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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: Makins, George Henry
Language: English
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[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


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--Hæmorrhage--Diagnosis--Prognosis--Treatment    55

CHAPTER IV

INJURIES TO THE BLOOD VESSELS

Nature of lesions; contusion, laceration, perforation--Results of
injuries--Primary hæmorrhage--Recurrent hæmorrhage--Secondary
hæmorrhage--Treatment of hæmorrhage--Traumatic aneurisms--Arterial
hæmatoma--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--Hæmorrhage,
extra-medullary, hæmatomyelia--Symptoms of injury to the spinal
cord--Concussion--Hæmorrhage--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--Hæmothorax--
Empyema--Diagnosis, prognosis, and treatment of hæmothorax--Cases
of hæmothorax                                                           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, fæcal extravasation, peritoneal infection, septicæmia--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 HÆMOTHORAX          392

84.  SUBCUTANEOUS DIVISION OF ABDOMINAL MUSCLES            409

85.  LATERAL INCOMPLETE WOUND OF SMALL INTESTINE. SLIT
     FORM                                                  416

86.  LATERAL PERFORATION OF SMALL INTESTINE. GUTTER FORM   417

87.  ENTRY AND EXIT WOUNDS IN A TRANSVERSE PERFORATION OF
     INTESTINE                                             418

88.  INNER ASPECT OF PIECE OF INTESTINE SHOWN IN FIG. 87   419

89.  IMPACTION OF OMENTUM IN EXIT WOUND OF ABDOMINAL WALL  421

90.  FRAGMENTS OF LARGE SHELLS                             475

91.  FRAGMENTS OF PERCUSSION AND TIME FUSES                477

92.  COMPLETE 1-LB. POM-POM SHELL                          479

93.  FRAGMENTS OF EXPLODED POM-POM SHELLS                  480

94.  PERCUSSION FUSE FROM 1-LB. POM-POM SHELL              481

95.  FRAGMENTS OF BOER SEGMENT SHELLS                      483

96.  NORMAL AND DEFORMED LEADEN SHRAPNEL BULLETS           485


_TEMPERATURE CHARTS_

1. CASE OF AXILLARY HÆMATOMA, BLOOD TEMPERATURE                119

2. CASE OF HÆMOTHORAX WITH RECURRENT HÆMORRHAGES               395

3. PRIMARY AND SECONDARY RISES OF TEMPERATURE IN HÆMOTHORAX,
   RECOVERING SPONTANEOUSLY                                    402

4. SECONDARY RISE OF TEMPERATURE IN HÆMOTHORAX                 403

5. FALLS OF TEMPERATURE IN HÆMOTHORAX FOLLOWING PARACENTESIS   404

6. SECONDARY HÆMOTHORAX, SPONTANEOUS FALL OF TEMPERATURE       405



SURGICAL EXPERIENCES

IN

SOUTH AFRICA



CHAPTER I

INTRODUCTORY


The following pages are intended to give an account of 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°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 septicæmia
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 defæcation 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
düssel 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 septicæmia, especially in connection with abdominal injuries,
severe head injuries and secondary to acute traumatic osteo-myelitis,
was the form most commonly seen. Pyæmia with secondary deposits 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
pyæmia 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 fasciæ, strength and
thickness of the bones, &c.

6. State of tension of the muscles, fasciæ, 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-Jörgensen), 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-Jörgensen]

The most important, as the most frequently employed, rifles projecting
small-calibre bullets were the Krag-Jörgensen, 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-     |
|                   |               |                    |      Jörgensen|
+-------------------+---------------+--------------------+---------------+
|Calibre of rifle   |    .303 in.   |     .276 in.       |  .254 in.     |
|Number of grooves  |       5       |        4           |     4         |
|One twist in       |10 in. to left |8-11/16 in. to right| 8 in. to left |
|Muzzle velocity    |   2,000 f.s.  |     2,262 f.s.     |  2,309 f.s.   |
|Sighted to         |   2,800 yds.  |     2,187 yds.     |  2,406 yds.   |
|Weight of cartridge| 416-1/2 grains|   384.5 grains     | 372.1 grains  |
|Weight of bullet   |   215 grains  |   173.3 grains     |  156.4 grains |
|Length of bullet   |    1.250 in.  |       1 in.        |  1.250 in.    |
|Calibre of bullet  |     .309 in.  |      .280 in.      |   .260 in.    |
|Charge of powder   | 31-1/2 grains |    38.0 grains     |    36 grains  |
|                   |   (cordite)   |    (smokeless)     |(nitro         |
|                   |               |                    |  -smokeless)  |
|Nature of alloy    |  Cupro-nickel |   Mantle: Steel    |Mantle: Mild   |
|  used for mantle  |               |   with alloy of    | steel coated  |
|  of bullet        |               |   copper on        | with copper   |
|                   |               |   surface          | nickel, the   |
|                   |               |                    | composition of|
|                   |               |                    | the latter    |
|                   |               |                    | being that of |
|                   |               |                    | the cupro-    |
|                   |               |                    | nickel of the |
|                   |               |                    | Lee-Enfield   |
|                   |               |                    | bullet        |
|Thickness of       |Mark II. bullet|         --         |   --          |
|  mantle           |               |                    |               |
|Tip                |     .036      |        .031        |   .022        |
|Sides .984 from tip|     .015      |        .015        |   .015        |
+-------------------+---------------+--------------------+---------------+

Some particulars of the four rifles and their projectiles are 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-Jörgensen 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-Jörgensen |
+---------------------+-------------+--------+----------------+
|                     |             |        |                |
| Initial velocity    |     630     |   718  |      720       |
| Remaining velocity: |             |        |                |
| At 100 metres       |     574     |   699  |      718       |
| At 1,000 metres     |     249     |   264  |      269       |
| At 2,000 metres     |     159     |   165  |      165.9     |
|                     |             |        |                |
+---------------------+-------------+--------+----------------+

Giving full importance to the effects of velocity as a factor in 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 patellæ 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-Jörgensen; 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-Jörgensen, 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-Jörgensen 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 débris 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-Jörgensen 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 vertebræ,
grooved the seventh and eighth and fractured the ninth and tenth ribs,
traversed the muscles of the back and finally lodged against the ilium;
the whole length of this track measured some 25 inches. Again, at 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 versâ. 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 hæmorrhage, 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 hæmorrhage 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 hæmorrhage into the subcutaneous tissue. In
this respect the contrast between the exit and entry apertures is
marked, since in the latter hæmorrhage is scarcely apparent. The
presence of such hæmorrhages 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-Jörgensen; 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-Jörgensen, 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-Jörgensen 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 hæmatoma
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
hæmorrhages, the patient's temperature rose high, and on the third day
the hæmatoma 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-Jörgensen, 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 hæmorrhage from the
anterior tibial artery necessitated exploration of the wound and
ligature of the vessel (Mr. Carré). 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 spinæ 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 spinæ 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 vertebræ 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. _Hæmorrhage._--This question is fully treated under the heading of
injuries to the blood-vessels. It will suffice here to say that
hæmorrhage 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 hæmorrhage. 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
hæmorrhage 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 hæmorrhage 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 hæmorrhage, 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 hæmorrhage.

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. _Hæmorrhage._--The fact that hæmorrhage 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 hæmorrhage 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 hæmorrhage 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
hæmorrhage, at any rate of an external nature. This subject will be
dealt with under the classical three headings of primary, recurrent, and
secondary hæmorrhage.

_Primary hæmorrhage._--A marked distinction needs to be drawn between
external and internal hæmorrhage. External hæmorrhage 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 hæmorrhage 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 hæmorrhage
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 hæmorrhage 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 hæmorrhages into the tissues of the
limbs indicated that blood does not readily travel along the wound
track. It was noteworthy that when hæmorrhage 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 hæmorrhage 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 hæmorrhage
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 hæmorrhage were rare, a
considerable number resulted from primary internal hæmorrhage. 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 hæmorrhage
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 hæmorrhage_ 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
hæmorrhage 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 hæmorrhage; 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
hæmorrhage is related in case 169, p. 432.

_Secondary hæmorrhage._--In simple wounds of the soft parts by
_small-calibre bullets_ this was decidedly rare. In wounds complicated
by fractures of the bones, especially when they exhibited the so-called
'explosive' character, secondary hæmorrhage 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 hæmorrhage 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 hæmorrhage 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 hæmorrhage three-quarters of the whole lumen of the vessel had
been devitalised. The resemblance of some cases of secondary hæmorrhage
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 hæmorrhage 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 hæmorrhages followed by a
sudden copious gush.

The forms of secondary hæmorrhage, 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 hæmorrhage are furnished
by cases of chest injury accompanied by hæmothorax and fully dealt with
under that heading (Chapter X.). Cases of interstitial secondary
hæmorrhage 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 hæmorrhage 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 pleuræ or joints were the seats of
the mischief. In the case of interstitial hæmorrhages I only remember to
have seen fever of such marked continued type in the subjects of
hæmophilia with recent effusions, although one is of course acquainted
with it in a less pronounced form as a result of hæmorrhage into
operation wounds.

In primary interstitial hæmorrhages 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 Hæmatoma. 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°. An abscess was at once suspected
and the swelling incised by Major Lougheed, R.A.M.C. A large
subperitoneal hæmatoma only was discovered, and evacuated. The
temperature at once fell and the after progress was uneventful, the
wound healing by primary union.


TREATMENT OF HÆMORRHAGE

_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
hæmorrhage 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 hæmorrhage, 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 hæmorrhage 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 hæmorrhage. 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
hæmorrhage, 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 hæmorrhage was followed by the development of a
traumatic aneurism in the ham.

_Secondary._--In secondary hæmorrhage 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 hæmorrhage from an arterial hæmatoma
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 hæmorrhage, 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 hæmatoma._--This condition was met
with comparatively frequently, and bears a very close relation to that
already described under the heading of interstitial hæmorrhages. 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 hæmatomata, and of the occurrence of the aseptic
form of secondary hæmorrhage, 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 hæmorrhage, which might or might not have been
associated with external bleeding. A hæmatoma 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
hæmatomata, 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 hæmatomata 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 hæmatoma developed in the axilla and upper third of
     the arm. This was incised (Colonel Stevenson) and a wound of
     the axillary artery in its third part discovered, and the
     vessel ligatured. The patient made an excellent recovery.

     (2) A patient received a wound at Doornkop which traversed the
     calf in an obliquely antero-posterior longitudinal direction.
     Three weeks later a soft fluctuating swelling developed at the
     inner margin of the tendo Achillis occupying the lower third of
     the leg. Neither pulsation nor murmur was detected. There was
     anæsthesia in the area of distribution of the posterior tibial
     nerve. No tendency to further increase was observed, and
     operation was postponed. The temperature was normal.

     (3) An Imperial Yeoman was struck at Zwartskopfontein at a
     range of one hundred yards. The man rode four miles on his
     horse after being hit, but the horse then fell and rolled over
     him twice. The man was treated successively in the Van Alen,
     Boshof, and Kimberley Hospitals, and from the last he was sent
     to Wynberg which place he reached on the twenty-third day. When
     admitted into No. 2 General Hospital the wounds of type form
     and size (_entry_, in posterior fold of axilla; _exit_, 1-1/2
     inch below junction of anterior fold with arm) were healed. The
     whole upper arm was swollen and discoloured, while an indurated
     mass extended along the line of the vessels into the axilla.
     This was considered a blood effusion; it was not obviously
     distensile, and pulsation was very slight. The brachial radial
     and ulnar pulses were absent. A fluctuating swelling was
     present along the anterior border of the deltoid. There were
     some signs of nerve contusion, but no paralysis, beyond tactile
     anæsthesia in the area of distribution of the median nerve.

     Four days later little alteration had been noticed beyond a
     tendency to variation in firmness of the different parts of the
     swelling. On the thirty-first day considerable enlargement was
     observed. This enlargement, together with continued rise of
     temperature, aroused the suspicion of suppuration, and an
     exploratory puncture with a von Graefe's knife was made by
     Major Lougheed, R.A.M.C., after consultation with Professor
     Chiene. Blood clot first escaped, followed by free arterial
     hæmorrhage. The incision was enlarged while compression of the
     third part of the subclavian was maintained; a large quantity
     of clot was turned out, and an obliquely oval wound half an
     inch in long diameter was found in the axillary artery.
     Ligatures were applied above and below the opening between the
     converging heads of the median nerve. The veins were not
     damaged. The wound healed by first intention. On the twelfth
     day a feeble radial pulse was perceptible, and shortly
     afterwards the man left for England, diminished median tactile
     sensation being the only remnant of the original symptoms.

     (4) A private of the 2nd Rifle Brigade was struck while
     doubling at Geluk, at a range of one hundred yards. The Mauser
     bullet entered four inches above the upper border of the left
     patella, internal to the mid line of the limb, and escaped in
     the centre of the popliteal space. The man lay in a farmhouse
     during the night and bled considerably from both wounds. He did
     not fall when struck, but could not walk. He was sent to No. 2
     General Hospital in Pretoria. On arrival there the external
     wounds were scabbed over, and a large tumour existed beneath
     the entrance wound. There was much discoloration from
     ecchymosis, but no pulsation could be detected. The posterior
     tibial pulse was good. At the end of ten days pulsation became
     marked both in the front of the limb and in the popliteal
     space. There were no symptoms of nerve injury. On the
     thirteenth day an Esmarch's bandage was applied and Major
     Lougheed laid the tumour open opposite the opening in the
     adductor magnus. Much clot was removed, and both artery and
     vein, which were found divided in the adductor canal, were
     ligatured.

     The foot remained very cold for the first twenty-four hours,
     but otherwise progress was satisfactory, the wound healing by
     first intention. No pulsation was palpable in the tibials at
     the end of a month.

For the last two cases I am very much indebted to Major Lougheed. I 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 hæmorrhage in
cases of hæmothorax. 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 hæmatoma 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 hæmatomata, 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 hæmoptysis and left
     hæmothorax. The left radial pulse was almost imperceptible.

     The entry wound did not close by primary union, and three weeks
     later an incision was made into the chest in consequence of the
     presence of fever, progressive emaciation, and weakness.
     Breaking down blood clot was evacuated: general improvement
     followed, and the radial pulse increased considerably in
     volume.

     A fortnight later sudden severe hæmorrhage occurred from the
     external wound, and the man rapidly collapsed and died. At the
     post-mortem a traumatic aneurism the size of an orange was
     found in connection with an oval wound in the first portion of
     the left subclavian artery which admitted the tip of the
     forefinger.

This case is noteworthy as an illustration of the magnitude of an artery
which can be wounded without leading to rapid death from primary
hæmorrhage, 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
     hæmorrhage of any importance occurred from the wound, but there
     was a typical hæmarthrosis, which subsided slowly. Twelve days
     after the injury a pulsating swelling the size of a hen's egg,
     to which attention was drawn on account of pain, was noted in
     popliteal space. The pulsation extended upwards in the line of
     the artery some 3 inches. The limb was placed on a splint and
     treated by rest, and a month later the aneurism had decreased
     to one half its former size, the wall having greatly increased
     in firmness. Pulsation was easily controlled by pressure above
     the tumour; there was no thrill present, but a high-pitched
     bellows murmur. The patient was sent home on February 1.

When admitted at Netley the patient came under the care of Major Dick,
R.A.M.C., who ligatured the popliteal artery on the proximal side by 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 hæmorrhage, and so much
     blood collected in the knee-joint that it was aspirated. On the
     eighth day secondary hæmorrhage occurred from the exit wound
     and the femoral artery was tied in Hunter's canal. No further
     hæmorrhage occurred, but at the end of three weeks feeble
     pulsation was palpable in the popliteal space, suggesting an
     aneurism; the latter decreased and the patient was sent home
     apparently well.

     (8) _Traumatic axillary aneurism._--Wounded at Karree. The
     bullet entered 2-1/2 inches below the acromial end of the right
     clavicle and emerged over the 9th rib in the posterior axillary
     line. The Mauser bullet was found in the patient's haversack.
     Both apertures were of the slit form, and healed per primam.
     Three weeks later at Wynberg a large arterial hæmatoma which
     pulsated was noted in the axilla. Signs of injury to the
     musculo-spiral nerve were also observed. The tumour altered
     little, but a fortnight later Major Burton, R.A.M.C., cut down
     upon it through the pectorals. The aneurism was of the third
     part of the axillary artery, and a ligature was applied at the
     lower margin of the pectoralis minor. The wound healed by
     primary union and the aneurism rapidly shrank. The patient left
     for England a month later; the musculo-spiral paralysis was
     improving. I am indebted to Major Burton for the notes of this
     case.

     (9) _Traumatic popliteal aneurism._--Wounded in Natal. _Entry_
     (Mauser), immediately above head of fibula. _Exit_, immediately
     inside semi-tendinosus tendon at level of central popliteal
     crease. Fulness but no pulsation was noted at end of three
     weeks; seven days later pulsation was evident, and an aneurism
     the size of a pigeon's egg, with firm walls, became localised
     and palpable. It gave rise to no symptoms, and patient refused
     operation during the three weeks he remained in hospital. The
     aneurism continued to contract, and the patient was sent home.
     The aneurism has since spontaneously consolidated.

_Aneurismal varix and varicose (arterio-venous)
aneurism._--Uncomplicated cases of aneurismal varix, as might 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-Jörgensen 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 hæmatoma 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 hæmorrhage, 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
hæmorrhage, 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 hæmorrhage. 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 hæmorrhage, either primary or recurrent.

     (10) _Carotid arterio-venous aneurism._--Wounded at Paardeberg.
     _Entry_ (Mauser) to the right side of the Pomum Adami, _exit_
     at anterior margin of left trapezius, two inches below the
     angle of the jaw. There was some hæmorrhage at the time from
     the exit wound, but no hæmoptysis; about four hours later,
     however, in the Field hospital bleeding was so free that an
     incision was made with the object of tying the common carotid.
     During the preliminary stages of the operation bleeding ceased
     and the wound was closed without exposing the vessel. The
     patient remained a week in the Field hospital, and then made a
     three day and night's journey in a bullock waggon to Modder
     River (40 miles), and fourteen days later he was transferred to
     the Base hospital at Wynberg, when the condition was as
     follows. Operation and bullet wounds healed. Considerable
     extravasation of blood in the posterior triangle. Beneath the
     sterno-mastoid in the course of the bullet track, swelling,
     thrill and pulsation over an area 1-1/2 inch wide in diameter.
     Loud machinery murmur audible to the patient when the left side
     of the head is placed on the pillow, and widely distributed on
     auscultation. The left eye appears prominent, but the pupils
     are normal and equal in size. Voice weak and husky, and there
     is cough. Laryngoscopic examination showed the cords to be
     untouched, but some swelling still persisted. No headache, but
     giddiness is troublesome at times. Pulse 100, regular but
     somewhat irritable.

     The patient was kept quiet in the supine position for a month,
     and during this time the condition in many ways improved. The
     voice improved in strength, the pulse steadied, falling to 80,
     the prominence of the left eye disappeared, and all the blood
     effusion in the posterior triangle became absorbed. Meanwhile
     the aneurism contracted at first, until it became oval in
     outline, with a long axis of 2 inches by 1-1/2 broad extending
     in the line of the wound track, but mainly situated in the exit
     half. During the last fortnight, however, it remained quite
     stationary in size, and as it showed no further signs of
     diminution in spite of the favourable conditions under which
     the patient had been placed, it was considered best to try to
     ensure its consolidation by a proximal ligature. Thrill had
     become slightly less pronounced, and was less evident to the
     patient himself, but was otherwise unchanged. The probabilities
     in this case seemed rather in favour of wound of the internal
     carotid artery, and it was decided to bare the upper part of
     the common carotid, follow up the main trunk, and if possible
     apply the ligature to the internal branch. On April 12, 61 days
     after the injury, the classical incision for securing the
     common carotid was made, and the sterno-mastoid slightly
     retracted. It was found that the sac of the aneurism extended
     over the bifurcation of the artery, reaching to the wall of the
     larynx. The omo-hyoid muscle was therefore divided, and the
     artery ligatured beneath, in order to ensure against any
     interference with the sac. Some difficulty was met with, for on
     opening the vascular cleft the vein was exposed and found to
     completely overlie the artery: although it was on the left side
     of the neck, the position of the vein was so completely
     superficial that there seemed no doubt that it had been
     displaced by the development of the aneurismal sac. A striking
     appearance was noted on exposure of the vein, the coats of
     which vibrated visibly, quivering in exact consonance with the
     palpable thrill. On tightening the silk ligature all pulsation
     ceased in the aneurism, and the vibratory thrill in the vein
     became much lessened.

     The patient made a good recovery, only disturbed by a slight
     attack of vomiting, and at the end of a week the wound had
     healed, and pulsation in the aneurism had completely ceased.
     The thrill persisted as before.

Six months later, a small sac still exists beneath the sterno-mastoid.
The pulse still reaches 110-120 in pace. The purring thrill is 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 hæmorrhage from
     the exit wound occurred at the time, and later on the way to
     Jacobsdal this was so profuse as to be nearly fatal. A
     considerable hæmorrhage also occurred on the tenth day. The
     patient made the journey to Modder River safely, and was then
     under the charge of Mr. Cheatle. A large diffuse pulsating
     swelling developed on the right side of the neck, with
     well-marked thrill and machinery murmur. During the next three
     weeks the swelling steadily contracted, and the patient was
     sent down to the Base one month after receiving the wound, when
     the condition was as follows. There is no evidence of any
     fracture of the jaw. On the right side of the neck a large
     aneurism fills the carotid triangle, extending from the
     mid-line backwards to the margin of the trapezius, and from the
     level of the top of the larynx upwards to the margin of the
     mandible. The wall is fairly firm, pulsation is both visible
     and palpable, and a well-marked thrill and machinery murmur are
     present. The latter annoys him by its buzzing when the head
     rests on the right side. The pupils are equal. Pulse somewhat
     irritable, about 100. The voice is weak and husky, and there is
     difficulty in swallowing solids. The actual swelling is
     somewhat remarkable in outline, on the one hand following up
     the course of the external carotid and facial arteries, and on
     the other extending backwards in the line of the wound track
     towards the exit. The patient was kept on his back with
     sandbags around the head during the next fortnight. For the
     first eight days such change as occurred was in the direction
     of localisation and contraction, but during the last six,
     evident extension occurred both backwards and downwards; this
     extension was accompanied by severe pain in the cutaneous
     cervical nerve area of the neck. The larynx became pushed over
     3/4 of an inch to the left of the median line, and the
     extension beneath the sterno-mastoid downwards raised a doubt
     as to whether the common carotid could be exposed without
     encroaching on the walls of the sac. Owing to indisposition I
     had not been able to see the patient for some days, but now,
     after consultation with Major Simpson and Mr. Watson, it was
     decided that the best plan would be to expose and tie the
     common carotid as high as could be safely done. The operation
     was performed six weeks after the injury, and somewhat to our
     surprise offered little difficulty. The carotid was exposed at
     the upper border of the omo-hyoid, only a small amount of
     infiltration having occurred in the vascular cleft. No
     dilatation of the jugular was noticeable, and when a silk
     ligature was applied to the artery all pulsation was
     controlled, and the thrill in the vein disappeared completely.
     The after progress was satisfactory, but four days later the
     wound was dressed, as the patient's temperature had risen above
     100°. The tumour was consolidated: no pulsation could be felt,
     but there was little apparent diminution in its size. A loud
     blowing murmur was audible, especially at the posterior part of
     the swelling.

