The common history of the symptoms after a wound of the kidney was moderate haemorrhage from the organ, persisting for two to four days. In one of the cases recounted below the haematuria was accompanied by the passage of ureteral clots, but this was not a common occurrence.

For the sake of comparison I have included one case of wound of the kidney from a large bullet, in which death was due to internal haemorrhage. In this instance the injury was a complex one, the lung certainly, and the back of the liver probably, being concurrently injured. None the less if the same track had been produced by a bullet of small calibre I believe the injury would not have proved a fatal one. I never saw such free renal haemorrhage in any of the Mauser or Lee-Metford wounds.

(197) Wound of right kidney.—Wounded at Modder River while lying in the prone position; retired 100 yards at the double with his company, and walked a further 1-1/2 mile. There was very slight bleeding. Entry (Mauser), in the tenth right intercostal space in the mid-axillary line; exit, in eleventh interspace, 2 inches from the spinous processes. Cylindrical blood-clots, 3 inches in length, were passed on the first two occasions of micturition after the accident, and the urine contained blood. For four days he could only lie on the wounded side. When seen on the third day the urine was normal, and there were no signs of injury to either thoracic or abdominal viscera. He returned to England well at the end of a month.

(198) Wound of right kidney.—Wounded at Modder River while kneeling to dress another man's wound. Entry (Mauser), in the seventh right intercostal space in the nipple line; exit, 1 inch to the right of the twelfth dorsal spine. The man was carried off the field, and during the first day vomited frequently. For two days there was blood in his urine, and he passed water four to five times daily. He returned to duty at the end of three weeks.

(199) Wound of the left kidney.—Wounded at Magersfontein. Entry (Mauser), 2 inches to the left and 1 inch below the left nipple. No exit. Lying in prone position when struck. Bloody urine was passed at normal intervals for four days, when the haematuria ceased. No thoracic signs, and no other sign of abdominal injury. There was tenderness in the left loin below the twelfth rib for some days, possibly over the position of the bullet, but the latter was neither localised nor removed.

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

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

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

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

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

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

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

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

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

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

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

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

The treatment of uncomplicated wounds of the kidney consisted in the ensurance of rest, either alone, or with the administration of opium if the haematuria was severe. The after-treatment in the event of the development of hydronephrosis is on ordinary lines. Tapping, or incision followed by extirpation of the injured viscus, if the less severe procedures failed. I never saw a case where renal haemorrhage suggested the removal of the kidney as a primary step, and much doubt whether such a case is likely to be met with, as the result of a wound from a bullet of small calibre.

Wounds of the liver.—Wounds of the liver were, I believe, responsible for more cases of death from primary haemorrhage than those of the kidney. I heard of a few cases in which this occurred, although I never saw one. Case 204 is of considerable interest as illustrating the result of an injury to one of the large bile ducts. Putting the deaths from primary haemorrhage on one side, the prognosis in hepatic wounds was as good as in those of the kidneys. A few fairly uncomplicated cases are quoted below, but wounds of the liver occurred in connection with a large number of other injuries both of the chest and abdomen, and except in the case of wound of the stomach, recorded on page 425, No. 164, and in case 188, I never saw any troublesome consequences ensue.

Nature of the lesions.—I never saw any case of so-called explosive lesion of the liver, such as have been described from experimental results; this may have been due to the fact that such patients rapidly expired, but such were never admitted into the hospitals.

The most favourable cases were those in which a simple perforation was effected; such were usually attended by a practical absence of symptoms, unless a large bile duct had been implicated, when a temporary biliary fistula resulted.

Biliary fistulae were, however, much more common when the bullet scored the surface of the organ. One such case is recounted under the heading of injuries to the stomach, No. 164. Here a deep gaping cleft with coarsely granular margins extended the whole antero-posterior length of the under surface of the left lobe, and the escape of bile was free. This was the nearest approach to one of the so-called explosive injuries I met with.

Case 207 is an example of a superficial injury from a bullet possibly of small calibre in which a superficial groove was followed by temporary escape of bile, and it is of interest to note a very similar condition in a shell injury (No. 210) recorded on p. 477.

Although both these cases recovered, I think notching and superficial grooving must be considered much more serious injuries than pure perforation. (See case 188, p. 442.)

The symptoms observed in these injuries have been already indicated in the above description of the nature of the lesions. They consisted in the pure perforations of practically nothing, in the grooves or the perforations implicating a large duct in the escape of bile. In two of the cases in which a biliary fistula was present transient jaundice was noticed.

In many cases the accompanying wound of the diaphragm gave rise to much discomfort; again, in the transverse wounds the action of the heart was often affected by the local cardiac shock accompanying the injury. In one case in which the colon was at the same time wounded (No. 188), an abscess formed at the site of the hepatic wound, as might have been expected.

As uncomplicated injuries, these wounds were little to be feared. Except as a source of haemorrhage in rapidly dying patients, I never heard of a fatality. As a complication of other injuries, however, the wound of the liver, as has been shown, was sometimes of importance. It was remarkable in case 204 how little trouble the biliary fistula gave rise to, although the bile was discharged across the pleural cavity.

