneumothorax, and possibly haemothorax, while wounds at
+the base gained their chief importance from the frequency of concurrent
+injury to the abdominal viscera. I had no experience of the immediate
+results of wound of the great vessels at the root of the lung, but
+assume that they led to speedy death.
+
+_Symptoms of wound of the lung._--I shall describe the whole complex
+usually observed, although it is obvious that the wound of the
+chest-wall is responsible for a large proportion of the signs.
+
+The majority of these injuries were accompanied by a certain degree of
+systemic shock, and this was more marked in wounds received at a short
+range. The shock was, however, rather to be attributed to the injury to
+the 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 walk
+or remain in the erect position after receiving these wounds; this
+feature was also noted in horses in whom a bullet passed through the
+lungs.
+
+The remarks made as to the pain accompanying fractures of the ribs apply
+equally here. Pain was not a prominent symptom, except in so far as the
+actual impact caused temporary suffering. It was striking how often
+patients who received wounds through the arm prior to the same bullet
+traversing the chest appreciated the chest wound only, yet the chest
+might 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 sometimes
+had 'all the wind knocked out of them' at the moment of impact, but when
+seen at the Field hospitals a short time later, the respirations were
+shallow, but easy and regular, and only moderately quickened; thus 24
+was a not uncommon rate. Naturally if accumulation of blood in the
+pleura began early and continued, these remarks do not hold good; and
+again in some older men of full-blooded type and the subjects of
+recurrent attacks of bronchitis, a considerable degree of pain,
+dyspnoea, and even cyanosis was sometimes present soon after the
+injury. The complication of wound of the diaphragm has already been
+referred to in this relation.
+
+Local respiratory immobility of the thoracic parietes and consequent
+asymmetry of movement were constant. This was especially a marked
+feature when the upper part of the chest was implicated on one side
+only. It rather corresponded, however, to the local shock observed in
+wounds of the limbs than to the instinctive immobility accompanying
+fractures of the ribs; since, as already explained, small-calibre bullet
+wounds of the ribs are not necessarily painful on movement, and the sign
+existed even when the bullet had passed by an intercostal space. This
+sign was naturally a transitory one.
+
+Haemoptysis was a fairly constant sign, but sometimes quite absent when
+no doubt could exist as to the perforation of the lung. As a rule, a
+considerable quantity of blood might be coughed up shortly after the
+injury; but I never knew this to be sufficient in amount to give rise
+to any misgivings as to danger from the haemorrhage. After the first
+evacuation of blood from the wounded lung, the sign varied much; in the
+majority of instances the patients continued to expectorate small
+quantities of blood mixed with mucus, for some three or four days, the
+blood gradually assuming a coagulated condition. Sometimes only the
+primary haemoptysis was noted, and still more rarely the expectoration of
+clots was continued for a week, or even longer. This probably depended
+partly on personal idiosyncrasy, partly on the size of the vessels which
+had been implicated in the track.
+
+Cough was not commonly the troublesome symptom noted in the contused
+wounds of the lung seen in civil practice accompanying fracture of the
+ribs. Moist sounds were usually audible on auscultation, but in many
+cases 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 apical
+wound; over about a third of the upper part of the thorax in another
+wound through the second intercostal space, and in this case oddly
+enough the emphysema was the only sign of injury to the lung; and very
+occasionally widely distributed--in the latter case there were also
+usually multiple fractures of the ribs. Neither issue of air from the
+external 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 of
+about half a dozen Martini-Henry wounds, but I do not think it occurred
+as often in 100 small-calibre wounds. The Martini-Henry wounds all
+recovered; but convalescence was very prolonged, and the same remark to
+a less degree holds good in the small-calibre cases.
+
+That the slow recovery in cases of pneumothorax in the Martini-Henry
+wounds was due mainly to the size of the opening in the thoracic
+parietes was, I think, proved by the fact that in the small-calibre
+bullet wounds, followed by the development of pneumothorax, the external
+wounds were usually large and irregular in type; also, that in the only
+pneumothorax which I saw produced during an extraction operation, the
+air was very rapidly absorbed. In the latter case, however, there was
+little reason to conclude that wound of the lung had occurred primarily,
+and certainly no opening existed at the time the thorax was incised.
+
+_Haemothorax._--This was the most frequent and also the most interesting
+of the complications of wound of the chest. In 90 per cent. or more of
+the cases, the haemorrhage was of parietal source, and due either to
+direct injury to the intercostal vessels by the bullet or to laceration
+by spicules of comminuted ribs. For this reason, the passage of the
+bullet whether by an intercostal space, or through a rib, provided the
+wound was not at the posterior part of the space where the artery
+crosses, was a point of considerable prognostic importance. Exclusion of
+the lung as the source of haemorrhage was, I think, amply justified by
+the absence of continuous recurrent or progressive haemoptysis in the
+majority of the cases, and by the very small trace of injury found in
+the lungs of patients who died some weeks after the injury. In such it
+was difficult to discriminate the tracks at all. I only happened to see
+one case where free haemoptysis, during the course of development of a
+haemothorax, pointed to the lung as the source of the blood.
+
+Haemorrhage into the pleural cavity occurred in some degree in a very
+large proportion of the chest wounds, but it was especially interesting
+to note how greatly its extent was influenced by the amount of transport
+to which the patients were subjected in the early stages after the
+injury. During the early part of the campaign, on the western side, I
+saw a large number of chest wounds, and had I been asked my opinion as
+to the relative frequency of occurrence of haemothorax I should have
+placed it at about 30 per cent. The patients in these early battles
+needed little wagon transport, and when sent down to the Base travelled
+in comfortable ambulance trains. After the commencement of the march
+from Modder River to Bloemfontein, however, these conditions were
+changed, and all the chest as other cases were exposed to the necessity
+of three days and nights' journey to the Stationary hospitals and
+afterwards to the long journey to Cape Town. Of these patients, at
+least 90 per cent. suffered with haemothorax of varying degrees of
+severity.
+
+In some cases, the least common, signs of considerable intra-pleural
+haemorrhage immediately followed the wound; in others, the accumulation
+of blood was gradual, and only manifest in any degree at the end of
+three or four days, when it became stationary if the patient was kept at
+rest. In a second series the haemorrhage was of the recurrent variety;
+these cases differing little in character from those of slight
+continuous haemorrhage. In a third, the bleeding was definitely of a
+secondary character, corresponding with one of the classes of secondary
+haemorrhage described in Chapter IV., and occurring on the eighth or
+tenth day from giving way of an imperfectly closed wounded vessel. In
+either of the two latter classes the development of the haemothorax often
+corresponded with a journey, or with allowing the patient to get up.
+
+The general course of these effusions was towards spontaneous absorption
+and recovery. Coagulation of the blood took place early, the fluid serum
+separated, and tended to undergo absorption with some rapidity, leaving
+a small amount of coagulum at the base, which evidenced its presence for
+many weeks by a persistence of a certain degree of dulness on
+percussion. Early coagulation, I think, accounted for the usual absence
+of gravitation ecchymosis as a sign.
+
+The course to recovery was sometimes broken by signs of slight pleuritic
+inflammation, which, as affecting the amount of effusion, will be spoken
+of under the heading of symptoms. In some cases the amount of blood was
+so great as to necessitate means being taken for its removal; in these a
+reaccumulation often took place. Occasionally an empyema followed in
+cases thus treated.
+
+The nature of the blood evacuated on tapping varied much. In very early
+aspirations unchanged blood was often met with, but clot sometimes made
+evacuation difficult and necessitated a second puncture. In the tappings
+done 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 fluid
+replaced normal blood. In the cases where early incision was resorted
+to, blood both fluid and in clots was often mixed with a certain
+proportion of lymph flakes, perhaps indicating the part taken by
+inflammatory reaction to the irritation of the clot in producing the
+rise of temperature.
+
+_Symptoms of haemothorax._--In the more severe cases of primary bleeding
+the symptoms did not, as a rule, reach their full height until the third
+or fourth day after the injury. The patients then often suffered
+severely. The pulse and temperature rose, and to general symptoms of
+loss of blood were added: occasional lividity of countenance; severe
+dyspnoea, accompanied by inability to lie on the sound side or to
+assume the supine position; absence of respiratory movement on the
+injured side; pain, restlessness, cough, and sometimes continuance of
+haemoptysis, small clots usually being expectorated.
+
+Accompanying these symptoms were the usual physical signs of fluid in
+the pleura in differing degrees and combination. Dulness of varying
+extent up to complete absence of resonance on one side, often
+accompanied in the incomplete cases by well-marked skodaic resonance
+anteriorly. Loss of vocal resonance, and fremitus; oegophony, tubular
+respiration over the root of the lung or at the upper limit of the
+dulness, and more or less extensive displacement of the heart. Obvious
+increase in girth, fulness of the intercostal spaces, or gravitation
+ecchymosis was rare. The latter was most common in instances in which
+multiple fracture of the ribs existed (see fig. 83). I think the rarity
+of the last sign must have been due to the early coagulation of the
+blood, and its retention by the pleura, as I saw well-marked gravitation
+ecchymosis in one or two cases of mediastinal haemorrhage.
+
+The above complex of symptoms was common to all the cases, but in the
+slighter ones they gave rise to little trouble, and cleared up with
+great rapidity.
+
+[Illustration: FIG. 83.--Gravitation Ecchymosis in a case of Haemothorax,
+accompanying fracture of three ribs from within. The influence of the
+fractures on the development of the ecchymosis is shown by the linear
+arrangement of the discoloration]
+
+The most interesting feature was offered by the temperature, as this was
+very liable to lead one astray. A primary rise always occurred with the
+collection of blood in the pleura, this reaching its height on the third
+or fourth day, usually about 102 deg. 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 the
+case, the primary fall not reaching the normal, and a second rise
+occurred which reached the same height as before or higher. The second
+rise was accompanied by sweating, quickened pulse, and the probability
+of the development of an empyema had always to be considered. I believe
+in most cases this secondary rise was an indication of a further
+increase in the haemorrhage, for the dulness usually increased in extent,
+and such rises were often seen when the patient had been moved or taken
+a journey. Again, the temperature often fell to normal after
+paracentesis and removal of the blood, to rise again with a fresh
+accumulation, which was not uncommon. I have already mentioned the large
+proportional incidence of haemothorax observed in the patients who had
+to travel down from Paardeberg, and I might instance another case
+related to me by Dr. Flockemann of the German ambulance, which was very
+striking. A Boer, wounded at Colesberg, developed a haemothorax which
+quieted down, and he was removed to Bloemfontein; on arrival at the
+latter place the temperature rose, and other signs of fever suggested
+the development of an empyema; an exploring needle, however, only
+brought blood to light. After a short stay at Bloemfontein the symptoms
+entirely subsided, and the man was sent to Kroonstadt, when an exactly
+similar attack resulted, again quieting down with rest.
+
+Similar recurrent attacks of haemorrhage and fever occurred, however, in
+patients confined to their beds without moving after the first journey.
+Some temperature charts, in illustration of this point, are added to the
+cases quoted later. The explanation of the recurrent haemorrhages is, I
+think, to be found in the reduction of the intra-thoracic pressure with
+coagulation and shrinkage of the clot in the pleura in the patients kept
+quiet in bed, while in the patients who had to travel it was probably
+the result of direct mechanical disturbance.
+
+In many of these cases a pleural rub was audible at the upper margin of
+the dulness with the development of the fresh symptoms. Whether this was
+due to actual pleurisy or to the rubbing of surfaces rough from the
+breaking down of slight recent adhesions which had formed a barrier to
+the effusion, I am unable to say, but the signs were fairly constant. In
+some instances the increase in the amount of fluid was, no doubt, due to
+pleural effusion resulting from irritation from the presence of
+blood-clot, or perhaps the shifting of the latter; in these the
+secondary rise of temperature may well be ascribed to the development of
+pleurisy.
+
+I am inclined to believe, however, that the primary rise of temperature
+was similar to that seen when blood accumulates in the peritoneal cavity
+as the result of trauma, and the secondary rises in most cases to those
+which we saw so frequently accompanying the interstitial secondary
+haemorrhages spoken of in Chapter IV., and are to be explained on the
+theory of absorption of a blood ferment. The secondary rises always
+occurred with a fresh effusion, often of blood, occasioning an
+extension, which broke down probable light adhesions and exposed a fresh
+area of normal pleural membrane to act as a surface for absorption.
