The Project Gutenberg EBook of Surgical Experiences in South Africa, 1899-1900, by George Henry Makins This eBook is for the use of anyone anywhere at no cost and with almost no restrictions whatsoever. You may copy it, give it away or re-use it under the terms of the Project Gutenberg License included with this eBook or online at www.gutenberg.net Title: Surgical Experiences in South Africa, 1899-1900 Being Mainly a Clinical Study of the Nature and Effects of Injuries Produced by Bullets of Small Calibre Author: George Henry Makins Release Date: May 3, 2007 [EBook #21280] Language: English Character set encoding: ISO-8859-1 *** START OF THIS PROJECT GUTENBERG EBOOK SURGICAL EXPERIENCES *** Produced by Jonathan Ingram, Josephine Paolucci and the Online Distributed Proofreading Team at http://www.pgdp.net [Illustration: FRONTISPIECE. Photo, H. KISCH Ladysmith. Engraved and Printed by Bale and Danielsson, Ltd.] SURGICAL EXPERIENCES IN SOUTH AFRICA 1899-1900 BEING MAINLY A CLINICAL STUDY OF THE NATURE AND EFFECTS OF INJURIES PRODUCED BY BULLETS OF SMALL CALIBRE BY GEORGE HENRY MAKINS, F.R.C.S. SURGEON TO ST. THOMAS'S HOSPITAL, LONDON JOINT LECTURER ON SURGERY IN THE MEDICAL SCHOOL OF ST. THOMAS'S HOSPITAL MEMBER OF THE COURT OF EXAMINERS OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND, AND LATE ONE OF THE CONSULTING SURGEONS TO THE SOUTH AFRICAN FIELD FORCE LONDON SMITH, ELDER, & CO., 15 WATERLOO PLACE 1901 TO SURGEON-GENERAL W. D. WILSON PRINCIPAL MEDICAL OFFICER TO THE SOUTH AFRICAN FIELD FORCE THE MEMBERS OF THE ROYAL ARMY MEDICAL CORPS EMPLOYED IN SOUTH AFRICA AND TO THE CIVIL SURGEONS TEMPORARILY ATTACHED TO THAT CORPS These Experiences are Dedicated AS AN EXPRESSION OF APPRECIATION OF THE INVARIABLE KINDNESS AND SYMPATHY EXTENDED TO THE AUTHOR WITHOUT WHICH THE BOOK COULD NOT HAVE BEEN WRITTEN PREFACE A word of explanation is perhaps necessary as to the form in which these experiences have been put together. The matter was originally collected with the object of sending a series of articles to the _British Medical Journal_. Various circumstances, however, of which the chief was the feeling that extending experience altered in many cases the views adopted at first sight, prevented the original intention from being carried into execution, and the articles, considerably expanded, are now published together. As to the illustrative cases introduced in support of various statements made in the text, only those have been chosen from my notes which were under my own observation for a considerable time, and many of these have been brought up to date since my return to England. I have, as a rule, avoided the inclusion of cases seen cursorily, and few simple ones have been quoted since their character is sufficiently indicated in the text. These remarks seem necessary since the mode of selection has resulted in the inclusion of a number of cases of exceptional severity, and any attempt to draw statistical conclusions from them would be most misleading. The first two chapters have been added with a view to affording some information, first, as to the conditions under which a great part of the surgical work was done, and, secondly, as to the mechanism and causation of the injuries, which would not readily be at hand in the case of the general surgical reader. For much of the information contained in Chapter II. I must express my indebtedness to the work of MM. Nimier and Laval, so frequently quoted. The only other object of this Preface is to express my thanks to the many who have aided me in the task of amplifying the observations on which the articles are founded, and I think no writer ever received more sympathetic and kindly help in such particulars than the author. My first thanks, those due to the Members of the Royal Army Medical Corps, I endeavour to express by the dedication of this volume. Any attempt to make individual acknowledgment to either the Members of the Service, or to the Civil Surgeons temporarily attached, would be impossible. I have, however, tried to associate the names of many of those in charge of cases in the recital of histories and treatment throughout. My thanks are not less due to the Military Heads of Departments at the War Office, who have helped me in the collection of details as to the subsequent course of many of the cases described, and in the acquisition of information regarding the weapons and ammunition treated of. I should particularly express my gratitude to Colonel Robb, of the Adjutant-General's Department, and Colonel Montgomery, of the Ordnance Department. I am greatly indebted to my former colleague Mr. Cheatle for two of the illustrations of wounds, and for permission to quote some of his other experience, and to Mr. Henry Catling, to whose skill I owe the majority of the skiagrams of the fractures under my observation at Wynberg and elsewhere. I must also express my thanks to Mr. Danielsson and his artist, Mr. Ford, for the trouble they have taken in converting my rough sketches into the illustrations contained in the volume. Lastly, my warmest gratitude is due to my friends, Mr. Cuthbert Wallace, who has read some of my chapters, and to Mr. F. C. Abbott, who has read the whole book for the press and suggested many improvements and modifications. 47 CHARLES STREET, BERKELEY SQUARE, W. _February_ 1901. CONTENTS PAGE CHAPTER I INTRODUCTORY Itinerary--Surgical outfit--Personal transport--General health of the troops--Climate--Consideration of the number of men killed and wounded--Transport of the wounded--Vehicles--Trains--Ships--Hospitals 1 CHAPTER II MODERN MILITARY RIFLES AND THEIR ACTION General type--Calibre, length, and weight of bullet--Velocity--Trajectory--Revolution--Varieties of rifle in common use by the Boers--Penetration--Comparison of bullets--Use of wax--Comparative efficiency of different types 40 CHAPTER III GENERAL CHARACTERS OF WOUNDS INFLICTED BY BULLETS OF SMALL CALIBRE Type wounds--Nature of external apertures--Direct course of wound track--Multiple wounds--Small bore and sharp localisation of tracks--Clinical course--Mode of healing--Suppuration--Wounds of irregular type--Ricochet--Mauser bullet--Lee-Metford bullet--Expanding bullets--Altered bullets--Large sporting bullets--Symptoms--Psychical disturbance and shock--Local shock--Pain--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 Bon