The treatment consisted in rest, and morphia in the cases of suspected progressive haemorrhage, or in the presence of great pain. In cases where bile was escaping, it was important to ensure a free vent for the secretion.

(204) Wound of liver. Biliary fistula.—Wounded at Magersfontein. Entry (Lee-Metford), below the seventh rib, in the left nipple line; exit, through the eighth rib, in the mid axillary line on the right side. The patient lay for seventeen hours on the field, during which time the bowels acted once, but there was no sickness. The bowels then remained confined. When seen on the third day the abdomen was normal and the chest resonant throughout on both sides; bile to the amount of some ounces escaped from the wound on the right side. Suffering no pain; temperature 99 deg., pulse 100. The bowels acted freely the following day.

During the next fortnight there was little change; [Symbol: ounce]ii-iij of bile escaped daily, and there was occasional diarrhoea. At the end of that time, however, the temperature rose; there was local redness and evidence of retention of pus. The wound was therefore enlarged, some fragments of rib removed, and a drainage tube inserted. After this the temperature fell, and for the next two months the patient suffered little except from the discharge from the sinus; this persisted for three months, becoming less in amount and less bile-stained, the fistula eventually closing in the fourteenth week, when the patient was sent home on parole.

(205) Wound of liver.—Entry (Mauser), 1 inch below and to the left of the ensiform cartilage; exit, in the sixth right intercostal space, just behind the posterior axillary line. The trooper was sitting bolt upright on his horse at the time; both were shot and fell together. 'Stitch' on coughing or laughing was the only sign noted after the accident; this rapidly subsided.

(206) Wound of the liver.—Wounded at Magersfontein. Entry (Mauser), through the seventh left costal cartilage, 1 inch from the base of the ensiform cartilage; exit, below the twelfth rib 2 inches to the right of the lumbar spines. The patient lay on the field some hours and was brought in at night very cold, and suffering with much shock. No signs of abdominal injury developed, but the pulse remained as slow as 66 for some days, and there was some pain and stiffness about back and sides, or on taking a deep breath. These signs persisted some days, but no others developed, and in six weeks the patient returned to duty.

Some three months later this patient suffered from a short severe attack suggesting local peritonitis, but he again returned to duty.

(207) Wound of the liver.—Wounded at Tweefontein. Entry, in eighth intercostal space in right mid axillary line; exit, 1-1/2 inch below the point of the ensiform cartilage, 1/2 an inch to the right of the mid line. The wounds were large, and although the impact had been oblique, they were possibly produced by a Martini-Henry or Guedes bullet.

On the second day bile began to escape from the exit aperture, and this together with a little pus continued to be discharged for a week, when the wound rapidly healed up. The only symptom which occasioned any trouble was a stitch on inspiration, probably attributable to the wound of the diaphragm. There was no fracture of the rib.

(208) Wound of the liver.—Wounded outside Heilbron at a range of fifty yards. Entry (Mauser), in the tenth right interspace 2 inches to the right of the dorsal spines; exit, through the gladiolus, immediately to the right of the median line, and just above the junction with the ensiform cartilage. There was considerable shock on reception of the injury, and a great feeling of dizziness. Continuous vomiting set in and persisted for the first two days, then became occasional, and ceased only at the end of a week. There was also occasional hiccough, and stitch on drawing a long breath. The respiration was shallow and rapid. The bowels acted twice shortly after the injury.

The pulse was rapid and small, and a week after the injury was still above 100. The abdomen was then normal and moving symmetrically, and the respiration fairly easy. There were no signs of chest trouble, but some mucous expectoration. A slight icteric tinge existed. The patient made a good recovery.

Wounds of the spleen.—Uncomplicated wounds of the spleen were necessarily rare, and beyond this the strict localisation of a track to the spleen is not a matter of great ease. None the less the spleen must have been implicated in a considerable number of the wounds crossing the chest and abdomen. I know of only one case in which a wound which crossed the splenic area caused death from haemorrhage, and of this I can give no details, as I never saw the patient. In this instance, however, a wound of the spleen was diagnosed after death from the position of the wounds. The patient continued to perform his duty as an officer in the fighting line for at least an hour after being struck, and then died rapidly apparently from an internal haemorrhage.

In case No. 201, included amongst the renal injuries, a wound of the spleen existed, but had given rise to no symptoms, and at the time of death, some three weeks later, was cicatrised. The only other assertion of importance that I can make is, that, as far as I could judge, wounds of the spleen from bullets of small calibre were not, as a rule, accompanied by haemorrhage, since I never saw a case in which dulness in the left flank suggested the presence of extravasated blood, and in no case that I saw was there any history of general symptoms pointing to the loss of blood.

This is only to be explained by our similar experience with regard to wounds of the liver unaccompanied by puncture of main vessels, and perhaps haemorrhage is still less to be expected in the case of the spleen, in consequence of the contractile muscular tunic with which the organ is provided.