+
+It is, of course, manifest that the fever might also be ascribed to the
+infection of the clot or serum from without, and in the first cases I
+saw I was inclined to take this view, since we had in every case the
+primary wounds of chest-wall, and possibly of lung, and in some the
+addition of a puncture by an exploring needle between the first and
+second rise. After a wider experience, however, I abandoned the
+infection theory, as it seemed opposed by the very infrequent sequence
+of suppuration. The effect of simple removal of the blood or serum was
+also often so striking as to strongly suggest that it alone was
+responsible for the fever. Exactly the same result, moreover, followed
+evacuation of the interstitial blood effusions already mentioned
+elsewhere.
+
+The common course of all the cases of haemothorax was to spontaneous
+recovery, the rapidity of the subsidence of the signs depending mainly
+on the quantity of the primary haemorrhage, and the occurrence of further
+increases. The blood serum tended to collect at the upper limit of the
+original blood effusion (as was often proved on tapping), and this was
+first absorbed; the clot deposited on the pleural surface and at the
+basal part of the cavity was, however, not absorbed with the same
+rapidity. In the majority of the patients when they left the hospitals,
+at the end of six weeks on an average, some dulness and deficiency of
+vesicular murmur always remained, and the clot and the surrounding
+surface, irritated by its presence, will, no doubt, be responsible for
+permanent adhesions in many cases. That such adhesions do form in the
+majority of cases I feel certain, as, although these patients when they
+left the hospital were to all intents and purposes apparently well, few
+of them could undertake sustained exertion without getting short of
+breath, and sometimes suffering from transitory pain, and for this
+reason it became customary to invalid them home.
+
+In a small proportion of the cases empyema followed; but I never saw
+this in any case that had neither been tapped nor opened, and I saw
+only one patient die from a chest wound uncomplicated by other injuries.
+This case was an interesting one of recurrent haemorrhage followed by
+inflammatory troubles:--
+
+[Illustration: TEMPERATURE CHART 2.--Secondary Haemorrhages in a case of
+Haemothorax. 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 pleurae 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 haemoptysis throughout was considerable, and the case
+     was possibly one of pulmonary haemothorax, as after death no
+     source of haemorrhage 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 this
+subject. During the whole campaign the single case of primary empyema
+that I saw was the one recorded below, which deserves special mention as
+illustrating the disadvantage of extracting bullets on the field. Under
+the conditions which necessarily accompanied this operation the
+ensurance of asepsis was impossible, and the additional wound no doubt
+proved 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 haemoptysis, 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 deg., 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 of
+haemothorax, 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 deg.,
+     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, or
+excision of a rib for draining a haemothorax. These operations in the
+early part of the campaign were more freely undertaken on the
+supposition that rise of temperature and other symptoms of fever pointed
+to incipient breaking down of the clot. Subsequent experience showed
+this not to be the case, and early operations for drainage ceased to be
+undertaken. In these operations a primary difficulty was met with in
+effectively clearing out the clot, a drain had to be left, and
+suppuration occurred later in a considerable proportion. The
+suppurations were most troublesome; local adhesions formed, and the pus
+collected in small pockets, which were difficult to find and to drain,
+and even when the collections seemed to have been successfully dealt
+with 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 day
+before I left Cape Town, in whom I had advised and witnessed an
+operation for the evacuation of clot in the presence of signs of fever a
+week after my arrival in the country, nine months previously. I saw
+another case where general infection followed incision of a haemothorax,
+but the patient fortunately recovered.
+
+The question of _pleurisy_ has already been mentioned in connection with
+haemothorax; 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 it
+occurred it was as often the result of cold and exposure as of the
+injury to the lung. Abscess of the lung I only saw once, and that in a
+case in which the injury to the chest was complicated by paraplegia from
+spinal injury and septicaemia, and it was possibly pyaemic.
+
+_Diagnosis._--No difficulties special to small-calibre wounds were
+experienced, except such as have been already dealt with. The only class
+of case which frequently gave rise to difficulty was haemothorax. Here
+two points especially needed consideration. (1) _The source of the
+haemorrhage as parietal or visceral._ As has been already foreshadowed,
+this was mainly to be decided by the amount and persistence of the
+haemoptysis, but naturally free haemoptysis did not negative concurrent
+parietal bleeding. Then the actual source of the bleeding other than
+from the lung had to be considered; in the great majority of cases the
+intercostal vessels were responsible, and attention to the course of the
+tracks 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 instance
+feebleness of the radial pulse, together with the position of the wound,
+was a valuable indication of injury to the subclavian artery, but
+weakened somewhat by the fact of retention of the bullet, and hence
+uncertainty as to the exact course that it had taken, and as to whether
+the bullet itself was not responsible for pressure on the vessel. Such
+indications, however, should make one very chary of interference with a
+haemothorax, even with extremely urgent symptoms, in the light of our
+present knowledge of the nature of the lesions to the great vessels
+produced by small-calibre bullets, and their tendency to be incomplete.
+
+(2) _The imminence of suppuration or its actual occurrence._--In most
+cases it sufficed to preserve an expectant attitude, and in the
+persistence or increase of symptoms, to have recourse to an exploratory
+puncture as the best means of solution of the difficulty.
+
+_Prognosis._--The prognosis both as to life and as to subsequent
+ill-effects was remarkably good; in many cases of uncomplicated injury
+to the lung the patients rejoined their regiments at the end of a month
+or six weeks. In the more serious cases complicated by the collection of
+blood in the pleura, convalescence was more prolonged, and an average
+time of six to eight weeks often elapsed before the patients could be
+safely discharged from hospital. In the more serious a certain amount of
+dulness always persisted at this time over the base of the lung, and the
+chest was usually somewhat contracted on the injured side, with evidence
+in the way of decreased vesicular murmur that the lung was still not
+free from compression. With regard to the persistence of dulness on
+percussion, it is well to bear in mind that a thin layer of blood
+apparently produces as serious impairment of resonance as a much larger
+quantity of serum. The signs appeared to favour the view that the space
+necessary for the location of the haemorrhage had been obtained at the
+expense of the lung rather than by distension of the thoracic parietes,
+and also, I think, denoted the presence of adhesions. Possibly they will
+entirely disappear with the return of full excursion movements of
+respiration, the latter being often still somewhat restricted when the
+patients left hospital. All the patients with such signs were liable to
+attacks of pain and shortness of breath on actual bodily exertion. I
+happened to meet with an officer, the subject of a Lee-Metford wound of
+the thorax, sustained five years previously, and he told me that he was
+nine months before he could take active exercise without feeling short
+of breath.
+
+As to the cases of haemothorax and empyema which needed drainage, all did
+well; but expansion of the lung was much less satisfactory than would
+have been expected, probably on account of especially firm adhesions.
+The importance of concurrent injury I need hardly dwell on; but I might
+add that perforation of one or both arms, the most common one, did not
+materially affect the general statements above made.
+
+_Treatment._--In the early stages of the pulmonary wounds rest was the
+all-important indication, and when this was assured few serious cases of
+haemothorax occurred. Beyond simple rest, the administration of opium
+with a view to checking internal haemorrhage was used with good effect.
+The wounds needed simple dressing only.
+
+The treatment of haemothorax at a later date, however, was of much
+interest and difficulty. I think the following lines may be laid down
+for guidance in such cases:--
+
+(i) Haemothorax, even of considerable severity, will undergo spontaneous
+cure. An early rise of temperature may be disregarded.
+
+(ii) Tapping the chest is indicated when pressure signs on the lung are
+sufficiently severe to cause serious symptoms, and the removal of the
+blood undoubtedly shortens the period of recovery, as well as relieves
+symptoms.
+
+In such cases the collection of blood has usually been rapid and
+continuous; hence a fresh haemorrhage is always probable when the local
+pressure has been removed. Tapping therefore should not necessarily mean
+complete evacuation, and should be followed by careful firm binding up
+of the chest, the administration of opium, and the most stringent
+precautions for rest.
+
+(iii) Tapping may be needed as a diagnostic aid, and in such
+circumstances as much fluid as can be removed should be evacuated with
+the same precautions as mentioned in the last paragraph.
+
+(iv) Tapping may be indicated for the evacuation of serum expressed from
+the blood-clot, or due to pleural effusion, on the same lines as in any
+other collection of fluid in the pleural cavity.
+
+(v) Early free incision is, as a rule, to be steadfastly avoided. Some
+cases already quoted fully illustrate its disadvantages.
+
+(vi) Cases in which an incision and the ligature of a parietal artery
+are indicated are very rare. I never saw such a one myself.
+
+(vii) If a haemothorax suppurates, it must be treated on the ordinary
+lines of an empyema. In view of the constant formation of adhesions and
+difficulty in drainage, a portion of a rib should always be resected in
+order to ensure sufficient space for after-treatment. The cavities, as a
+rule, are better irrigated, the usual precautions being taken where
+there is any reason to fear that the lung is still in communication with
+the cavity.
+
+Care in carrying out asepsis in tapping, which should be performed with
+an aspirator, need hardly be more than mentioned. It will be noted that
+in some of the cases quoted suppuration followed tapping, but it must be
+remembered that in these the two primary wounds already existed as
+possible channels of infection.
+
+Retained bullets of small calibre in the thoracic cavity were not
+common, unless the lodgment had occurred in the bodies of the vertebrae.
+I saw very few. Shrapnel bullets and fragments of shells, however, were,
+in proportion to the frequency of wounds from such projectiles, more
+commonly retained. The rules to be followed in such cases do not
+materially deviate from those to be observed in the body generally.
+
+When the bullet is causing no trouble, and is lodged in either the bone
+of 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 in
+the pleural cavity, and any symptoms of its presence exist, it may be
+justifiable to remove it. I saw this done in one case for the removal of
+a shrapnel bullet from the lower reflexion of the pleura on account of
+fixed pain and tenderness complained of by the patient. The bullet, a
+shrapnel, had perforated the arm, which the patient was sure was by his
+side at the moment of injury, and the X-rays showed it to lie at the
+bottom of the pleural cavity, where we assumed it had fallen. When,
+however, the bullet was removed by Mr. Watson, he found that the fixed
+pain and tenderness had been the result of a fracture of a rib from the
+inner side, not involving loss of continuity; hence the actual
+indication for the operation had been a delusive one, since the bullet
+had not fallen, but expended its last force in injuring the rib. The
+patient made an excellent recovery, and rejoined his regiment at the end
+of six weeks. I saw several cases in which the bullet was lodged in
+either the lung or bones of the spine do well with no interference. The
+great disadvantage of primary removal in inducing an artificial
+pneumo-thorax and in laying open a haemothorax is obvious.
+
+In case of lodgment of the bullet in the lung, bearing in mind the
+infrequency of untoward symptoms, the latter should be watched for prior
+to interference.
+
+The following cases illustrate some typical instances of wound of chest
+accompanied by the development of haemothorax:--
+
+[Illustration: TEMPERATURE CHART 3.--Primary Haemothorax, with rise of
+temperature. Secondary rise, with fresh effusion and pneumonia.
+Spontaneous recovery. Case No. 154]
+
+     (154) _Severe haemothorax. 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 haemothorax, accompanied by a temperature
+     which reached 102 deg. on the fourth day, and on the evening of the
+     tenth 103 deg.. 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 deg. 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 Haemothorax. Secondary rise
+of temperature, with increase in the effusion. Spontaneous recovery.
+Case No. 155]
+
+     (155) _Severe haemothorax. 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 haemoptysis, 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 haemoptysis, respiration was
+     fairly easy, 24 per minute, but accompanied by slight
+     dilatation of the alae nasi, and the temperature, which had been
+     ranging from 99 deg. to 100 deg., began to rise steadily, on the
+     fifteenth day reaching 102.5 deg.. 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.--Haemothorax, primary and secondary
+rises of temperature, on each occasion falling on the evacuation of the
+blood. Case No. 156]
+
+     (156) _Severe haemothorax. 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 deg. 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. Secondary
+development of Haemothorax, with rise of temperature. Spontaneous
+recovery. Case No 157]
+
+     (157) _Moderate haemothorax. 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 deg.. About the twentieth
+     day the temperature commenced to rise, and on the twenty-third
+     and four following evenings reached 102 deg.. 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 more
+eager interest than that dealing with wounds of the abdomen. In none was
+greater expectation indulged in with regard to probable advance in
+active surgical treatment, and in none did greater disappointment lie in
+store for us.
+
+Wounds of the solid viscera, it is true, proved to be of minor
+importance when produced by bullets of small calibre; but wounds of the
+intestinal tract, although they showed themselves capable of spontaneous
+recovery in a certain proportion of the cases observed, afforded but
+slight opportunity for surgical skill, and results generally deviated
+but slightly from those of past experience. Such success as was met with
+depended rather on the mechanical genesis and nature of the wounds than
+upon the efforts of the surgeon, and operative surgery scored but few
+successes.
