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The Project Gutenberg eBook of Surgical Experiences in South
Africa, 1899-1900
This eBook is for the use of anyone anywhere in the United States and most
other parts of the world at no cost and with almost no restrictions
whatsoever. You may copy it, give it away or re-use it under the terms of
the Project Gutenberg License included with this eBook or online at
www.gutenberg.org. If you are not located in the United States, you will
have to check the laws of the country where you are located before using
this eBook.
Title: Surgical Experiences in South Africa, 1899-1900
Author: George Henry Makins
Release date: May 3, 2007 [eBook #21280]
Most recently updated: January 2, 2021
Language: English
Other information and formats: www.gutenberg.org/ebooks/21280
Credits: Produced by Jonathan Ingram, Josephine Paolucci and the
Online Distributed Proofreading Team at https://www.pgdp.net
*** START OF THE PROJECT GUTENBERG EBOOK SURGICAL
EXPERIENCES IN SOUTH AFRICA, 1899-1900 ***
Africa, 1899-1900
This eBook is for the use of anyone anywhere in the United States and most
other parts of the world at no cost and with almost no restrictions
whatsoever. You may copy it, give it away or re-use it under the terms of
the Project Gutenberg License included with this eBook or online at
www.gutenberg.org. If you are not located in the United States, you will
have to check the laws of the country where you are located before using
this eBook.
Title: Surgical Experiences in South Africa, 1899-1900
Author: George Henry Makins
Release date: May 3, 2007 [eBook #21280]
Most recently updated: January 2, 2021
Language: English
Other information and formats: www.gutenberg.org/ebooks/21280
Credits: Produced by Jonathan Ingram, Josephine Paolucci and the
Online Distributed Proofreading Team at https://www.pgdp.net
*** START OF THE PROJECT GUTENBERG EBOOK SURGICAL
EXPERIENCES IN SOUTH AFRICA, 1899-1900 ***
Page 4
FRONTISPIECE.
Photo, H. Kisch Ladysmith. Engraved and Printed by
Bale and Danielsson, Ltd.
SURGICAL EXPERIENCES
IN
SOUTH AFRICA
Photo, H. Kisch Ladysmith. Engraved and Printed by
Bale and Danielsson, Ltd.
SURGICAL EXPERIENCES
IN
SOUTH AFRICA
Page 5
1899-1900
BEING MAINLY A CLINICAL STUDY OF THE NATURE
AND EFFECTS OF INJURIES PRODUCED BY BULLETS
OF SMALL CALIBRE
BY
BEING MAINLY A CLINICAL STUDY OF THE NATURE
AND EFFECTS OF INJURIES PRODUCED BY BULLETS
OF SMALL CALIBRE
BY
Page 6
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
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
Page 7
AS AN EXPRESSION OF APPRECIATION
OF THE INVARIABLE KINDNESS AND SYMPATHY EXTENDED
TO THE AUTHOR
WITHOUT WHICH THE BOOK COULD NOT
HAVE BEEN WRITTEN
OF THE INVARIABLE KINDNESS AND SYMPATHY EXTENDED
TO THE AUTHOR
WITHOUT WHICH THE BOOK COULD NOT
HAVE BEEN WRITTEN
Page 8
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,
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,
Page 9
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.
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.