I can quote no case of certain injury to the spleen, except that already referred to discovered at a post-mortem examination, but many wounds were observed in positions of which the following may be taken as a type. Entry, through the seventh left costal cartilage, 3/4 of an inch from the sternal margin; exit, 2-1/2 inches from the left lumbar spines at the level of the last rib.

As an instance of the doctrine of chances I might quote the position of the wound in the patient who lay in the next bed. Both patients were wounded while fighting at Almonds Nek. Entry, through right seventh costal cartilage, 3/4 of an inch from the sternal margin; exit, 1-1/2 inch from the lumbar spines, at the level of the last right rib.

In neither of these cases did anything except the position of the external apertures point to the infliction of visceral injury.

General remarks as to the prognosis in abdominal injuries. The prognosis in each form of individual visceral injury has been already considered, but a few points affecting these injuries as a class should perhaps be further considered.

First, as to the influence of range on the severity of the injuries inflicted; I am not able to confirm the greater danger of short range, except in so far as there is no doubt that more shock attends such injuries, and possibly some of the most severely wounded were killed outright as a direct consequence of the greater striking force of the bullet.

Among the cases in which but slight effects were noted, however, many were said to have been hit within a range of 200 yards, as for instance the two injuries quoted under the heading of wounds of the spleen.

I personally saw no cases in which explosive injuries of the solid viscera were to be ascribed to this cause.

Secondly, as to the immediate prognosis in all abdominal injuries, the ensurance of rest and limitation as far as possible of transport were of the highest importance, either in the case of wound of the alimentary canal, or in wounds of the solid viscera in which haemorrhage was a possible result.

Thirdly, as to the later prognosis in these injuries; very few men are fit to resume active service without a prolonged period of rest. In spite of the insignificance of the primary symptoms, or of the favourable course taken by the injuries, active exertion was almost always followed for some months by the appearance of vague pains and occasionally by indications of recurrent peritoneal symptoms, pointing to the disturbance of quiescent haemorrhages, or of adhesions. Wounds of the kidney are apparently those least liable to be followed by trouble.

Lastly, the prognosis was influenced in the case of many of the viscera by coexisting injury to other organs or parts.

For instance, at least thirty per cent. of the abdominal wounds were complicated by wound of the thorax; and in the lower segment of the abdomen injury to the extra-peritoneal portions of the pelvic organs was common.

Both the immediate and ultimate prognosis were influenced greatly by this fact.

As to the individual injuries:

1. Wounds in the intestinal area, except in certain directions, often traverse the abdomen without inflicting a perforating injury on the bowel.

2. If the alimentary canal is perforated, injuries in certain segments, even if perforating, may be followed by spontaneous recovery. I should say the prognosis from this point of view is best in the ascending colon, then in the rectum; after these most favourable segments, I should place the others in the following order: stomach, sigmoid flexure, descending colon. As to perforating wounds of the transverse colon and small intestine, I believe spontaneous recovery to be very rare.

3. Wounds of the solid viscera generally, usually heal spontaneously, and give no trouble unless one of the great vessels has been injured. I include in this category all organs except the pancreas, of wounds of which I had no experience.

4. Wounds of the bladder, if of the nature of pure perforations in the intra-peritoneal segment, often heal spontaneously.

5. As a rule, injuries to the organs in their intra-peritoneal course have a far better prognosis than those which implicate the organs in their uncovered portions.

6. The small calibre of the bullet is alone responsible for the favourable results observed.

7. The danger or otherwise of an intestinal injury depends mainly on mechanical conditions; for instance, the fixity of the ascending colon, and its comparative freedom from a covering of small intestine capable by movement of diffusing any infective material, account chiefly for such favourable results as are seen when that segment of the bowel is implicated.

WOUNDS OF THE EXTERNAL GENITAL ORGANS

Wounds of the scrotum were not uncommon, especially in connection with perforations of the upper part of the thigh. They offered no special feature, beyond the common tendency of every-day experience to the development of extensive ecchymosis.

Wounds of the testicles I saw on several occasions. I remember only one out of some half-dozen in which castration became necessary. I was told of one case, for the accuracy of which I cannot vouch, in which destruction of one testicle was followed by an attack of melancholia, culminating in the suicide of the patient.

Wounds of the penis also occurred, but as a rule were unimportant. I append a case, however; in which the penile urethra was wounded, which is of some interest.

(209) Wounded at Heilbron. Range 1,500 yards. Entry, 2-1/2 inches below the right anterior superior iliac spine; the bullet traversed the groin superficially in the line of Poupart's ligament, emerged, and crossed both penis and scrotum. The trooper was in the saddle when struck, and the penis probably somewhat coiled up. Three wounds were found, one at the junction of the penis and scrotum which opened the urethra, a second one about 3/4 of an inch along the under surface of the penis, and a third on the left side of the base of the prepuce. A considerable amount of oedema and ecchymosis of the scrotum developed, but no extravasation of urine. A catheter was kept in the urethra for some days, and the opening eventually closed by granulation.