+
+It is true that to the Civil Surgeon accustomed to surroundings replete
+with every modern appliance and convenience, and the possibility of
+exercising the most stringent precautions against the introduction of
+sepsis from without, abdominal operations presented difficulties only
+faintly appreciated in advance; but this alone scarcely accounted for
+the want of success attending the active treatment of wounds of the
+intestine when occasion demanded. Failure was rather to be referred to
+the severity of the local injury to be dealt with, or to the operations
+being necessarily undertaken at too late a date. Many fatalities, again,
+were due to the association of other injuries, a large proportion of the
+wound tracks involving other organs or parts beyond the boundaries of
+the abdominal cavity.
+
+The frequent association of wounds of the thoracic cavity with those of
+the abdomen afforded many of the most striking examples of immunity from
+serious consequences as a result of wound of the pleura. It must be
+conceded that in a large number of such injuries only the extreme limits
+of the pleural sac were encroached upon, yet in some the tracks passed
+through the lungs, although without serious consequences. Under the
+heading of injury to the large intestine a somewhat special form of
+pleural septicaemia will be referred to.
+
+It may at once be stated that such favourable results as occurred in
+abdominal injuries were practically limited to wounds caused by bullets
+of small calibre, and that, although in the short chapter dealing with
+shell injuries a few recoveries from visceral wounds will be mentioned,
+I never met with a penetrating visceral injury from a Martini-Henry or
+large sporting bullet which did not prove fatal.
+
+_Wounds of the abdominal wall._--It is somewhat paradoxical to say that
+these injuries possessed special interest from their comparative rarity
+of occurrence, since they were not of intrinsic importance. Their
+infrequency depended on the difficulty of striking the body in such a
+plane as to implicate the belly wall alone, and their interest in the
+diagnostic difficulty which they gave rise to.
+
+In many cases the position of the openings and the strongly oval or
+gutter character possessed by them were sufficient proof of the
+superficial passage of the bullet; in others we had to bear in mind that
+the position of the patient when struck was rarely that of rest in the
+supine position, in which the surgical examination was made, and
+considerable difficulty arose. Some superficial tracks crossing the
+belly wall have already been referred to in the chapter on wounds in
+general and in that dealing with injuries to the chest, in which the
+above characters sufficed to indicate that penetration of the abdominal
+cavity had not occurred. In other instances a definite subcutaneous
+gutter could be traced, and often in these a well-marked cord in the
+abdominal wall corresponding to the track could be felt at a later date.
+Again, limitation to the abdominal wall was sometimes proved by the
+position of the retained bullet, or sometimes by the presence in the
+track of foreign bodies carried in with the projectile. See case 160.
+
+Fig. 84 illustrates an example where the limitation to the abdominal
+wall was evident on inspection. Here the division of the thick muscles
+of the abdominal wall had led to the formation of a swelling exactly
+similar to that seen after the subcutaneous rupture of a muscle, and two
+soft fluctuating tumours bounded by contracted muscle existed in the
+substance of the oblique and rectus muscles.
+
+[Illustration: FIG. 84.--Wound of Abdominal Wall (Lee-Metford). Division
+of fibres of external oblique and rectus abdominis muscles. Case 159]
+
+The cases which presented the most serious diagnostic difficulty in this
+relation were those in which the wound was situated in the thicker
+muscular 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 exploration
+necessary for treatment of the fracture decided the point. In many of
+the wounds affecting the lateral portion of the abdominal wall the
+question of penetration could never be definitely cleared up, as wounds
+of the colon sometimes gave rise to absolutely no symptoms.
+
+In a certain proportion of the injuries the peritoneal cavity was no
+doubt perforated without the infliction of any further visceral injury,
+and in these also the doubt as to the occurrence of penetration was
+never 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
+     haemothorax, 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 of
+visceral injury._--This accident occurred with a sufficient degree of
+frequency to obtain the greatest importance, both from the point of view
+of diagnosis and prognosis, and as affecting the question of operative
+interference. Amongst the cases reported below a number occurred in
+which it was impossible to settle the question whether injury to the
+bowel had occurred or not, and I will here shortly give what explanation
+I can for the apparent escape of the intestine from serious injury.
+
+We may first recall the general question of the escape of structures
+lying to one or other side of the track of the bullet. I believe that
+there can be no doubt as to the accuracy of the remarks already made as
+to the escape of such structures as the nerves by means of displacement,
+and that the occurrence of such escapes is manifestly dependent on the
+degree of fixity of the nerve or the special segment of it implicated.
+The general tendency of the tissues around the tracks to escape
+extensive 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 in
+allowing that the small intestine is exceptionally well arranged to
+escape injury. First of all, it is very moveable; secondly, it is so
+arranged that in certain directions a bullet may pass almost parallel to
+the long axis of the coils; thirdly, it is elastic, capable of
+compression, and light, and hence offers but a small degree of
+resistance to the passage of the bullet across the abdominal cavity.
+
+Certain evidence both clinical and pathological supports the contention
+that the small intestine may escape injury from the passing bullet.
+
+First of all, the fact may be broadly stated that injuries to the small
+intestine were fatal in the great majority of certainly diagnosed cases,
+while, on the other hand, many tracks crossed the area occupied by the
+small intestine without serious symptoms of any kind resulting.
+Secondly, experience showed that when the bullet crossed the line of the
+fixed portions of the large intestine the gut rarely escaped, and that,
+although a considerable proportion of these cases recovered
+spontaneously, in a large number of them immediate symptoms, or
+secondary complications, clearly substantiated the nature of the
+original injury. As far as my experience went, however, I never saw any
+instance in which an undoubted injury of the small intestine was
+followed by the development of a local peritoneal suppuration and
+recovery, a sequence by no means uncommon in the case of wounds of the
+large intestine. Although, therefore, I am not prepared to deny the
+possibility of spontaneous recovery from an injury to the small
+intestine, under certain conditions which will be stated later, I
+believe that in the immense majority of cases in which a bullet crossed
+the small intestine area without the supervention of serious symptoms,
+the small intestine escaped perforating injury.
+
+Beyond the clinical evidence offered above, certain pathological
+observations support the view that the intestine escapes perforation by
+displacement. Most of my knowledge on this subject was derived from the
+limited number of abdominal sections I performed on cases of injury to
+the small intestine, and may be summed up as follows.
+
+The small intestine may present evidence of lateral contusion in the
+shape of elongated ecchymoses, either parallel, oblique, or transverse
+to its long axis. These ecchymoses resemble in extent and outline those
+which ordinarily surround a wound of the intestinal wall produced by a
+bullet (see fig. 87, p. 418).
+
+The wall of the small intestine may be wounded to an extent short of
+perforation, either the peritoneal coat alone being split, or the wound
+implicating the muscular coat and producing an appearance similar to
+that seen when the intestine is dragged upon during an operation, but
+without so much gaping of the edges (see fig. 85, p. 416).
+
+I met with these conditions in association with co-existing complete
+perforations of the small intestine, and in one case of intra-peritoneal
+haemorrhage in which no complete perforation was discoverable (No. 169,
+p. 432).
+
+The implication and perforation of the small intestine are to some
+extent influenced by the direction of the wound. A striking case is
+included below, No. 201, in which a bullet passed from the loin to the
+iliac fossa on each side of the body, approximately parallel to the
+course of the inner margin of the colon, and I also saw some other
+wounds in this direction in which no evidence of injury to the small
+intestine was detected, and which got well. Again wounds from flank to
+flank were, as a rule, very fatal; but I saw more than one instance
+where these wounds were situated immediately below the crest of the
+ilium, in which the intestine escaped injury (see case 171). A very
+striking observation was made by Mr. Cheatle in such a wound. The
+patient died as a result of a double perforation of both caecum and
+sigmoid flexure; none the less the bullet had crossed the small
+intestine 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 lateral
+displacement an impossibility, the gut often escaped perforation.
+
+As a rule, the wounds of the abdomen which from their position proved
+the most dangerous to the intestine were--
+
+1. Wounds passing from one flank to the other were very dangerous, as
+crossing complicated coils of the small intestine, and two fixed
+portions of the colon. This danger was most marked when the wounds were
+situated between the eighth rib in the mid axillary line and the crest
+of the ilium; above this level the liver, or possibly liver and stomach,
+were sometimes alone implicated, and the cases did well. Again, when the
+wounds crossed the false pelvis the patients sometimes escaped all
+injury to viscera.
+
+2. Antero-posterior wounds in the small intestine area were very fatal
+if the course was direct; in such the small intestine seldom escaped
+injury.
+
+3. Wounds with a certain degree of obliquity from anterior wall to
+flank, or from flank to loin, were on the other hand comparatively
+favourable, as the small intestine often escaped, and if any gut was
+wounded, it was often the colon.
+
+4. Vertical wounds implicating the chest and abdomen, or the abdomen and
+pelvis, were on the whole not very unfavourable. For instance, when the
+bullet entered by the buttock and emerged below the umbilicus, a number
+of patients escaped fatal injury; this depended on the comparatively
+good prognosis in wounds of the rectum and bladder. A good many
+patients in whom the bullet entered by the upper part of the loin, and
+escaped 1-1/2 inch within the anterior superior spine of the ilium, also
+did well. The same holds good when the wounds either entered or emerged
+under the anterior costal margin of the thorax, either prior to or after
+traversing the thorax.
+
+Wounds passing directly backward from the iliac regions were in my
+experience very unfavourable; but I believe mainly as a result of
+haemorrhage from the iliac arteries.
+
+_The occurrence of wounds of the abdomen of an 'explosive'
+character._--The vast majority of the abdominal wounds observed in the
+Stationary or Base hospitals were of the type dimensions. A certain
+number of the abdominal injuries which proved fatal on the field or
+shortly afterwards were described as explosive in character, and were
+referred by the observers to the employment of expanding bullets.
+
+A few words on this subject seem necessary, because it seems doubtful
+whether such injuries could be produced by any of the forms of expanding
+bullet of small calibre in use, unless the track crossed one of the
+bones in the abdominal or pelvic wall. That this was sometimes the case
+there is no doubt: thus I saw two cases in which the splenic flexure of
+the colon was wounded, in which the external opening was large, and a
+comminuted fracture of the ribs of the left side existed. One can well
+believe that bullets passing through the pelvic bones might 'set up' to
+a considerable extent, and although I never happened to see such a case,
+an explanation of some of the wounds described by others might be found
+in this occurrence.
+
+In instances in which the soft parts alone were perforated, I am
+disinclined to believe that bullets of small calibre, either regulation
+or soft-nosed, were responsible for the injuries. I had the opportunity
+of examining two Mauser bullets of the Jeffreys variety which crossed
+the abdomen and caused death. In the first (figured on page 94, fig. 40)
+very little alteration beyond slight shortening had occurred. In the
+second the deformity was almost the same, except that the side of the
+bullet was indented, probably from impact with some object prior to its
+entry into the body. In each case the bullet was of course travelling at
+a low rate of velocity; hence no very strong inference can be drawn
+from either. In the case of the second specimen, which was removed by
+Mr. Cheatle, a remarkable observation was made, which tends to throw
+some light on one possible mode of production of large exit apertures.
+This bullet crossed the caecum, making two small type openings; but
+later, when it crossed the sigmoid flexure, it tore two large irregular
+openings in the gut. This might be explained on the ground that the
+velocity was so small as only just to allow of perforation, which
+therefore took the nature of a tear. I am inclined to suggest, as a more
+likely explanation, that the spent bullet turned head over heels in its
+course across the abdomen, and made lateral or irregular impact with the
+last piece of bowel it touched. A slightly greater degree of force would
+have allowed a similar large and irregular opening to be made in the
+abdominal wall also.
+
+In this relation the question will naturally be raised as to how far the
+explosive appearances may have been due to high velocity alone on the
+part of the bullet. I am disinclined from my general experience to
+believe that explosive injuries of the soft parts were to be thus
+explained. On the other hand, I believe that the possession of a low
+degree of velocity very greatly increased the danger in abdominal
+wounds. I believe that the bowel was, under these circumstances, less
+likely to escape by displacement, and was more widely torn when wounded;
+again, that inexact impact led to increase of size in the external
+apertures, and the bullet was of course more often retained.
+
+Mr. Watson Cheyne[19] published a very remarkable instance of one of the
+dangers of an injury from a spent bullet, in which, in spite of
+non-penetration of the abdominal cavity, the small intestine was
+ruptured in two places.
+
+I believe the majority of the wounds designated as explosive were the
+result of the passage of large leaden bullets, either of the
+Martini-Henry or Express type. The small opportunity of observing such
+injuries in the hospitals of course depended on the fact that the
+majority were rapidly fatal.