     On the morning of the fifth day the patient mentioned that he
     again heard the whirr during the night. There had been no sign
     of any cerebral disturbance and the pupils had remained equal
     throughout.

     A week after the operation the stitches were removed, there was
     evidence of some blood clot in the lower part of the wound, and
     this later liquefied and was let out on the eleventh day. At
     that time a slight bubbling thrill could be felt at the upper
     part of the tumour, also slight pulsation in the line of the
     external carotid and at the most posterior part of the sac. The
     latter was much contracted, diminished in size and apparently
     solid, so that it was hoped that such pulsation as existed was
     communicated. Ten months later, no trace of the aneurismal sac
     exists. Neck normal, except for purring thrill. Voice strong
     and good. Pulse 100. Following his usual work.

     (12) _Carotid arterio-venous aneurism_.--Wounded at Paardeberg.
     Aperture of _entry_ (Mauser), at the posterior border of the
     left sterno-mastoid, 1 inch above the clavicle; _exit_, near
     the posterior border of the right sterno-mastoid, 2 inches from
     the sterno-clavicular joint. The injury was followed by very
     free hæmorrhage, mainly from the wound of entry, some 'quarts'
     of blood escaping; at any rate his clothes were saturated. The
     voice was hoarse and weak, and there was much difficulty in
     swallowing; for the first twenty-four hours he could swallow
     nothing, but gradual improvement took place. The patient was
     carried two miles to the Field hospital, and three days later
     travelled 36-40 miles in a bullock waggon to Modder River.
     Thence he travelled to Orange River 55 miles by train on the
     next day. A swelling was first noted when the wound was dressed
     some seven days after the injury. No evidence was ever existent
     of gross damage to either trachea or oesophagus beyond the
     initial dysphagia. The hoarseness of voice due to left
     laryngeal paralysis slowly improved, and was probably the
     effect of concussion or contusion of the left recurrent
     laryngeal nerve. During the patient's stay at Orange River a
     large pulsating swelling with a strong thrill developed. This
     was at first diffuse, but under the influence of rest it
     steadily contracted and localised. During this period the
     patient was seen several times by Mr. Cheatle, who noted
     considerable temporary enlargement of the thyroid gland.

     At the end of eight weeks he had been allowed up some days, and
     travelled 570 miles to Wynberg. The aneurism was about 1-1/2
     inch in diameter, smooth and rounded, extending just beneath
     the left clavicle and nearly the whole width of the
     sterno-mastoid, but well defined in all directions. There was
     well-marked expansile pulsation, purring thrill along the
     jugular vein and over the tumour, and loud machinery murmur
     widely diffused along the whole neck and into the thorax. The
     voice was still weak and husky, but there was no dysphagia or
     dyspnoea. The left pupil was larger than the right.

     The patient acquired enteric fever at Wynberg and when
     convalescent was sent to Netley, whence he returned home. The
     aneurism caused little discomfort. It may possibly have been of
     the inferior thyroid artery.

     (13) _Innominate arterio-venous varix_.--Wounded at Modder
     River. _Entry_ (Mauser) posterior margin of left
     sterno-mastoid, close above the clavicle. _Exit_ in anterior
     axillary line one inch below the right anterior axillary fold.
     Soon after the injury a considerable amount of blood was
     coughed up, and occasional hæmoptysis persisted for the next
     four days. The patient was moved from the Field hospital by
     train to Orange River, a journey of 55 miles and some four
     hours' duration, on the fourth day. When examined there was
     slight fulness over an area roughly circular and about 2-1/2
     inches in extent, of which the sterno-clavicular joint lay just
     within the centre. Over this area there was faint pulsation
     with a strongly marked thrill and loud systolic bruit. The
     radial pulses were even, the right pupil larger than the left.
     No pain, and no dyspnoea. The right eye was partially closed,
     but could be opened by the levator palpebræ superioris. The
     patient was shortly afterwards sent to the Base, and when seen
     there twenty-five days after the injury, there was little
     change in the condition except that the fulness had
     disappeared, the thrill was more marked, and a typical
     machinery murmur transmitted along both carotid and subclavian
     arteries had developed. There was no headache and the man
     himself did not notice the bruit. Evidence of mediastinal
     hæmorrhage existed in the presence of subcutaneous
     discoloration of the abdominal wall, below the ensiform
     cartilage and extending slightly over the costal margin of the
     thorax. In the absence of an aneurismal swelling, or of the
     development of any further symptoms, the patient was sent home
     to Netley in January.

I saw this patient in Glasgow a year later. He was employed as 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 hæmorrhage, but the injury was followed by some
     difficulty in swallowing, and hæmoptysis, which lasted for the
     first two days. The right radial pulse was noted to be smaller
     than the left, and weakness in flexion of the fingers, with
     hyperæsthesia in the ulnar nerve distribution, was observed.
     The right pupil was also noted to be larger than the left.

     The patient was sent down to the Base, and on the twenty-fourth
     day the condition was as follows. A pulsating swelling existed
     extending 1-1/4 inch upwards beneath the right sterno-mastoid,
     from the mid line of the neck backwards to the centre of the
     posterior triangle, and downwards over 2 inches of the first
     intercostal space, which latter was dull on percussion. There
     was some evidence of a bounding wall, but it was thin and the
     tumour was soft and yielding. A loud machinery murmur was
     audible over the tumour, over nearly the whole extent of the
     thorax, and in the distal vessels as far as the temporal
     upwards, and the brachial as far down as the bend of the elbow.
     The murmur was audible to the patient with his ears closed.
     Over the swelling a strong thrill was palpable; this extended
     some little distance into the distal vessels and felt
     remarkably superficial. It was particularly evident in the line
     and course of the anterior jugular vein, and appeared to be
     extinguished by local pressure. Although readily felt in the
     posterior triangle, it was impalpable on deep pressure in the
     suprasternal notch, a fact which seemed in favour of localising
     the aneurismal varix to the subclavian artery and vein. The
     right pulse was good, although smaller than the left, and was
     said to have improved in volume. The right pupil was slightly
     larger than the left, but reacted normally. There was no pain
     or difficulty in swallowing. Weakness in power of flexion of
     the fingers persisted, and there was some impairment of
     sensation in the area of distribution of the ulnar nerve.

     Three weeks later no material change had occurred, except that
     the swelling was perhaps softer and the thrill more
     superficial, and at the end of two months the patient was sent
     to England.

I saw this patient a year later in Glasgow, when the condition was 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 hæmarthrosis was
     present, also a well-marked thrill and machinery murmur in the
     popliteal vessels with no evidence of a tumour. The leg was
     normal except for slight enlargement of the internal saphenous
     vein and its branches, probably independent of the arterial
     lesion.

     (19) _Femoral._--Wounded at Magersfontein. _Entry_ (Mauser), 7
     inches below left anterior superior iliac spine. _Exit_, at
     inner aspect of thigh. One month later slight fulness without
     pulsation was discovered on the inner side of the femoral
     vessels just above the level of the wound track. Some
     blood-staining still remained in the fold between the scrotum
     and thigh. Machinery murmur and a well-marked thrill, most
     palpable to the inner side of the superficial femoral artery,
     were noted. No further symptoms developed and the patient was
     sent home.

_Prognosis and treatment._--No one can help being struck with 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 hæmorrhage 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
hæmorrhage 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 hæmatomata._--(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
herniæ 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 × 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 × 3-1/2 in.). The measurements were taken eight days after
infliction of the wounds. The right limb was amputated later for
secondary hæmorrhage]

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 hæmorrhage, 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 hæmarthrosis 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 anæmia, and
emaciation, were marked. Pyæmia, 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 septicæmia, or from a combination of
this with secondary hæmorrhage.

_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 anæsthetise 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 hæmorrhage. 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 fossæ. 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 anæsthetic 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 fæces.

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 hæmarthrosis 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 anæsthetic
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 hæmorrhage is
not proceeding, developments should be awaited before proceeding to
amputation. In the case of bone fragment punctures, secondary hæmorrhage
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
hæmorrhage, 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 hæmorrhage followed as a
rule, and often death.

Intermediate amputations were indicated in cases of septic infection and
those of hæmorrhage; they seldom did well, and should be avoided if
possible. Secondary amputations for sepsis or hæmorrhage 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 hæmarthrosis. 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 hæmarthrosis. 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
hæmorrhage, as was the case generally, usually ceased spontaneously. The
importance of injury to the vessels was rather in view of secondary
hæmorrhage, 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 hæmorrhage, 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 hæmorrhage, 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 hæmorrhage 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 hæmophilic 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 hæmorrhage a few days
     later, combined with the degree of septic infection, ended the
     man's life. On examination of the joint, a groove forming
     three-fourths of a tunnel was found in the external tuberosity
     of the tibia, leading into the knee-joint beneath the external
     semilunar cartilage. The bullet had then passed upwards over
     the outer border of the cartilage, bruised the margin of the
     external condyle of the femur in such a manner as to depress
     the outer compact layer, and finally escaped from the joint
     near the upper reflection of the synovial membrane. The
     synovial membrane was granular in appearance and reddened, but
     there was no suppuration outside the confines of the joint,
     except in a cavity corresponding to 2 inches of the track
     before it actually perforated the tibia. A localised abscess
     had evidently formed here and been diffused into the joint by
     the movement of flexion already described.

     (44) A man wounded during General Hamilton's advance on
     Heilbron was struck on the outer aspect of the heel. An oval
     opening of some size led down to a track in the os calcis; the
     bullet was retained. The foot was dressed, and put up later in
     a plaster-of-Paris splint. On the tenth day the splint was
     removed to see to the wound, which looked satisfactory and was
     re-dressed.

     A few hours later the man was seized with very severe pain in
     the ankle, and a day later I was asked to see him by Mr.
     Alexander. The man was anæsthetised, and I examined the wound
     with care, and also removed the retained bullet from the inner
     margin of the leg. The bullet was reversed, having no doubt
     suffered ricochet, hence the large aperture of entry, but it
     was in no way deformed. I could not certainly determine the
     presence of any fluid in the ankle-joint, and as the pain was
     apparently localised to the distribution of the
     musculo-cutaneous nerve, I decided not to freely open the
     joint. In this, however, I erred, and two days later, after
     consultation, the joint was freely incised by Mr. Alexander. It
     was then found that the bullet in its passage had just touched
     the posterior aspect of the tibia and wounded the ankle-joint.
     A localised collection of pus which had formed in the deep part
     of the wound had been diffused into the joint by the movements
     made when the splint was removed, in a similar manner to that
     described in the last case. This joint also did badly, and an
     amputation of the leg had to be performed by Mr. Alexander to
     save the man's life.

These two cases are particularly instructive as showing, first, 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 septicæmic 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 hæmarthrosis 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 patellæ 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 hæmorrhage 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° F., and the man seemed somewhat
     heavy and dull. The patient was examined by Major Fiaschi and
     Mr. Watson Cheyne, and it was decided to explore the wound. Mr.
     Cheyne removed fragments both of external and internal tables,
     one of the latter having made a punctiform opening, not
     admitting the finest probe, in the dura-mater. The bullet was
     traced into the nasal fossæ, where it was subsequently
     localised with the aid of the Roentgen rays when the patient
     came under my observation at Wynberg some days later (fig. 60).

_Gunshot fracture of the skull with concurrent brain injury._--This 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
_débris_ 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 _débris_ 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 hæmorrhages 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 hæmorrhages 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 fæces had been passed involuntarily.

     The wound was cleansed and bone fragments removed. The patient
     had to travel in a wagon for the next three days until the
     column halted. The progress of the case was unsatisfactory, as
     the wound became infected, and the man eventually died on the
     14th day of general septicæmia, but with little evidence of
     local extension of septic inflammation.

     In this instance the head was no doubt struck by a bullet which
     had previously made ricochet contact with the ground. I saw
     several such cases.

Closely connected with such injuries are those in which large 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 anæsthesia over the area supplied by the outer branch
     of the supra-orbital nerve, extending from the supra-orbital
     notch backwards into the parietal region, but none over the
     area supplied by the second division of the fifth nerve.

     On the tenth day there were no signs of cerebral disturbance
     except a pulse of 48. The eyeball was suppurating, and the
     temperature rose to 99° at night. The lids were still swollen
     and closed.

     A few days later the eyeball was removed and at the same time a
     flap was raised and the fracture explored (Major Burton,
     R.A.M.C.). An opening somewhat angular, 1/3 of an inch in
     diameter, was found with a thin margin in the outer table of
     the skull (fig. 62); when this was enlarged with a Hoffman's
     forceps, an opening in the dura was discovered, and
     cerebro-spinal fluid escaped. A piece of the inner table of the
     skull (fig. 63), 3/4 by 1/3 an inch in size, was discovered
     projecting downwards vertically into the brain. This latter was
     removed and the wound closed. Healing by primary union
     followed, and no further symptoms were observed.

     [Illustration: FIG. 63.--Fragment of Inner Table depending
     vertically from lower margin of puncture shown in fig. 62. The
     centre was perforated. Exact size]

     (51) _Transverse frontal wound._--Wounded at Paardeberg. The
     man was sitting down at the time he was struck, in the belief
     that he was out of the range of fire. The _entry_ and _exit_
     wounds were almost symmetrical, placed on the two sides of the
     forehead at the margin of the hairy scalp, 2-1/4 inches above
     the level of the external angular processes of the frontal
     bone. The patient lost consciousness for about half an hour,
     then rose and walked half a mile to the Field hospital. The
     wounds were dressed, and after a stay of three days in
     hospital, the man was sent the three days' journey to Modder
     River; during the journey he got in and out of the wagon when
     he wished. After two days' stay at Modder, a journey was again
     made by rail to De Aar (122-1/2 miles). The wounds were healed.
     The man stayed at De Aar nearly a month, and then, rejoining
     his regiment, made a two days' march of some 22 miles on hot
     days. He had to fall out twice on the way by reason of
     headache, feeling dizzy, and 'things looking black.' He did not
     own to any loss of memory or intellectual trouble, but was
     invalided to England. This patient returned to South Africa
     later, and is now on active service.

     (52) _Transverse frontal wound._--Within a few days an almost
     identical symmetrical wound in the frontal region occurred in
     the same district, from a near range. The patient became
     immediately unconscious, and remained so until his death some
     four days later, his symptoms being in no way alleviated by
     operation and the removal of a quantity of bone fragments and
     cerebral _débris_. At the _post-mortem_ examination, extensive
     destruction of both hemispheres of the brain was revealed, and
     large fissures extended into the base of the skull.

III. _Glancing or oblique perforating wounds of varying depth in 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 diploë (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
hæmorrhage 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 hæmatoma, beneath which a loose
     fragment of bone was readily palpable. When brought into the
     Field hospital, twenty-four hours after the injury, the man
     appeared to understand when spoken to, but made no answers to
     questions. The urine was passed unconsciously, the bowels were
     confined.

     He was drowsy, the pupils widely dilated, the pulse 68, of good
     strength, and the temperature 104°. He slept well the following
     night and midday there was little change, except that the
     pupils acted to light, and the pulse had risen to 88, becoming
     dicrotic and small. The temperature was 103°, the tongue furred
     and dry, but he was lying with the mouth wide open.

     At 2 P.M. the wound was explored. The entry led down to a
     typical gutter fracture in the squamous portion of the temporal
     bone, at the point of junction of the vertical with the
     horizontal part; the floor of the gutter had been displaced
     inwards as a single fragment (fig. 70). A flap was raised in
     the frontal region, where a scale of outer table (fig. 71),
     clothed with diploic tissue, was found loose. Beneath this a
     puncture on the frontal bone, about corresponding in size to
     the bullet, was discovered. This opening was enlarged, and a
     bullet detected and removed. The bullet was a Guedes, with no
     marks of rifling, and was in no way deformed. At least a square
     inch of the right frontal lobe was pulped, so that the bullet
     lay in a cavity.

     The patient improved somewhat during the next two days, and on
     the third took a 16 hours' journey to Bloemfontein, where Mr.
     Bowlby (who was present at the operation) kindly took him into
     the Portland Hospital. The pulse gradually rose to 112, the
     temperature remained on an average from 102° to 103°, the
     respiration rose to 36, the face became somewhat livid, and on
     the sixth day death occurred rather suddenly, apparently from
     respiratory failure. For two days before his death the patient
     sometimes asked for food, &c.; there was occasional twitching
     of the left angle of the mouth, and, when the posterior wound
     was manipulated, some twitching of the fingers of the left
     hand. When the wound was dressed on the fourth day, there were
     breaking-down blood-clot and signs of incipient suppuration.

     Mr. Bowlby made a _post-mortem_ examination, and found
     considerable pulping of the tip of the right frontal and left
     temporo-sphenoidal lobes, and a thick layer of hæmorrhage
     extending over the whole base of the brain.

[Illustration: FIG. 71.--Scale of outer table of Frontal Bone and
Diploë. 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. Hæmorrhage 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 hæmorrhage, 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 hæmorrhage, 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 hæmorrhage,
as compression is more readily developed.

The degree of injury to the brain depended on the depth of the track,
the resistance offered by the bones of any individual skull, the 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 hæmorrhages more or less broke up the structure of the
brain, such hæmorrhages 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 fossæ 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 débris, 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 hæmorrhage, 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, hæmorrhage 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 hæmorrhages 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 hæmorrhage; 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 hæmorrhage 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° or 100°, and
if the patient survived a day or two, it often rose to 103° or 104°. 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 hæmorrhage, 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 hæmorrhage, 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
hæmorrhage, 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°. 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 diploë
     and a crown of bone removed; considerable comminution of the
     inner table had occurred, several large fragments having
     perforated the dura-mater. The latter did not pulsate; it was
     therefore freely incised, and many more fragments of bone and a
     large quantity of blood-clot removed.

     The first effect of the operation was slight, but ten days
     later rapid improvement commenced, the first sign being
     acceleration of the pulse, which rose to 70. On the eighteenth
     day the original symptoms still remained to a diminished
     extent, but a fortnight later there remained traces of the
     facial weakness only, and there was little difference in the
     grip of the two hands. The patient was shortly afterwards sent
     home. Ten months later he returned to South Africa on active
     service.

     (61) _Fronto-parietal gutter fracture._--Wounded at Graspan.
     _Entry_ (Mauser), 1 inch within the margin of the hairy scalp,
     1/2 an inch to the left of the median line; _exit_, 3-1/2
     inches posterior in same line. Complete right-sided hemiplegia.
     The wounds were explored on the fourth day (Major Moffatt,
     R.A.M.C.) and a gutter fracture involving the frontal and
     parietal bones exposed. The dura-mater was lacerated and brain
     matter from the frontal lobe escaped freely. A large number of
     bone fragments were removed. On the fourth day after the
     operation, the patient became unconscious with right-sided
     twitchings, but rapidly improved, and at the end of three
     weeks, except for slight headache, he was well, the power of
     the right side being good. Ten months later he rejoined his
     regiment in South Africa, no apparent ill effects remaining.

     (62) _Fronto-parietal perforating fracture._--Wounded at
     Magersfontein. _Entry_, within the margin of the hairy scalp;
     _exit_, behind and below the left parietal eminence, the track
     crossing about the centre of the fissure of Rolando. Right
     hemiplegia, the lower half of the face only being involved. The
     wounds were explored and a large number of fragments of bone
     and a quantity of pulped cerebral matter removed. Six days
     later the hemiplegia persisted, speech was slow, headache was
     troublesome and the pulse not above 45. After this, gradual
     improvement took place, and a month later the lower extremity
     and face had regained good power. The upper extremity remained
     flaccid and paralysed, except for some slight power of movement
     of the shoulder.

     (63) _Fronto-parietal perforating fracture._--Wounded at
     Magersfontein. _Entry_ (Mauser), 2-1/2 inches from the median
     line, 3-1/2 inches from the occipital protuberance; _exit_, 3/4
     of an inch from the median line, 4-1/2 inches from the
     glabella; sanious fluid escaped from both ears. There was left
     facial paralysis, complete paralysis of the left upper
     extremity, and partial paralysis of the left lower extremity.
     The patient was deaf, drowsy, and the pulse 45.

     Exploration showed the entry wound to be in the parietal, the
     exit to involve both parietal and frontal bones. The openings
     were enlarged, and a number of fragments of bone, together with
     pulped cerebral matter and blood-clot, were removed. The wound
     healed, except at the front part, where a small prominence
     suggested a hernia cerebri.

     The patient improved slowly; fourteen days after the operation
     he could hear well, and the flow from the ears had ceased. The
     facial weakness was slight, the upper extremity was still
     powerless, but he could move the lower and draw it up in bed.
     At the end of six weeks the wound had healed, and he was got up
     and dressed.

     At the end of two months he was well enough to be sent home;
     there was only a trace of facial weakness; the right upper
     extremity, however, was powerless and slightly rigid,
     occasional twitchings occurring in it. Considerable power had
     been regained in the lower extremity, so that the patient could
     walk with help, but foot-drop persisted; the gait was spastic
     in character, the reflexes were much exaggerated, and there was
     marked clonus. The patient was sensible, but his manner
     suggested some mental weakness. Both the openings in the skull
     were closed by very firm material, apparently bony.

     This patient became a Commissionaire some ten months later. His
     mental condition is normal, and loss of memory seems confined
     to the events immediately following the injury. The lower
     extremity has improved, but the upper is useless.

     (64) _Parietal injury: retained bullet._--Wounded at
     Paardeberg. Aperture of _entry_ (Mauser), 1 inch diagonally
     below and anterior to left parietal eminence. No exit. The
     patient was trephined by the surgeons of the German ambulance
     at Jacobsdal.

     Sixteen days later he arrived at the Base. A circular pulsating
     trephine opening was then to be felt beneath the flap, but no
     information was forthcoming as to the bullet. The patient
     could speak, but lost words and the gist of sentences; he
     could remember nothing as to himself since the day of the
     injury. There was right facial weakness; he could not close the
     right eye or whistle, but there was little apparent want of
     symmetry; there was weakness in the grip of both hands, more
     marked on the right side; both lower extremities could be
     moved. The reflexes were normal, although the left limb was
     slightly rigid. The pupils were equal, reflex normal; slight
     nystagmus. Pulse 72, small and regular. Temperature normal.
     Rapid improvement followed.

     During the fourth week the temperature rose to 103°, and
     remained elevated for six days, but no local or general signs
     appeared; at the end of five weeks there was little evidence of
     the paralysis remaining. The patient was discharged from the
     service on his return home.

In the upper part of the occipital region glancing or 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°. Pulse 56 full. Tongue
     clean. No sickness, no difficulty in micturition.

     Fifty-six hours after the injury the wound was opened up and
     cleaned, and an oval fractured opening about 3/4 by 1/2 inch
     was exposed 3/4 inch to the left, and 2 inches above the
     occipital protuberance. The margins of the opening showed
     several small fragments of lead attached to the bone. A
     3/4-inch trephine was applied at the left extremity of the
     opening, and it was found that about a square inch of the
     internal table was comminuted and driven into the brain,
     together with several small fragments of lead. On introducing
     the finger, about 1-1/2 square inches of the occipital lobe
     were found to be pulped, and the finger could be swept across
     the tentorium. There was no sinus hæmorrhage (nor did the
     history suggest that hæmorrhage had ever been severe). The
     cavity was carefully sponged out, and the wound closed with a
     drainage aperture. Little change followed in the patient's
     condition, and on the sixth day he was sent to the Base
     hospital.