I only once saw a patient with an injury to the deep urethra; in this case concurrent injury to other pelvic organs led to death on the third day. As a good many of the patients with pelvic wounds died rapidly, the accident may have been more common than my experience would suggest.

FOOTNOTES:

[19] British Med. Journal, May 12, 1900, i. 1195.

[20] 'On Traumatic Rupture of the Colon.' Annals of Surgery, vol. xxx. 1899, p. 137.

[21] Two of these died.

[22] The cases of injury to the solid viscera are those only which happen to be quoted in the text, and give no idea of relative mortality.

[23] British Medical Journal, May 12, 1900, vol. i. p. 1194.



CHAPTER XII

ON SHELL WOUNDS

The title of this work hardly allows of its conclusion without a brief mention of the shell wounds observed during the campaign.

As already pointed out, these formed but a very small proportion of the injuries treated in the hospitals, and beyond this they possessed comparatively small surgical interest, since, as a rule, the features presented were those of mere lacerated wounds, while the more severe of the cases which survived only offered scope for operations of the mutilating class so uncongenial to modern surgical instincts.

The fatal wounds consisted in extensive lacerations resulting in the destruction of the head or limbs, the laying open of the abdominal or thoracic cavities, or the production of visceral injuries beyond the possibility of repair. Of such injuries no further mention will be made.

A very great variety of shells was employed during the campaign, especially on the part of the Boers, and the frontispiece gives some idea of these. The photograph was taken by Mr. Kisch after the relief of Ladysmith. For the want of more extended knowledge I shall confine myself to the description of a few injuries caused by two classes of large shell, those of the Vickers-Maxim or 'Pom-pom,' and two varieties of shrapnel.

The large shells employed may be divided into classes according to the metal used in their construction, and the nature of the explosive with which they were filled. These details are of some surgical import, because they affect the nature of the fragments into which the shells are broken up.

Fragments of shells constructed with cast iron and burst with powder, and also of forged steel exploded with lyddite, are depicted in fig. 90.



Examination of fragment C of a cast-iron shell exploded by powder shows the characteristic granular fracture, and edges, although sharp, yet of a comparatively rounded nature. The fragment is also heavier for its surface measurement, as the metal is thicker than that seen in the remaining fragments, although the cast-iron shell was of a much smaller calibre than the steel one. The lesser degree of penetrative power, and increased capacity to contuse, possessed by such fragments are obvious.

A B and D are fragments of a large forged steel howitzer shell exploded by lyddite, such as were cast by our guns. The photograph well shows the more tenacious structure of the metal in the incomplete longitudinal fissuring exhibited, while the margins are of a sharp knifelike character, well calculated to penetrate or, in the case of superficial injuries, to produce wounds of a more sharply incised character than the cast-iron shell. Fragments A and B also show an appearance suggestive of partial fusion, characteristic of high explosive action, in the turning of the prominent margins.

The larger fragments of such shells were responsible for the most serious mutilating injuries, while small fragments sometimes caused comparatively simple perforating wounds. I remember a fragment of the fused character not larger than a small nut which had perforated the front of the thigh of a Boer, and lodged near the inner surface of the femur. Removal of the fragment was followed by a free gush of haemorrhage. When the wound was opened up an opening was found in the external circumflex artery, haemorrhage from which had been controlled by the impaction of the piece of shell. As an example of the cutting power of sharp fragments of shell I might instance the case of another Boer in whom light passing contact had been made by the missile. A gaping incised wound extended from above the angle of the scapula down to the outer surface of the buttock. The wound involved the latissimus dorsi, and the external and internal oblique muscles of the abdomen. The separate muscular layers were sharply defined in the lateral parts of the floor of the wound, and remained so for some time during the gradual contraction of the large granulating surface produced. The degree of contusion was in fact slight, while the incised character was strongly marked.

In some cases the fragments merely struck the soldiers on the flat without producing any wound. In one such case a blow upon the epigastrium was, according to the patient, followed by the vomiting of a considerable amount of blood. A fluid diet was ordered, and no further ill effects were noted. The following case illustrates an oblique blow of a perforating character, which was nevertheless recovered from.



(210) Shell-wound of abdomen. Injury to liver.—Wounded at Paardeberg by a fragment of shell. Aperture of entry, a ragged opening in the median line. The fragment of shell was retained over the ninth costal cartilage in the nipple line. The wound bled freely, but the man was taken into camp, and then four miles on to the hospital, where he was anaesthetised and the fragment extracted. The wound of entry was at the same time enlarged, cleansed, and partly sutured. The patient vomited once after the anaesthetic, and the bowels remained confined for three or four days after the injury. The extraction wound healed readily, but a considerable amount of slimy, bile-stained discharge was still escaping from the ragged entrance wound on the man's arrival at the Base on the fourteenth day. The abdomen was then normal in appearance, and as to physical signs, except for a tympanitic note over the hepatic area to the right of the wound. The temperature was normal, the pulse 90, the tongue clean, and the bowels were acting. At the end of four weeks pleurisy, with effusion, developed on the right side; the chest was aspirated and [Symbol: ounce]xx of clear serum drawn off. The man then rapidly improved; the bile-stained discharge ceased at the end of five weeks, and a small granulating wound eventually closed at the end of two months, when the man returned to England.