+
+_Nature of the anatomical lesion in wounds of the intestine._--The
+openings in the parietal peritoneum tended to assume the slit or star
+forms, probably on account of the elasticity of the membrane. A diagram
+of one of these forms is appended to fig. 89. In this instance the
+opening in the peritoneum was made from the abdominal aspect, prior to
+the 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 abdominal
+wall.
+
+In the intestinal wall the openings varied in character according to the
+mode of impact.
+
+In some cases the gut was merely contused by lateral contact of the
+passing bullet. The result of this was evidenced later by the presence
+of localised oval patches of ecchymosis. These were identical in
+appearance with the patches shown surrounding the wounds in fig. 87.
+
+[Illustration: FIG. 85.--Lateral Slit in Small Intestine produced by
+passage of bullet. Slit somewhat obscured by deposition of inflammatory
+lymph. (St. Thomas's Hospital Museum)]
+
+More forcible lateral impact produced a split of the peritoneum, or of
+this together with the muscular coat. Such a lateral slit is shown in
+fig. 85, although the clearness of outline is somewhat impaired by the
+presence of a considerable amount of inflammatory lymph.
+
+Fig. 86 exhibits a lateral injury of a more pronounced form. The bullet
+here struck the most prominent portion of the under surface of the
+bowel, and produced a circular perforation not very unlike one produced
+by rectangular impact, except in the lesser degree of eversion of the
+mucous membrane. Here again the appearance is somewhat altered by the
+presence of a considerable amount of lymph, but this is of less
+importance in this figure because the lymph is localised to the portion
+of the bowel in the immediate neighbourhood of the opening which had
+suffered contusion and erasion.
+
+[Illustration: FIG. 86.--Gutter Wound of Small Intestine caused by
+lateral impact. Position of shallow portion of gutter indicated by
+deposition of inflammatory lymph. Circular perforation. (St. Thomas's
+Hospital Museum)]
+
+Fig. 87, A B, illustrates a symmetrical perforation of the small
+intestine; the aperture of entry (A) is roughly circular, and a ring of
+mucous membrane protrudes and partially closes the opening. The aperture
+of exit is a curved slit, again partially occluded by the mucous
+membrane. The same amount of difference between the two apertures did
+not always exist; in many cases both were circular, and apparently
+symmetrical. 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 no
+doubt an opening due to lateral impact similar to that seen in fig. 86.
+In the recent condition little difference existed between the three
+apertures.
+
+The localised ecchymosis surrounding the apertures is quite
+characteristic of this form of injury, and is a valuable aid to finding
+the openings during an operation.
+
+Fig. 88 shows the interior of the same segment of bowel, as fig. 87. It
+shows the localised ecchymosis as seen from the inner surface, here
+rather more extensive from the fact that the blood spreads more readily
+in the submucous tissue.
+
+[Illustration: FIG. 87.--Perforating Wounds of Small Intestine. A.
+Entry; note circular outline and eversion of mucous membrane. B. Wound
+of exit; curved slit-like character, eversion of mucous membrane. Note
+the 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 the
+regular outline and the small size of the wounds. Another feature not
+illustrated by the figures should also be mentioned. In the ruptures of
+intestine with which we are acquainted in civil practice the wound in
+the gut is almost without exception situated at the free border of the
+bowel, but in these injuries it was just as frequently at the mesenteric
+margin. The importance of this factor is considerable, since wounds
+near the mesenteric edge are much more likely to be accompanied by
+haemorrhage, and thus the opportunity for diffusion of infection is
+considerably multiplied, to say nothing of the danger from loss of
+blood.
+
+Beyond these more or less pure perforations, long slits or gutters were
+occasionally cut. I saw instances of these in the case of the ascending
+colon, and in the small curvature of the stomach. The comparative fixity
+of the portion of bowel struck is a matter of great importance in the
+production of this form of injury.
+
+[Illustration: FIG. 88.--The same piece of Intestine as that shown in
+fig. 87, laid open to show the ecchymosis on the inner aspect of the
+Bowel. The two indicating lines lead to the openings, which appear
+slit-like, and are sunk at the bottom of folds. (St. Thomas's Hospital
+Museum)]
+
+It may be well to add that, although the figures inserted are all taken
+from small-intestine wounds, the nature of the wounds of the
+peritoneum-clad part of the large intestine in no way differed from
+them, except in so far as fixity of the bowel exposed it to a more
+extensive wound when the bullet took a parallel course to its long axis.
+
+A more important point in the injuries to the large intestine was the
+possibility of an extra-peritoneal wound. I saw several such lesions of
+the colon, every one of which ended fatally. I became still more fully
+convinced of the greater seriousness of extra- to intra-peritoneal
+rupture of this portion of the gut than I was when I expressed a similar
+opinion in a former paper.[20] It will be seen later that the results of
+intra- and extra-peritoneal wounds of the bladder fully confirm this
+view, as all extra-peritoneal injuries died, while many intra-peritoneal
+perforations recovered spontaneously.
+
+_Wounds of the mesentery._--I had little experience of this injury; in
+fact, case 169, on which I operated, was my sole observation. It stands
+to reason, however, that injuries to the mesentery would be much more
+frequent proportionately to wounds of the gut than is the case in the
+ruptures seen in civil practice, since the whole area of the mesentery
+is equally open to injury. Viewing the extreme danger of haemorrhage into
+the peritoneal cavity in these injuries, I should be inclined to expect
+that a considerable proportion of those deaths from abdominal wounds
+which took place on the field of battle were due to this source.
+
+_Wounds of the omentum._--Here, again, I am unable to express any
+opinion, although the supposition that haemorrhage from this source took
+place is natural.
+
+Prolapse of omentum was comparatively rare, except in cases with large
+wounds; it was apparently seen with some frequency among patients who
+died rapidly on the field of battle. I only saw it twice, and on each
+occasion in shell wounds. The wounds from small-calibre bullets were as
+a rule too small to allow of external prolapse.
+
+Fig. 89, however, illustrates a very interesting observation. A patient
+in the German Ambulance in Heilbron, under Dr. Flockemann, died as a
+result of suppuration and haemorrhage secondary to an injury to the
+colon. At the autopsy a portion of the omentum was found adherent in the
+wound of exit, but it had not reached the external surface. The chief
+interest of the observation lies in the light it throws on the mechanism
+of these injuries. It is impossible to conceive that a small-calibre
+bullet coming into direct contact with the omentum could do anything but
+perforate it. It, therefore, appears clear that in a displacement like
+that figured, only lateral impact occurred with the omentum, which was
+carried 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 an
+exit track leading from the abdominal cavity. A. Outline of opening in
+the peritoneum]
+
+_Results of injury to the intestine._ 1. _Escape of contents and
+infection of the peritoneal cavity._--I think there is little special to
+be said on this subject. The escape of contents into the peritoneal
+cavity was by no means free, unless the injury was multiple. Thus in one
+case of injury to the small intestine, No. 166, on which I operated,
+there was absolutely no gross escape until the bowel was removed from
+the abdominal cavity, when the contents spurted out freely. In one case
+of very oblique injury to the colon there was a considerable quantity of
+faecal matter in a localised space, but as a rule the ordinary condition
+best described as 'peritoneal infection' from the wound was found. The
+bad effect of anything like free escape was well shown in multiple
+perforations; in these suppurative peritonitis rapidly developed and the
+patients died at the end of thirty-six hours or less. A typical case is
+quoted in No. 168.
+
+2. _Peritoneal infection, and general septicaemia._--As is evident from
+the results quoted among the cases, the degree which this reached varied
+greatly. It may of course be assumed that in some measure it occurred in
+every case in which the bowel was perforated, but it was sometimes so
+slight as to be scarcely noticeable. This may be said to have been most
+common in injuries to the large intestine. Wounds of the caecum,
+ascending and descending colon, the sigmoid flexure, or the rectum, were
+sometimes followed by no serious symptoms, either local or general.
+Again in these portions of the bowel the development of local signs, and
+the later formation of an abscess, were by no means uncommon.
+
+In the case of the small intestine I never observed this sequence, and
+the same may be said of the transverse colon, which in its anatomical
+arrangement and position so nearly approximates to the small bowel. In
+suspected wounds of these portions of the bowel either the symptoms were
+so slight as to render it doubtful whether a perforation had occurred,
+or marked signs of general peritoneal septicaemia developed, and death
+resulted.
+
+The condition of the peritoneum in fatal cases varied much. In some a
+dry peritonitis, or one in which a considerable quantity of slightly
+turbid fluid was effused, was found. In others a rapid suppurative
+process, accompanied by the effusion of large quantities of plastic
+lymph, was met with. My experience suggested that the latter condition
+was the result of free infection from multiple wounds of the gut, the
+former the accompaniment of single wounds. Hence I should ascribe the
+difference mainly to the extent of the primary infection.
+
+This is perhaps a suitable place to further discuss the explanation of
+the escape of a considerable number of the patients who received wounds
+of the abdomen, possibly implicating the bowel. Although this was not, I
+think, so common an occurrence as has been sometimes assumed, yet many
+examples were met with. Several reasons have been advanced.
+
+(1) Great importance has been given to the fact that many of the men
+were wounded while in a state of hunger, no food having been taken for
+twelve or more hours before the reception of the injury. In view of the
+well-proved fact in these, as in other intestinal injuries, that free
+intestinal escape does not occur, and that it is usually a mere question
+of infection, this explanation, in my opinion, is of small importance.
+It might with far more justice be pointed out that many of these wounded
+men were for them in the happy position of not having friends freely
+dosing them with brandy and water after the reception of the injury, and
+this was possibly an element of some importance.
+
+Some of the men did, however, drink freely, and in one case which
+terminated fatally a comrade gave a man wounded through the belly an
+immediate dose of Beecham's pills.
+
+(2) Mr. Treves has suggested that the effect of the severe trauma on the
+muscular coat of the bowel is to cause a cessation of peristaltic
+movement. This, as in the case of 'local shock' elsewhere, may no doubt
+be of importance, and to it should be added the simultaneous cessation
+of abdominal respiratory movements in the segment of the belly wall
+covering the injured part. The occurrence of general cessation of
+peristaltic movement is, however, to some extent opposed by the fact
+that in a certain number of the cases early passage of motions was seen
+just as happens in the intestinal ruptures seen in civil practice.
+
+I should be inclined to ascribe the escape from serious infection in
+these injuries to the same cause which accounts for their comparative
+insignificance in other regions--namely, the small calibre of the bullet
+and consequent small size of the lesion: in point of fact to the minimal
+nature of the primary infection. I very much doubt if any patient who
+had more than one complete perforation of the small intestine got well
+during the whole campaign. This opinion is, moreover, supported by the
+fact that the prognosis was so far better in cases of injury to the
+large than to the small intestine, in which former segment of the bowel
+we have the advantages of a position beyond the region in which
+intestinal movement is most free, the unlikelihood of multiple injury,
+and a drier and more solid type of faecal contents.
+
+In the instances in which recovery followed perforating injuries without
+any bad signs we can only assume a minimal infection, and sufficient
+irritation and reaction on the part of the bowel to produce rapid
+adhesion between contiguous coils, and thus provisional closure.
+
+The other mode of spontaneous recovery which I saw several times take
+place in the injuries to the large bowel consisted in the limitation of
+the spread of infection by early adhesions and the development of a
+local abscess. The non-observance of this process in any case of injury
+to the small intestine raises very great doubts in my mind as to the
+frequent recovery of patients in whom the small intestine was
+perforated.
+
+
+INJURIES TO THE INTESTINAL TRACT
+
+1. _Wounds of the stomach._--A considerable number of wounds in such a
+situation as to have possibly implicated the stomach were observed, and
+of these a certain number recovered spontaneously. The only two
+instances that came under my own observation are recorded below. It will
+be noted that in each the special symptoms were the classic ones of
+vomiting and haematemesis. In the first case blood was also passed per
+anum, and in the second the diagnosis was reinforced by the escape of
+stomach contents from the external wound.
+
+The second case was a surgical disappointment. No doubt the fatal issue
+was mainly dependent on the fact that the external wound had to be kept
+open to allow of the escape of the abundant discharge from the wounded
+liver. In the absence of the hepatic wound, however, I believe it would
+have been possible for this patient to have got well spontaneously, in
+view of the firm adhesions which had formed around the opening in the
+stomach, and the consequent localisation which had been effected.
+Another unfortunate element in this case was the comminuted fracture of
+the seventh costal cartilage, which maintained the patency of the
+aperture of exit. The latter point, however, was of doubtful importance
+from this aspect, as the vent provided for the gastric and biliary
+secretions may have been the safety-valve that had allowed localisation
+to develop.