     Three weeks later the wound was firmly healed. The patient
     still complained of frontal headache, and wore a shade, as the
     light hurt his eyes and made them water freely. The pupils
     acted, but were wide; objects could be distinguished, and also
     persons. Otherwise, the man's condition was good: he began to
     get up, and at the end of six weeks returned to England.

     A year later the man was earning his living as a Commissionaire
     porter. He complains of giddiness when he stoops, or when he
     looks upwards, and at times he suffers much with headache both
     in the region of the injury and across the temples.

     There is a bony defect and slight pulsation at the site of the
     injury, but no prominence. When attempts are made to read the
     lines run together, and a dark shadow comes before his eyes. He
     speaks of the latter as still terribly weak. Speech is slow and
     somewhat simple, but he makes no mistakes as to words. Memory
     is bad for recent events.

     Mr. Fisher makes the following report as to the eyes: Pupils
     and movement of eyes normal in every respect. No changes in
     fundi.

          Vision, R. 5/12 with--0.5   5/6
                  L. 5/9  with--0.5   5/5

[Illustration: FIG. 73.--Right Visual Field, in case 65. Injury to 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
     hæmorrhage.

     After the operation the patient slept better, but still
     complained of headache, and when he arrived at the Base, the
     flap became oedematous, and the stitch holes and also the
     central part of the wound suppurated. The temperature rose to
     101°. The wound was therefore re-opened, and a number of
     additional fragments of bone, some as deeply situated as 2
     inches from the surface, were removed. Steady improvement
     followed, and at the end of a further three weeks the wound was
     healed, the headache had ceased, and there were no abnormal
     symptoms, except that light was unpleasant to the right eye,
     and the field of vision was manifestly contracted (Mr. Pooley).

     A year later the man was employed as a letter-carrier. He
     complains of headache at times, and on six occasions has had
     'fainting fits.' He says that the latter commence with tremor,
     that his legs then give way and he falls. In a quarter of an
     hour he gets up, and feels no further inconvenience. Speech is
     perfect, there is no deafness. The bone defect is very nearly
     completely closed.

     Mr. Fisher reports as follows as to the vision. There is a high
     degree of hypermetropia in each eye, the R. has nearly 6.0 D
     and the L. about 5.0 D. With correction he gets practically
     full direct vision with each.

[Illustration: FIG. 75.--Right Visual Field, in case 66. Injury to 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 hæmorrhage had occurred from each wound, the scalp
     was puffy, and the bones yielded on pressure over the left
     parietal bone, indicating considerable comminution.

     The night was so cold that no operation could be considered, so
     the head was partly shaved, the wounds cleansed, and a dressing
     applied. The next morning the Division marched at 5 A.M., and
     it was considered wise to leave the man at Lindley in the local
     hospital.

[Illustration: FIG. 77.--Right Visual Field, in case 67. Injury to 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 vertebræ, one third of
     the bodies of each of which were driven into an extensive
     laceration of the lung; it then grooved the inner surfaces of
     the eighth and ninth ribs, fractured the tenth and eleventh,
     and passing the twelfth traversed the deep muscles of the back
     to the pelvis. Beyond the injury to the occipital lobe, the
     cerebellum was found to be lacerated and extensively bruised
     and ecchymosed.

_Complications._--_Hernia cerebri_ as a primary feature has already 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 herniæ 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
hæmorrhage, 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° 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 herniæ
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 hæmorrhages, were far more often the cause of the
paralysis than surface hæmorrhage, 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 hæmorrhage (Mr. Jameson) some three weeks later.

     Vision was affected at the time of the accident; the fingers
     could be seen, but not counted. After ligation of the carotid
     the condition was possibly worse, and this needs mention as
     transitory loss of power in the left upper extremity also
     followed the operation.

Fractures of the bony wall were of every degree. The most severe that 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 hæmorrhage 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 anæsthesia was common. This was
often transitory when the result of vibratory concussion, contusion, or
pressure from hæmorrhage. 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
hæmorrhages from choroidal ruptures of a similar nature to those seen in
the brain and spinal cord. The actual hæmorrhagic areæ varied in size;
but, as far as my experience went, gross hæmorrhages 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
hæmorrhage, although this existed, but rather to intravaginal hæmorrhage
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 palpebræ superioris acted very slightly;
     the right, however, better than the left.

     There were marked right proptosis, less left proptosis, and
     slight patchy subconjunctival hæmorrhage of both eyes. The
     pupils were dilated, motionless, and not concentric.

     The patient was invalided as totally blind (November, 1900).

Mr. Lang, who saw this patient on his return to England, kindly
furnishes me with the following note as to the condition. There was
extensive damage to both eyes, hæmorrhage, 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. Anæsthesia in the whole area of
     distribution of the frontal nerve.

     At the end of three weeks, fingers could be recognised, but a
     large blind spot existed in the centre of the field of vision.
     The general movements of the globe were fair, but the upper lid
     could not be raised. The proptosis and subconjunctival
     hæmorrhage cleared up.

     Little further improvement occurred; six months later the
     patient could only count the fingers excentrically. A very
     extensive scotoma was present. The optic disc was much
     atrophied, the calibre of the arteries diminished and the veins
     full (Mr. Critchett). The ptosis persisted. It was doubtful in
     this case whether the ptosis depended on injury to the nerve of
     supply, or on laceration and fixation of the levator palpebræ
     superioris. The latter seemed the more probable, as the
     superior rectus acted. The absence of any sign of gross
     bleeding into the anterior chamber is opposed to the existence
     of a perforating lesion of the globe in this case.

     (78) _Entry_ (Mauser), from cranial cavity, just within the
     centre of the roof of the right orbit; _exit_, from the orbit
     by a notch in the lower orbital margin internal to the
     infra-orbital foramen; track thence beneath the soft parts of
     the face to emerge from the margin of the upper lip near the
     left angle of the mouth. Collapse of globe, proptosis,
     subconjunctival hæmorrhage, oedema and ecchymosis of lids.

     Shrunken ball removed on twenty-fourth day (Major Burton,
     R.A.M.C.).

     (79) _Entry_ (Mauser), at the posterior border of the left
     mastoid process, 3/4 inch above the tip; _exit_, in the inner
     third of the left upper eyelid. Globe excised at end of seven
     days. Facial paralysis and deafness.

     (80) _Entry_ (Mauser), from cranial cavity through centre of
     roof of orbit; _exit_, through maxillary antrum. Total
     blindness. Movements of ball good, no loss of tension.
     Proptosis, subconjunctival hæmorrhage, ecchymosis of eyelids.
     No improvement in sight followed. One month later the globe
     suppurated and was removed. The bullet had divided the optic
     nerve and contused the ball.

_Prognosis and treatment of wounds of the orbit._--Except in those 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 fossæ 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 hæmorrhage 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 hæmorrhage and remarkably
     abundant salivation (I was inclined to think that the latter
     symptom was particularly well marked in gunshot fractures of
     the body of the mandible), and very great swelling of the floor
     of the mouth.

     The patient could not bear any form of apparatus, but was
     assiduous in washing out his mouth, and made a good recovery,
     the fragments being in good apposition.

     (83) _Entry_ (Mauser), over the right malar eminence; the
     bullet carried away all the right upper and lower molars,
     fractured the mandible, and was retained in the neck.

     A fortnight later an abscess formed in the lower part of the
     neck, which was opened (Mr. Pooley), and portions of the mantle
     and leaden core, together with numerous fragments of the teeth,
     were removed. The bullet had undergone fragmentation on impact,
     probably on the last one (teeth of mandible), and still
     retained sufficient force to enter the neck.

This case affords an interesting example of transmission of force 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 septicæmia thirty-six hours later. Death occurred just as
     the Division received marching orders, and no _post-mortem_
     examination was made. As a result of palpation at the time of
     the tracheotomy, the probabilities seemed against the presence
     of the tooth plate in the pharynx, but the absence of positive
     evidence scarcely allows the case to be certainly classed as
     one of cellulitis and septicæmia secondary to wound of the
     tongue.


WOUNDS OF THE NECK

Wounds of the neck were not unfrequent and were of the 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 hæmorrhage 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
     hæmothorax. No damage to neck structures.

     (86) _Entry_ (Mauser), over Pomum Adami; _exit_, below right
     scapular spine. Median and musculo-spiral paralysis.

     (87) _Entry_, a large oval aperture through ninth right rib,
     1/2 an inch external to scapular angle; _exit_, anterior border
     of sterno-mastoid opposite Pomum Adami. Second entry, opposite
     angle of mandible; exit, in centre of cheek.

     Wound of lung. Musculo-spiral paralysis still persisting at the
     end of nine months.

     (88) _Entry_ (Mauser), 2 inches above left clavicle at margin
     of trapezius; _exit_, 1 inch from sternum in left first
     intercostal space. Contusion of brachial plexus, with mixed
     signs, which disappeared in two months. No signs of vascular
     injury.

See also cases of cervical aneurism, &c.

_Wounds of the pharynx._--I saw only three cases of wound of 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 hæmorrhage.

     Infection of the posterior portion of the track from the
     pharynx resulted, and suppuration continued for some weeks: a
     small sequestrum eventually needed to be removed from the tip
     of the transverse process of the atlas.

     (90) _Entry_ (Mauser), through mouth; the bullet pierced the
     soft palate and the posterior wall of the pharynx, and passed
     out between the transverse process of atlas and the occiput. No
     serious pharyngeal symptoms.

     (91) _Entry_ (Mauser), through the mouth, knocking out the left
     upper canine and bicuspid teeth. Perforation of the soft palate
     just to the right of the base of the uvula and the posterior
     wall of the pharynx; _exit_, 1-1/2 inch internal to and 1/2 an
     inch below the tip of the right mastoid process. Hæmorrhage
     persisted for half an hour, and the patient could not swallow
     solids for a week. Great occipital neuralgia followed the
     wound.

_Wounds of the larynx._--I saw only one wound of the larynx (see No. 10,
p. 135). In this instance the thyroid cartilage was wounded on either
side at the level of the Pomum Adami. Transitory hæmorrhage 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 hæmorrhage into the right
     posterior triangle, emphysema at the episternal notch,
     dysphagia, and complete obliteration of the cardiac area of
     dulness. Respiration was rapid (40) and extremely noisy. Pulse
     130, small and weak.

     A tracheotomy was performed (Mr. Stewart), but the patient died
     an hour later. When the operation was performed a considerable
     amount of mucus from the oesophagus was discovered in the
     wound. The bullet had passed obliquely between trachea and
     oesophagus, wounding both tubes.

     (93) _Entry_, at the centre of the margin of the left
     trapezius; _exit_, in mid line of the neck over the trachea.
     Dyspnoea was noted the next morning, which increased during a
     journey in a wagon. On the third day the dyspnoea was more
     troublesome and emphysema began to develop in the neck. A
     tracheotomy was performed (Mr. Hunter), and the tube was kept
     in for four days. No further trouble was experienced, and the
     wound shortly closed, and the patient, a surgeon, returned to
     his duties. Temporary signs of median nerve concussion and
     contusion were noted.



CHAPTER VIII

INJURIES TO THE VERTEBRAL COLUMN AND SPINAL CORD


Every degree of local injury to the constituent vertebræ and 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 hyperæsthesia, due to implication of the issuing nerves, to
symptoms of spinal hæmorrhage, such as are portrayed in the following:--

     (94) A private in the Black Watch was wounded at Magersfontein
     from within a distance of 1,000 yards. Among other wounds, one
     track entered 1 inch to the right of the second lumbar spinous
     process, and emerged 1 inch internal to the right anterior
     superior iliac spine. There were signs of wound of the kidney,
     and in addition, retention of urine, incontinence of fæces,
     complete motor and sensory paralysis of the right lower
     extremity, and total absence of all reflexes. Anæsthesia
     existed over the whole area of skin supplied by the nerves of
     the sacral plexus, hyperæsthesia over that supplied by the
     lumbar nerves.

     On the tenth day subsequent to the injury, the hyperæsthesia in
     the area of lumbar supply was replaced by normal sensation,
     motor power began to be slowly regained in the muscles supplied
     by the anterior crural and obturator nerves, and the patellar
     reflex returned. At this time lowered sensation returned in the
     area supplied by the sacral plexus, but no improvement in motor
     power took place, and no control was regained over the bladder
     and rectum.

     During the succeeding week some sciatic hyperæsthesia
     developed, but on the twenty-eighth day the patient developed
     secondary peritonitis from other causes and died on the
     thirty-first. A fracture of the transverse process existed, but
     unfortunately the spinal canal was not opened for examination
     and no details can be given as to the condition of the cord.
     (See case 201, p. 463.)

Fractures of the _spinous processes_, or those involving both the
process and laminæ, were not uncommon. Isolated separation of the
spinous process was usually the result of wounds crossing the back
obliquely or transversely. Examples of this injury were numerous,
especially in the dorsal region, as being the most prominent,
particularly when the patients assumed the prone position when advancing
on the enemy.

Cervical injuries, owing to the comparatively sheltered position of the
more deeply sunk spines, and from the fact that the head was usually
under cover of a stone or ant-heap, were less common; in one instance
hyperæsthesia was noted in one upper extremity as the result of a
crossing bullet having struck the fourth cervical spine. In a man
wounded at Paardeberg Drift the bullet entered at the centre of the
buttock, traversed the bones of the pelvis, and, leaving that cavity
above the crest of the ilium, crossed the spine to emerge in the
opposite loin. Suppuration occurred, and when the wound was laid open
the third and fourth lumbar spinous processes were found to be loosened,
but still connected to the surrounding soft parts. There were no nerve
symptoms in this case; these would not have been expected, since by the
time that the bullet had traversed the bones of the pelvis its velocity
must have been considerably lessened, even if high at the moment of
primary impact. In another case a dorsal spine, together with its
lamina, was separated and moveable; the only nerve symptoms were slight
pain and a crop of herpes on the line of distribution of the
corresponding intercostal nerve, the bullet having probably struck the
nerve in passing across the intercostal space. In one instance of a
retained bullet lying beneath the skin of the back, its passage between
two contiguous dorsal spines without fracture of either was determined
during an extraction operation.

When the prone position was assumed by the men, more or less
longitudinal wounds in the course of the spine were naturally liable to
occur. These tracks assumed somewhat greater importance than the
transverse ones, because the injury to bone was more often multiple, and
the laminæ were frequently implicated. The relative importance of such
injuries was dependent on the velocity of the bullet and the depth at
which it travelled. As an instance of a more serious character the
following may be given:--

     (95) In a Highlander wounded at Magersfontein, probably at a
     range within 1,000 yards, the bullet entered at the right side
     of the sixth cervical vertebra; tracking downwards, it loosened
     the laminæ of the fifth and sixth dorsal vertebræ from the
     pedicles, and separated the tip of the seventh spine. The
     bullet was extracted from beneath the skin at the latter spot,
     its force having been no doubt exhausted by the resistance of
     the firm neural arches supported by the weight of the man's
     body. Symptoms of total transverse lesion of the cord followed,
     and the patient died at the end of fifty-four days. The bone
     had not apparently been sufficiently depressed to exert
     continuous pressure, but the cord was diffluent and actually
     destroyed over an area corresponding with the fourth, fifth,
     sixth, and seventh dorsal segments.

I saw no instance of wound of the _neural arch_ from a direct shot in
the back in any of our men, neither was I ever able to detect an injury
to the articular processes as a localised lesion.

Injuries to the _centra_ were very frequent, but differed
extraordinarily in their importance. Perforation by bullets travelling
at a relatively low grade of velocity, but still one sufficient to allow
them to pass through the body, produced in many instances no symptoms
whatever when the track did not lie in immediate contiguity to the
spinal canal or perforate it.

In all the wounds which I had the opportunity of examining post mortem,
the fracture was of the nature of a pure perforation of the cancellous
tissue of the centrum, with no comminution beyond slight splintering of
the compact tissue at the aperture of exit. In one instance the bullet
passed in a coronal direction so close to the back of the centrum as to
leave a septum of only the thickness of stout paper between the track
and the spinal canal. In this case signs of total transverse lesion were
present. I never happened to meet with a case in which the canal was
encroached upon from the front by displaced bone. In some cases at the
end of six weeks there was difficulty in determining the position of the
openings, and section of the bone was necessary in order to assure
oneself as to the direction of the track.

In some instances the centra were pierced in the coronal direction with
varying degrees of obliquity; in others the direction was more sagittal;
in two of the latter the bullet was retained in the spinal canal. The
tracks were sometimes confined to one vertebra, but often implicated
two. In others the bullet passed longitudinally through the thorax,
grooving or perforating one or more centra.

The accompanying evidences of nerve injury varied from nil to those of
pressure or irritation of the nerve roots, transient signs of spinal
concussion, signs of contusion and hæmorrhage, or to evidence of total
transverse lesion. Instances of all these conditions will be quoted
under the heading of injuries to the cord or nerves.

_Signs of injury to the vertebræ._--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 laminæ 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 VERTEBRÆ

_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 hæmorrhages 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
hæmorrhage sometimes still persisted.

_Hæmorrhage._--This occurred as surface extravasation and in the form of
parenchymatous hæmorrhages. 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 hæmorrhage 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 hæmorrhage 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) hæmorrhage 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 hæmorrhage_ (_hæmato-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
hæmorrhages of various sizes and extending for a longitudinal area of
some three inches.

As to the frequency with which hæmorrhage 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 hæmorrhage.

Hæmorrhages 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 hæmatomyelia 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 hyperæsthesia or pain,
pointing to a combination with the least extensive degrees of
hæmorrhage; 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 hæmorrhage._--The symptoms of this condition developed
differently according to whether concurrent concussion existed.
Occasionally very typical instances of pure hæmorrhage 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 fæces, but the latter unaccompanied by
     the marked abdominal intestinal distension so characteristic in
     cases of total transverse lesion. The right side of the chest
     continued to work well, but the intercostals of the left side
     were paralysed. No disturbance of the normal action or
     condition of the pupils was noted. After the first few days the
     condition began to improve.

     Three weeks later, the chest was moving symmetrically and well,
     sensation and motor power had returned in considerable degree
     in the left lower extremity, with marked increase in both the
     plantar and patellar reflexes; sensation had returned in both
     upper extremities, a slight amount of motor power was regained
     in the right, but the left remained entirely flaccid and
     incapable of movement.

     At the end of a month power was regained over both bladder and
     rectum, some slight movement of the left thumb was possible,
     and a certain degree of hyperæsthesia developed over the back
     of the forearm.

     At the end of six weeks there was little further alteration,
     but that in the direction of improvement. There was some
     wasting of the muscles of the left upper extremity, and this
     was most marked in the muscles supplied by the ulnar nerve.

     At the end of ten weeks the patient had been up some days; he
     could stand and walk, but was unable to rise from the sitting
     posture without help. The plantar and patellar reflexes were
     much exaggerated, and there was ankle clonus, most marked in
     the left limb. The right upper extremity was normal, but weak;
     there was wrist-drop on the left side and the deltoid was
     wasted and powerless; on the other hand the fingers could be
     flexed, and although the elbow could not be, there were signs
     of returning power in the biceps, and some movements of the
     shoulder could be performed by the capsular muscles. It was
     remarkable that common sensation was more acute in the left
     than the right lower extremity, but I attributed this to the
     remains of hyperæsthesia on the left side. The patient left for
     home shortly after the last note.

In both these cases the absence of marked hyperæsthesia or pain points
to medullary hæmorrhage (hæmato-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 hyperæsthesia and pain
indicated a combination of pressure and irritation of the nerve roots by
surface hæmorrhage on the affected side. In case 97 the persistence for
four weeks of paralysis of the bladder and rectum suggested medullary
hæmorrhage 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 hæmorrhage. 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 hæmorrhages.
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° or at times to
     102°; for this no definite cause was discovered. In the tenth
     week the condition was as follows: The temperature has become
     normal. The patient has lost flesh to a considerable extent
     since the reception of the injury. The lower extremities are
     much wasted, especially the peroneal muscles. Patellar reflexes
     can be obtained, but the knee jerks are uncertain. Unevenly
     distributed paralysis exists in both lower extremities.
     Left--Sensation fairly good throughout. Quadriceps very weak;
     does not react to electrical stimulation. Calf muscles act
     fairly. Anterior tibial and musculo-cutaneous groups are
     paralysed. Right--Quadriceps acts better than on left, muscles
     below the knee paralysed, and in the same area there is
     complete absence of sensation. The patient complains of
     shooting pains in both legs, and there is some deep muscular
     tenderness.

     Three weeks later an abundant crop of vesicles appeared over
     the front of the right thigh and leg, above and below the knee.
     Sensation in the limb at the same time returned to a
     considerable degree, anæsthesia persisting on the outer aspect
     of the thigh only.

     At the end of four months very considerable improvement had
     taken place, but there was no return of motor power in the
     right leg, or the muscles supplied by the peroneal nerve in the
     left leg. There was some general oedema of the legs,
     especially of the right, possibly in connection with the
     herpetic eruption which was now disappearing. Muscular
     tenderness had disappeared. There was also definite improvement
     in the size and tone of the peroneal muscles, although no motor
     power was regained.

     At the end of five months, slight gradual improvement was still
     taking place, but the loss of power was nearly as extensive as
     when the last note was taken. The skin of the right leg was
     glossy, that of the left apparently normal. At times some
     hyperæsthesia of the soles was noted, and the plantar reflex
     was very brisk.

     The right anterior tibial and musculo-cutaneous groups of
     muscles reacted to the strongest faradic current, not to any
     galvanic current below 20-25 m.a., contraction very sluggish.
     The same muscles in the left leg also reacted to the strongest
     faradic current, but only locally, with no sort of effect on
     the tendons. Similar contractions could be induced in the right
     quadriceps, but none in the left (Dr. Turney).

     Appreciation of heat and cold applied to the skin was fair,
     but, in the case of heat, distinctly slow in the right leg and
     foot.

     At the end of seven months improvement was still taking place;
     the patient could now stand, walk a little with crutches, and
     even ascend and descend a staircase.

       *       *       *       *       *

     _Severe concussion, contusion, or medullary hæmorrhage
     producing signs of total transverse lesion, and complete
     transverse section._--The symptoms of these conditions will be
     taken together, because, with very slight variations, they may
     be considered as lesions of equal degree as to severity, bad
     prognosis, and unsuitability for active interference.

     All were characterised by the exhibition of the same essential
     phenomena, symmetrical abolition of sensation and motor power
     on either side of the body, absence of any signs of irritation
     in the paralysed area, and loss of patellar reflex. In a small
     number of the cases of medullary hæmorrhage some return of
     sensation was observed prior to death; in a still smaller,
     traces of motor power, and in one or two irritability of the
     muscles or feeble reflexes pointed to the fact that destruction
     of the cord was not absolute. As abstracts of a series of cases
     are appended on page 330, it is only necessary to add a few
     remarks as to any slight peculiarities which seemed directly
     dependent on the mode of causation.