Fig. 91 is inserted to illustrate the multifarious nature of the fragments into which the component parts of shells may break up. The pieces are for the most part of brass, and formed parts of either time or percussion fuses.

Fig. 92 represents the one-pound Vickers-Maxim shell in its actual size. The wounds produced by this shell are of some interest, since the Vickers-Maxim may be said to have been on trial during this campaign. The general opinion seems to have been to the effect that the moral influence produced by the continuous rapid firing of the gun and the attendant unpleasant noise were its chief virtues. A considerable number of wounds must, however, have been produced by it, which, if not of great magnitude and severity, were, at any rate, calculated to put the recipients out of action, and these wounds, moreover, were slower in healing than many of the rifle-bullet injuries.

The shell is so small that it was said to occasionally strike the body as a whole, and perforate. I was shown a case in which a wounded officer was confident that an entire shell had perforated his arm. The entry wound was at the outer part of the front of the forearm, the exit at the inner aspect of the arm, just above the elbow. Two ragged contused wounds existed, which healed slowly, but no serious nervous or vascular injury had been produced. Although it is probable that only a fragment perforated in this case, it is of interest in connection with the following.

In a case shown to me by Sir William Thomson in the Irish Hospital at Bloemfontein, an entire shell had passed between the left arm and body of a trooper, perforating the haversack, as also a non-commissioned officer's notebook contained within it, without exploding. The only injury sustained by the trooper was a contusion on the inner aspect of the elbow-joint, with slight signs of contusion of the ulnar nerve. The case is of some importance, as showing that a comparatively resistent body can be perforated without necessary explosion on the part of the shell; hence the possibility of a similar perforation of the soft parts of the body.



Fig. 93 is of a number of fragments of Vickers-Maxim shells, and it was by such that the great majority of the wounds were produced.

Wounds from fragments of these shells were, indeed, not at all rare. They were met with on any position; but, as far as my experience went, they were more common on the lower extremities than in other parts of the body, if the sufferers were in the erect position when wounded. I saw a good many wounds in the neighbourhood of the knee, some of which implicated the joint. When the injuries were received by patients in the lying or crouching positions, any part of the body was equally likely to be affected, or, again, the presence of large stones or rocks in the vicinity might determine the scattering of the flying fragments at a more dangerous height than when the shells burst from contact with the actual ground.

The relation of one or two examples of wounds from pom-pom fragments may not be without interest, the more so as they illustrate the favourable influence of a low degree of velocity on the part of a projectile. I saw three wounds produced by the percussion fuses of these shells, an experience which shows that they were not very uncommon.



(211) Perforating shell-wound of abdomen.—Wounded at Magersfontein by the fuse screw of a small shell (Vickers-Maxim). Aperture of entry ragged, roughly circular, and 2 inches in diameter, with much-contused margins situated in the median line, nearly midway between the ensiform cartilage and umbilicus. The screw was lodged in the abdominal wall at the margin of the thorax, just outside the left nipple line. The aperture of entry was cleansed by Major Harris, R.A.M.C., who determined the fact that penetration of the peritoneal cavity had occurred, and removed the fuse (see fig. 94) by a separate incision. The patient made an uneventful and uninterrupted recovery, the wound healing by granulation and leaving little weakness of the abdominal wall. He returned to England at the end of five weeks.

In a second case the fuse, together with a fragment of the iron case, entered the buttock by a ragged opening. The fragment of iron escaped by an exit aperture of about the same size. When the patient arrived at the Base some days after the injury, a hard body was felt in the wound, and on exploration the fuse was found and removed.

In a third case the fuse struck the side of the foot below the outer malleolus and comminuted the astragalus, and then passing forwards lodged beneath the extensor tendons of the toes. The wound was explored at the time of the injury and some fragments of bone removed; considerable cellulitis supervened, and the fuse was only discovered some days later when the patient came under the care of Sir W. Thomson in the Irish Hospital in Pretoria. It was there removed, together with some more fragments of bone, and the wound slowly granulated. The patient then returned to England, when the wound rapidly healed after the removal of some further necrosed fragments of cancellous tissue. The astragalus had been reduced to a mere shell of compact tissue, and the convexity of the articular surface was altogether lost. The deformity, together with the formation of adhesions in the ankle-joint, led to the development of a firm anchylosis.



My friend Mr. Abbott removed a similar fuse from the substance of the lung after the lapse of nine months, the patient having developed an empyema, and a chronic fistula, which rapidly closed after the removal of the foreign body.



I will add one further case, that illustrated by plate XXV. In this a fragment of a pom-pom shell entered the outer aspect of the right shoulder to escape on the inner aspect of the arm, just below the confines of the axilla. An oblique, non-comminuted fracture of the humerus resulted, which in spite of moderate suppuration united well in the course of six weeks. The case is of particular interest as illustrating the nature of the fracture to be expected when the velocity retained by the missile is low.