+
+I believe that the secondary haemorrhage was the main element in robbing
+us of a success in this case, and that this depended on the digestion of
+the wound by the gastric secretion. The early troubles which arose in
+the treatment of this patient well illustrate the difficulties by which
+the military surgeon is at times met; but the patient was admirably
+attended to and nursed by my friend Mr. Pershouse, and an orderly who
+was 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 deg., 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 deg.. 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 faecal 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 deg., 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 haemorrhage
+     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 the
+results attending them. Wounds were met with in every part of the small
+gut; but I saw no case in which an injury to the duodenum could be
+specially diagnosed.
+
+As to the symptoms which attended these injuries, it is somewhat
+difficult to speak with precision, and it must be left to my readers to
+form an opinion as to how many of the cases recounted below were really
+instances of perforating wounds. My own view is that in the majority of
+the cases that got well spontaneously, the injury was not of a
+perforating nature, and that for reasons which have been already set
+forth. It will, however, be at once noted that in all the five cases in
+which the injury was certainly diagnosed in hospital death occurred.
+
+The cases of injury to the small intestine are perhaps best arranged in
+three classes.
+
+1. Those who died upon the field, or shortly after removal from it. In
+these the external wounds were often large, the omentum was not rarely
+prolapsed, and escape of faeces sometimes occurred early. Shock from the
+severity of the lesion, and haemorrhage, were no doubt important factors
+in the early lethal issue in this class. Many of the injuries were no
+doubt produced by bullets striking irregularly, by ricochets, by bullets
+of the expanding forms, or by bullets of large calibre. As being beyond
+the bounds of surgical aid, this class possessed the least interest.
+
+2. Cases brought into the Field, or even the Stationary hospitals, with
+symptoms of moderate severity, or even of an insignificant character,
+in which evidence of septic peritonitis suddenly developed and death
+ensued.
+
+3. Cases in which the position of the wounds raised the possibility of
+injury to the intestine, but in which the symptoms were slight or of
+moderate severity, and which recovered spontaneously.
+
+The whole crux in diagnosis lay in the attempt to separate the two
+latter classes, and, personally, I must own to having been no nearer a
+position of being able to form an opinion on this point, in the late
+than in the early stage of my stay in South Africa. The advent of
+peritoneal septicaemia was in many instances the only determining moment.
+On this matter I can only add that, in civil practice, an exploratory
+abdominal section is often the only means of determination of a rupture
+of the bowel wall.
+
+With regard to the cases of suspected injury to the bowel which
+recovered spontaneously, the symptoms were somewhat special in their
+comparative 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 common
+average. Respiration was never greatly quickened, 24 was a common rate.
+The temperature rarely exceeded 100 deg.. Vomiting was occasionally severe,
+but usually not persistent, ceasing on the second day. A good quantity
+of urine was passed. As to the local signs, these again were of a
+limited nature; distension did not occur, or was slight; movement of the
+abdominal wall was only restricted in the neighbourhood of the wound,
+the affected area amounted to a quarter, or at most half, the abdominal
+wall, and rigidity was localised to a similar segment. Local tenderness
+usually existed; but, as a rule, there was little or no dulness to point
+to the occurrence either of fluid effusion or a considerable deposition
+of lymph.
+
+Again many of the patients suffered with very slight symptoms of
+constitutional shock, although there was considerable variation in this
+particular.
+
+     (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 deg.. 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 deg.,
+     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 faecal 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 deg., 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 septicaemia 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 deg.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 deg.. 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 deg., 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 haemorrhage.
+     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 deg.,
+     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 deg., 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 deg. 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 deg., 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 deg..
+     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 faeces 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 deg.;
+     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 deg.. 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 deg. 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 large
+bowel were observed, and spontaneous recoveries were seen in all parts
+except the transverse colon, which, as already remarked, is near akin
+to the small intestine with regard to its position and anatomical
+arrangement.
+
+The only case of perforation of the vermiform appendix that I heard of,
+one under the care of Mr. Stonham, died of peritoneal septicaemia.
+Several cases of recovery from wounds of the caecum and ascending colon
+are recounted below. The only points of importance in the nature of the
+signs of these injuries were their primary insignificance, and the
+comparative frequency with which _local_ peritoneal suppuration followed
+them. The absence of a similar sequence in some of the cases in which
+wounds of the small intestine were assumed, was, in my opinion, one of
+the strongest reasons for doubting the correctness of the diagnosis. It
+is also a significant fact that injuries of the ascending colon--that is
+to say, of the portion of the large bowel which perhaps lies most free
+from the area occupied by the small intestine--were those which most
+frequently recovered.
+
+The following cases afford examples of the course followed in a number
+of injuries to the large intestine, and illustrate both the
+uncomplicated and the complicated modes of spontaneous recovery.
+
+No. 180 affords a good example of an extra-peritoneal injury, and of the
+especially fatal character of such lesions. This case was also one of my
+surgical disappointments.
+
+Nos. 182, 183 are of great interest in several particulars. First, the
+aperture of exit was large and allowed the escape of faeces, not a very
+common feature in wounds not proving immediately fatal. Secondly, in
+neither were any peritoneal signs observed. Thirdly, in each the exit
+wound communicated with the pleura, and the patients died from
+septicaemia mainly due to absorption from the surface of that membrane
+(_Pleural septicaemia_).
+
+No. 190 is a most striking instance of spontaneous cure, since no doubt
+can exist that both rectum and bladder were perforated.
+
+     (180*) _Injury to the caecum 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 faecal 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 deg. F.
+     The wound suppurated freely, however, and although there were
+     no further signs of peritoneal septicaemia, 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 septicaemia 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 deg., 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 deg.; 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 caecum. Entry wound nearly and exit quite
+     healed. Cannot flex right thigh. The following operation was
+     performed. Appendix incision, about [Symbol: ounce]j of faecal
+     fluid and faeces in a localised cavity on outer and anterior
+     aspect of caecum evacuated; adhesions very firm. Cavity sloughy
+     throughout and caecum 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; faecal-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 faeces took place from the anterior wound, while the
+     bowels were acting, as a result of a dose of castor oil. No
+     further escape of faeces 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 spinae. 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 deg., pulse 120. No appearance of faeces in wound.
+
+     When seen on the sixth day the condition was as
+     follows:--Patient cheerful and not in great pain. Temperature
+     99.2 deg.; pulse 120; respirations 48, very shallow. Abdomen soft,
+     moving freely, no distension or general tenderness. Fluid faeces
+     escaping in abundance from the wound in loin. Redness of skin
+     and swelling below level of wound, and cellular emphysema
+     above. Faecal-smelling fluid was also escaping from the thoracic
+     wound.
+
+     The wound was enlarged, but the patient rapidly sank, and died
+     of septicaemia 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 faeces took
+     place from it. In this also faecal matter passed freely into the
+     left pleural cavity, and faecal 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 septicaemia 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 caecum._--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 defaecation. 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 caecum_.--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 deg.. 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 caecum._--Wounded outside Heilbron.
+     _Entry_ (Mauser), in the right loin, 2-1/2 inches above the
+     iliac crest, at the margin of the erector spinae; _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 deg.. 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.)
+     Faecal-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
+     haemorrhage occurred from the loin wound, which was opened up,
+     but no evident source was discovered; haemorrhage 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
+     caecum. 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
+     haemorrhage 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 faecal 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 faecal 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 faeces, 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 first
+two (191, 192) illustrate extra-peritoneal injuries to the rectum. In
+neither did positive evidence exist of wound of the bowel, but the
+symptoms in each rendered this accident probable. Case 193 is an
+illustration of apparent escape of the anal canal in a wound in which
+from the position of the external apertures this escape would have
+appeared impossible.
+
+Wounds of the extra-peritoneal portion of the rectum, as a rule,
+appeared to have a somewhat better prognosis than would have been
+expected; in any case, the prognosis was far better than that obtaining
+in wounds of the base of the urinary bladder. My experience on the
+subject of these wounds was, however, limited to the two cases quoted.
+
+Case 194 is inserted as an example of the complicated nature of the
+abdominal injuries not so very unfrequently met with. It illustrates
+well the difficulty which may arise at any stage in the course of
+treatment of an injury, in the certain determination or exclusion of
+wound 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 faeces, and later slime, constantly
+     escaped, but no faecal 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 deg., 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 deg. 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 deg. and 101 deg. 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 haematoma. 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 discouraging
+character compared with the prognosis in abdominal injuries as a whole.
+The cases were of two classes, however: those that died within
+twenty-four hours, and those that died at the end of from three days to
+a week.
+
+Cases falling into the first category are obviously of little importance
+from the point of view of surgical treatment. Many of them died from the
+widespread nature of the injury, and the shock produced by it; others
+from haemorrhage from the large abdominal vessels. It is unlikely that
+any could have been saved, even under the most satisfactory conditions.
+
+In the following small table, therefore, I have included only the cases
+which have been already quoted, which survived long enough to be
+amenable to surgical treatment, and which were for some days under my
+own observation. Some of them, in fact almost all, I watched until they
+were either convalescent, or died, and in six I performed operations.
+
+I am aware, and have short details of the histories of eight patients
+wounded in the same battles who died prior to the termination of the
+first thirty-six hours; but these are not included, for the reason
+stated above, and also because I am uncertain whether all the injuries
+were 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 intestinal
+canal implicated, and also as to whether the perforation was certain, or
+only assumed from the position of the external apertures and the
+presence of abdominal symptoms of a noticeable grade.
+
+From this analysis it appears clear--
+
+1. That wounds of the stomach have a comparatively good prognosis, and
+that they may recover spontaneously. It is true that only two examples
+are included in my table; but I was at various times shown patients with
+similar injuries and histories, and a number of cases which have been
+published appear to substantiate the opinion. From our experience of the
+occasional spontaneous recovery of gastric perforations from disease, I
+think we might be prepared to expect that the stomach would offer a
+comparatively favourable seat for these wounds. It may be pointed out,
+however, that haematemesis, the main feature in the symptoms pointing to
+wound, is by no means direct proof of more than contusion.
+
+2. That perforating wounds of the small intestine are very fatal
+injuries; every patient in whom the condition was _certainly_ diagnosed
+died.
+
+3. That in the cases in which a perforation was inferred from the
+position of the external apertures and the symptoms, not one patient
+suffered from the secondary complications--_e.g._ local peritonitis and
+suppuration, which were common in the case of the large intestine, and
+which we are accustomed to see after perforation from disease. This
+renders the occurrence of actual perforation in the majority of the
+cases a matter of very grave doubt.
+
+If spontaneous recovery does take place after this injury, it is only in
+cases in which the wounds are single, and slight in character.
+
+4. That in eight cases in which perforation of the large intestine was
+certain, four recoveries took place; but in each instance suppuration
+occurred. I am, however, quite prepared to believe that perforation may
+have occurred in some or all of the other four cases included as
+'possible,' provided the wounds were intra-peritoneal.
+
+Wounds of the caecum and ascending colon are those which have the best
+prognosis, and after these of the rectum. The comparatively good
+prognosis in these parts is what would be expected, on account of their
+greater fixity, and lesser tendency to be covered by the small
+intestine.
+
+An extra-peritoneal wound of any of these portions of the bowel is more
+dangerous than an intra-peritoneal, and more likely to give rise to
+septicaemia.
+
+Of the cases included in my table eighteen of the possible intestinal
+injuries were observed among the wounded of the four battles of the
+Kimberley relief force. These cases I saw early and followed to their
+termination, and I believe the list contains the great majority of all
+the patients who received intestinal wounds in those battles. On inquiry
+I 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 which
+death took place within the first week, but which went direct to the
+Base and did not come under my observation. These exceptions being made,
+we have a fairly complete series, from which some deductions may be
+drawn. The cases included are marked with an asterisk.
+
+Of the eighteen cases, eight or 44.4 per cent. died. These were made up
+as follows:--Stomach, one case; this patient died at the end of fourteen
+days, as a result of secondary haemorrhage and septicaemia. It was
+complicated by a severe wound of the liver and also one of the lung.
+
+Small intestine, four certain cases; all died, two after operation in
+the stage of septicaemia, and one after operation from recurrent
+haemorrhage, possibly from the mesentery. Of the other six cases one can
+only say that the position of the wounds was such as to render wound of
+the intestine possible, and that all suffered with abdominal symptoms of
+some severity.
+
+Large intestine. Of six cases in which wound was certain, three died,
+one after operation. One recovered after operation, two recovered with
+local peritoneal suppuration. In one case the injury could only be
+returned as possible.
+
+In connection with this subject I have received permission from Mr.