     It may be first stated that these severe injuries were
     accompanied by signs of a very high degree of shock. In fact,
     the shock observed in them was more severe than in any other
     small-calibre bullet injuries that I witnessed. The patients
     lay still with the eyes closed, great pallor of surface,
     sometimes moaning with pain, the sensorium much benumbed, or
     occasionally early delirium was noted. The pulse was small,
     often slow and irregular, and the respiration shallow. The
     originally quiet state was often changed to one of great
     restlessness of the unparalysed part of the body, with the
     appearance of reaction.

     The degree of primary pain varied greatly, but as a rule it was
     considerable; in some cases it was excruciating in the parts
     above the level of the totally destructive lesion, and commonly
     of the zonal variety. A hyperæsthetic zone at the lower limit
     of sensation usually existed.

     In the majority of the cases pain must have depended on
     meningeal hæmorrhage. In one of the cases related, positive
     evidence was offered as to this particular by the autopsy,
     although this was made as long as six weeks after the original
     injury, since no other source of pressure or irritation was
     discovered. When I first saw this patient some twenty-four
     hours after the injury he was moaning with pain, although a
     strong and plucky man; I hastened to give him an injection of
     morphia, and assured him that it would relieve his suffering:
     as I left I heard him say to his neighbour: 'That is no use;
     they gave me three last night, and I was no better,' and his
     remark proved true.

     In high dorsal and cervical injuries the temperature rose high,
     in one case to 108° F.; I had no opportunity, however, of
     observing the temperature in any case immediately before and
     after death. During the hot weather the profuse sweating of the
     upper part of the body contrasted very strongly with the dry
     skin of the paralysed part.

     The heart's action was often particularly irregular in the
     dorsal injuries, and the respiration slow and irregular; as
     these cases, however, were often complicated by severe
     concurrent injuries to internal organs, the irregularities
     could hardly be ascribed to the spinal-cord lesion alone. In
     cases of pure diaphragmatic respiration, the rate did not as a
     rule exceed the normal of 16 or 20 to the minute, and it was
     quite regular; this was noted soon after the injury and
     persisted throughout the course of the cases. As is usually the
     case, both respiration and the heart's action were most
     embarrassed in the cases in which abdominal distension was a
     prominent feature. In some of the neck cases the Cheyne-Stokes
     type of respiration was very strongly marked.

     In cases of low dorsal injury intestinal distension was
     extreme, and I think more troublesome than the same condition
     as seen in civil practice. The distension was accompanied by
     most persistent vomiting, continuing for days, and in the cases
     that lived for some time severe gastric crises of the same type
     occurred in some instances.

     Priapism was a common symptom; but, as is seen from the cases
     quoted, was rarely due to any gross direct laceration of the
     cord.

     Trophic sores were both early to develop, and extensive;
     primary decubitus occurred in all the cases I saw, and steady
     extension followed. In one case a remarkable symmetrical
     serpiginous ulceration developed in the area of distribution of
     the cutaneous branches of the external popliteal nerve on the
     outer side of the leg.

     The paralysis in nearly every case was of the utterly flaccid
     type, and wasting of the muscles was early and extreme. This
     was occasionally accentuated by the supervention of myelitis.

     Opportunities for making observations on the quantity of urine
     secreted were not great, and I can offer no remark as to the
     occurrence of polyuria. In one rapidly fatal case, however,
     suppression of urine occurred.

     (99) _Lumbar region. Transverse lesion._--Range under 1,000
     yards. Wound of _entry_ (Mauser), over the seventh rib 1 inch
     from the left posterior axillary fold; _exit_, over the centre
     of the right iliac crest. Complete symmetrical motor and
     sensory paralysis of lower extremities, entire abolition of
     reflexes, retention of urine.

     On the ninth day there was some return of sensation in the
     lower extremities, and a cremasteric reflex was to be obtained.
     A large bedsore had developed over the sacrum. No further
     change occurred in the lower extremities. The patient became
     progressively emaciated and exhausted, cystitis persisted, the
     bedsore deepened. The man eventually developed signs of a large
     basal abscess in the left lung, and died on the forty-second
     day.

     At the _post-mortem_ a fracture of the first lumbar lamina was
     discovered, with some splintering of the bone; the lumbar
     spinous process was attached and in its normal position.
     Opposite the centre of the cauda equina were the remains of a
     considerable hæmorrhage, both extra- and intra-dural, the
     nerves appearing somewhat compressed, but of normal
     consistency. The muscles of the back were infiltrated with
     putrid pus on both sides. A pulmonary abscess cavity the size
     of a hen's egg occupied the upper part of the lower lobe of the
     left lung. The kidneys were congested, and the bladder
     thickened and chronically inflamed.

     (100) _Cervico-dorsal region. Total transverse lesion._--Wound
     of _entry_ (Mauser), to the right of the sixth cervical
     vertebra: the bullet was removed on the field from the left of
     the seventh dorsal spinous process, which was somewhat
     prominent. Complete motor and sensory paralysis extended
     upwards to the third intercostal space; the breathing was
     almost entirely diaphragmatic. Retention of urine. Entire
     abolition of reflexes in lower limbs and trunk. Hyperæsthesia
     was present in both upper extremities, with a zone of
     hyperæsthesia around the chest. The patient suffered greatly
     for some weeks from pain in the hyperæsthetic area, he
     developed severe cystitis and later incontinence of urine. A
     large trophic sacral bed-sore steadily increased in depth and
     size.

     About ten days before death, which occurred on the fifty-third
     day from exhaustion and septicæmia, the patient complained of
     pains in his legs; but there was no return of sensation,
     motion, or reflexes.

     At the _post-mortem_, the seventh dorsal spinous process was
     found to be loose and the laminæ of the fifth, sixth, and
     seventh vertebræ were separated from the pedicles, and somewhat
     depressed on the left side. These laminæ were adherent to the
     dura, as were also a few small separated bony spiculæ. There
     was no sign of old hæmorrhage. The spinal cord was practically
     gone between the levels of the fourth and seventh dorsal
     vertebræ, and diffluent from myelitis up to the third cervical.

     (101) _Dorsal region; total transverse lesion._--Wound of
     _entry_ (Mauser), in the left supra-spinous fossa of the
     scapula; _exit_, between the eleventh and twelfth ribs of the
     right side. Complete motor and sensory paralysis, with absence
     of reflexes from mid-dorsal region downwards. Upper
     intercostals working. Retention of urine, penis turgid.
     Sensation perfect to lower extremity of sternum. Early trophic
     sacral bed-sores developed and steadily increased in depth and
     extent, slighter ones developed on the heels. The paralysis was
     flaccid throughout. The patient gradually emaciated with fever,
     and died on the seventy-eighth day.

     At the _post-mortem_ the wound proved not to have penetrated
     the thorax, and both the vertebral spines and laminæ were
     intact, no trace of bony injury being discoverable. Opposite
     the sixth dorsal vertebra, for a distance of 1-1/2 inch, the
     cord and dura were adherent, and over the same area the cord
     was represented by soft custard-like material. There was no
     sign of old hæmorrhage.

     (102) _Dorsal region; total transverse lesion; slight
     extra-dural hæmorrhage._--Wound of _entry_ (Mauser), at the
     posterior aspect of the right shoulder; _exit_, 2 inches to the
     left of the spine below the ninth rib.

     Complete motor and sensory paralysis below the site of the
     lesion, with absence of superficial and deep reflexes.
     Retention of urine. Great abdominal distension, pain, and
     vomiting. Bed-sores over the sacrum developed on the third day;
     meanwhile the vomiting continued on and off for a week, and
     very severe girdle pain persisted.

     One month later when seen at the Base hospital considerable
     improvement had occurred. Sensation had returned in both lower
     limbs; but flaccid paralysis persisted and both were wasted,
     especially the left. There was no return of reflexes in the
     lower limbs, the urine was passed in gushes, and the patient
     was cognisant when these occurred. The sacral bed-sores were,
     however, very extensive and becoming larger and deeper.

     At the end of the fifth week slight power was regained in the
     flexors and abductors of the right thigh, and the same muscles
     of the left limb could be made to contract feebly. Meanwhile
     the patient suffered with severe fever, accompanied by frequent
     rigors and profuse sweats; the bed-sore continued to extend,
     and the urine was foul and contained pus.

     The patient continued in a similar condition, progressive
     emaciation and exhaustion taking place, and at the end of six
     weeks he died.

     At the _post-mortem_ the bullet was found to have tracked
     beneath the right scapula, entering the chest by the fifth
     intercostal space and lacerating the right lung; thence it
     entered the eighth dorsal centrum and tunnelled both this and
     the ninth diagonally, to escape beneath the ninth rib. On
     opening the spinal canal the tunnel was found to be separated
     only by the compact tissue of the centrum from the cavity,
     while a thin extra-dural hæmorrhage separated the dura from the
     bones anteriorly. The spinal cord exhibited no sign of pressure
     and was firm and continuous, but up to the lower limit of the
     dorsal region there was septic myelitis and meningitis, the
     result of pus having tracked up the canal from the sacral
     bedsore. Suppurative cystitis and pyelitis were present. The
     patient was the subject of an old urethral stricture which had
     given rise to trouble during treatment.

     (103) _Dorsal region; total transverse lesion; slight
     intra-dural hæmorrhage._--Wound of _entry_ (Mauser), below
     spine of scapula, close to right axilla; _exit_, 2-1/2 inches
     to left of tenth dorsal spinous process.

     Complete motor and sensory paralysis below ensiform cartilage,
     with well-marked hyperæsthetic zone around trunk. All reflexes
     absent. Retention of urine. Incontinence of fæces. Bed-sores in
     sacral region developed during the first two days, and
     seventeen days later well-developed serpiginous trophic sores
     developed on the outer side of each leg and continued to
     increase slowly until death. The paralysis remained of the
     absolutely flaccid variety. Great emaciation occurred,
     accompanied by hectic fever, the temperature ranging from
     normal to 102.5°. During the third week double pleurisy
     developed.

     At the _post-mortem_ no bone injury could be detected. The cord
     and dura-mater were adherent over an area corresponding to the
     fifth to the eighth dorsal vertebræ, and opposite the seventh
     the cord was soft and of the consistence of butter. A small
     intra-dural hæmorrhage was still evident below the main lesion,
     not extensive enough to give rise to serious compression.
     General adhesions in each pleura. Cystitis.

[Illustration: FIG. 79.--Appearance of Spinal Cord enclosed in 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 hæmorrhage existed]

     (104) _Dorsal region; section of cord; retained bullet._--Wound
     of _entry_ (Mauser), in seventh right intercostal space, 4-1/2
     inches from the dorsal spinous processes, oval in outline;
     bullet retained.

     Complete motor and sensory paralysis, with absence of reflexes
     below umbilicus. Retention of urine, incontinence of fæces.
     Large sacral bed-sore developed rapidly. Right hæmothorax.

     The patient emaciated rapidly, and for the last fourteen days
     the temperature ranged to 104°, the bed-sore steadily
     increasing in size. Death occurred on the forty-second day.

     At the _post-mortem_ a Mauser bullet was found embedded in the
     centrum of the twelfth dorsal vertebra. The bullet was slightly
     curved; its anterior extremity had passed across the spinal
     canal, and wounding the dura posteriorly rested against the
     left lamina. The plating of the mantle of the bullet was
     stripped from half the area of the tip. The dura was not
     adherent, and the cord was softened for half an inch above the
     point of section; above this it was normal, the vessels
     coursing normally to the softened spot. Below the point of
     section the cord was blanched, but offered no other macroscopic
     evidence of disease. No evidence of either intra- or
     extra-dural hæmorrhage was detectible.

[Illustration: FIG. 80.--Complete division of Spinal Cord. The bullet 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 hæmorrhage had occurred, the
     blood-clot had assumed a dark orange colour, and on first
     opening the viscus the appearance was that of a mass of fæces.
     The mucous lining elsewhere was slaty grey, with small
     hæmorrhages. The kidneys were large, but no abscesses or
     pyelitis were present.

     (105) _Cervico-dorsal region; total transverse lesion._--Wound
     of _entry_ (Mauser), opposite right sixth cervical transverse
     process; _exit_, on left side of third dorsal spinous process.
     Slight grasping power was present in the hands, and the patient
     could hold his arms across his chest. Complete motor and
     sensory paralysis, with absence of all reflexes below. The
     pupils were moderately contracted. Retention of urine. On the
     second day blebs appeared on each buttock, and the patient
     complained of very severe pain in the neck: the temperature
     rose to 103°, and on the third day he died suddenly. No
     _post-mortem_ examination was made.

I observed two similar cases in the Field Hospital at Orange River, 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 × 3-1/4 inches; long axis obliquely crossing
     infra-spinous fossa of right scapula; bullet retained
     (Martini-Henry). Spine of third dorsal vertebra loose, and a
     distinct thickening to its right side. Complete symmetrical
     paralysis extending up to upper extremities. No sensation on
     surface of trunk below cervical area. Respiration entirely
     diaphragmatic. Retention of urine, penis turgid. Total absence
     of reflexes, superficial and deep. Reddening of buttocks, but
     no bullæ.

     General hyperæsthesia of upper extremities, with severe
     spasmodic attacks of pain.

     On the third day an exploration was decided upon, in view of
     the local deformity, and the severe pain in the upper
     extremities. The third dorsal spine was found to be loose, as a
     result of bilateral fracture of the neural arch; the bullet had
     crossed the right limit of the spinal canal, and destroyed the
     body of the vertebra, and passing onwards had entered the left
     pleural cavity, into which air entered freely from the
     operation wound.

     The patient was relieved from his pain by the exploration, and
     lived four days. On the second day after operation, however,
     the temperature rose to 107°, while on the last two days the
     temperature was normal in the mornings, rising to 105° in the
     evenings. No alteration resulted in the trunk symptoms.

_Diagnosis._--The pure question of the fact of injury of the spinal cord
needs no discussion; but it is necessary to make some remarks on the
discrimination between concussion, contusion and hæmorrhage, meningeal
and medullary hæmorrhage, 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 hæmorrhage 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
hæmorrhage 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 hæmorrhage, 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 hyperæsthesia. I think its presence may also be assumed in
cases of total transverse lesion due to medullary hæmorrhage or severe
concussion, accompanied by well-marked pain and hyperæsthesia 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 hæmorrhage, and partial and total section of the
cord.

First, with regard to compression of the cord, the possible sources are
three; (i) extra-dural hæmorrhage, 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 anæsthetic 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 hæmorrhage. 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 hæmorrhage.
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 hæmorrhage. 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 hæmorrhage 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 hæmorrhage 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, septicæmia 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 hæmorrhage, 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
hæmorrhage 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 hæmorrhage.

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
hæmorrhage 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 hæmorrhage 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 hæmorrhage 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 hyperæsthesia 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 rôle 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 hyperæsthesia and pain combined with loss
of power. In cases in which pain and hyperæsthesia 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
     hyperæsthesia was present in both palms and down the front of
     the forearms. The grip in either hand was weak, this being
     possibly explained in part by the hyperæsthesia of the palms,
     as all movements of the upper extremities could be made,
     although not with full power. On the fourth day the condition
     was much improved on the left side, and at the end of a week
     the left upper extremity was normal; the right (side of entry,
     and therefore exposed to greater force from the bullet)
     improved more slowly, becoming normal only at the end of three
     weeks.

I observed an identical case of injury to the cervical roots, and 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 hyperæsthesia.

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,
hyperæsthesia often developed as a later sign, and was probably due to
the irritation of hæmorrhage, when the sensory portion of the nerve
began to regain functional capacity. The date of appearance of the
hyperæsthesia 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 hyperæsthesia 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
     hyperæsthesia and deep muscular tenderness developed, but no
     wasting. Several crops of herpetic vesicles also developed over
     the distribution of the radial nerve in the hand. This pain was
     followed by spastic contracture, first of the ulnar fingers and
     later of the wrist and elbow, which could only be straightened
     by the application of considerable force. The limb was,
     therefore, kept straight by the application of a splint; and
     warm baths, and a blister applied over the course of the ulnar
     nerve, were resorted to: under this treatment the condition
     improved until the patient was well enough to be transferred as
     a prisoner, and I saw him no more.

     (109) _Peroneal nerve branches._--Wounded at Colenso. _Entry_,
     at the anterior margin of the fibula 5 inches above the
     external malleolus; the track crossed the anterior aspect of
     the leg obliquely, to its _exit_ 1 inch above the centre of the
     ankle joint. Incomplete paralysis of the peronei muscles
     followed, combined with progressive wasting of the whole limb,
     which at the end of a month was marked, and then commenced to
     improve.

     (110) In a second case the wound took a similar course in the
     centre of the leg, crossing the line of the branches of the
     musculo-cutaneous nerve. Motor paralysis of the peronei
     followed, together with general lowering of tactile sensation
     in the musculo-cutaneous area.

_Traumatic neurosis._--In connection with the cases just quoted, 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 anæsthesia 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
hæmorrhage 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 hæmorrhage from
     the left ear. The injury was followed by complete deafness, and
     facial paralysis, which showed no sign of improvement.

     There was complete anæsthesia over the area of distribution of
     the third division of the fifth nerve; this improved rapidly,
     and at the end of five weeks was hardly to be detected; neither
     at that time could any impairment of power on the part of the
     muscles of mastication be detected. No impairment of the sense
     of taste was noted.

     (113) _Entry_, above the anterior extremity of the zygoma,
     bullet retained. Primary hæmorrhage from ear. Complete facial
     paralysis and deafness. Anæsthesia over distribution of
     temporal branch of temporo-malar nerve, part of supra-orbital
     area, auriculo-temporal nerve, and small occipital cervical
     nerve. The muscles of mastication acted well. Ecchymosis below
     the right mastoid process.

     (114) Wounded at Paardeberg. 300 yards. _Entry_, at the
     posterior border of the right mastoid process, 3/4 of an inch
     above the tip; _exit_, the inner third of the left upper
     eyelid. (Eye destroyed.) Complete right facial paralysis; deaf,
     on right side cannot hear tick of watch either held close or in
     contact. Purulent otitis media.

In this place I might mention two other cases of lesion of the 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 palpebræ 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
     hyperæsthesia of the whole left upper extremity, most severe in
     the circumflex area. The hyperæsthesia gradually disappeared in
     a few days, and was clearly due to concussion and possibly
     slight contusion of the cervical nerve roots. The spinal
     accessory paralysis improved, so that the patient returned to
     the front at the end of a month: when I saw him some four
     months later the shoulders were held quite symmetrically.

The _twelfth nerve_ was occasionally damaged in wounds of the floor 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 anæsthesia, and great occipital neuralgia,
but none of motor paralysis from injury to the deeper muscular branches.
I take it that the smallness of the branches, and the multiple 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 hyperæsthesia 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 hæmorrhage 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, anæsthesia or
hyperæsthesia 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. Hyperæsthesia developed in more than one case in which
injury to the psoas had led to hæmorrhage 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
hæmorrhage 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
     fæces persisted for five weeks, and retention of urine during
     three weeks.

     This patient subsequently died on the homeward voyage, but I am
     unable to say from what cause.

     (117) _Entry_, over third sacral vertebra; _exit_, 2 inches
     from the median line, and 1-1/2 inch above Poupart's ligament
     on the anterior abdominal wall. Incontinence, with involuntary
     passage of fæces, persisted during the first twenty-four hours,
     and for two days the urine had to be withdrawn with a catheter.
     No further signs of nerve injury were noted.

The same explanation of the comparative rarity of injuries to the 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
anæsthesia 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 anæsthesia. At the end of the first fortnight there was
     evident wasting of the muscles, but some power was returning in
     the triceps. At the end of a month the man left for England,
     with fair power in the triceps, but well-marked wrist-drop. A
     year later the wrist-drop still persisted.

     (120) _Plexus injury._--Wound of _entry_, over pomum Adami;
     _exit_, below scapular spine, about centre. Complete median and
     musculo-spiral paralysis.

     (121) _Median, musculo-cutaneous, and musculo-spiral
     nerves._--The wound traversed the axilla from just beneath the
     anterior fold; three weeks later a firm mass in the axilla
     corresponded to the wound track. Hyperæsthesia developed in the
     area of median distribution, with deep pain in the muscles.
     There was rigidity of the biceps cubiti and slight wasting in
     the radial extensors. The patient improved slowly, and
     eventually was discharged and passed out of sight.

     (122) _Brachial nerves._--Wounded at Paardeberg. Range 500
     yards. _Entry_, at the front of the arm, 2 inches below the
     junction of the anterior axillary fold; _exit_, a little lower,
     at the back of the arm, in the line of junction of the
     posterior axillary fold.

     Considerable shock attended the primary injury; when reaction
     had taken place, complete motor and sensory paralysis was noted
     of the whole upper extremity, with the exception of some power
     of movement of the posterior interosseous group of muscles.
     Three weeks later the patient could extend the wrist, but
     sensation was imperfect in the arm, and completely absent in
     the forearm and hand. The track was now hard and palpable, but
     there was no hyperæsthesia in any area; when the track was
     manipulated slight formication in the hand was experienced. The
     biceps and triceps were equally paralysed. There was no wasting
     in any of the muscles.

     (123) _Brachial nerves._--Wounded at Modder River. _Entry_,
     through the anterior axillary fold at its junction with the
     arm; _exit_, on the posterior wall of the thorax, 1/2 an inch
     from the median line at a level with the angle of the scapula.
     Complete musculo-spiral paralysis; hæmothorax. Three weeks
     later, radial sensation returned; but the triceps was very
     weak, and wrist-drop was complete. There was some wasting of
     the muscles supplied by the median and ulnar nerves, and
     complete obliteration of the radial pulse. A year later the
     musculo-spiral paralysis still persisted.

     (124) _Musculo-spiral and median._--Wounded at Magersfontein.
     _Entry_, 3 inches below the anterior axillary fold, on the
     inner aspect of the arm; track passed obliquely downwards
     behind the humerus to a point on the outer aspect of the arm
     1-1/2 inch below the level of the entry. The humerus escaped
     injury. Musculo-spiral paralysis was complete; hyperæsthesia in
     the distribution of the median followed some days later. One
     month subsequently radial sensation had returned, and a feeling
     of numbness had taken the place of the median hyperæsthesia.
     The triceps and marginal muscles were much wasted, and only
     interosseous extension was possible in the fingers.

     (125) _Brachial nerves._--Wounded at Magersfontein. _Entry_ and
     _exit_, in the upper third of the arm internal to the humerus.
     Complete median paralysis, anæsthesia in the ulnar area, and in
     the radial supply to the dorsum of the middle and ring fingers.
     Could flex, extend, and adduct and abduct the wrist; some power
     of flexion in index finger, in others none. The flexion of the
     wrist was dependent on the ulnar supply to the muscles of the
     forearm. No wasting of the interossei, skin normal except for a
     large trophic blister on the dorsum of the hand. Little
     improvement had taken place in this patient at the end of a
     year.

     (126) _Brachial nerves._--Wounded at Magersfontein. The wound
     traversed the lower part of the upper third of the arm,
     fracturing the humerus. Immediate complete loss of power in the
     arm was experienced, together with loss of all sensation. Three
     weeks later the humerus was united; the fracture was evidently
     the result of passing contact, and not of direct impact. The
     paralysis was still complete in the distribution of the median,
     ulnar, and musculo-spiral nerves. There was considerable
     wasting of the hand and forearm, and a good deal of thickening
     in the lower third of the arm.