The above instances show that such peculiarities as belong to wounds produced by pom-pom shells depend on the comparatively small size and weight of the fragments, and on the small degree of impetus with which they are propelled.



Fig. 95 illustrates a form of shrapnel employed by the Boers, the case of which is of cast metal arranged in definite segments, while the interior is filled with small fragments of iron so shaped as to pack in concentric layers. As to the wounds produced by the contained fragments I have no experience, since I never saw one of the pieces of iron removed. This no doubt depended in part on the very unsatisfactory practice made by the Boers with shrapnel generally. Even when they fired English shrapnel, the shells were, as a rule, exploded far too high to cause any serious danger to the men beneath. I saw on one occasion a large number of shrapnel shells exploded over a body of Imperial Yeomanry, but as a result of the great height at which all the shells were exploded, not a single casualty resulted.

The segment casing of the shell, however, I several times saw removed from the body. The fragment shown in fig. 95 was removed from the buttock of a man after one of Lord Methuen's early battles. It may be remarked that the buttock is rather a common, and also a favourable, seat for shell wounds with retention of the fragment. This no doubt depends on the fact that the buttock is one of the few superficial regions in which sufficient depth of tissue exists for the retention or the passage of so large an object as a fragment of shell.

Fig. 96 is of a number of leaden shrapnel bullets from our own shells. A normal undeformed bullet, such as was the usual cause of wounds, is shown at the left-hand upper corner. The remainder show common forms of deformity caused by striking on the ground or against rocks. I attribute small importance to the deformed bullets, as I never saw one removed, and it is probable that a ricochet shrapnel bullet would rarely retain sufficient force to penetrate. The lower fragments are inserted to illustrate a fact that would scarcely have been assumed, that these bullets on impact occasionally suffer a fracture of a somewhat crystalline nature. The occurrence of this gross form of fracture is of some interest in relation to the extreme fragmentation sometimes undergone by the hardened leaden cores of the small-calibre bullets.

A considerable number of wounds from leaden shrapnel bullets were met with among our own men, as well as among the Boers. The wounds possessed little special interest, except from the fact that the bullets were often retained. I saw bullets in the chest on several occasions, also in the abdomen, pelvis, the neighbourhood of joints, and in the limbs.

I saw one patient who had suffered no less than six perforating wounds as the result of the bursting of one shrapnel shell.

I will here quote one case of interest as completing the various forms of perforating wound of the abdomen met with during the campaign.



(212) Perforating shrapnel-wound of abdomen.—Boer wounded at Graspan. Aperture of entry (shrapnel), opposite eighth left costal cartilage, 1 inch external to nipple line. The opening was circular, and surrounded by an area of ecchymosis 4 inches in diameter; exit, 4-1/2 inches above and to the right of the umbilicus. Patient was at first in a Boer ambulance, and only seen by me on the ninth day. At that date he was dressed and walking with a gauze pad and bandage over the wounds. From the exit wound, which was 1 inch in diameter, protruded a piece of sloughing omentum, the margin of the wound being everted and raised over a circular indurated area.

It was thought best to allow the sloughing omentum, which was very foul, to separate spontaneously, and then to return the stump. At the end of three weeks, however, the slough had not only separated, but the stump had retracted, and only a small granulating surface was left, which healed spontaneously.

I have little to say regarding the treatment of shell wounds. The mutilating injuries, if not of a fatal character, necessitated treatment of a corresponding nature to the damage. In all such cases the general rules of surgery indicate the lines to be followed.

In the case of shrapnel wounds the bullets were often better removed; but when in dangerous positions, as sunk deeply in the chest, abdomen, or pelvis, they were best left, unless some very special indication for removal existed. Large fragments of shell always demanded removal.

In conclusion I will only make the further remark, that shell wounds, with the exception of clean leaden shrapnel tracks, always suppurated.

I make this closing statement with the view of emphasising the influence exerted on the aseptic course of modern rifle wounds by the small calibre of the bullet, since both bullet and shell wounds were exposed to the same surrounding conditions.



INDEX

Abdomen, injuries to, 407 General prognosis in, 470

Abdominal wounds: Explosive, 414 Non-perforating, 409 Perforating, 411

Abscess of the brain, 287

Acetabulum, fracture of, 193

Acetylene light, 30

Ambulance: Foreign, 30 Trolly (McCormack-Brook), 18 Wagons, 19

Amputations: Effect of transport on, 110 for fracture, 177

Aneurisms: Effect of rest on, 127 Gangrene after, 152 Traumatic, 122 False, 123 True, 126 Treatment of, 127

Aneurismal varix: Arm and forearm, 147 Effect on circulation, 134 Carotid, 146 Femoral, 147 Mode of development, 130 Popliteal, 147 Prognosis in, 144 Signs of, 131 Treatment of, 144