Page 10
CONTENTS
PAGE
CHAPTER I
INTRODUCTORY
ItineraryLinen Holdall with surgical instrumentsSurgical 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—
PAGE
CHAPTER I
INTRODUCTORY
ItineraryLinen Holdall with surgical instrumentsSurgical 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—
Page 11
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 extremity154
CHAPTER VI
INJURIES TO THE JOINTS
General character—Vibration synovitis—Wounds of joints—Classification
—Course and symptoms—General treatment—Special joints225
CHAPTER VII
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 extremity154
CHAPTER VI
INJURIES TO THE JOINTS
General character—Vibration synovitis—Wounds of joints—Classification
—Course and symptoms—General treatment—Special joints225
CHAPTER VII
Page 12
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—Treatment314
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
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—Treatment314
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
Page 13
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
hæmothorax374
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
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
hæmothorax374
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
Page 14
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 wounds474
Index of Contents487
ILLUSTRATIONS
PLATES
Varieties of Ammunition collected at LadysmithFrontispiece
1. Section of Mauser Aperture of Entry To face p. 73
2. Section of Mauser Aperture of Exit 76
3. Punctured Fracture of Clavicle162
4. Comminuted Fracture of Shaft of Humerus180
5. Comminuted Fracture of Humerus accompanied by an Explosive
Exit182
6. Comminuted Fracture of Humerus due to Oblique Impact184
7. Same Fracture healed186
8. Low Velocity Fracture of Humerus With Retained Bullet188
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 wounds474
Index of Contents487
ILLUSTRATIONS
PLATES
Varieties of Ammunition collected at LadysmithFrontispiece
1. Section of Mauser Aperture of Entry To face p. 73
2. Section of Mauser Aperture of Exit 76
3. Punctured Fracture of Clavicle162
4. Comminuted Fracture of Shaft of Humerus180
5. Comminuted Fracture of Humerus accompanied by an Explosive
Exit182
6. Comminuted Fracture of Humerus due to Oblique Impact184
7. Same Fracture healed186
8. Low Velocity Fracture of Humerus With Retained Bullet188
Page 15
9. Localised Fracture of Humerus Showing Fragmentation of the
Bullet190
10. Wedge-shaped Fracture of the Radius192
11. Fracture of the Metacarpus, showing Fragmentation of the
Bullet194
12. Finely Comminuted Fracture of the Femur196
13. The same Fracture Healed198
14. Stellate 'Butterfly' Fracture of the Femur200
15. Lateral Impact of Bullet, with Comminution of the Femur202
16. Rectangular Impact of Bullet, with highly Oblique Line of Fracture
of the Femur204
17. Punctured Fracture of the Femur with Exit Bone-flap206
18. Fractured Patella208
19. Oblique Comminuted Fracture of the Tibia210
20. Transverse Fracture of the Tibia212
21. Puncture of the Tibia, with an Oblique Fissure214
22. Notched Fracture of the Tibia216
23. Punctured Fracture of the Fibula218
24. The same Fracture, Lateral View 220
25. Vickers-Maxim Fracture of the Humerus 482
Bullet190
10. Wedge-shaped Fracture of the Radius192
11. Fracture of the Metacarpus, showing Fragmentation of the
Bullet194
12. Finely Comminuted Fracture of the Femur196
13. The same Fracture Healed198
14. Stellate 'Butterfly' Fracture of the Femur200
15. Lateral Impact of Bullet, with Comminution of the Femur202
16. Rectangular Impact of Bullet, with highly Oblique Line of Fracture
of the Femur204
17. Punctured Fracture of the Femur with Exit Bone-flap206
18. Fractured Patella208
19. Oblique Comminuted Fracture of the Tibia210
20. Transverse Fracture of the Tibia212
21. Puncture of the Tibia, with an Oblique Fissure214
22. Notched Fracture of the Tibia216
23. Punctured Fracture of the Fibula218
24. The same Fracture, Lateral View 220
25. Vickers-Maxim Fracture of the Humerus 482
Page 16
IN THE TEXT
FIG. PAGE
1. Linen Hold-all with Instruments4
2. Instrument Hold-all Rolled for Packing5