     Four months after the original injury, the nerves were explored
     by Mr. Eve, who kindly gives me the following information. All
     the nerves and vessels of the arm were united into one firm
     bundle by cicatricial tissue. When dissected clear, the median
     nerve was found to be thickened and enlarged for about 1-1/2
     inch of its length; the ulnar was not completely freed, but was
     found to be continuous and indurated; the musculo-spiral was
     also intact, but at its entrance into the humeral groove a mass
     of callus was felt. A sclerosed and thickened portion of the
     median nerve 3-1/2 inches in length was resected, also 1 inch
     of sclerosed ulnar nerve, and both were sutured. The
     musculo-spiral nerve was left for future exploration. A small
     traumatic aneurism was found on the brachial artery, and the
     vessel was ligatured above it.

     Ten months later no improvement in the median or ulnar nerves.
     Electrical reaction present in musculo-spiral group of
     muscles.

     (127) _Musculo-spiral._--Transverse wound through arm posterior
     to humerus. Slight suppuration. Triceps weakened only, complete
     paralysis of radial extensors and posterior interosseous group.
     Radial sensation lowered only.

     (128) _Musculo-spiral._--_Entry_, 2 inches above and 1/2 an
     inch behind the external humeral condyle; _exit_, at the inner
     edge of the biceps, 1/2 an inch lower in the arm than the
     entry. It is doubtful whether the paralysis was noted at first,
     but a few days later complete posterior interosseous paralysis
     and lowered radial sensation were remarked. No change except a
     deepening of the anæsthesia, and the development of formication
     on manipulation of the wound occurred, and at the end of three
     weeks the nerve was exposed (Mr. Watson), and it was found that
     a notch had been cut in its outer border, which had opened out
     into a V shape. The margins of this notch were refreshed and
     the gap closed. Ten days later radial sensation was fairly
     good, but the motor symptoms remained unchanged. Nine months
     later steady but very slow improvement was reported.

     (129) _Ulnar and musculo-cutaneous nerves._--_Entry_, back of
     forearm; the bullet passed between the bones and was retained
     at the posterior aspect of the arm. Three weeks later the hand
     was glossy and stiff, the fingers extended and adducted, the
     thumb was held stiffly in the palm with no power of extension.
     The forearm was held semiprone, and the elbow flexed by a rigid
     biceps. Six months later the same position was maintained, but
     the contracture disappeared under an anæsthetic.

     (130) _Median and posterior interosseous._--_Entry_, over the
     external margin of the radius at the centre of the forearm;
     _exit_, at the inner margin of the olecranon 1-1/2 inch below
     the tip. Lowered cutaneous sensation in median distribution,
     and loss of median flexion of wrist and fingers. Complete
     wrist-drop. The triceps supinator longus and extensor carpi
     radialis longior were perfect. Twelve days later the wrist
     could be raised into a direct line with forearm, but there was
     no change in the median symptoms. A week after this the
     anæsthetic median area became hyperæsthetic both as to skin and
     on deep pressure over the muscles.

     (131) _Sacral plexus. Great sciatic nerve._--Wounded at Modder
     River. _Entry_, in left loin; _exit_, at lower margin of
     buttock. The wound was followed immediately by complete
     peroneal paralysis, both motor and sensory. Fourteen days later
     hyperæsthesia developed in the area of distribution of the
     internal popliteal nerve, the superficial pain being greatest
     in the sole; the muscles of the calf were also very tender on
     manipulation. The pain increased, and at the end of twenty-four
     days the patient's sufferings were so great that Mr. Thornton
     cut down upon and exposed the nerve. It was found embedded in
     firm cicatricial tissue close to the sciatic notch; this
     compressed the nerve to such a degree that a waist was apparent
     upon it.

     The nerve was freed and resumed its normal outline. For a few
     days the patient was much relieved, but the neuralgia then
     returned in greater intensity than ever. Morphia was injected
     hypodermically, and other hypnotics employed, but with little
     effect, the patient developing the hysterical condition so
     common in the subjects of severe sciatica. Some five weeks
     later a sudden improvement took place, the morphia was
     decreased, and the patient became sufficiently well to return
     to England, but there was still deep tenderness in the calf,
     and well-marked hyperæsthesia of the sole.

     A year later the patient had been discharged from the Service,
     but was earning his living in a shop. He walked fairly well,
     but still with foot-drop, and complained of tenderness in the
     sole. I am indebted to Dr. Turney for the following report on
     the condition of the muscles.

     Calf muscles practically normal. In the anterior tibial and
     peroneal groups the faradic irritability is much diminished,
     that in the peroneus longus being the lowest of all.
     Contraction can be induced in the extensor longus hallucis,
     extensor longus digitorum, and peroneus brevis; but reaction is
     doubtful in the case of the tibialis anticus and peroneus
     longus.

     With the galvanic current contraction is sluggish, and the
     irritability diminished. No serious changes are present except
     in the peroneus longus. ACC > KCC at 10 M. A.

     (132) _Great sciatic._--_Entry_, at outer aspect of the thigh,
     just above the centre; _exit_, at the junction of the inner and
     posterior aspects of thigh, about 2 inches lower. The wound was
     produced by a ricochet bullet, and beyond the perforation of
     the sciatic nerve the femur was fractured obliquely (see plate
     XVI.). Hyperæsthesia of the sole was noted early, and when I
     saw the patient three months later, there was wasting of the
     muscles of the leg, and foot-drop, although he walked with a
     stick.

     These symptoms persisted, and on his return to England an
     exploration was made by Sir Thomas Smith, and the two fragments
     of mantle seen in the skiagram were removed from the substance
     of the sciatic nerve. Eight months after the injury, the
     patient still walked with foot-drop; there was modified
     sensation in the musculo-cutaneous area, and a feeling as if
     the bones of the foot were uncovered when he walked. The
     circumference of the affected leg was more than 1 inch less
     than that of the sound one. Steady but slow improvement was
     taking place.

     (133) _Great sciatic_.--In a third patient with a buttock
     track, the symptoms were identical with those observed in case
     131. In this an exploration showed that the nerve had been
     perforated. Although the symptoms were never so severe as in
     No. 131, yet recovery was very much slower and less complete,
     the muscular weakness remained more marked, and the skin
     exhibited more evidence of trophic lesion. Some contracture of
     the knee and rigid foot-drop took place, and at the end of
     twelve months the patient walked poorly with a stick.
     Improvement is, however, continuing.

     (134) _Great sciatic_.--Wounded at Ladysmith. _Entry_,
     immediately below left buttock fold; _exit_, at anterior aspect
     of thigh, 3-1/2 inches below Poupart's ligament. The left leg
     was paralysed, and patient was sent down to the Base, where he
     remained two months. The wound closed by primary union, the
     paralysis improved, and the man rejoined his regiment. After he
     had been in camp four days, his leg gave way, and he returned
     to hospital, where he contracted enteric fever. Later, he was
     sent home, and eight months after the reception of the injury
     his condition was as follows:

     Left lower limb somewhat wasted, a diminution of 1 inch in the
     circumference of the leg and 1/2 an inch in the thigh being
     found. The patient walks with foot-drop, and the flexor muscles
     of the knee are weak. On examination the peroneal muscles
     reacted but sluggishly to faradic irritation. There is complete
     anæsthesia of the foot to above the ankle, and up to the knee
     tactile sensation and appreciation of pain were dulled. The
     left plantar reflex was absent, the right slight, the left
     patellar reflex was abnormally brisk. There was neither ankle
     nor patellar clonus, and the other reflexes were present and
     normal. The gait was spastic, and the patient was more troubled
     by a contraction of the calf muscles, which prevented his
     putting the heel to the ground, than by the foot-drop.

     Beyond these local phenomena there was marked tremor of the
     upper extremities on any exertion, and slight lateral
     nystagmus. The patient was not sure that this had not been
     present ever since he recovered from the enteric fever, but it
     was sufficiently marked to give rise to the suspicion of the
     development of disseminated sclerosis.

     The patient was a hard-headed, sensible man. He remained in the
     hospital under the care of Dr. Turney, to whom I am indebted
     for notes of the case, forty-six days. During this period he
     was treated by faradic electricity, and, with some checks,
     notably the development of passive effusion into the left
     knee-joint, and a fugitive attack of redness over the dorsum of
     the foot, both suggesting trophic changes, steadily improved.
     The anæsthesia became limited to the outer half of the leg, at
     the end of one month was limited to the dorsum of the foot
     only, and at the end of six weeks entirely disappeared.
     Meanwhile the tendency to drawing up of the heel by the calf
     muscles became less, and the gait improved. The man left the
     hospital at the end of two months, very satisfied with his
     condition, although the tremor of the hands was still present
     in a lessened degree.

     (135) _External popliteal._--Wounded at Magersfontein, 250-300
     yards. _Entry_, at the outer side of the thigh, 5 inches above
     the lower extremity of the external condyle; _exit_, at the
     inner margin of the adductors, at a level 4 inches higher in
     the thigh. The track crossed behind the femur. Complete
     peroneal motor paralysis and anæsthesia, except in the hinder
     part of the region supplied by the mixed external saphenous.
     Slight hyperæsthesia of the sole. Improving at the end of three
     weeks, but paralysis still nearly complete.

     (136) _External popliteal._--Wounded at Magersfontein. _Entry_,
     5 inches below the highest part of the right iliac crest, on
     outer aspect of hip; _exit_, at the posterior margin of the
     gracilis, 2 inches from the perineum. Complete peroneal
     paralysis followed, which rapidly improved, and on the
     twenty-second day was nearly well.

     (137) _Internal popliteal. Secondary anæsthesia_.--_Shell_
     wounds of the right popliteal space. Wounded at Belmont.
     Anæsthesia of the outer side of the calf, the leg and sole of
     foot. No motor paralysis. As cicatrisation progressed, the
     anæsthesia became more marked and was complete over the whole
     of the external saphenous area.

     (138) _Internal popliteal._--Wounded at Paardeberg. 400-500
     yards. _Entry_, about the centre of the outer half of the
     patella; _exit_, at the centre of the calf, about 2 inches from
     the popliteal crease. Five days after the injury severe burning
     pain developed in the sole. A fortnight later the pain was much
     less severe, but varied in degree with the heat of the weather,
     being worse when cool. At this date, however, rubbing became
     comforting.

     (139) _External popliteal._---Wounded at Magersfontein.
     _Entry_, 1 inch above the upper end of the internal margin of
     the patella; _exit_, at the margin of leg, just below the outer
     tuberosity of the tibia. Complete peroneal paralysis followed
     the injury. A month later the nerve was bared and found
     slightly thickened. An improvement in cutaneous sensation
     followed quickly, and a much slower improvement in the motor
     power commenced.

     (140) _External popliteal nerve._--Wounded at Beacon Hill. A
     _bayonet_ entered over upper quarter of fibula, and passed
     between the bones of leg into the calf. An aneurismal varix of
     the calf vessels developed, also incomplete peroneal paralysis.
     The scar was raised from the nerve (Major Simpson, R.A.M.C.)
     six weeks later, and at the end of a fortnight the power and
     sensation were both much improved and the patient returned to
     England.

     (141) _External popliteal._--Wounded at Modder River. _Entry_,
     1/2 an inch above the internal border of the patella; _exit_,
     1-1/2 inch from the head of the fibula and over that bone. The
     wound was followed by peroneal paralysis. Six weeks later
     sensation was still diminished in the anterior tibial and
     musculo-cutaneous nerve areas, and marked foot-drop, little
     improved, persisted. The patient came to England, and at the
     end of twelve months is reported as very little improved.

     (142) _Anterior tibial._--_Entry_, 1 inch in front and below
     the external malleolus; _exit_, at the centre of the sole, just
     anterior to the bases of the metatarsal bones. Wasting and
     paralysis of extensor brevis digitorum.

     (143) _Small sciatic and small saphenous._--Wounded at
     Magersfontein. 200 yards. Two wounds: (i) _Entry_, below the
     centre of the twelfth rib on the left side; _exit_, immediately
     to the left of the buttock furrow at upper part, (ii) _Entry_,
     in the right loin, midway between the last rib and iliac crest;
     _exit_, just within the centre of the left buttock; the two
     wounds crossed diagonally. Hyperæsthesia in area of
     distribution of small saphenous and small sciatic nerves, which
     rapidly improved.

     (144) _Lumbar plexus._--Boer, wounded at Magersfontein.
     _Entry_, eleventh interspace, posterior axillary line; _exit_,
     tenth interspace, right mid-axillary line. Impaired sensation
     in area of distribution of external cutaneous and crural branch
     of genito-crural nerves. At the end of a fortnight anæsthesia
     was less apparent, but a feeling of numbness persisted, which
     soon disappeared.

_Prognosis and treatment._--In considering the prognosis in cases 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 hyperæsthesia,
whether preceded by anæsthesia 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
ischæmia 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 hæmorrhage was a
prominent symptom; in another, a piece of lung was prolapsed from a
wound in the back, and twice I observed pneumothorax, an uncommon
sequela to wounds from bullets of small calibre.

It may be remarked, however, that all these more serious injuries were
recovered from, also that when we consider that the patients were
comparatively young and healthy subjects, the favourable prognosis was
what might have reasonably been expected. When, as occasionally
happened, a patient of more mature years, with enlarged facial
capillaries, received a wound of the lung, the course was in no way so
favourable as that witnessed in the case of the younger men.

In support of this opinion I may add that wounds from shrapnel and
fragments of shell also did remarkably well, although they sometimes
gave rise to more troublesome symptoms than did wounds produced by
bullets of the Mauser type. Again, these injuries as a whole were of
nothing like so serious a nature as the lacerations of the lung produced
by fractured ribs, which we commonly have to treat in civil practice,
and are not accustomed to regard as especially dangerous.

It is also a striking fact that the most common and troublesome
complication of wounds of the chest, hæmothorax, 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 vertebræ 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 anæsthesia, 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 hæmorrhage_ 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 hæmorrhage 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 hæmothorax.

_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 herniæ 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 hæmorrhage, but sudden
stoppage of the heart's action. This is to be inferred from the fact
that severe external hæmorrhage 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
hæmo-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 pleuræ, and passed immediately beneath the
     heart. The liver was also perforated, but the spleen and
     stomach probably escaped as far as could be judged from the
     symptoms. The patient afterwards developed a pneumo-hæmo-thorax
     on the right side. The immediate symptoms were great distress
     in breathing and rapid irregular pulse. The difficulty in
     respiration was probably in part accounted for by the injuries
     to the lung and diaphragm. The pulse remained from 112 to 120
     for three days, at first soft and hardly perceptible, later
     very irregular, and dropping one every fifth or sixth beat; and
     it seemed fair to attribute this to the shock to the nervous
     mechanism of the heart. The patient recovered from the chest
     injury.

     In some other patients in whom the track passed close below the
     heart a disturbance of the pulse rate was noted, but this was
     in some cases a slowing, not below 48, in others quickening to
     100, with irregularity both in force and beat.

     (146) _Entry_, in the fourth right interspace, 3 inches from
     the middle line; _exit_, in the seventh left interspace, in the
     mid-axillary line. This wound was received at a distance of
     500-600 yards, but the bullet penetrated both sides of a stout
     silver cigarette case and some cigarettes before entering the
     body. There were minor signs of pulmonary injury, 'coughing day
     and night,' and slight discoloration of the sputum on three or
     four occasions. The respirations were quickened to 32, and as
     much as ten days after the injury the pulse only beat 48 to the
     minute; it then rose to 56, but beat in a very deliberate
     manner.

In other cases the signs were almost nil.

     (147) _Entry_, in the fourth right intercostal space 3/4 of an
     inch from the sternum; _exit_, in the sixth left interspace in
     the posterior axillary line. This patient had no symptoms,
     beyond quickening of the pulse to 100, and a 'feeling of
     tightness at the heart.' He shortly returned to active duty.

     (148) _Entry_, situated in the third right interspace 3 inches
     from the sternal margin; _exit_, in the fourth left space 2-3/4
     inches from the sternal margin. In this case the bullet without
     doubt passed through the anterior mediastinum, and slight
     injury to the lung was evidenced by transient hæmoptysis.

Some remarks regarding wounds of the thoracic vessels have already 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 hæmorrhage from the wound
     of entry caused great anxiety; this ceased spontaneously,
     however, and, beyond transient hæmoptysis and a right
     pneumo-thorax, no further trouble occurred.

     (150) _Entry_, in the ninth interspace, just anterior to the
     anterior axillary line; _exit_, through the right half of the
     sternum, 1/2 an inch below the upper border. No primary
     hæmorrhage of importance followed, but I believe this patient
     subsequently died. The wound was received at a range of within
     fifty yards.

_Wounds of the lungs._--Numerically, pulmonary wounds formed the 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 hæmothorax 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 hæmothorax 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 hæmothorax, 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.

Hæmoptysis 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 hæmorrhage. 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 hæmoptysis 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.

_Hæmothorax._--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 hæmorrhage 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 hæmorrhage was, I think, amply justified by
the absence of continuous recurrent or progressive hæmoptysis 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 hæmoptysis, during the course of development of a
hæmothorax, pointed to the lung as the source of the blood.

Hæmorrhage 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 hæmothorax 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 hæmothorax of varying degrees of
severity.

In some cases, the least common, signs of considerable intra-pleural
hæmorrhage 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 hæmorrhage was of the recurrent variety;
these cases differing little in character from those of slight
continuous hæmorrhage. In a third, the bleeding was definitely of a
secondary character, corresponding with one of the classes of secondary
hæmorrhage 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 hæmothorax 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 hæmothorax._--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
hæmoptysis, 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 hæmorrhage.

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 Hæmothorax,
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° 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 hæmorrhage, 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 hæmothorax 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 hæmothorax 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 hæmorrhage 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 hæmorrhages 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
hæmorrhages 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 hæmothorax was to spontaneous
recovery, the rapidity of the subsidence of the signs depending mainly
on the quantity of the primary hæmorrhage, 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 hæmorrhage followed by
inflammatory troubles:--

[Illustration: TEMPERATURE CHART 2.--Secondary Hæmorrhages in a case of
Hæmothorax. Case No. 151]

     (151) The wound was received at short range, probably at from
     100 to 200 yards. _Entry_, 1 inch from the left axillary margin
     in the first intercostal space; _exit_, at the back of the
     right arm 1-1/2 inch below the acromial angle; both pleuræ were
     therefore crossed. The patient expectorated at first fluid,
     then clotted, blood in considerable quantity. When brought into
     the advanced Base hospital on the third day, there were signs
     of blood in the left pleura, cellular emphysema over the right
     side of the chest, and signs of collapse of the right lung. The
     temperature chart gives shortly the course of the case: the
     right pneumo-thorax cleared up spontaneously, also the
     emphysema; but the left pleura needed tapping to relieve
     symptoms of pressure on four occasions, the 13th, 15th, 19th,
     and 25th days respectively. On the first two occasions blood
     was removed, on the third blood serum only, and on the last
     pus. The patient was relieved after each aspiration; after the
     third, the temperature fell to normal, the general condition
     also improved, and he promised to do well. None the less,
     reaccumulation took place, the evacuated fluid assumed an
     inflammatory character, and an incision to evacuate pus was
     eventually followed by death on the twenty-seventh day. The
     amount of hæmoptysis throughout was considerable, and the case
     was possibly one of pulmonary hæmothorax, as after death no
     source of hæmorrhage could be localised in the intercostal
     space. The track in the lung was almost healed, and although a
     part of it allowed the introduction of a probe for about an
     inch, it could be traced no further even on section of the
     organ, and no special vessel could be located as the original
     bleeding spot.

_Empyema._--I may here add the little that I have to say on 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 hæmoptysis, but the
     patient suffered with some dyspnoea throughout. After a three
     days' stay in the Field hospital, where the subcutaneous bullet
     was removed, the patient was transported by wagon and train to
     the Base, a journey of about 600 miles.

     On the fifth day pus escaped from the extraction wound, and
     when the case was examined at the Base, the temperature was
     101°, the pulse over 100, the respirations 30, and the whole
     side of the chest was dull, with the exception of a patch of
     boxy resonance over the apex anteriorly. On the following day
     the chest was drained, and a considerable amount of pus
     evacuated, which was mixed with breaking-down blood-clot. A
     fortnight later a second operation had to be performed to
     improve the drainage, and the patient made a tedious recovery.

The following case well illustrates the symptoms in a severe case of
hæmothorax, and empyema following aspiration:--

     (153) The patient was wounded at Paardeberg at a range of from
     500 to 700 yards. _Entry_, just to the left of the episternal
     notch; _exit_, in the fifth left interspace posteriorly, midway
     between the spine and vertebral margin of the scapula. A
     quantity of bright blood was brought up at once, and later
     blood was coughed up in clots.

     There was no great pain at the moment of the injury; the man
     again got up to the firing line, and later walked two miles to
     the Field hospital without aid. He remained here a week, when
     he was sent down to the Base, and during the first three days'
     journey in the wagon he began to get worse. On the fourth day
     cough began to be very troublesome.

     When he arrived at the Base, fifteen days after the original
     injury, there was much dyspnoea; the temperature was 102°,
     and the pulse 110. The left side of the chest was dull
     throughout; an aspirating needle was introduced, and a pint of
     very dark liquid blood drawn off. The whole of the blood was
     not removed on account of the very severe cough and pain which
     the evacuation occasioned. The man appeared to steadily improve
     until three weeks later, when the temperature, which throughout
     had been uneven, became consistently high, and signs of fluid
     at the base increased. An aspirating needle was introduced, and
     16 ounces of pus were drawn off. Two days later a piece of rib
     was resected (Mr. Pegg) and another pint of pus evacuated.
     After this, rapid improvement took place, and in ten days the
     man was able to be up and dressed, although a small amount of
     discharge still persisted. He eventually made an excellent
     recovery.

Secondary empyemata not uncommonly followed incision of the chest, or
excision of a rib for draining a hæmothorax. 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 hæmothorax,
but the patient fortunately recovered.

The question of _pleurisy_ has already been mentioned in connection with
hæmothorax; 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 septicæmia, and it was possibly pyæmic.

_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 hæmothorax. Here
two points especially needed consideration. (1) _The source of the
hæmorrhage as parietal or visceral._ As has been already foreshadowed,
this was mainly to be decided by the amount and persistence of the
hæmoptysis, but naturally free hæmoptysis 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
hæmothorax, 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 hæmorrhage 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 hæmothorax 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
hæmothorax occurred. Beyond simple rest, the administration of opium
with a view to checking internal hæmorrhage was used with good effect.
The wounds needed simple dressing only.