Anosmia, 348

Antrum, wounds of, 306

Aphasia: Amnesic, 276 Ataxic, 273 Functional, 351

Arterial haematoma, 123 Prognosis in, 126 Treatment of, 126

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

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

Biliary fistula, 467

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

Bones. See Fractures

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

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

Bread, 7

Buck wagon, 21

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

Cauda equina, injury to, 325, 330

Cellulitis, 34

Cervical nerve roots, injury to, 107 Plexus, 357

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

Cheek, wounds of, 309

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

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

Civil surgeons, 38

Climate, 8, 36, 71

Comparison of South African with other campaigns, 14

Compression of brain, 267 Spinal cord, 319

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

Contour wounds, 65

Contusion: Nerves, 343 Spinal cord, 316

Costal cartilages, fractures of, 379

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

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

Deadliness of modern weapons, 16

Diaphragm, wounds of, 381

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

Drink, 8

Dust, 8, 35 Bacteriology of, 36

Empyema, 394, 396

Enteric fever, 9

Epilepsy, traumatic, 291

Equipment of foreign ambulances, 31 Surgical, 4

Erysipelas, 34

Expanding bullets, 91

Explosive bullets, 95

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

Eye, injuries to, 299

Facial paralysis: Cortical, 273-277 Peripheral, 355

First field dressings, 107

Flies, 36

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

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

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

Fragmentation of bullets, 88

Fuses of shells, wounds by, 481

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

Genital organs, wounds of, 472

Guedes rifle, 65

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

Haemarthrosis, 232

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

Haemorrhoids, 10

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

Head, injuries to, 241

Health of the troops, 7

Heart, wounds of, 382 in neighbourhood of, 384

Hemianopsia, 276 Altitudinal, 277 Lateral, 276

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

Hospital ships, 24 Tents, 32 Trains, 23

Hydronephrosis, 464

Impact, irregular, 80, 82

Instruments, 4

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

Irregular wounds, 97

Itinerary, 2

Jam, 7

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

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

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

Joints, retained bullets in or near, 229, 230

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

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

Kidney, wounds of, 461

Krag-Joergensen rifle, 65

Laminectomy, 335, 340

Larynx, wounds of, 312

Leaden bullets, 95

Lee-Metford rifle, 53, 64

Lewtas, Col. I. M. S., cases of aneurism, 144

Lightning stroke, 10

Liver, wounds of, 466

Local shock, 103 in fractures, 172

Lower jaw, fractures of, 306

Lungs, wounds of, 385 Diagnosis, 398 Effect of velocity on, 385 Prognosis, 399 Retained bullets in, 401 Symptoms of, 386 Treatment of, 400

Lyddite shells, 475

MacCormac, Sir W.: Aneurism, 150 Fractures, 167

Malar bone, fractures, 305

Mandible, fractures, 306

Mantles, stability of, 51, 83

Martini-Henry rifle, 48 Wounds by, 96

Mastoid process, 299

Mauser rifle, 64

Meat, 7

Mediastinal wounds, 382, 384

Mesentery, wounds of, 420

Mills-Roberts, Mr. H. R.: Spinal haemorrhage, 321

'Modders, the,' 9

Mortality, general, 11 amongst officers, 14 in battles of Kimberley Relief Force, 12

Nasal fossae, bullet in, 244

Neck, wounds of, 309

Nerves, injuries to, 341 Concussion, 341, 343, 346 Contusion, 343, 347 Displacement of, 342 Laceration, 344, 348 Perforation, 345 Prognosis in, 370 Scar, implication of, 345, 350 Section, 344 Symptoms of, 346 Treatment of, 371 Velocity in relation to, 341

Nerves, special: Cranial: Fifth, 353 Fourth, 353 Eighth, 353, 354 Eleventh, 356 Olfactory, 352 Optic, 352 Seventh, 354, 372 Sixth, 353 Tenth, 356 Third, 353 Twelfth, 357 Spinal: Brachial, 357 Cervical, 347, 357 Lumbar, 359 Sacral, 359 Sacro-coccygeal, 360 Thoracic, 358

Neuritis: Ascending, 350 Peripheral, 355 Traumatic, 349

Neurosis, traumatic 351

Nose, wounds of, 305, 348

Nurses, 38

Officers, mortality among, 14

Olecranon, fracture of, 183, 237

Omentum, wounds of, 420 Prolapse of, 420

Operations: Difficulties of, 35 in field, 296 in Field hospitals, 109

Orbit, wounds of, 299 Prognosis and treatment of, 304

Osteomyelitis in fractures, 174

Outfit, surgical, 3

Pain in wounds, 103

Paraplegia, functional, 337

Penetration of bullets, 49

Penis, wounds of, 472

Peritoneal infection, 412

Pharynx, wounds of, 311

Pleural septicaemia, 437

Pleurisy, 390, 398

Pneumonia, 9, 398

Pneumo-thorax, 388

Pom-pom shells, 478

Portland Hospital, 34

Psychical disturbance, 101

Rain, 9, 36

Range of fire: Difficulty of judging influence on mortality, 17

Rectum, wounds of, 443, 444

Removal of wounded from the field, 18

Respiration in spinal injuries, 329

Retained bullets. See Bullets

Reversed bullets, 81

Revolution of bullet, 45, 46

Ribs, fractures of, 377 Signs of, 379

Ricochet, 82 Effect on wound type, 249 Lee-Metford, 89 Mauser, 84 Within body, Abdomen, 415 Skull, 249