3. Tin Water-bottle for Emergency Operations6
4. Buggy on the Veldt7
5. McCormack-Brook Wheeled Stretcher Carriage19
6. Indian Tonga20
7. Service Ambulance Wagon21
8. Buck-wagon Loaded with Wounded Men22
9. Interior of a Wagon of No. 2 Hospital Train24
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 War47
15. Sections of Four Bullets To Show Relative Thickness of Mantles51
16. Entry and Exit Mauser Wounds56
FIG. PAGE
1. Linen Hold-all with Instruments4
2. Instrument Hold-all Rolled for Packing5
3. Tin Water-bottle for Emergency Operations6
4. Buggy on the Veldt7
5. McCormack-Brook Wheeled Stretcher Carriage19
6. Indian Tonga20
7. Service Ambulance Wagon21
8. Buck-wagon Loaded with Wounded Men22
9. Interior of a Wagon of No. 2 Hospital Train24
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 War47
15. Sections of Four Bullets To Show Relative Thickness of Mantles51
16. Entry and Exit Mauser Wounds56
Page 17
17. Gutter Wound of Shoulder56
18. Oblique Gutter Exit Wound 57
19. Oval Entry, Starred Exit Wounds58
20. Circular Entry, Slit Exit Wounds59
21. Circular Entry, Starred Exit Wounds59
22. Entry and Exit Wounds in Six Successive Spots made by same
Bullet61
23. Four Successive Entry and Exit Wounds of same Bullet62
24. Superficial Abdomino-thoracic Track64
25. Superficial Linear Ecchymosis of Thigh65
25a. Sections of Mauser Entry and Exit Wounds74
25b. Prolapsed Omentum77
26. Sections of Four Bullets82
27. Normal Mauser Bullet83
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
18. Oblique Gutter Exit Wound 57
19. Oval Entry, Starred Exit Wounds58
20. Circular Entry, Slit Exit Wounds59
21. Circular Entry, Starred Exit Wounds59
22. Entry and Exit Wounds in Six Successive Spots made by same
Bullet61
23. Four Successive Entry and Exit Wounds of same Bullet62
24. Superficial Abdomino-thoracic Track64
25. Superficial Linear Ecchymosis of Thigh65
25a. Sections of Mauser Entry and Exit Wounds74
25b. Prolapsed Omentum77
26. Sections of Four Bullets82
27. Normal Mauser Bullet83
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
Page 18
33. Spiral Ricochet88
34. Normal Lee-Metford Bullet89
35. Apical Lee-Metford Ricochets90
36. " " " 91
37. Four Types of Soft-nosed Bullets92
38. 'Set-up' Soft-nosed Lee-Metford Bullets92
39. Flattened, Solid-based Mantle From Ricochet93
40. Mauser Bullet, Jeffreys-Tweedie Modification94
41. Section of Mark IV. and Soft-nosed Mauser94
42. Tampered Bullets95
43. Large Leaden Sporting Bullets98
44. Explosive Wound of Back100
45. Dead Men on Field of Battle102
46. Flattened Leaden Cores from Mantled Bullets105
47. Explosive Exit Wound over Fractured Ulna156
48. Explosive Exit Wound over Fractured Humerus158
49. Explosive Exit and Entry Wounds of Legs159
50. Types of Gunshot Fracture161
34. Normal Lee-Metford Bullet89
35. Apical Lee-Metford Ricochets90
36. " " " 91
37. Four Types of Soft-nosed Bullets92
38. 'Set-up' Soft-nosed Lee-Metford Bullets92
39. Flattened, Solid-based Mantle From Ricochet93
40. Mauser Bullet, Jeffreys-Tweedie Modification94
41. Section of Mark IV. and Soft-nosed Mauser94
42. Tampered Bullets95
43. Large Leaden Sporting Bullets98
44. Explosive Wound of Back100
45. Dead Men on Field of Battle102
46. Flattened Leaden Cores from Mantled Bullets105
47. Explosive Exit Wound over Fractured Ulna156
48. Explosive Exit Wound over Fractured Humerus158
49. Explosive Exit and Entry Wounds of Legs159
50. Types of Gunshot Fracture161
Page 19
51. Lower End of Fractured Femur164
52. Oblique Perforation of Femur, Separation of Fragment at Exit
Aperture in Bone169
53. Gutter Fracture of Head of Humerus178
53a. Diagram of 'Butterfly' Type180
54. Wire Gauze Splint 187
55. Gutter Fracture of Pelvis 191
55a. 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
52. Oblique Perforation of Femur, Separation of Fragment at Exit
Aperture in Bone169
53. Gutter Fracture of Head of Humerus178
53a. Diagram of 'Butterfly' Type180
54. Wire Gauze Splint 187
55. Gutter Fracture of Pelvis 191
55a. 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
Page 20
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 Hæmothorax392
84. Subcutaneous Division of Abdominal Muscles409