+Watson Cheyne to quote the statistics published by him[23] concerning
+the abdominal wounds observed after the fighting at Karree Siding, on
+March 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 haemorrhage
+     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 deg.. 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 the
+incidence of abdominal injuries compared with those in general in one
+definite battle. This amounted to the high number of 15 in 154 or 9.74
+per cent. wounded. I am inclined to think that this is a higher
+proportion than the average of the campaign, and that more of the men
+must have been exposed in the erect position than was ordinarily the
+case during the fighting.
+
+The statistics also show that 33.33 per cent. of the patients with
+abdominal injuries died within from twenty-four to twenty-eight hours,
+and that the percentage of deaths had risen to 73.33 per cent. at the
+end of the third day. These numbers again seem high, but in this
+relation it may be noted that, as a small force only was present, and as
+all the patients were together, Mr. Cheyne had unusually good
+opportunities for seeing all the cases.
+
+One other point is doubtful from the report, and that is what percentage
+of the wounds were caused by bullets of small calibre. In one case it is
+definitely stated that the wound was large, and in the second that gas
+escaped from the wound; both of these may have been instances in which a
+large bullet, or some expanding form, had been employed, and there is no
+doubt that the use of such projectiles was more common at this stage of
+the campaign than it was earlier.
+
+_Treatment of injuries to the intestine._--Some general rules for the
+immediate treatment of all cases may be laid down. First, the patients
+must be removed with as little disturbance as possible, and absolute
+starvation must be insisted upon. If the patients be suffering from
+severe shock, hypodermic injections of strychnine should be
+administered, or possibly some stimulant by the rectum.
+
+After a battle, when these cases may be brought in in considerable
+number, they should be collected and placed in the same tent. The
+objection to congregating a number of severely wounded patients together
+must be disregarded in the face of the manifest advantage of being able
+to treat all alike in the matter of feeding. After the battles of the
+Kimberley relief force, Surgeon-General Wilson, at my request, had all
+the abdominal cases placed in a large marquee, where we were able to
+carefully watch the whole of the patients from hour to hour, and little
+chance existed for any indiscretion on the part of the patients in the
+way of eating or drinking.
+
+If possible, the patients should be kept absolutely quiet until they are
+evidently out of danger. A week's stay at Orange River sufficed for this
+object in the cases referred to. The avoidance of transport is
+manifestly 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 in
+tea-spoonfuls only.
+
+In doubtful cases the use of morphia must be avoided.
+
+Operative treatment is required in a certain number of the cases, but in
+the majority of instances we are met with the extreme difficulty that in
+a very large proportion of the occasions upon which these wounds are
+received an exploratory abdominal section is not warranted in
+consequence of the conditions under which it has to be performed.
+
+A word must be added as to these difficulties; they are in part purely
+of an administrative nature, partly surgical. After a great battle the
+wounded are numerous, and amongst them a very considerable proportion of
+the wounds and injuries are of such a nature as to do extremely well if
+promptly dealt with, and each of these makes small demands on the time
+of the staff. Abdominal operations, on the other hand, are
+unsatisfactory from a prognostic point of view, and their performance
+requires much time and the assistance of a considerable number of the
+men, who are obliged to neglect the treatment of the more promising
+cases for those of doubtful issue. This difficulty, although not
+surgical in its nature, is nevertheless a practical one of great
+importance and appeals strongly to the Principal Medical Officers in
+charge of the arrangements. It is only to be avoided by an increase of
+the staff, which is not likely to be made except on very special
+occasions.
+
+Other difficulties are purely surgical. First, the difficulty
+of diagnosing with certainty a perforating lesion. In the presence of
+the fact that many incomplete lesions follow wounds crossing the
+intestinal area, and that these give rise to modified symptoms, I
+believe this determination to be impossible without the aid of an
+exploratory incision. Here we are met with the remaining surgical
+difficulties--disadvantages such as the absence of sufficient aid to the
+operating surgeon, difficulties connected with the temperature, wind,
+and dust, and as to the subsequent treatment of the patient. Again
+difficulty in obtaining the most important adjunct, suitable water, or
+indeed any water in a sufficient quantity.
+
+It is of course obvious that conditions may exist in which all these
+troubles may be avoided. Again, the practical difficulty adverted to
+above does not come in the way when a single man happens to sustain an
+abdominal wound on the march. Under such circumstances an exploration
+may be not only justifiable, but obligatory, and the general rules of
+surgery must be followed rather than such incomplete indications as are
+suggested below.
+
+My own experience led me to the following conclusions:
+
+1. A wound in the intestinal area should be watched with care. In the
+face of the numerous recoveries in such cases, habitual abdominal
+exploration is not justified, under the conditions usually prevailing in
+the field.
+
+2. The very large class of patients excluded by this rule from operation
+leads us to a smaller and less satisfactory number to be divided into
+two categories:
+
+Patients who die during the first twelve hours. The whole of these are
+naturally unfit for operation, and their general condition when seen
+often precludes any thought of it.
+
+Patients with very severe injuries, as evidenced by the escape of faeces,
+or with wounds from flank to flank or taking an antero-posterior course
+in the small intestinal area. These patients die, and the majority of
+them will always die whether operated upon or not. The undertaking of
+operations upon them is unpleasant to the surgeon, as being unlikely to
+be attended with any great degree of success, whence the impression may
+gain ground that patients are killed by the operations. None the less, I
+think these operations ought to be undertaken when the attendant
+conditions allow, and it is from this class of case that the real
+successes will be drawn in the future. The history of such injuries,
+after all, corresponds exactly with what we were long familiar with in
+traumatic ruptures in civil practice, and now know may be avoided by a
+sufficiently 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 in
+doubtful cases, brings us face to face with a large proportion of
+patients in the early or late stage of peritoneal septicaemia. These
+cases run on exactly the same lines as those in which the same condition
+is secondary to spontaneous perforation of the bowel, in which we
+consider it our duty to operate, and in which a definite percentage of
+recoveries is obtained. Hence another unpleasant duty is here imposed
+upon the surgeon. Two such cases on which I operated are recounted
+above, and although I cannot say they give much encouragement, I should
+add that in the only one I left untouched, I regretted my want of
+courage for the five days during which the patient continued to carry on
+a miserable existence.
+
+4. The treatment of the cases in which an expectant attitude is followed
+by the advent of localised suppuration presents no difficulty; simple
+incision alone is needed, and healing follows.
+
+As a rule this is a late condition. In one case of injury to the
+ascending colon recounted above, however, considerable local escape of
+faeces had occurred, and a successful result was obtained by a local
+incision on the third day without suture of the bowel. In this case I
+believe the wound in the bowel to have been of the nature of a long
+slit, but the surrounding adhesions were so firm as to render any
+interference with them a great risk, and a successful result was
+obtained at the cost of a somewhat prolonged recovery. I am convinced
+that the best course was followed here. (No. 131.)
+
+When the suppuration was of a less acute character, it was generally
+advisable to allow the pus to make its way towards the surface before
+interference.
+
+5. Cases of injury to the colon in which the posterior aspect is
+involved should be treated by free opening up of the wound, and either
+by suture of the bowel or else its fixation to the surface. I operated
+on one such case, and although the patient eventually died on the eighth
+day, from septicaemia, he certainly had a chance. Two cases where the
+opening looked so free that one almost thought the wound could be
+regarded as a lumbar colotomy did badly; in both infection of the
+pleura took place, besides extension of suppuration into the
+retro-peritoneal areolar tissue. In the future I should always feel
+inclined to enlarge such wounds and bring the bowel to the surface.
+
+As regards actual technique the majority of the wounds are particularly
+well suited to suture; three stitches across the opening and one at
+either end of the resulting crease sufficed to close the opening
+effectively. The openings in the small intestine were not as a rule
+difficult 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 the
+large gut. Under ordinary circumstances the only instruments specially
+needed are a needle and some silk. At my first two operations, as my
+instruments had gone astray, the wounds were readily closed by a needle
+and cotton borrowed from the wife of a railway porter.
+
+If aseptic sponges or pads are not available, boiled squares of ordinary
+lint may be employed for the belly, and towels wrung out of 1 to 20
+carbolic acid solution used to surround the field of operation. Whenever
+there is any likelihood of the necessity for operations, water boiled
+and filtered should be kept ready in special bottles.
+
+When septic peritonitis was already present, the ordinary procedure of
+dry mopping, followed by irrigation, was necessary, before closing the
+belly.
+
+The after-treatment should be on the usual lines as to feeding, &c.
+
+I am unaware to what degree success followed intestinal operations
+generally during the campaign. I saw only one case in which the small
+intestine had been treated by excision and the insertion of a Murphy's
+button in which a cure followed: this case was in the Scottish Royal Red
+Cross hospital under the care of Mr. Luke. I heard of two cases in which
+the large intestine was successfully sutured, and of one other in which
+recovery followed the removal of a considerable length of the small
+bowel for multiple wounds.
+
+In concluding these most unsatisfactory remarks, I should add that the
+impressions are those that were gained as the result of the conditions
+by which we were bound in South Africa, and which might recur even in a
+more civilised region. Under really satisfactory conditions nothing I
+saw in my South African experience would lead me to recommend any
+deviation from the ordinary rules of modern surgery, except in so far as
+I should be more readily inclined to believe that wounds in certain
+positions already indicated might occur without perforation of the bowel
+when produced by bullets of small calibre; and further in cases where I
+believed the fixed portion of the large bowel was the segment of the
+alimentary canal that had been exposed to risk, I should not be inclined
+to operate hastily.
+
+A careful consideration of the whole of the cases that I saw leaves me
+with the firm impression that perforating wounds of the small intestine
+differ in no way in their results and consequences when produced by
+small-calibre bullets, from those of every-day experience, although when
+there is reason merely to suspect their presence an exploration is not
+indicated under circumstances that may add a fresh danger to the
+patient.
+
+_Wounds of the urinary bladder._--Perforating wounds of the bladder are
+the injuries nearest akin to those we have just considered, but a great
+gulf separates them, in so far as the escape of a few drops or even a
+considerable quantity of normal urine does not necessarily mean
+peritoneal infection. The difference in this particular was very
+forcibly demonstrated in my experience, since an uncomplicated
+perforation of the bladder in the intra-peritoneal portion of the viscus
+proved to be an injury that not infrequently recovered spontaneously, I
+believe in a considerable proportion of the cases.
+
+I include only one such case in my list because it was the only example
+which happened to be under my personal observation during its whole
+course, but from time to time I was shown several others in which the
+position of the external apertures and the transient presence of
+haematuria left little doubt as to the nature of the injury. The case
+recounted above, No. 190, is of especial interest, since the patient
+recovered from an injury which involved both the bladder and a fixed
+portion of the large intestine in contact with its posterior surface.
+
+In another, No. 194, a transient inflammatory thickening pointed to a
+local inflammation of a non-infective character, since no suppuration
+ensued, and this may have been a case of extra-peritoneal wound; on the
+other hand, the bladder may have entirely escaped injury. In wounds of
+the portions of the viscus not clad in peritoneum, as a rule, a very
+different prognosis obtains. Two typical cases are related, which I
+believe fairly represent the general results which follow when the
+bladder is either wounded behind the symphysis or at the base. The first
+case, No. 195, exemplifies a very characteristic form of wound when
+small-calibred bullets are concerned. The bullet, taking a course more
+or less parallel to that of the wall of the viscus, cut a long slit in
+its anterior wall. This bullet in its onward passage comminuted the
+horizontal ramus of the pubes, and lodged in the thigh. Into the latter
+region the greater part of the extravasated urine escaped. I think the
+history of this case fully shows that I made a blunder in not performing
+a proper exploration, instead of contenting myself with an incision in
+the thigh. My only excuse was that the patient at the time I saw him was
+in a very collapsed state, and a severe grade of abdominal distension
+suggested that septic peritonitis was already in an advanced stage. In
+point of fact, the patient at once improved, sufficiently so to be able
+to undergo a second exploration at a later date by Mr. Hanwell at the
+Base, only dying of septicaemia at the end of twenty-one days. Even a
+free supra-pubic vent might, I believe, have given him a chance of life.
+
+When the perforation was at the base of the bladder, however, the
+prognosis was very bad, and, as far as I know, not a single patient
+escaped death. The increase of risk in an extra-peritoneal wound of this
+viscus is indeed very great, while an intra-peritoneal perforation may
+be considered an injury of lesser severity, provided the urine be of
+normal 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 deg.. 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 deg., pulse 120. No sickness, tongue
+     moist, bowels confined. Retention of urine. The condition of
+     the patient was very grave; but he was anaesthetised, 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 septicaemia, 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 deg., 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 in
+these injuries. For the intra-peritoneal lesions an expectant plan of
+treatment may be followed by uncomplicated recovery. Mention has already
+been made of a case in which a Mauser bullet was retained in the bladder
+and was subsequently passed per urethram. In such a case a cystotomy
+would be indicated were the bullet discovered in the viscus.