Rifles: Bore, 41 Guedes, 47, 54 Krag-Joergensen, 47, 54 Lee-Metford, 47, 64 Martini-Henry, 47, 97 Mauser, 47, 64 Modern principles of, 40 Trajectory, 44 Varieties employed, 47, 48

Scalp wounds, 242, 264

Scapula, fractures of, 177, 379

Scrotum, wounds of, 472

Septic disease, 34

Septicaemia: General, 34 in enteric fever, 9 Peritoneal, 421 Pleural, 437

Shells, 474 Varieties of, 475 Vickers-Maxim, 478 Lyddite, 476 Shrapnel, 483

Shell wounds: of abdomen, 480, 485 Proportionate occurrence of, 11

Shell fuse wounds, 481

Ships, hospital, 24

Shock: General, 101 Local, 103 Treatment of, 110

Shrapnel, 483

Simla, 25

Skull. See Fractures Fractures independent of gross brain lesion, 242 with brain lesion, 248

Spinal column: Injuries to, 314 Fractures of centra, 317 Spinous processes, 315 Transverse processes, 314

Spinal cord, injuries to, 315 Compression by bullets, 319 Concussion, 319 Contusion, 320 Diagnosis, 335 Haemato-myelia, 322 Section of, 323 Shock accompanying, 328 Signs of, 323 Transport of, 339 Treatment of, 339

Spinal haemorrhage: Epidural, 321 Haemato-myelia, 322 Peri-pial, 321

Spleen, wounds of, 469

Splints: Aluminium, 177 Field cane, 209, 221 Hodgen's, 211 Wire gauze, 187

Sternum, fractures of, 379

Stevenson, Col. W. F.: Local shock, 106 Explosive wounds, 159

Stokes, Sir W.: Treatment of aneurism, 151

Stomach, wounds of, 424

Stonham, Mr. C.: Wound of vermiform appendix, 437

Sunstroke, 10

Suppuration of wounds, 78 in fracture, 173

Synovitis, vibration, 226

Temperature of air, 8, 36 in blood effusions, 118, 391, 393

Tents, 32

Testicle, wounds of, 472

Tetanus, 34

Thirst, 8

Thomson, Sir W.: Pom-pom wounds, 479 Wound of nose, 305

Thoracic vessels, wounds of, 384

Tonga, the, 19

Tongue, wounds of, 309

Trachea, wounds of, 312

Traction engines, 23

Trains, hospital, 23

Trajectory, 44

Transport: after battles, 26 of wounded men from field, 18 of wounded of the Kimberley Relief Force, 25 of chest injuries, 386 of fractures, 176 of spinal injuries, 339

Traumatic aneurism. See Aneurism

Traumatic epilepsy, 291

Traumatic gangrene, 34

Traumatic neurosis, 107, 351

Treves, Mr. F.: on cessation of intestinal peristalsis, 423

Trolly (McCormack-Brook), 19

Upper jaws, 306

Urethra, wounds of, 472

Urinary Bladder. See Bladder

Varix. See Aneurismal varix

Vegetables, 7

Veldt sores, 10

Velocity of bullet: Circumstances influencing, 43 Initial, 42, 49 Remaining of various rifles, 49

Velocity, influence of: on fractures of long bones, 163 on fractures of short and flat bones, 168 on wounds of abdomen, 414 of chest, 385 of joints, 226, 230 of lungs, 385 of nerves, 341 of skull, 251 of spine, 319

Vermiform appendix, wounds of, 437

Vibration synovitis, 226

Vickers-Maxim shell, 478

Vomiting in spinal injuries, 329

Wagons: Ambulance, 20 Buck, 22 Ox, 20

Warfare, deadliness of, 40

Water in South Africa: Character of, 8, 36 Transport of, 5

Waxed bullets, 52

Wobble, 80, 81, 251

Wounded men, removal from the field, 18

Wounds, general: Aperture of entry, 55, 72 Aperture of exit, 58, 74 Climate, influence on, 71 Clinical, course of, 69 Contour tracks, 65 Direct nature of tracks, 63 Directions of tracks, 66 Displacement of structures, 68 Explosive exit wounds, 97 Foreign bodies in, 71 First field dressing, 107 Haemorrhage, 104 Irregular types of, 80, 97 Mode of healing, 72 Multiple character, 67 Nature of tracts, 68 Pain, 103 Prognosis, 106 Psychical disturbance, 101 Shock, 101 Small bore, 67 Superficial tracts, 65 Suppuration, 69, 78 Symptoms, 100 Tracks, nature of, 68 Treatment, 107

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