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 Hæmothorax392
84. Subcutaneous Division of Abdominal Muscles409
Page 21
85. Lateral Incomplete Wound of Small Intestine. Slit Form416
86. Lateral Perforation of Small Intestine. Gutter Form417
87. Entry and Exit Wounds in a Transverse Perforation of Intestine418
88. Inner Aspect of Piece of Intestine Shown in Fig. 87419
89. Impaction of Omentum in Exit Wound of Abdominal Wall421
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 Shell481
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
86. Lateral Perforation of Small Intestine. Gutter Form417
87. Entry and Exit Wounds in a Transverse Perforation of Intestine418
88. Inner Aspect of Piece of Intestine Shown in Fig. 87419
89. Impaction of Omentum in Exit Wound of Abdominal Wall421
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 Shell481
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
Page 22
5. Falls of Temperature in Hæmothorax following Paracentesis 404
6. Secondary Hæmothorax, Spontaneous Fall of Temperature 405
6. Secondary Hæmothorax, Spontaneous Fall of Temperature 405
Page 23
SURGICAL EXPERIENCES
IN
IN
Page 24
SOUTH AFRICA
Page 25
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
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
Page 26
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
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
Page 27
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.
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
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.
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
Page 28
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.
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.
Page 29
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.
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 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.
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.)
Page 30
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.
Fig. 3.—Tin Water-
bottle for the march
(Military Equipment
Company)
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.
Fig. 3.—Tin Water-
bottle for the march
(Military Equipment
Company)
Page 31
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
(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
Page 32
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 diarrhœa 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 diarrhœa, 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
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 diarrhœa 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 diarrhœa, 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
Page 33
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
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
Page 34
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
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
Page 35
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 of Killed Wounded Missing Total Percentage
troops of
engaged killed and
wounded
to number of
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 of Killed Wounded Missing Total Percentage
troops of
engaged killed and
wounded
to number of
Page 36
men
engaged
Belmont:
Officers 297 3 23 0 26 8.75
Non.-com.
8,396 55 206 4 265 3.15
officers and men
Total 8,693 58 229 4 291 3.34
Graspan:
Officers 326 3 7 0 10 3.06
Non.-com.
8,213 18 163 7 188 2.29
officers and men
Total 8,539 21 170 7 198 2.31
Modder River:
Officers 335 3 19 0 22 6.56
Non.-com.
9,856 67 377 18 462 4.68
officers and men
Total 10,191 70 396 18 484 4.74
Magersfontein:
Officers 379 18 48 2 68 17.94
Non.-com.
11,068 148 669 101 918 8.29
officers and men
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.
engaged
Belmont:
Officers 297 3 23 0 26 8.75
Non.-com.
8,396 55 206 4 265 3.15
officers and men
Total 8,693 58 229 4 291 3.34
Graspan:
Officers 326 3 7 0 10 3.06
Non.-com.
8,213 18 163 7 188 2.29
officers and men
Total 8,539 21 170 7 198 2.31
Modder River:
Officers 335 3 19 0 22 6.56
Non.-com.
9,856 67 377 18 462 4.68
officers and men
Total 10,191 70 396 18 484 4.74
Magersfontein:
Officers 379 18 48 2 68 17.94
Non.-com.