The treatment of hæmothorax at a later date, however, was of much
interest and difficulty. I think the following lines may be laid down
for guidance in such cases:--

(i) Hæmothorax, 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 hæmorrhage 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 hæmothorax 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 vertebræ.
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 hæmothorax 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 hæmothorax:--

[Illustration: TEMPERATURE CHART 3.--Primary Hæmothorax, with rise of
temperature. Secondary rise, with fresh effusion and pneumonia.
Spontaneous recovery. Case No. 154]

     (154) _Severe hæmothorax. Spontaneous recovery._--Wounded at
     Modder River at a distance of 30 yards. _Entry_, at the
     junction of the left anterior axillary fold with the
     chest-wall; _exit_, immediately to the left of the seventh
     dorsal spinous process. The patient arrived at the Base with
     signs of an extensive hæmothorax, accompanied by a temperature
     which reached 102° on the fourth day, and on the evening of the
     tenth 103°. The man was very ill, and an exploring needle was
     inserted, by which about an ounce of blood was evacuated. The
     signs of fluid in the left pleura were accompanied by those of
     consolidation over the lower fourth of the right lung, and the
     sputa were rusty. Evidence of perforation of the left axillary
     artery existed in feebleness of the radial pulse; and there was
     musculo-spiral paralysis.

     After the preliminary puncture, the man refused any further
     operative treatment, although a second rise of temperature
     commenced on the fifteenth day, culminating in a temperature of
     103.2° on the eighteenth. The further treatment of the patient
     consisted in the ensurance of rest and the alleviation of pain.
     A steady fall in the temperature extended over another three
     weeks, together with diminution in the signs of fluid in the
     pleura. At the end of seventy-four days the man was sent home,
     some slight dulness at the left base, and contraction of the
     chest sufficient to influence the spine in the way of lateral
     curvature, being the only remaining signs.

[Illustration: TEMPERATURE CHART 4.--Primary Hæmothorax. Secondary rise
of temperature, with increase in the effusion. Spontaneous recovery.
Case No. 155]

     (155) _Severe hæmothorax. Secondary effusion. Spontaneous
     recovery._--Wounded at Koodoosberg Drift, at a distance of 200
     yards. _Entry_, at angle of the right scapula; _exit_, at the
     junction of the left anterior axillary fold with the
     chest-wall. No signs of spinal cord injury. The patient was
     brought in from the field twelve miles by an ambulance wagon on
     the second day, and in crossing the Modder River he was
     accidentally upset into the stream. For the first four days
     there was no hæmoptysis, but for the succeeding nine days small
     brightish red clots were expectorated. There was some
     tenderness over the ribs from the fifth to the ninth in the
     axillary line, and on the ninth day some gravitation ecchymosis
     appeared over the same region. Cough was an early troublesome
     symptom in this case, and when admitted to the Base hospital,
     about the seventh day, there was evidence of fluid extending
     about a third of the way up the back.

     On the tenth day after admission a pleural rub was detected at
     the upper margin of the dulness, and the latter shortly
     extended upwards over a little more than half the back.
     Meanwhile, there was no further hæmoptysis, respiration was
     fairly easy, 24 per minute, but accompanied by slight
     dilatation of the alæ nasi, and the temperature, which had been
     ranging from 99° to 100°, began to rise steadily, on the
     fifteenth day reaching 102.5°. The patient refused even an
     exploratory puncture, and was treated on the expectant plan.
     The temperature slowly subsided, with a steady improvement in
     the physical signs, and at the end of about ten weeks he left
     for home with only slight dulness and incapacity for active
     exertion remaining. (Now again on active service.)

[Illustration: TEMPERATURE CHART 5.--Hæmothorax, primary and secondary
rises of temperature, on each occasion falling on the evacuation of the
blood. Case No. 156]

     (156) _Severe hæmothorax. Recurrent secondary effusion. Tapping
     on two occasions. Cure._--The patient was wounded at
     Paardeberg, and arrived at the Base on the eighteenth day.
     _Entry_, below the first rib, just external to its junction
     with the costal cartilage; _exit_, through the ninth rib, just
     within the posterior axillary line. The whole right side of the
     chest was dull, with signs of the presence of fluid, the heart
     being displaced to the left. There was considerable distress;
     the respirations averaged 40, the pulse 100, and the
     temperature reached 101.5° the first evening after arrival.

     On the nineteenth day the thorax was aspirated (Mr. Hanwell)
     and 50 ounces of dirty red-coloured fluid, half clot, half
     serum, were evacuated. Considerable relief was afforded; the
     respirations became slightly less frequent; the heart returned
     to a normal position, and distant tubular respiration was
     audible. The temperature dropped to normal the third day after
     evacuation of the fluid, but on the sixth day it again
     commenced to rise, and meanwhile fluid again began to collect.

     On the twenty-sixth day a second aspiration resulted in the
     evacuation of 35 ounces of bloody fluid in which flakes of
     lymph were found. Three days later the temperature became
     normal. The respirations fell to 22, and the patient made an
     uninterrupted recovery.

[Illustration: TEMPERATURE CHART 6.--Wound of Lung. Secondary
development of Hæmothorax, with rise of temperature. Spontaneous
recovery. Case No 157]

     (157) _Moderate hæmothorax. Secondary effusion at the end of
     twenty days. Spontaneous recovery._--Wounded at Paardeberg;
     range from 700 to 1,000 yards. _Entry_, in the centre of the
     second right intercostal space, anteriorly; _exit_, at the
     level of the sixth rib posteriorly, through the scapula, close
     to its vertebral margin.

     The patient arrived at the Base on the sixth day; he said he
     expectorated some blood at the end of about ten minutes after
     being shot, and experienced a 'half-choking sensation.' A small
     quantity of phlegm and occasional clots had been expectorated
     since. He had walked about a good deal; movement occasioned
     cough, and he became 'blown' very rapidly.

     On admission there were signs of fluid in the lower third of
     the pleural cavity, but no general symptoms beyond an evening
     rise of temperature to an average of 99°. About the twentieth
     day the temperature commenced to rise, and on the twenty-third
     and four following evenings reached 102°. The fever was
     accompanied by some distress, and a well-marked increase in the
     physical signs of the presence of fluid in the chest. The pulse
     rose to 96, and the respirations considerably above the average
     of 24, which was at first noted. A strictly expectant attitude
     was maintained, and the temperature steadily fell in a curve
     corresponding to the rise, gradually reaching the normal at the
     end of a week. The physical signs at the base steadily cleared
     up, and at the end of six weeks the patient returned to England
     convalescent.



CHAPTER XI

INJURIES TO THE ABDOMEN


Perhaps no chapter of military surgery was looked forward to with 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 septicæmia 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
     hæmothorax, but no abdominal signs; the former was probably
     parietal in origin, secondary to the fractured rib, and the
     whole wound non-penetrating as far as the abdominal cavity was
     concerned.

     (161) Wounded at Magersfontein. _Entry_ (Mauser), 1-1/2 inch
     external to and 1/2 inch below the left posterior superior
     iliac spine; _exit_, 1 inch internal horizontally to the left
     anterior superior spine.

     No signs of intra-peritoneal injury were noted, but free
     suppuration occurred in left loin; the ilium was tunnelled.

     The same patient was wounded by a Jeffrey bullet in the hand;
     the third metacarpal was pulverised, although the bullet, which
     was longitudinally flanged, was retained.

     (162) Wounded outside Heilbron. _Entry_, below the eighth right
     costal cartilage; _exit_, below the eighth cartilage of the
     left side. The wound of entry was slightly oval; that of exit
     continued out as a 'flame'-like groove for 2 inches. A week
     later the wound track could be palpated as an evident hard
     continuous cord.

_Penetration of the intestinal area without definite evidence 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
hæmorrhage 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 cæcum 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
hæmorrhage 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 cæcum, 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
hæmorrhage, 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 hæmorrhage 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 hæmorrhage 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 hæmorrhage 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
fæcal 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 septicæmia._--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 cæcum,
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 septicæmia 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 fæcal 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 hæmatemesis. 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 hæmorrhage 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°, and did not become normal till the fourteenth day. The
     pulse averaged 80. The abdomen, meanwhile, moved fairly well,
     respirations 18 to 20. Some tenderness was present in the
     epigastrium and towards the spleen. Resonance throughout.
     Ordinary diet was now resumed, and beyond slight epigastric
     pain on deep inspiration, no further symptoms were observed,
     and the patient left for England at the end of the month. The
     spleen may have been traversed in this patient, as well as the
     lower margin of the right lung.

     (164*) Wounded at Enslin. _Entry_ (Mauser), 3/4 of an inch from
     the spine, opposite the eighth intercostal space; _exit_,
     through the seventh left costal cartilage, 1 inch from the
     median line. The patient was lying in the prone position when
     shot: he vomited blood freely, and the bowels acted three times
     before he was seen forty hours after the accident, each motion
     containing dark blood.

     On the commencement of the third day the patient's expression
     was extremely anxious, and he was suffering great pain. Pulse
     96, temperature 100°. Tongue moist, occasional vomiting, bowels
     open yesterday. Has taken fluid nourishment since injury. The
     abdomen moved with respiration, but was moderately distended,
     especially in the line of the transverse colon; it was
     tympanitic on percussion, there was no dulness in the flanks,
     and only moderate rigidity of the wall on palpation. Frothy
     fluid stained with bile and fæcal in odour was escaping from
     the wound of exit, and the everted margins of the latter were
     bile-stained.

     A vertical incision was carried downwards from the wound for 4
     inches. A rugged furrow was found on the under surface of the
     left lobe of the liver; the stomach was contracted and firmly
     adherent by recent lymph to the under surface of the liver and
     the diaphragm. The transverse colon was much distended. On
     separating the stomach a slit wound was found at the lesser
     curvature, immediately to the right of the oesophagus. This
     wound was closed with some difficulty with two tiers of
     sutures; the cavity was mopped out, and then irrigated with
     boiled water; a plug was introduced along the line of the
     furrow in the liver, and the lower part of the abdominal
     incision closed.

     The patient stood the operation well, and was removed to his
     tent; during the day, however, two thunder showers occurred
     during each of which water, several inches if not a foot deep,
     rushed through the camp. After the second flood he was removed
     to the operating room, the only house we had, and slept there.
     The pulse rose to 120, and respiration to 26, and there was
     pain, which was subdued by 1/3 grain of morphia, administered
     subcutaneously. A fair amount of urine was passed, and the
     bowels acted once, the motion containing blood.

     On the second day after operation there was some improvement;
     the pulse still numbered 116, and the temperature was raised to
     100°, but the belly moved fairly, and pain was moderate.
     Abundant foul-smelling, bile-stained discharge came from the
     wound when the plug was removed. Rectal feeding was
     supplemented by small quantities of milk and soda by the mouth.

     The condition did not materially change, but on the fourth day
     it was evident that the suturing of the stomach wound had given
     way, and liquid food escaped readily when taken. The discharge
     remained bile-stained and very foul. No extension of
     inflammation to the general peritoneal cavity occurred, but it
     was evident that the patient was suffering from constitutional
     infection from the foul wound, the lower part of which opened
     up somewhat after the removal of the stitches on the seventh
     day. The wound was irrigated three times daily with 1-300
     creolin lotion, but remained very foul. The man slowly lost
     strength, although escape from the stomach considerably
     decreased. On the tenth day a sudden severe hæmorrhage
     occurred, presumably from a large branch of the coeliac axis.
     The bleeding was readily controlled by a plug, and did not
     recur; but the patient rapidly sank, and died on the twelfth
     day after the operation, and fourteen days after reception of
     the injury. No _post-mortem_ examination was made.

2. _Wounds of the small intestine._--These were comparatively common,
but offered little that was special either in their symptoms or 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 fæces sometimes occurred early. Shock from the
severity of the lesion, and hæmorrhage, 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 septicæmia 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°. 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°. Pulse 96, regular, and of good strength. Tongue moist and
     little furred.

     The abdomen was opened at 5 A.M. on the fourth day, as the
     local signs had become more pronounced, and the patient had
     passed a restless night in great abdominal pain. A local
     incision was chosen, as the wound was presumably in the sigmoid
     flexure. The sigmoid flexure was adherent to the abdominal wall
     opposite the wound of exit, and a dark ecchymosed patch was
     found, but no perforation could be detected. Foul pus and gas
     escaped freely from the pelvis, but no wound of the large bowel
     could be discovered here. On enlarging the incision upwards
     three openings were found in a coil of jejunum, probably that
     about five feet from the duodenal junction usually provided
     with the longest mesentery. No fourth opening could be found.
     The openings were circular, about 1/3 inch in diameter, clean
     cut, with a ring of everted mucous membrane, and the wall of
     the bowel in the neighbourhood was thickened. All three
     openings were included within a length of 2-1/2 inches. There
     was no surrounding ecchymosis of the bowel wall. Very little
     escaped intestinal contents were found in the situation of the
     bowel. The latter had apparently been retracted upwards, and
     lay to the left of the lumbar spine. The wounds were readily
     closed by five Lembert's sutures, three crossing the openings,
     and one at each end. The belly was then washed out with boiled
     water and closed. The delay in finding the wounds due to the
     mistaken impression that they would be found in the pelvis
     materially prolonged the operation, which lasted an hour and a
     half. The patient never rallied, and died seventeen hours
     later. It is possible that a wound in the sigmoid flexure was
     present which had already closed at the time of operation.

     (166*) Wounded at Magersfontein. _Entry_ (Mauser), opposite
     central point of left ilium; _exit_, 1-1/2 inch above the
     centre of the right Poupart's ligament. Vomiting commenced soon
     after the injury, and this was continuous until the patient's
     arrival in the Stationary hospital on the fourth day, when the
     condition was as follows:--

     Face extremely anxious in expression. Temperature 101°,
     sweating freely. Pulse 110, fair strength. Tongue moist.
     Abdomen much distended, rigid, motionless, tympanitic
     throughout. Bowels confined. No urine had been passed for
     twenty-four hours, [Symbol: ounce]ij in bladder on
     catheterisation, clear, and containing no blood.

     Abdominal section. Median incision. A considerable quantity of
     bloody effusion was evacuated. Intestine generally congested
     and distended. No lymph. Two wounds were found in the ileum on
     the opposite sides of one coil; the openings were circular,
     with the mucous membrane everted. No escape of fæcal matter was
     visible until the intestine was delivered, when intestinal
     contents spurted freely across the room. The openings were
     sutured with five Lembert's stitches. The bowel was punctured
     in two places to relieve distension, and then returned into the
     belly, after washing with boiled water.

     Four pints of saline solution were infused into the median
     basilic vein, and 1/30 grain strychnine sulph. was injected
     hypodermically.

     The patient did not rally, and died twelve hours after the
     operation.

     (167*) Wounded at Graspan. _Entry_ (Lee-Metford), midway
     between the umbilicus and pubes; _exit_, 1 inch to the left of
     the fifth lumbar spine. The patient was seen on the third day
     in the following condition: in great pain, expression extremely
     anxious, vomiting constantly. Pulse 150 running, respirations
     48. Temperature 100°, sweating freely. Great distension,
     rigidity, and general tenderness of immobile abdomen. No
     improvement followed the administration of brandy and
     hypodermic injection of strychnine 1/30 grain, and operation
     was deemed hopeless.

     In the evening the patient was apparently dying. Face blue and
     sunken and covered with sweat, eyes dull, speechless, pulse
     imperceptible, restlessness extreme, bowels acting
     involuntarily, no urine in bladder.

     The man was placed in a tent by himself, and to my surprise was
     alive and better the next morning; the expression was still
     anxious, but the face brighter and not sweating; the pulse
     only numbered 100, but was very weak, and the hands and feet
     were cold. The condition of the abdomen was unaltered, but the
     thoracic respiration had decreased in rapidity from 48 to 28.

     His condition still seemed to preclude any chance of successful
     intervention, but none the less life was retained until the
     morning of the seventh day, the state alternating between a
     moribund one and one of slight improvement. He was lucid at
     times, although for the most part wandering, and was so
     restless that no covering could be kept upon him. Vomiting was
     continuous, so that no nourishment could be retained; the
     bowels acted frequently involuntarily, and little or no urine
     was passed. Meanwhile, the abdomen became flat, then sunken, an
     area of induration and tenderness about 6 inches in diameter
     developing around the wound of entry. Slight variations in the
     pulse, and from normal to subnormal in the temperature, were
     noted, and death eventually occurred from septicæmia and
     inanition.

     (168*) Wounded at Driefontein. _Entry_ (Mauser), above the
     posterior third of the left iliac crest, at the margin of the
     last lumbar transverse process (probably through ilio-lumbar
     ligament); _exit_, 1 inch below and to the left of the
     umbilicus.

     The patient was wounded at 3 P.M., but not brought into the
     Field hospital until 9 P.M., when the temperature of the tents
     was below 28°F. He was considerably collapsed, suffering much
     pain, and vomited freely. The abdomen was flat, but very
     tender. Bowels confined. The column had to move at 5 A.M. the
     next morning, when the temperature was still near freezing, and
     during the day continuous fighting prevented any chance of
     operation. The man steadily sank during the day, and died
     thirty-six hours after the reception of the injury.

     _Post-mortem condition._--Belly not distended, dull anteriorly
     in patches, and right flank dull throughout. When the belly was
     opened, extensive adhesion of omentum and intestine enclosing
     numerous collections of pus were disclosed, and on disturbing
     the adhesions a large collection of turbid blood-stained fluid
     was set free from the right loin. The great omentum was much
     thickened and matted, with deposition of thick patches of
     lymph; very firm recent adhesions also united numerous coils of
     small intestine. The pus was foetid, but no appreciable
     quantity of intestinal contents was detected in it. The lower
     half or more of the small intestine was injected, reddened, and
     thickened. The wounds which were situated in the lower part of
     the jejunum and ileum were multiple, and seven perforations
     were detected; besides these the intestine was marked by
     bruises, and some gutter slits affecting the serous and
     muscular coats only. Considerable ecchymosis surrounded these
     latter. The clean perforations were circular, less than 1/4
     inch in diameter, and for the most part closed by eversion of
     the mucous membrane. Intestinal contents were not apparent, but
     escaped freely on manipulation of the bowel.

     (169*) Wounded at Magersfontein. _Entry_ (Mauser), over the
     eighth rib in the anterior axillary line; _exit_, 1 inch to the
     left of second lumbar spinous process, just below the last rib.
     Vomiting commenced almost immediately after reception of the
     injury, and the bowels acted frequently. This condition
     persisted until the fourth day, when the patient was brought
     down to Orange River, and the signs were as follows.
     Considerable pain in left half of abdomen, pulse 110, fair
     strength, temperature 101°. Some general distension of abdomen
     with complete disappearance of hepatic dulness. Some movement
     of right half of abdomen, left half immobile, dulness extending
     from the flank as far forwards as linea semilunaris. An
     incision was made in left linea semilunaris, and Oj blood
     evacuated from the left loin. There was no lymph on the
     intestines nor sign of inflammation. No perforation was
     discovered in either stomach or intestine, but on two coils of
     jejunum there were deep slits 3/4 inch long, extending through
     both peritoneal and muscular coats. Beyond these wounds, on
     other coils oval patches of ecchymosis, due to direct bruising,
     were present. The peritoneal cavity was sponged free of all
     blood and irrigated with boiled water; no bleeding point was
     discovered, and the abdomen was closed.

     The next morning the patient was comfortable; temperature
     100.2°, pulse 100. Tongue clean and moist; he vomited once
     during the night.

     Some bloody discharge had collected in the dressing, and at the
     lower angle of wound there was a local swelling, apparently in
     the abdominal wall. The flank was resonant.

     During the afternoon the patient became faint, and when seen at
     6 P.M. was in a state of collapse, in which he shortly died.

     Death was apparently due to renewal of the previous hæmorrhage.
     No _post-mortem_ examination was made.

     (170*) Wounded at Magersfontein. _Entry_ (Mauser), 1/2 inch to
     the left of the second sacral spine; _exit_, immediately below
     the left anterior superior iliac spine; the patient was
     kneeling at the time, and the same bullet traversed his left
     thigh in the lower third. When seen on the third day, the
     lower part of the abdomen was motionless, tumid, and tender.
     The bowels had been confined for three days; there had been no
     sickness, and the tongue was moist and clean. Temperature 100°,
     pulse 90, fair strength, respirations 38. The patient had once
     had an attack of acute appendicitis, and he himself said he was
     sure he now had 'peritonitis,' as he had pain exactly similar
     in the belly to that he had suffered in his previous illness.

     No further signs, however, developed under an expectant
     treatment, and he remained some two months in hospital, while
     the wound in the thigh and a third injury to the elbow-joint
     were healing.

     (171) _Entry_ (Mauser), at the highest point of the left crista
     ilii; _exit_, through the right ilium, 2 inches horizontally
     anterior to the posterior superior spine. Absolutely no
     abdominal symptoms followed. The bowels were confined five
     days, and then opened by enema. The patient complained of some
     stiffness in the lumbo-sacral region, but the right
     synchondrosis was no doubt implicated in the track.

     (172) Wounded at Paardeberg (range 800 yards). _Entry_
     (Mauser), 2 inches diagonally below and to the right of the
     umbilicus; _exit_, not discoverable. For the first two days the
     patient had to lie out with the regiment; on the fourth he was
     removed to the Field hospital. During the first three days the
     patient vomited (green matter) frequently, and the belly was
     hard and painful; as biscuit was the only available food, no
     nourishment was taken. The bowels acted on the second night. At
     the end of a week the patient was sent by bullock wagon (three
     days and nights) to Modder River, and then down to Capetown,
     where he walked into the hospital on the thirteenth day,
     apparently well.

     Two days later the temperature rose to 104°, and enteric fever
     was diagnosed, no local signs pointing to the injury existing.
     The patient made a good recovery.

     (173) Wounded at Colenso. _Entry_ (Mauser), at junction of
     outer 2/5 with inner 3/5 of line from right anterior superior
     iliac spine to umbilicus; _exit_, at upper part of right great
     sacro-sciatic foramen, in line of posterior superior iliac
     spine. Advancing on foot when struck; he then fell and crept
     fifty yards to behind a rock, where he remained seven and a
     half hours. For two days subsequently he vomited freely; the
     bowels acted nine hours after the injury, and then became
     constipated. No further symptoms were noted, and at the end of
     three weeks the abdomen was absolutely normal. The man is now
     again on active service.

     (174*) Wounded at Modder River while retiring on foot. _Entry_
     (Mauser), at highest point of right iliac crest; _exit_, 2-1/2
     inches to right of and 1/2 inch above level of umbilicus. The
     injury was not followed by sickness, and the bowels remained
     confined. During the first two days 'pain struck across the
     abdomen' when micturition was performed.

     When the patient came under observation on the third day the
     condition was as follows:--Complains of little pain,
     temperature normal, pulse 72, respirations 24, tongue moist,
     bowels confined. Rigidity of abdominal wall and deficient
     mobility of nearly whole right half of belly, the whole lower
     half of which moves little with respiration. No track palpable
     in abdominal parietes. No dulness, no distension. The
     temperature rose to 99.5° at night. On the fourth day the
     bowels acted freely, the pulse fell to 60, the respirations
     were 24, and the temperature normal.

     Tenderness and rigidity persisted in the right flank to the end
     of a week, after which time no further signs persisted.

     (175*) Wounded at Modder River while lying on right side. Range
     500 yards. Walked 400 yards after injury. _Entry_ (Mauser), at
     the junction of the posterior and middle thirds of the right
     iliac crest; _exit_, 3 inches to right of and 1/2 inch below
     the level of the umbilicus. The injury was followed by no signs
     of intra-abdominal lesion; on the third day the temperature was
     normal, pulse 80, and the tongue clean and moist. Some soreness
     at times and tenderness on pressure were complained of, but the
     man was discharged well at the end of one month.