+
+As to extra-peritoneal injuries it is difficult to lay down guiding
+lines. I believe the ideal treatment would be a supra-pubic cystotomy
+and drainage of the bladder by a Sprengel's pump apparatus, such as we
+employ at home. Under these circumstances, with the possibility of
+keeping the bladder actually empty, I believe good results might be
+obtained. Certainly drainage of the bladder by a catheter tied in proved
+worse than useless, and I very much doubt whether a simple supra-pubic
+opening would give any better results under the circumstances under
+which a patient has to be treated in a Field hospital.
+
+Cases might, however, occur in which oblique passage of the bullet cuts
+a groove and makes a large opening in the peritoneum-clad portion of the
+viscus. Under satisfactory conditions a laparotomy would be here
+indicated. I take it that this condition would most probably be
+accompanied by retention of bloody urine, which fact would arouse
+suspicion.
+
+
+INJURIES TO THE SOLID ABDOMINAL VISCERA
+
+_Wounds of the kidney._--Tracks implicating the kidneys were of
+comparatively common occurrence. As uncomplicated injuries they healed
+rapidly, and without producing any serious symptoms beyond transient
+haematuria.
+
+The nature of the lesion appeared to vary with the direction of the
+wound. In many cases a simple puncture no doubt alone existed, an injury
+no more to be feared than the exploratory punctures often made for
+surgical purposes. In other cases the wounds may have been of the nature
+of 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 the
+loin, and in the case of the right organ a transverse rupture was
+produced, which was followed by the development of a hydro-nephrosis,
+and later by suppuration. This injury was probably the result of a wound
+from a short range, as the patient was one of those wounded in the early
+part of the day at the battle of Magersfontein. It was complicated by a
+wound of the spleen and an injury to the spinal cord producing
+incomplete paraplegia accompanied by retention of urine. The last
+complication was responsible for the death of the patient, since
+ascending infection from the bladder led to the development of
+pyo-nephrosis and death from secondary peritonitis.
+
+Case 202 is an instance of a transverse wound of the upper part of the
+abdominal cavity; it is impossible to say what further complications
+were present. The early development of a tympanitic abscess suggested an
+injury to the colon, but this was not by any means certain. The
+condition of the kidney was very likely similar to that in the last
+case, but the ultimate recovery of the patient left this a matter of
+doubt. The case was also one dependent on a short-range wound, since the
+patient, one of the Scandinavian contingent, was wounded at
+Magersfontein during close fighting.
+
+The common history of the symptoms after a wound of the kidney was
+moderate haemorrhage from the organ, persisting for two to four days. In
+one of the cases recounted below the haematuria was accompanied by the
+passage of ureteral clots, but this was not a common occurrence.
+
+For the sake of comparison I have included one case of wound of the
+kidney from a large bullet, in which death was due to internal
+haemorrhage. In this instance the injury was a complex one, the lung
+certainly, and the back of the liver probably, being concurrently
+injured. None the less if the same track had been produced by a bullet
+of small calibre I believe the injury would not have proved a fatal one.
+I never saw such free renal haemorrhage in any of the Mauser or
+Lee-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 haematuria 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 haematuria 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 deg.. 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 haematuria, 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 caecum, [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
+     haematemesis. Urine normal, and in good quantity. Temperature
+     100 deg.. 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 deg., pulse 92.
+
+     A week later the man was much improved, suffering no pain.
+     Temperature ranged from 99 to 100 deg., 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 faecal 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 haematoma
+     (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 haematemesis. Later there was some haemoptysis. 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
+     haemorrhage, 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 the
+ensurance of rest, either alone, or with the administration of opium if
+the haematuria was severe. The after-treatment in the event of the
+development of hydronephrosis is on ordinary lines. Tapping, or incision
+followed by extirpation of the injured viscus, if the less severe
+procedures failed. I never saw a case where renal haemorrhage suggested
+the removal of the kidney as a primary step, and much doubt whether such
+a case is likely to be met with, as the result of a wound from a bullet
+of small calibre.
+
+_Wounds of the liver._--Wounds of the liver were, I believe, responsible
+for more cases of death from primary haemorrhage than those of the
+kidney. I heard of a few cases in which this occurred, although I never
+saw one. Case 204 is of considerable interest as illustrating the result
+of an injury to one of the large bile ducts. Putting the deaths from
+primary haemorrhage on one side, the prognosis in hepatic wounds was as
+good as in those of the kidneys. A few fairly uncomplicated cases are
+quoted below, but wounds of the liver occurred in connection with a
+large number of other injuries both of the chest and abdomen, and except
+in the case of wound of the stomach, recorded on page 425, No. 164, and
+in case 188, I never saw any troublesome consequences ensue.
+
+_Nature of the lesions._--I never saw any case of so-called explosive
+lesion of the liver, such as have been described from experimental
+results; this may have been due to the fact that such patients rapidly
+expired, but such were never admitted into the hospitals.
+
+The most favourable cases were those in which a simple perforation was
+effected; such were usually attended by a practical absence of symptoms,
+unless a large bile duct had been implicated, when a temporary biliary
+fistula resulted.
+
+Biliary fistulae were, however, much more common when the bullet scored
+the surface of the organ. One such case is recounted under the heading
+of injuries to the stomach, No. 164. Here a deep gaping cleft with
+coarsely granular margins extended the whole antero-posterior length of
+the 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 injuries
+I met with.
+
+Case 207 is an example of a superficial injury from a bullet possibly of
+small calibre in which a superficial groove was followed by temporary
+escape of bile, and it is of interest to note a very similar condition
+in a shell injury (No. 210) recorded on p. 477.
+
+Although both these cases recovered, I think notching and superficial
+grooving must be considered much more serious injuries than pure
+perforation. (See case 188, p. 442.)
+
+The symptoms observed in these injuries have been already indicated in
+the above description of the nature of the lesions. They consisted in
+the pure perforations of practically nothing, in the grooves or the
+perforations implicating a large duct in the escape of bile. In two of
+the cases in which a biliary fistula was present transient jaundice was
+noticed.
+
+In many cases the accompanying wound of the diaphragm gave rise to much
+discomfort; again, in the transverse wounds the action of the heart was
+often affected by the local cardiac shock accompanying the injury. In
+one case in which the colon was at the same time wounded (No. 188), an
+abscess formed at the site of the hepatic wound, as might have been
+expected.
+
+As uncomplicated injuries, these wounds were little to be feared. Except
+as a source of haemorrhage in rapidly dying patients, I never heard of a
+fatality. As a complication of other injuries, however, the wound of the
+liver, as has been shown, was sometimes of importance. It was remarkable
+in 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 suspected
+progressive haemorrhage, or in the presence of great pain. In cases where
+bile was escaping, it was important to ensure a free vent for the
+secretion.
+
+     (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 deg., 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 were
+necessarily rare, and beyond this the strict localisation of a track to
+the spleen is not a matter of great ease. None the less the spleen must
+have been implicated in a considerable number of the wounds crossing the
+chest and abdomen. I know of only one case in which a wound which
+crossed the splenic area caused death from haemorrhage, and of this I can
+give 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 the
+wounds. The patient continued to perform his duty as an officer in the
+fighting line for at least an hour after being struck, and then died
+rapidly apparently from an internal haemorrhage.
+
+In case No. 201, included amongst the renal injuries, a wound of the
+spleen existed, but had given rise to no symptoms, and at the time of
+death, some three weeks later, was cicatrised. The only other assertion
+of importance that I can make is, that, as far as I could judge, wounds
+of the spleen from bullets of small calibre were not, as a rule,
+accompanied by haemorrhage, since I never saw a case in which dulness in
+the left flank suggested the presence of extravasated blood, and in no
+case that I saw was there any history of general symptoms pointing to
+the loss of blood.
+
+This is only to be explained by our similar experience with regard to
+wounds of the liver unaccompanied by puncture of main vessels, and
+perhaps haemorrhage is still less to be expected in the case of the
+spleen, in consequence of the contractile muscular tunic with which the
+organ is provided.
+
+I can quote no case of certain injury to the spleen, except that already
+referred to discovered at a _post-mortem_ examination, but many wounds
+were observed in positions of which the following may be taken as a
+type. _Entry_, through the seventh left costal cartilage, 3/4 of an inch
+from the sternal margin; _exit_, 2-1/2 inches from the left lumbar
+spines at the level of the last rib.
+
+As an instance of the doctrine of chances I might quote the position of
+the wound in the patient who lay in the next bed. Both patients were
+wounded while fighting at Almonds Nek. _Entry_, through right seventh
+costal cartilage, 3/4 of an inch from the sternal margin; _exit_, 1-1/2
+inch from the lumbar spines, at the level of the last right rib.
+
+In neither of these cases did anything except the position of the
+external apertures point to the infliction of visceral injury.
+
+_General remarks as to the prognosis in abdominal injuries._ The
+prognosis in each form of individual visceral injury has been already
+considered, but a few points affecting these injuries as a class should
+perhaps be further considered.
+
+First, as to the influence of range on the severity of the injuries
+inflicted; 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 such
+injuries, and possibly some of the most severely wounded were killed
+outright as a direct consequence of the greater striking force of the
+bullet.
+
+Among the cases in which but slight effects were noted, however, many
+were said to have been hit within a range of 200 yards, as for instance
+the two injuries quoted under the heading of wounds of the spleen.
+
+I personally saw no cases in which explosive injuries of the solid
+viscera were to be ascribed to this cause.
+
+Secondly, as to the immediate prognosis in all abdominal injuries, the
+ensurance of rest and limitation as far as possible of transport were of
+the highest importance, either in the case of wound of the alimentary
+canal, or in wounds of the solid viscera in which haemorrhage was a
+possible result.
+
+Thirdly, as to the later prognosis in these injuries; very few men are
+fit to resume active service without a prolonged period of rest. In
+spite of the insignificance of the primary symptoms, or of the
+favourable course taken by the injuries, active exertion was almost
+always followed for some months by the appearance of vague pains and
+occasionally by indications of recurrent peritoneal symptoms, pointing
+to the disturbance of quiescent haemorrhages, or of adhesions. Wounds of
+the kidney are apparently those least liable to be followed by trouble.
+
+Lastly, the prognosis was influenced in the case of many of the viscera
+by coexisting injury to other organs or parts.
+
+For instance, at least thirty per cent. of the abdominal wounds were
+complicated by wound of the thorax; and in the lower segment of the
+abdomen injury to the extra-peritoneal portions of the pelvic organs was
+common.
+
+Both the immediate and ultimate prognosis were influenced greatly by
+this fact.
+
+As to the individual injuries:
+
+1. Wounds in the intestinal area, except in certain directions, often
+traverse the abdomen without inflicting a perforating injury on the
+bowel.
+
+2. If the alimentary canal is perforated, injuries in certain segments,
+even if perforating, may be followed by spontaneous recovery. I should
+say the prognosis from this point of view is best in the ascending
+colon, then in the rectum; after these most favourable segments, I
+should place the others in the following order: stomach, sigmoid
+flexure, descending colon. As to perforating wounds of the transverse
+colon and small intestine, I believe spontaneous recovery to be very
+rare.
+
+3. Wounds of the solid viscera generally, usually heal spontaneously,
+and give no trouble unless one of the great vessels has been injured. I
+include in this category all organs except the pancreas, of wounds of
+which I had no experience.
+
+4. Wounds of the bladder, if of the nature of pure perforations in the
+intra-peritoneal segment, often heal spontaneously.
+
+5. As a rule, injuries to the organs in their intra-peritoneal course
+have a far better prognosis than those which implicate the organs in
+their uncovered portions.
+
+6. The small calibre of the bullet is alone responsible for the
+favourable results observed.
+
+7. The danger or otherwise of an intestinal injury depends mainly on
+mechanical conditions; for instance, the fixity of the ascending colon,
+and its comparative freedom from a covering of small intestine capable
+by movement of diffusing any infective material, account chiefly for
+such favourable results as are seen when that segment of the bowel is
+implicated.
+
+
+WOUNDS OF THE EXTERNAL GENITAL ORGANS
+
+Wounds of the _scrotum_ were not uncommon, especially in connection with
+perforations of the upper part of the thigh. They offered no special
+feature, beyond the common tendency of every-day experience to the
+development of extensive ecchymosis.