     (176*) Wounded while doubling in retirement at Modder River.
     _Entry_ (Mauser), immediately above the junction of the
     posterior and middle thirds of the left iliac crest; _exit_, 1
     inch below costal margin (eighth rib), 3 inches to the right of
     the median line. The bullet was lying in the anterior wound,
     whence it was removed by the orderly who applied the first
     dressing on the field. The patient remained on the field seven
     and a half hours, and when brought into hospital at once
     commenced to vomit. The ejected matter, at first green in
     colour, during the next forty-eight hours changed to a dirty
     brown. Meanwhile, the abdomen was somewhat painful. When seen
     on the third day he had ceased to vomit for three hours. The
     face was slightly anxious, and the patient lay on the ground
     with the lower extremities extended. Temperature 99°, pulse 72,
     fair strength. Respirations 32, shallow. Tongue moist, lightly
     furred, bowels not open for four days. He slept fairly last
     night. Abdomen soft, moving well with respiration, no
     distension, slight tenderness below and to the right of the
     umbilicus, and local dulness in right flank.

     The next day the pulse fell to 60 and the bowels acted, but
     there was no change in the local condition. The man looked
     somewhat ill until the end of a week, but was then sent to the
     Base, and at the expiration of a month was sent home well.

     (177*) Wounded at Modder River. Two apertures of _entry_
     (Mauser); (_a_) below cartilage of eighth rib in left nipple
     line; (_b_) 2 inches below and 4-1/2 inches to the left of the
     median line. No exit wound discovered, and no track could be
     palpated between the two openings, which were both circular and
     depressed. When seen on fourth day there was tenderness in the
     lower half of the abdomen, and the left thigh was held in a
     flexed position. Respirations 20, respiratory movement confined
     to upper half of abdominal wall. Pulse 70, temperature 99°.
     Tongue moist, covered with white fur; bowels confined since the
     accident; no sickness. The patient remained under observation
     thirteen days, during which time pain and difficulty in
     movement of the left thigh persisted, also slight tenderness in
     the lower part of the abdomen; but at the end of a month he was
     sent to England well, but unfit to take further part in the
     campaign. I thought the bullet might be in the left psoas, but
     it was not localised.

     (178*) Wounded at Modder River. _Entry_ (Mauser), 3-1/2 inches
     above and 1-1/2 inch within the left anterior superior iliac
     spine; _exit_, 1-1/2 inch to the right of the tenth dorsal
     spinous process. The same bullet had perforated the forearm
     just above the wrist prior to entering the abdomen. No local or
     constitutional signs indicated either bowel injury or
     perforation of liver. The man, however, was suffering from a
     slight attack of dysentery, passing blood and mucus per rectum
     with great tenesmus. He was sent to the Base at the end of a
     week, and returned to England well three weeks later. He
     attributed his dysentery to the wound, as the symptoms did not
     exist prior to its reception; but as the disease coincided
     exactly with what was very prevalent amongst the troops at the
     time, I do not think there was any connection between it and
     the injury.

     (179) Wounded near Thaba-nchu. _Entry_, over the centre of the
     sacrum at the upper border of fourth segment; _exit_, 1-1/2
     inch above left Poupart's ligament, 2 inches from the median
     line. Aperture of entry oval, with long vertical axis. Exit
     wound a transverse slit, with slight tendency to starring (see
     fig. 19, p. 58). One hour after being shot the patient vomited
     once. There was some evidence of shock and considerable pain.
     The bowels acted involuntarily simultaneously with the
     vomiting, and incontinence of fæces and retention of urine
     persisted for four days. The vomit was bilious in appearance;
     no blood was seen either in it or the motions.

     Forty-six hours after the injury the condition was as follows:
     Face slightly anxious and pale; skin moist, temperature 100.4°;
     pulse 116, regular and of fair strength; respirations 24;
     abdomen slightly tumid; tenderness over lower half, especially
     on left side; the lower half moves little with respiration.

     Twenty-four hours later the patient had improved. He was
     comfortable and hopeful; slept well with morphia 1/3 grain
     hypodermically. Tongue moist, covered with white fur; has been
     taking milk only, [Symbol: ounce]ij every half-hour. No
     sickness. Temperature

     99°. Pulse 104. Respirations 24. Abdomen flatter; general
     respiratory movement; tenderness now mainly localised to an
     area 2-1/2 inches in diameter, to the left of the umbilicus,
     above exit wound.

     The patient continued to improve, and on the fifth day
     travelled six hours in a bullock wagon to Bloemfontein. Soon
     after arrival his temperature was normal: pulse 80,
     respirations 16, with good abdominal movement. Local tenderness
     persisted in the same area, but was less in degree. Tongue
     rather dry, bowels confined. Micturition normal. Two drachms of
     castor oil and an enema were given.

     On the ninth day patient was practically well, except for
     slight deep tenderness. He remained in bed on ordinary light
     diet, but at the end of the third week he was seized by a
     sudden attack of pain, the temperature rising to 103° and the
     pulse to 140, the abdomen becoming swollen and tender. He was
     then under the charge of Mr. Bowlby, who ordered some opium,
     and the symptoms rapidly subsided. Although this wound crossed
     the small intestine area, it is probable that the symptoms may
     have been due to an injury of the rectum or sigmoid flexure.

3. _Wounds of the large intestine._--Injuries to every part of the 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 septicæmia.
Several cases of recovery from wounds of the cæcum 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 fæces, 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
septicæmia mainly due to absorption from the surface of that membrane
(_Pleural septicæmia_).

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 cæcum and ascending colon._--Boer,
     wounded at Graspan while sheltering behind a rock, lying on his
     back.

     _Entry_ (Lee-Metford), in right thigh, 3 inches below and 1
     inch within anterior superior spine of ilium; _exit_, in back,
     on a level with the fourth lumbar spinous process and 3 inches
     from that point.

     Half an hour after the wound the patient commenced to suffer
     severe stabbing pain; he lay on the field one hour; later he
     was taken to a Field hospital, and on the second day was sent
     by train a distance of twenty-five miles.

     When seen at the end of fifty hours the condition was as
     follows. Face anxious, complexion dusky. Great abdominal pain,
     especially about the umbilicus. Vomiting frequent and
     distressing; bowels confined since the accident; tongue dry and
     furred. Urine scanty. Pulse full and strong, 125; respirations,
     entirely thoracic, 30.

     Abdomen generally distended and tympanitic, wall rigid and
     motionless. Dulness in right flank, together with superficial
     oedema and emphysema.

     Abdominal section fifty-three and a half hours after accident.
     Incision in right linea semilunaris. Great omentum adherent to
     ascending colon, which was covered with plastic lymph. Gas and
     intestinal contents escaped from an opening at the line of
     reflexion of the peritoneum from the ascending colon;
     retro-peritoneal extravasation and emphysema extended the whole
     length of the ascending colon and around duodenum, the wall of
     the colon itself exhibiting subperitoneal emphysema. The colon
     was freed and the rent sewn up with interrupted sutures. About
     [Symbol: ounce] iv of foul fæcal fluid were evacuated from
     loin, and a free counter-opening made. The opening in the ilium
     by which the bullet had entered the abdomen was found at the
     brim of the pelvis; the loin and peritoneal cavity were sponged
     dry and flushed with boiled water; no lymph was seen on the
     small intestine. A large gauze plug was inserted into the
     posterior wound, one end of the plug being brought out of the
     operation incision.

     During the succeeding six days progress was not unsatisfactory:
     the abdomen became soft, moved with respiration, there was no
     sickness, and the bowels acted. The pulse fell to 90,
     respirations to 20, and the temperature did not exceed 102° F.
     The wound suppurated freely, however, and although there were
     no further signs of peritoneal septicæmia, it was evident that
     general infection had taken place, and on the sixth day a
     parotid bubo developed on the right side, which was opened.

     On the seventh day the patient suddenly commenced to fail
     rapidly; vomiting was almost continuous--at first curdled milk,
     later frothy watery fluid--and on the eighth day he died. The
     abdomen remained soft, sunken, and flaccid, and death no doubt
     resulted from general septicæmia rather than from peritoneal
     infection, absorption taking place from the large foul cavity
     behind the colon. As the cavity in part surrounded the
     descending duodenum, this possibly accounted for the attack of
     vomiting which preceded death.

     (181*) _Ascending colon._--Wounded at Graspan while lying in
     prone position. _Entry_ (Mauser), over ninth rib in line of
     right linea semilunaris; _exit_, in right buttock, just below
     and behind the top of the great trochanter.

     The injury was followed by little abdominal pain, but a strange
     sensation of local gurgling was noted. The bowels acted as soon
     as the patient reached camp, some hours after being wounded.
     There was no sickness and nothing abnormal was noted in the
     motions, except that they were loose and light-coloured.

     On the evening of the third day the patient came under
     observation in the ambulance train for Capetown. He looked
     somewhat anxious and ill, but he complained of little pain; the
     temperature was 102°, pulse 88, fair strength, soft and
     regular. There was local dulness, tenderness, and deficiency of
     movement in the right iliac region. As it was night, he was
     removed from the train and an operation was performed the next
     morning.

     Prior to operation the condition was as follows: Pulse 84,
     temperature 100°; respiration easy, 20. Tongue moist, but
     thickly coated in centre. Abdomen moves fairly, and is
     resonant, except in right lower quadrant. No distension.
     Dulness, tenderness, and rigidity in right iliac region, marked
     to outer side of cæcum. Entry wound nearly and exit quite
     healed. Cannot flex right thigh. The following operation was
     performed. Appendix incision, about [Symbol: ounce]j of fæcal
     fluid and fæces in a localised cavity on outer and anterior
     aspect of cæcum evacuated; adhesions very firm. Cavity sloughy
     throughout and cæcum covered with dull grey lymph. The opening
     in the bowel was not localised, and it was considered wiser to
     treat the case like one of perforation from appendicitis than
     to run the risk of breaking down adhesions. A small awl-like
     opening was found in the ilium with powdered bone at its
     entrance leading to the wound of exit.

     The after-treatment of the case gave rise to no anxiety, but
     healing of the resulting sinus was slow; fæcal-smelling pus
     escaped for some days, and a number of small sloughs came away.
     On the twelfth day the patient was sent down to Wynberg, where
     he remained twelve weeks. A counter-incision was needed in the
     loin to drain the suppurating cavity three weeks after the
     primary operation, and five weeks after the operation an escape
     of gas and fæces took place from the anterior wound, while the
     bowels were acting, as a result of a dose of castor oil. No
     further escape of fæces occurred, and he left for England with
     a small sinus only. No extension of inflammation into the
     original wound track ever occurred, both openings and the canal
     healing by primary union.

     The sinus remained open, and occasionally discharged for a
     further period of six months, and then healed firmly; since
     when the patient has been in perfect health.

     (182*) _Splenic flexure, descending colon._--Wounded at
     Magersfontein. _Entry_ (Mauser), in sixth left intercostal
     space in mid-axillary line; _exit_, in left loin, below last
     rib, at outer margin of erector spinæ. The patient remained in
     the Field hospital three days, during which time he exhibited
     no serious abdominal symptoms, but during the journey to Orange
     River (53-1/2 miles) he was sick. He remained at Orange River
     two days, and while there an enema was administered, producing
     a normal motion. The abdomen was slightly distended; it moved
     fairly, there was slight rigidity, but little tenderness.
     Temperature 100.8°, pulse 120. No appearance of fæces in wound.

     When seen on the sixth day the condition was as
     follows:--Patient cheerful and not in great pain. Temperature
     99.2°; pulse 120; respirations 48, very shallow. Abdomen soft,
     moving freely, no distension or general tenderness. Fluid fæces
     escaping in abundance from the wound in loin. Redness of skin
     and swelling below level of wound, and cellular emphysema
     above. Fæcal-smelling fluid was also escaping from the thoracic
     wound.

     The wound was enlarged, but the patient rapidly sank, and died
     of septicæmia on the seventh day.

     (183*) An exactly similar case came under observation from the
     battle of Modder River, except that the opening in the loin was
     somewhat larger, and earlier and freer escape of fæces took
     place from it. In this also fæcal matter passed freely into the
     left pleural cavity, and fæcal matter was expectorated, while
     there was an almost complete absence of abdominal symptoms.
     Death occurred on the fourth day.

     No _post-mortem_ examination was made in either case, but I
     believe in both the extra-peritoneal aspect of the colon was
     implicated and that the septicæmia was in great part due to
     absorption from the pleural rather than the peritoneal cavity,
     since in neither case were the abdominal symptoms a prominent
     feature.

     (184) _Possible wound of cæcum._--Wounded at Spion Kop. Bullet
     (Mauser) perforated the right forearm, then entered belly.
     _Entry_, 3 inches from the right anterior superior iliac spine,
     in the line of the supra-pubic fold of the belly wall (a
     transverse slit); _exit_, in right buttock, on a level with the
     tip of the great trochanter and 2 inches within it. The wound
     was received immediately after breakfast had been eaten. There
     was retention of urine and constipation for three days, but no
     sickness. Local pain and tenderness were severe, and at the end
     of three weeks there was still local tenderness, slight
     induration, and dragging pain on defæcation. The patient
     returned to England at the end of a month well, except for
     slight local tenderness.

     (185) _Possible wound of colon._--Wounded at Paardeberg; range
     200 yards. Walking at time. The bullet (Mauser) perforated the
     left forearm, just below the elbow-joint. _Entry_, into belly 1
     inch anterior to the tip of the left eleventh costal cartilage;
     no exit.

     The injury was followed by pain in the left half of the abdomen
     and vomiting, which continued for two days. The bowels acted on
     the third day; no nourishment was taken for two days, but a
     small quantity of water was allowed. No further symptoms were
     noted, and at the end of a fortnight the patient was well,
     except for slight local tenderness. The bullet could not be
     detected with the X-rays.

     (186) _Wound of cæcum_.--Wounded at Paardeberg. _Entry_
     (Mauser), 2 inches diagonally above and within right anterior
     superior iliac spine; _exit_, immediately to the right of the
     fifth lumbar spinous process; the patient was lying on his left
     side when struck. A burning pain down the right thigh
     immediately followed the accident, and lasted some days. There
     was no sickness, the bowels were confined three days, and there
     was pain across the back and down the thigh.

     On the tenth day he arrived at the Base, when he was lying on
     his back suffering considerable pain. The temperature ranged to
     101°. There was diarrhoea and cystitis, with a considerable
     amount of pus in the urine, which was very offensive. A small
     fluctuating spot existed on the back, just to the right of the
     original exit wound which was firmly healed. The abdomen moved
     fairly with respiration in its upper part, but was motionless
     below, especially in the right iliac fossa; some induration was
     to be felt here. The right thigh was kept flexed.

     During the next few days the pus disappeared from the urine,
     and with this change the induration in the right iliac fossa
     increased. An incision (Mr. Gairdner) was made into the
     fluctuating spot behind, and pus evacuated. The patient
     recovered.

     (187) _Possible wound of cæcum._--Wounded outside Heilbron.
     _Entry_ (Mauser), in the right loin, 2-1/2 inches above the
     iliac crest, at the margin of the erector spinæ; _exit_, 1-1/2
     inch above and within the right anterior superior spine of the
     ilium. There was little shock. The patient was brought six
     miles in a wagon into camp, and slept comfortably with a small
     morphia injection. Prior to the accident the patient was
     suffering from diarrhoea, but afterwards the bowels were
     confined. The next morning there had been no sickness and
     little pain. The tongue was moist and clean, the pulse 80, the
     respirations 24, the belly moved generally, although
     inspiration was shallow; the temperature was 99°. Slight
     tenderness in the belly to the inner side of the exit wound,
     but no dulness.

     The patient was starved for the first thirty-six hours, a
     little warm water then being allowed. No symptoms developed,
     and a perfect recovery followed.

     (188) _Colon_, _liver_.--Wounded outside Heilbron. _Entry_
     (Mauser), midway between the last right rib and the crista
     ilii; _exit_, below the eighth costal cartilage in nipple line.
     There were no serious primary symptoms, but ten days after the
     accident the temperature rose, swelling and pain developed in
     the right loin, and on the fourteenth day a large tympanitic
     abscess was opened (Dr. Flockemann, German Ambulance.)
     Fæcal-smelling gas and pus were evacuated. There was no
     extension of the abscess forwards. A week later the patient had
     much improved, although there were evident signs of general
     absorption, and the discharge from the abscess cavity was
     abundant and very foul. On the thirteenth day a serious
     hæmorrhage occurred from the loin wound, which was opened up,
     but no evident source was discovered; hæmorrhage was repeated
     the next day, and the man died.

     At the _post-mortem_ examination a large quantity of
     chocolate-coloured fluid was found free in the abdomen and
     pelvis. A chain of small local abscesses was found surrounding
     the ascending colon, and a larger one over the front of the
     cæcum. The wall of the ascending colon was generally thickened,
     and from this, in three places, openings with rounded margins
     connected the abscess cavities with the lumen of the bowel. One
     of the openings, larger than the others, was possibly the
     aperture of entry of the bullet; the others were apparently
     spontaneous.

     At the anterior border of the right lobe of the liver an
     abscess cavity existed in connection with the wound of the
     liver, and this was continuous with the aperture of exit,
     although not discharging. The aperture of exit was plugged by a
     tag of omentum (see fig. 89). No obvious source of the
     hæmorrhage was forthcoming, but it probably originated in one
     of the large branches of the vena cava. The bullet had struck
     the transverse process of the lumbar vertebra, but had not
     given rise to any signs of spinal concussion.

     (189*) _Ascending colon._--Wounded at Modder River. _Entry_
     (Mauser), midway between the tip of the tenth right rib and the
     iliac crest. Bullet retained. A second wound existed over the
     centre of the left sterno-mastoid, and the bullet here was also
     retained and never localised. The patient stated that he
     brought up blood at short intervals for half an hour
     immediately after he was wounded. This might have been
     explained by the wound in the neck, but no difficulty in
     swallowing was noted. The bowels acted the day after he was
     shot, and, except for some local tenderness and immobility, no
     abdominal signs were noted. Three weeks later a swelling was
     obvious to the right side of the umbilicus, and a tympanitic
     abscess developed; this was opened, and a deformed Mauser
     bullet extracted. Foul pus, but no fæcal matter, was evacuated,
     and after discharging for a fortnight the wound closed, and the
     man was sent home as 'well.' In this case I assumed a wound of
     the ascending colon had occurred.

     (190*) _Rectum and bladder._--Wounded at Graspan, while
     retiring at the double. _Entry_ (Mauser), 1 inch to the right
     of the coccyx; _exit_, 1 inch above the junction of the middle
     and outer thirds of left Poupart's ligament. The man suffered
     with some pain in the abdomen, and for first two days with
     retention of urine. The urine was drawn off with the catheter,
     and contained blood. During the next five days micturition was
     hourly or more frequent; gas was passed _per urethram_, and the
     urine was very foul, containing evident fæcal matter.
     Micturition continued frequent, with purulent cystitis for one
     month. Local tenderness, pain, and immobility developed over
     the lower quarter of the abdomen, extending to the right iliac
     fossa. A local abscess pointed a little to the right of the mid
     line, and 2 inches above the symphysis, and from this
     foul-smelling pus, but no fæces, was discharged for three
     months, during which period the surrounding dulness and
     induration gradually decreased and the sinus healed. When the
     patient left for England there was still occasional slight
     discharge from the original wound of entry, and there was
     slight discomfort on micturition, but he was otherwise well.

     A year later the man had resumed active duty, and, except for
     occasional pain on stooping, considered himself well.

The following cases are appended as of some general interest. The 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 fæces, and later slime, constantly
     escaped, but no fæcal matter ever escaped from the wound in the
     buttock. There was no history of previous dysentery, and rectal
     examination afforded no information. The buttock wound had to
     be opened up, disclosing a tunnel in the ilium.

     The wounds granulated slowly with continuous suppuration, but
     were healed, and the patient returned home at the end of
     fourteen weeks, the bowels acting normally.

     (192) Wounded at Paardeberg. _Entry_ (Mauser), at the junction
     of the middle and posterior thirds of the left iliac crest; the
     bullet was retained, and removed (Mr. Pegg) from the back of
     the right thigh, 3 inches below the back of the great
     trochanter. After the injury retention of urine followed, with
     incapacity to control loose motions, though solid ones could be
     retained. The retention was treated by catheterisation, which
     was followed by cystitis. The power of micturition was slowly
     recovered, and three weeks later he could pass water, at times
     in a dribbling stream only; the cystitis had improved. The man
     returned to England very much improved, but not quite well, at
     the end of five weeks.

     (193) Wounded at Modder River. _Entry_, in the right buttock,
     near the outer border at the upper part; _exit_, at the lower
     part of outer border of left buttock. The line of the wound
     exactly crossed the position of the anus, but no sign of injury
     to the rectum could be discovered.

     (194) Wounded at Magersfontein. _Entry_ (Mauser), 1/2 inch
     below the margin of the iliac crest, at the junction of its
     middle and posterior thirds, and on a level with the fifth
     lumbar spinous process; _exit_, below the cartilage of the
     eighth rib, just within the left nipple line. Struck while
     retiring; fell at once, and remained thirty hours on the field.
     Patient stated that he vomited 'blood like coffee grounds' six
     times while lying on the field, and twice after being brought
     in. His bowels were confined for three days. His right lower
     extremity was paralysed.

     On the fifth day there was considerable induration around the
     wound of exit, and the upper half of the abdomen was immobile
     and tender. The temperature rose to 100°, and the pulse was 96.
     Shortly afterwards a similar condition was noted in the lower
     half of the abdomen; the temperature continued to be raised and
     the pulse quickened, when on the thirteenth day a considerable
     quantity of pus was passed per rectum, and diarrhoea set in;
     this continued for three days, with marked improvement in the
     general symptoms. Micturition, which had been painful, became
     normal; the pulse and temperature fell, and the expression
     became less anxious. The patient continued to sleep badly,
     however, and complained of pain.

     At the end of the third week he still looked ill, but was
     easier. Temperature normal in the morning, 100° in evening,
     pulse 80. Tongue thickly furred, but moist. Still on milk diet;
     appetite bad; bowels irregular.

     The abdomen moved little in the lower half, induration
     persisted in the left iliac fossa, the left thigh continued
     flexed, and resonance was impaired to the left of the
     umbilicus.

     At the end of six weeks a distinct hard swelling in two parts,
     separated by a resonant area, was noted to the left of the
     umbilicus and in the left iliac fossa. The abdomen moved
     fairly, and there was little tenderness over the swelling.
     During the next week the swelling appeared to increase and to
     fluctuate; at the same time the temperature again began to rise
     to 100° and 101° at eve. The swelling was taken to be a
     localised peritoneal suppuration, and an incision was made over
     it; but this led down to a free peritoneal cavity, with a
     tumour pressing up from the posterior abdominal wall. The wound
     was therefore closed, and a fresh extra-peritoneal incision
     made, immediately above Poupart's ligament, when the swelling
     proved to be a large retro-peritoneal hæmatoma. As the cavity
     extended into the pelvis and up to the level of the costal
     margin, it was deemed wise only to evacuate a part of the
     blood-clot. The origin of the bleeding was not determined, and
     the wound was closed and healed by first intention. The man
     continued to improve, and left for home five weeks later.