+
+Wounds of the _testicles_ I saw on several occasions. I remember only
+one out of some half-dozen in which castration became necessary. I was
+told of one case, for the accuracy of which I cannot vouch, in which
+destruction 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. I
+append a case, however; in which the penile urethra was wounded, which
+is 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 this
+case concurrent injury to other pelvic organs led to death on the third
+day. As a good many of the patients with pelvic wounds died rapidly, the
+accident 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 which
+happen 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 brief
+mention of the shell wounds observed during the campaign.
+
+As already pointed out, these formed but a very small proportion of the
+injuries treated in the hospitals, and beyond this they possessed
+comparatively small surgical interest, since, as a rule, the features
+presented were those of mere lacerated wounds, while the more severe of
+the cases which survived only offered scope for operations of the
+mutilating class so uncongenial to modern surgical instincts.
+
+The fatal wounds consisted in extensive lacerations resulting in the
+destruction of the head or limbs, the laying open of the abdominal or
+thoracic cavities, or the production of visceral injuries beyond the
+possibility 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 some
+idea of these. The photograph was taken by Mr. Kisch after the relief of
+Ladysmith. For the want of more extended knowledge I shall confine
+myself to the description of a few injuries caused by two classes of
+large shell, those of the Vickers-Maxim or 'Pom-pom,' and two varieties
+of shrapnel.
+
+The large shells employed may be divided into classes according to the
+metal used in their construction, and the nature of the explosive with
+which they were filled. These details are of some surgical import,
+because they affect the nature of the fragments into which the shells
+are 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 Steel
+Howitzer Shell exploded by lyddite. C. Fragment of Cast-iron Shell
+exploded by powder. B exhibits transverse markings which might be
+mistaken for the lines seen in the Boer segment shells, but which really
+correspond to the area of fixation of the copper driving band]
+
+Examination of fragment C of a cast-iron shell exploded by powder shows
+the characteristic granular fracture, and edges, although sharp, yet of
+a comparatively rounded nature. The fragment is also heavier for its
+surface measurement, as the metal is thicker than that seen in the
+remaining fragments, although the cast-iron shell was of a much smaller
+calibre than the steel one. The lesser degree of penetrative power, and
+increased capacity to contuse, possessed by such fragments are obvious.
+
+A B and D are fragments of a large forged steel howitzer shell exploded
+by lyddite, such as were cast by our guns. The photograph well shows the
+more tenacious structure of the metal in the incomplete longitudinal
+fissuring exhibited, while the margins are of a sharp knifelike
+character, well calculated to penetrate or, in the case of superficial
+injuries, to produce wounds of a more sharply incised character than the
+cast-iron shell. Fragments A and B also show an appearance suggestive of
+partial fusion, characteristic of high explosive action, in the turning
+of the prominent margins.
+
+The larger fragments of such shells were responsible for the most
+serious mutilating injuries, while small fragments sometimes caused
+comparatively simple perforating wounds. I remember a fragment of the
+fused character not larger than a small nut which had perforated the
+front of the thigh of a Boer, and lodged near the inner surface of the
+femur. Removal of the fragment was followed by a free gush of
+haemorrhage. When the wound was opened up an opening was found in the
+external circumflex artery, haemorrhage from which had been controlled by
+the impaction of the piece of shell. As an example of the cutting power
+of sharp fragments of shell I might instance the case of another Boer in
+whom light passing contact had been made by the missile. A gaping
+incised wound extended from above the angle of the scapula down to the
+outer surface of the buttock. The wound involved the latissimus dorsi,
+and the external and internal oblique muscles of the abdomen. The
+separate muscular layers were sharply defined in the lateral parts of
+the floor of the wound, and remained so for some time during the gradual
+contraction of the large granulating surface produced. The degree of
+contusion was in fact slight, while the incised character was strongly
+marked.
+
+In some cases the fragments merely struck the soldiers on the flat
+without producing any wound. In one such case a blow upon the
+epigastrium was, according to the patient, followed by the vomiting of a
+considerable amount of blood. A fluid diet was ordered, and no further
+ill effects were noted. The following case illustrates an oblique blow
+of a perforating character, which was nevertheless recovered from.
+
+[Illustration: FIG. 91.--Various portions of Brass Percussion and Time
+Fuses]
+
+     (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 anaesthetised and the
+     fragment extracted. The wound of entry was at the same time
+     enlarged, cleansed, and partly sutured. The patient vomited
+     once after the anaesthetic, 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 the
+fragments into which the component parts of shells may break up. The
+pieces are for the most part of brass, and formed parts of either time
+or 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 the
+Vickers-Maxim may be said to have been on trial during this campaign.
+The general opinion seems to have been to the effect that the moral
+influence produced by the continuous rapid firing of the gun and the
+attendant unpleasant noise were its chief virtues. A considerable number
+of wounds must, however, have been produced by it, which, if not of
+great magnitude and severity, were, at any rate, calculated to put the
+recipients out of action, and these wounds, moreover, were slower in
+healing than many of the rifle-bullet injuries.
+
+The shell is so small that it was said to occasionally strike the body
+as a whole, and perforate. I was shown a case in which a wounded officer
+was confident that an entire shell had perforated his arm. The entry
+wound was at the outer part of the front of the forearm, the exit at the
+inner aspect of the arm, just above the elbow. Two ragged contused
+wounds existed, which healed slowly, but no serious nervous or vascular
+injury had been produced. Although it is probable that only a fragment
+perforated in this case, it is of interest in connection with the
+following.
+
+In a case shown to me by Sir William Thomson in the Irish Hospital at
+Bloemfontein, an entire shell had passed between the left arm and body
+of a trooper, perforating the haversack, as also a non-commissioned
+officer's notebook contained within it, without exploding. The only
+injury sustained by the trooper was a contusion on the inner aspect of
+the elbow-joint, with slight signs of contusion of the ulnar nerve. The
+case is of some importance, as showing that a comparatively resistent
+body can be perforated without necessary explosion on the part of the
+shell; hence the possibility of a similar perforation of the soft parts
+of the body.
+
+[Illustration: FIG. 92.--Unexploded 1-lb. Vickers-Maxim Shell. (Actual
+size)]
+
+Fig. 93 is of a number of fragments of Vickers-Maxim shells, and it was
+by 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 of
+the body, if the sufferers were in the erect position when wounded. I
+saw a good many wounds in the neighbourhood of the knee, some of which
+implicated the joint. When the injuries were received by patients in the
+lying or crouching positions, any part of the body was equally likely to
+be affected, or, again, the presence of large stones or rocks in the
+vicinity might determine the scattering of the flying fragments at a
+more dangerous height than when the shells burst from contact with the
+actual ground.
+
+The relation of one or two examples of wounds from pom-pom fragments may
+not be without interest, the more so as they illustrate the favourable
+influence of a low degree of velocity on the part of a projectile. I saw
+three wounds produced by the percussion fuses of these shells, an
+experience which shows that they were not very uncommon.
+
+[Illustration: FIG. 93.--Fragments of Vickers-Maxim 1-lb. Shells. The
+centre fragment of the lower row is the point of a steel armour-piercing
+shell; although unsuitable for the purpose, they were occasionally
+employed 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 by
+an exit aperture of about the same size. When the patient arrived at the
+Base some days after the injury, a hard body was felt in the wound, and
+on exploration the fuse was found and removed.
+
+In a third case the fuse struck the side of the foot below the outer
+malleolus and comminuted the astragalus, and then passing forwards
+lodged beneath the extensor tendons of the toes. The wound was explored
+at the time of the injury and some fragments of bone removed;
+considerable cellulitis supervened, and the fuse was only discovered
+some days later when the patient came under the care of Sir W. Thomson
+in the Irish Hospital in Pretoria. It was there removed, together with
+some more fragments of bone, and the wound slowly granulated. The
+patient then returned to England, when the wound rapidly healed after
+the removal of some further necrosed fragments of cancellous tissue. The
+astragalus had been reduced to a mere shell of compact tissue, and the
+convexity of the articular surface was altogether lost. The deformity,
+together with the formation of adhesions in the ankle-joint, led to the
+development 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 the
+lung after the lapse of nine months, the patient having developed an
+empyema, and a chronic fistula, which rapidly closed after the removal
+of the foreign body.
+
+[Illustration: PLATE XXV
+
+OBLIQUE FRACTURE OF THE HUMERUS CAUSED BY A FRAGMENT OF A VICKERS-MAXIM
+OR POM-POM SHELL
+
+The entire absence of comminution is very striking]
+
+I will add one further case, that illustrated by plate XXV. In this a
+fragment of a pom-pom shell entered the outer aspect of the right
+shoulder to escape on the inner aspect of the arm, just below the
+confines of the axilla. An oblique, non-comminuted fracture of the
+humerus resulted, which in spite of moderate suppuration united well in
+the course of six weeks. The case is of particular interest as
+illustrating the nature of the fracture to be expected when the velocity
+retained by the missile is low.
+
+The above instances show that such peculiarities as belong to wounds
+produced by pom-pom shells depend on the comparatively small size and
+weight of the fragments, and on the small degree of impetus with which
+they are propelled.
+
+[Illustration: FIG. 95.--Boer Segment Shell, or Shrapnel. The large
+fragment is a piece of the case, the smaller are two of the pieces of
+iron packed within]
+
+Fig. 95 illustrates a form of shrapnel employed by the Boers, the case
+of which is of cast metal arranged in definite segments, while the
+interior is filled with small fragments of iron so shaped as to pack in
+concentric layers. As to the wounds produced by the contained fragments
+I have no experience, since I never saw one of the pieces of iron
+removed. This no doubt depended in part on the very unsatisfactory
+practice made by the Boers with shrapnel generally. Even when they fired
+English shrapnel, the shells were, as a rule, exploded far too high to
+cause any serious danger to the men beneath. I saw on one occasion a
+large number of shrapnel shells exploded over a body of Imperial
+Yeomanry, but as a result of the great height at which all the shells
+were exploded, not a single casualty resulted.
+
+The segment casing of the shell, however, I several times saw removed
+from the body. The fragment shown in fig. 95 was removed from the
+buttock of a man after one of Lord Methuen's early battles. It may be
+remarked that the buttock is rather a common, and also a favourable,
+seat for shell wounds with retention of the fragment. This no doubt
+depends on the fact that the buttock is one of the few superficial
+regions in which sufficient depth of tissue exists for the retention or
+the 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. A
+normal undeformed bullet, such as was the usual cause of wounds, is
+shown at the left-hand upper corner. The remainder show common forms of
+deformity caused by striking on the ground or against rocks. I attribute
+small importance to the deformed bullets, as I never saw one removed,
+and it is probable that a ricochet shrapnel bullet would rarely retain
+sufficient force to penetrate. The lower fragments are inserted to
+illustrate a fact that would scarcely have been assumed, that these
+bullets on impact occasionally suffer a fracture of a somewhat
+crystalline nature. The occurrence of this gross form of fracture is of
+some interest in relation to the extreme fragmentation sometimes
+undergone by the hardened leaden cores of the small-calibre bullets.
+
+A considerable number of wounds from leaden shrapnel bullets were met
+with among our own men, as well as among the Boers. The wounds possessed
+little special interest, except from the fact that the bullets were
+often retained. I saw bullets in the chest on several occasions, also in
+the abdomen, pelvis, the neighbourhood of joints, and in the limbs.
+
+I saw one patient who had suffered no less than six perforating wounds
+as the result of the bursting of one shrapnel shell.
+
+I will here quote one case of interest as completing the various forms
+of perforating wound of the abdomen met with during the campaign.
+
+[Illustration: FIG. 96.--Normal, Deformed, and Fractured Leaden Shrapnel
+Bullets]
+
+     (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. The
+mutilating injuries, if not of a fatal character, necessitated treatment
+of a corresponding nature to the damage. In all such cases the general
+rules 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 for
+removal 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 influence
+exerted on the aseptic course of modern rifle wounds by the small
+calibre of the bullet, since both bullet and shell wounds were exposed
+to 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 haematoma, 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-Joergensen, 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.:
+  Haemothorax, 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
+
+
+Haemarthrosis, 232
+
+Haemorrhage, 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
+
+Haemorrhoids, 10
+
+Haemothorax, 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-Joergensen 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 haemorrhage, 321
+
+'Modders, the,' 9
+
+Mortality, general, 11
+  amongst officers, 14
+  in battles of Kimberley Relief Force, 12
+
+
+Nasal _fossae_, 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 septicaemia, 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-Joergensen, 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
+
+Septicaemia:
+  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
+  Haemato-myelia, 322
+  Section of, 323
+  Shock accompanying, 328
+  Signs of, 323
+  Transport of, 339
+  Treatment of, 339
+
+Spinal haemorrhage:
+  Epidural, 321
+  Haemato-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
+  Haemorrhage, 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
+
+       *       *       *       *       *
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+1899-1900, by George Henry Makins
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