     This patient has continued to improve since his return, but the
     left thigh is still somewhat flexed.

_Prognosis in intestinal injuries._--This was of a most 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 hæmorrhage 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 hæmatemesis, 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 cæcum 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
septicæmia.

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 hæmorrhage and septicæmia. 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 septicæmia, and one after operation from recurrent
hæmorrhage, 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 hæmorrhage
     at the time. His condition when I saw him was fair, and there
     was no marked abdominal tenderness. On April 1 his morning
     temperature was 101°. There were no signs of general
     peritonitis, and his condition was good.

     CASE VII.--The bullet had entered from behind, about the tip of
     the twelfth rib on the left side, and had left about the middle
     of the epigastrium, and rather to the left of the middle line.

     Vomiting was still going on, but not of blood. There was much
     tenderness and rigidity of the abdomen, and he was almost
     pulseless. On April 1 his general condition was better, but the
     abdomen was very rigid and tender. (Subsequently died.)

     CASE VIII.--The point of entrance of the bullet was about 2
     inches from the anterior end of the seventh left intercostal
     space, and of exit rather lower down and further back on the
     right side. The patient said that he had vomited brown fluid
     after the injury. There was much abdominal pain, but his
     general condition was fair. On April 1 there was still much
     pain, but his general condition was good.

     CASE IX.--The bullet had entered about 1-1/2 inch in front of
     the anterior inferior spine on the right side, had gone
     directly backwards, and had come out in the buttock. The
     patient, however, suffered very little. On March 31 there was
     slight tympanites and tenderness in the right iliac fossa. The
     bowels acted well, and no blood was passed. On April 1 he was
     very well, and it was considered very doubtful if any viscus
     was wounded.

     CASE X.--The point of entrance was in the middle of the right
     buttock, a little above the level of the trochanter; the exit
     was through the anterior abdominal wall in the right semilunar
     line at the level of the umbilicus. The patient was decidedly
     ill; the abdomen was a good deal distended, and pressure on it
     caused an escape of gas through the anterior opening. There was
     a good deal of abdominal tenderness and rigidity. I opened the
     abdomen outside the right linea semilunaris, and found a
     perforation in the anterior wall of the _ascending colon_,
     without any adhesions around, which was easily stitched up. The
     posterior opening was found about 2 inches lower down, with a
     piece of omentum firmly adherent to it and completely closing
     it. As the patient was in a bad state, I thought it better,
     instead of excising the piece of intestine beyond the holes or
     tearing off the omentum, to leave the wounds alone, merely
     cleaning out the peritoneal cavity as well as I could and
     arranging for free drainage. He rallied from the operation very
     well, and for twenty-four hours it looked as if he might get
     better; but he gradually got worse and died on April 2.'

The above statistics are particularly valuable, as they give 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 fæces,
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 septicæmia. 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
fæces 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 septicæmia, 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
hæmaturia 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 septicæmia 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°. Pulse 80, good strength. The patient was then sent to
     the Base. At the end of seventeen days there was still a little
     tenderness in the left iliac fossa; but the man was otherwise
     well, and at the end of a month he was sent home.

     (195) _Extra-peritoneal wound of the bladder._--Wounded at
     Magersfontein. _Entry_ (Mauser), at the fore part of the right
     buttock. No exit. The patient was seen on the third day. He had
     an expression of extreme anxiety, and complained of very great
     pain in the abdomen and thigh. The abdomen was greatly
     distended and tympanitic, and the left thigh and groin were
     very much swollen and oedematous, with some redness of
     surface. Temperature 100°, pulse 120. No sickness, tongue
     moist, bowels confined. Retention of urine. The condition of
     the patient was very grave; but he was anæsthetised, clear
     urine was withdrawn from the bladder by catheter, and an
     incision was made into the thigh just below the inner third of
     Poupart's ligament, where fluctuation was evident. Two pints of
     bloody urine were evacuated, and when a finger was introduced
     it passed over a fracture of the pubes into the pelvis, but not
     into the peritoneal cavity. In view of the patient's condition
     it was not thought wise to proceed further, and he somewhat
     improved later, and was sent to the Base. Loss of power in the
     right lower extremity pointed to injury to the anterior crural
     nerve.

     On the patient's arrival at Wynberg there were signs of local
     peritonitis in the lower half of the abdomen, and all his urine
     was passed from the wound in the left thigh. Some days later
     this wound was enlarged to allow of the freer exit of pus, and
     a fragment of bone was removed. The wound granulated healthily,
     but the man steadily emaciated and lost ground, with signs of
     chronic septicæmia, and he died on the twenty-first day. At the
     _post-mortem_ examination a transverse wound of the anterior
     wall of the bladder behind the pubes, below the peritoneal
     reflexion, was found gaping somewhat widely, and 2 inches in
     length. There was little sign of previous peritonitis. The
     retained bullet was discovered beneath the femoral vessels in
     the left thigh.

     (196) _Extra-peritoneal perforation of the bladder._--Wounded
     at Paardeberg. _Entry_ (Mauser), 3 inches above the left tuber
     ischii; _exit_, above the symphysis, immediately over the right
     margin of the penis. The patient was retiring to fetch
     ammunition when shot. Urine was noted to escape from both
     apertures the day after, and this continued until he was sent
     down to the Base on the fourteenth day. The patient was then
     considerably emaciated, complained of great pain, especially
     down the left thigh (sciatic nerve), the temperature averaged
     100°, the pulse 80, tongue clean and moist, bowels acted
     regularly, no sign of injury to the rectum. He was taking food
     fairly, but was very sleepless. Urine was passed per urethram,
     and also escaped by both wounds. The abdomen was flaccid and
     sunken, respiratory movements being confined to the upper half.

     As there was evidence of considerable infiltration in the
     buttock, the original entry wound was enlarged, and a catheter
     was tied into the bladder. Little change occurred in the
     symptoms and the local condition, urine and pus continued to
     escape freely from the posterior wound, and the patient
     gradually sank, dying on the thirty-eighth day. At the
     _post-mortem_ examination the peritoneum was found intact and
     unaltered, but there was extensive pelvic cellulitis around the
     bladder, a large slough and some pus lying in the cavum Retzii.
     An aperture of entry still open existed in the centre of the
     anterior wall of the bladder, and a patent exit opening at the
     base of the trigone. The bullet had passed out of the pelvis by
     the great sciatic notch.

The above remarks and cases sufficiently set forth the prognosis 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
hæmaturia.

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 hæmorrhage from the organ, persisting for two to four days. In
one of the cases recounted below the hæmaturia 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
hæmorrhage. 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 hæmorrhage 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 hæmaturia ceased. No thoracic signs, and no other sign of
     abdominal injury. There was tenderness in the left loin below
     the twelfth rib for some days, possibly over the position of
     the bullet, but the latter was neither localised nor removed.

     (200) _Wound of the right kidney._--Wounded at Magersfontein
     while retiring on his feet. _Entry_ (Mauser), immediately to
     the right of the second lumbar spinous process; bullet retained
     and lay beneath margin of ninth right costal cartilage. The man
     passed urine containing blood twelve times during the first
     day, and hæmaturia continued until the evening of the third
     day. On the third day the belly was tumid and did not move
     well; there was no dulness in the right flank. Pulse 120, fair
     strength. Temperature 99°. Respirations 20. Tongue moist,
     bowels confined for four days. The fifth day the pulse fell to
     76, and the bowels were moved by an enema. Great tenderness
     over bullet. The tenderness persisted over the bullet and also
     in the right flank until the tenth day, when the bullet was
     removed. At the end of a month the patient returned to England
     well but during the third week there was occasionally blood in
     the urine.

     (201) _Wound of both kidneys (rupture of right) and
     spleen._--Wounded at Magersfontein. _Entry_ (Mauser), (_a_) 1
     inch to right of second lumbar spinous process; (_b_) above
     angle of left ninth rib: _exits_, (_a_) 1 inch internal to
     right anterior superior iliac spine; (_b_) in seventh
     intercostal space in mid-axillary line. The wound on the right
     side gave rise to a lesion of the lumbar bulb (see p. 315), and
     the patient suffered throughout with retention. There was
     complete paralysis of the right lower extremity, both motor and
     sensory. For ten days there was hæmaturia, and very severe
     cystitis developed, while the patient suffered with severe
     abdominal pain. The cystitis persisted, also retention, which
     gradually gave way to dribbling, while irregular rise of
     temperature and tenderness in the loins pointed to ascending
     inflammation in the ureters. The patient gradually lost
     ground, and a month later suddenly developed signs of
     peritonitis, severe vomiting, distension, and dulness in the
     right flank; and in two days he died.

     At the _post-mortem_ examination the following condition was
     found:--On the right side general pleural adhesions, recent
     lymph over ascending colon and cæcum, [Symbol: ounce]vj of
     bloody fluid in a localised cavity between colon, kidney,
     stomach, and liver. Lower quarter of right kidney in half its
     width separated from main part of organ, yellow in colour, and
     enveloped in disintegrating clot. Blood-staining of psoas
     sheath; no injury to vertebral column or to bowel detected.

     On the left side recent pleural adhesions and consolidation of
     base of lung, rent of diaphragm; spleen soft and disorganised
     and presenting a yellow cicatrix at its upper end, and at
     antero-external aspect of left kidney was a soft yellow
     puckered spot about the size of a florin, dipping 3/4 of an
     inch into the organ, which was otherwise healthy, beyond
     congestion. The capsules of both kidneys were adherent, but
     there was no sign of suppuration.

     (202) _Wound of right kidney. Traumatic
     hydronephrosis._--Wounded at Magersfontein. _Entry_
     (Lee-Metford), in the eleventh intercostal space in the
     posterior axillary line; _exit_, in the tenth right interspace,
     in mid axillary line. The patient was in the prone position
     when struck, and lay on the field from 5 A.M. until 6 P.M.
     There was no sickness, and the bowels did not act. When seen on
     the fourth day he was cheerful, but in some pain. The abdominal
     wall moved well, but was rigid; there was some general
     distension, and very marked local distension of the gastric
     area extending across to the right, so that a depressed band
     extended between the upper and lower parts of the belly. There
     was marked local dulness in the right flank, which did not
     shift on movement; the abdomen was elsewhere tympanitic. Tongue
     furred, bowels confined; there has been no sickness, and no
     hæmatemesis. Urine normal, and in good quantity. Temperature
     100°. Pulse 84, good strength. There was impairment of
     sensation in the area of distribution of the external cutaneous
     and crural branch of the genito-crural nerves.

     On the sixth day the bowels acted, after the administration of
     [Symbol: ounce]j of sulphate of magnesia, and the distension was
     much lessened, although the belly retained its unusual
     appearance. The dulness in the flank was unaltered. Temperature
     100.8°, pulse 92.

     A week later the man was much improved, suffering no pain.
     Temperature ranged from 99 to 100°, and the pulse about 80. The
     abdomen was normal in appearance, except for general prominence
     of the right thorax in the hepatic area.

     During the third week a large tympanitic abscess developed at
     the aperture of exit, and this was opened (Mr. S. W. F.
     Richardson) through the chest, and a large collection of
     foul-smelling pus, but no fæcal matter, evacuated. The patient
     again improved, but a fortnight later a swelling and apparent
     signs of local peritonitis developed in the right inguinal and
     lower umbilical and lumbar regions. An incision made over this,
     however, disclosed a normal peritoneal cavity and was closed.

     At the end of ten weeks the patient was sent to the Base
     hospital; a large firm swelling was then evident, extending
     from the liver to the inguinal region, and nearly to the median
     line. This gradually increased until it filled half the belly;
     it was at first thought to be a retro-peritoneal hæmatoma
     (similar to that described in case 194), but it became quite
     soft and fluctuating, and was then tapped, and [Symbol:
     ounce]50 of blood-stained fluid, which proved to be urine, were
     removed. The urine rapidly reaccumulated, and the cavity was
     then laid freely open. Urine continued to discharge in large
     quantity for two months, the man meanwhile remaining well, and
     passing a somewhat variable daily quantity of urine ([Symbol:
     ounce]xxiv-[Symbol: ounce]lx).

     At the end of six months the wound had healed, and the man was
     serving as an orderly in the hospital.

     (203) _Wound of right kidney and lung._--Wounded near
     Paardekraal, while crawling on hands and knees. _Entry_
     (Martini-Henry, or small bullet making lateral impact), just
     above the right nipple, opening ragged and large, bullet
     retained. There was very severe shock, accompanied by vomiting,
     but no hæmatemesis. Later there was some hæmoptysis. Pulse 120,
     respirations 48.

     Twenty-four hours later the vomiting had ceased; the patient
     had passed a restless night, in spite of an injection of
     morphia. He lay on his right side, pale and collapsed, but
     answered questions and was quite collected. Pulse
     imperceptible, respirations 56; the abdomen moved freely. The
     urine had been passed twice, and was chiefly blood. The patient
     died shortly afterwards, apparently mainly from internal
     hæmorrhage, although restlessness was not a prominent feature.
     As the Column was on the march no autopsy was possible.

The treatment of uncomplicated wounds of the kidney consisted in the
ensurance of rest, either alone, or with the administration of opium if
the hæmaturia 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 hæmorrhage 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 hæmorrhage 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 hæmorrhage 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 fistulæ 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 hæmorrhage 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 hæmorrhage, 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°, 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 hæmorrhage, 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 hæmorrhage.

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 hæmorrhage, 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 hæmorrhage 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 hæmorrhage 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 hæmorrhages, 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
hæmorrhage. When the wound was opened up an opening was found in the
external circumflex artery, hæmorrhage 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 anæsthetised and the
     fragment extracted. The wound of entry was at the same time
     enlarged, cleansed, and partly sutured. The patient vomited
     once after the anæsthetic, and the bowels remained confined for
     three or four days after the injury. The extraction wound
     healed readily, but a considerable amount of slimy,
     bile-stained discharge was still escaping from the ragged
     entrance wound on the man's arrival at the Base on the
     fourteenth day. The abdomen was then normal in appearance, and
     as to physical signs, except for a tympanitic note over the
     hepatic area to the right of the wound. The temperature was
     normal, the pulse 90, the tongue clean, and the bowels were
     acting. At the end of four weeks pleurisy, with effusion,
     developed on the right side; the chest was aspirated and
     [Symbol: ounce]xx of clear serum drawn off. The man then
     rapidly improved; the bile-stained discharge ceased at the end
     of five weeks, and a small granulating wound eventually closed
     at the end of two months, when the man returned to England.

Fig. 91 is inserted to illustrate the multifarious nature of 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 hæmatoma, 123
  Prognosis in, 126
  Treatment of, 126

Arteries:
  Compression by cicatrices, 113
  Contusion of, 112
  Division of, 114
  Perforation of, 114

Arterio-venous aneurism:
  Arm and forearm, 150
  Cervical, 149
  Femoral, 150
  Leg, 150
  Popliteal, 151
  Treatment of, 148


Biliary fistula, 467

Bladder:
  Wounds of, 443, 457
  Extra-peritoneal, 458
  Intra-peritoneal, 457
  Retained bullet in, 110, 460

Bones. See Fractures

Bowlby, Mr.:
  Retained bullets in joints, 229, 230
  Wound of pharynx, 311

Brain:
  Abscess of, 287
  Cerebral irritation, 269
  Compression of, 267
  Concussion of, 266
  Effect of ricochet on, 249
  Explosive injury of, 247, 248
  Frontal injuries, 247, 249, 266
  Fronto-parietal injuries, 273
  Occipital injuries, 276
  Parietal injuries, 273
  Prognosis in cerebral injuries, 289
  Treatment, 289

Bread, 7

Buck wagon, 21

Bullets:
  Characters directly affecting wounds:
    Aseptic nature, 70
    Calibre, 41
    Composition of, 51
    Deformities of, 81
    Fragmentation, 88
    Length, 41
    Mantles of, 52, 82, 83
    Penetration, 49
    Revolution, 45
    Ricochet, 82
    Shape, 42
    Stability, 51
    Striking force, 50
    Velocity of flight, 42
    Weight, 42
  Effect of resistance of bones on, 86, 87, 88, 93
  Retention of, 71, 79
    Indications for removal of, 110
    in bladder, 110, 460
    in chest, 381, 401
    in nasal fossa, 244
    in or near joints, 229, 230
    in skull, 244, 249, 260, 266, 284, 298
    in spinal canal, 337
  Reversal of, 81
  Varieties of:
    Determination of, 105
    Expanding, 91
    Explosive, 95
    Guedes, 48, 51
    Krag-Jörgensen, 48, 51
    Jeffreys, 94
    Large leaden, 95
    Lee-Metford, 52, 89
    Mark IV., 94
    Mauser, 52, 83
    Soft-nosed, 93
    Tampered, 95
    Tweedie, 94
    Waxed, 52


Cauda equina, injury to, 325, 330

Cellulitis, 34

Cervical nerve roots, injury to, 107
  Plexus, 357

Cheatle, Mr. G. L.:
  Entry and exit wounds, 72
  First field dressing, 107
  Wound of heart, 383
  "     "   intestine, 413

Cheek, wounds of, 309

Chest, injuries to, 374
  Character of wounds, 377
  Influence of small calibre of bullet on, 374
  Martini wounds, 374, 388
  Non-penetrating wounds, 375
  Penetrating wounds, 376

Cheyne, Mr. W. W., F.R.S.:
  Abdominal wounds, 449
  Spent bullets, 243, 449

Civil surgeons, 38

Climate, 8, 36, 71

Comparison of South African with other campaigns, 14

Compression of brain, 267
  Spinal cord, 319

Concussion of brain, 266
  Eye, 300
  Joints, 226
  Nerves, 341, 343
  Spinal cord, 315

Contour wounds, 65

Contusion:
  Nerves, 343
  Spinal cord, 316

Costal cartilages, fractures of, 379

Cox, Dep. Insp.-Gen.:
  Case of varix, 148


Day, Mr. J. J.:
  Fractures of the skull, 251

Deadliness of modern weapons, 16

Diaphragm, wounds of, 381

Displacement of structures by the bullet, 68
  Abdomen, 411
  Nerves, 342
  Vessels, 382, 384
  Viscera, 310, 382, 411

Drink, 8

Dust, 8, 35
  Bacteriology of, 36


Empyema, 394, 396

Enteric fever, 9

Epilepsy, traumatic, 291

Equipment of foreign ambulances, 31
  Surgical, 4

Erysipelas, 34

Expanding bullets, 91

Explosive bullets, 95

Explosive wounds:
  of abdomen, 414
  of fractures, 155
  of head, 245
  of leg, 221
  of soft parts, 97
  of thigh, 197

Eye, injuries to, 299

Facial paralysis:
  Cortical, 273-277
  Peripheral, 355

First field dressings, 107

Flies, 36

Flockemann, Dr.:
  Hæmothorax, 393
  Injury to abdomen, 420

Fractures:
  Course of healing of, 172
  Explosive wounds in, 155
  into joints, 163, 228
  Limb bones, 154
  Local shock in, 172
  Long bones, types of, 161
    Longitudinal, 163
    Notch, 165
    Oblique, 165
    Perforating, 166
    Stellate, 161
    Transverse, 166
    Wedge, 165
  Osteomyelitis in, 174
  Pom-pom fractures, 483
  Prognosis, general, in, 174
  Special features of, 155
  Special bones:
    Acetabulum, 193
    Carpus, 183
    Clavicle, 178
    Femur, 193
    Fibula, 219
    Humerus, 178
    Jaws, 306
    Malar, 305
    Mastoid process, 299
    Metacarpus, 185
    Metatarsus, 224
    Orbital walls, 300
    Patella, 215
    Pelvis, 189
    Radius, 183
    Ribs, 377
    Scapula, 177, 379
    Skull:
      Base, 262
      Glancing, 254
      Gutter, 255
      Perforating, deep, 245
        Superficial, 259
      Treatment of, 293
    Spine, 314
    Sternum, 379
    Tarsus, 223
    Tibia, 217
  Short and flat bones, 168
  Suppuration of soft parts in, 173
  Symptoms of, 171
  Treatment of:
    General, 175
    Femur, 205
    Leg, 221
    Upper Extremity, 135
  Variation in character during the campaign, 154

Fractures in Franco-German war (Sir W. MacCormac), 167

Fragmentation of bullets, 88

Fuses of shells, wounds by, 481


Gangrene:
  Acute traumatic, 34
  After ligature of main vessels, 152

Genital organs, wounds of, 472

Guedes rifle, 65

Gutter wounds:
  of bladder, 458
  of bones, 231
  of intestine, 417
  of joints, 231
  of liver, 466
  of pelvis, 189
  of scalp, 242
  of skull, 255
  of soft parts, 157


Hæmarthrosis, 232

Hæmorrhage, 104, 114
  Control by bullets, 116
          by loop of nerve, 116
  Deaths from, 116
  Fever dependent upon, 118
  Internal, 116
  Interstitial, 118
  Primary, 114
  Recurrent, 117
  Secondary, 117
  Treatment of, 120

Hæmorrhoids, 10

Hæmothorax, 386, 389
  Behaviour of blood in, 390
  Course of, 390, 394
  Diagnosis of, 398
  Effect of transport on, 389
  Empyema after, 394
  Pleuritic effusion in, 390
  Prognosis in, 399
  Recurrent bleeding in, 393
  Parietal, 389, 398
  Pulmonary, 386, 389
  Symptoms of, 391
  Temperature in, 391, 393
  Treatment of, 400

Head, injuries to, 241

Health of the troops, 7

Heart, wounds of, 382
  in neighbourhood of, 384

Hemianopsia, 276
  Altitudinal, 277
  Lateral, 276

Hospitals:
  Field, 29, 37
  Foreign, 30
  General, 31, 38
  Improvised, 28, 39
  Indian Field, 29
  Stationary, 27, 31, 33, 37
  Varieties of, 28

Hospital ships, 24
  Tents, 32
  Trains, 23

Hydronephrosis, 464


Impact, irregular, 80, 82

Instruments, 4

Intestine, injuries to:
  Diagnosis of, 428
  Difficulties of operation, 453
  Indications for operation, 454
  Lateral contusion, 416
  Prognosis, 446
  Treatment, 452
  Wounds of, 415
    Extra-peritoneal, 419
    Large intestine, 436, 444
    Results of, 421
    Small intestine, 427

Irregular wounds, 97

Itinerary, 2


Jam, 7

Jaws, fractures of:
  Lower, 306
  Upper, 306
  Treatment of, 308

Jenner, L. L., bacteriology of dust, 36

Joints, injuries to, 225
  Arterial wounds in, 121, 233
  Classification of, 229
  Course after, 232
  Fractures into, 228
  Signs and symptoms, 232
  Suppuration of, 233
  Treatment, general, 235

Joints, retained bullets in or near, 229, 230

Joints, special:
  Ankle, 239
  Elbow, 236
  Hand, 237
  Hip, 238
  Knee, 238
  Shoulders, 236
  Tarsus, 240


Ker, J. E., cases of aneurism, 152

Kidney, wounds of, 461

Krag-Jörgensen rifle, 65


Laminectomy, 335, 340

Larynx, wounds of, 312

Leaden bullets, 95

Lee-Metford rifle,