11,068 148 669 101 918 8.29
officers and men
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.
Page 37
TABLE II
Showing Proportion of Mortality amongst Men Hit, (a) on the Field,
(b) during the First Forty-eight Hours
Percentage
mortality
Died
Total
Number within To
number To force
of troops Killed forty- Total men
of men employed
engaged eight hit
hit
hours
Belmont:
Officers 297 26 3 3 6 23 2.02
Non.-com.
officers and 8,396 265 55 8 63 23.77 0.75
men
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 8,213 188 18 3 21 11.17 0.25
men
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 9,856 462 67 9 76 16.45 0.77
men
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 11,068 918 148 20 168 18.30 1.51
men
Showing Proportion of Mortality amongst Men Hit, (a) on the Field,
(b) during the First Forty-eight Hours
Percentage
mortality
Died
Total
Number within To
number To force
of troops Killed forty- Total men
of men employed
engaged eight hit
hit
hours
Belmont:
Officers 297 26 3 3 6 23 2.02
Non.-com.
officers and 8,396 265 55 8 63 23.77 0.75
men
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 8,213 188 18 3 21 11.17 0.25
men
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 9,856 462 67 9 76 16.45 0.77
men
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 11,068 918 148 20 168 18.30 1.51
men
Page 38
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
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
Page 39
these are added to the 315, we find that the proportion of mortal injuries
reaches 19.92 per cent.
TABLE III[4]
1815. 1854. 1871. 1877. 1899.
Franco- Russo-
Crimean Kimberley
Waterloo German Turkish
War Relief Force
War War
(English (English (German (Russian (English
troops) troops) troops) troops) troops)
Number of
36,240 97,864 887,876 300,000 15,748
troops engaged
Number of
1,759 2,775 17,570 32,780 315
killed
Percentage 4.85 2.81 1.97 10.92 2
Number of
5,892 12,094 96,189 71,268 1,512
wounded
Percentage 16.25 12.35 10.83 23.75 9.60
Number of
807 — 4,009 — 132
missing
Percentage 2.19 — 0.45 — .83
-Total killed,
wounded, and 8,458 14,849 117,768 104,050 1,959
missing
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
reaches 19.92 per cent.
TABLE III[4]
1815. 1854. 1871. 1877. 1899.
Franco- Russo-
Crimean Kimberley
Waterloo German Turkish
War Relief Force
War War
(English (English (German (Russian (English
troops) troops) troops) troops) troops)
Number of
36,240 97,864 887,876 300,000 15,748
troops engaged
Number of
1,759 2,775 17,570 32,780 315
killed
Percentage 4.85 2.81 1.97 10.92 2
Number of
5,892 12,094 96,189 71,268 1,512
wounded
Percentage 16.25 12.35 10.83 23.75 9.60
Number of
807 — 4,009 — 132
missing
Percentage 2.19 — 0.45 — .83
-Total killed,
wounded, and 8,458 14,849 117,768 104,050 1,959
missing
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
Page 40
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
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
Page 41
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
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
Page 42
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
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
Page 43
the sides with rough jolting, unless quite helpless. I occasionally made long
journeys in this vehicle with much comfort.
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
journeys in this vehicle with much comfort.
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
Page 44
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.
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.,
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.
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.,
Page 45
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.
Fig. 7.—Service Ambulance Wagon, the six front
mulesremoved.
(Photo by Mr. C. S. Wallace)
During the later stages of the campaign, a very large number of 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
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.
Fig. 7.—Service Ambulance Wagon, the six front
mulesremoved.
(Photo by Mr. C. S. Wallace)
During the later stages of the campaign, a very large number of 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
Page 46
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.
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.
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.
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.
Page 47
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
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
Page 48
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.
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
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.
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
Page 49
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.
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 (591½ 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.
arrival at Durban; but on the other hand it would ensure that really suitable
vessels were always provided.
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 (591½ 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.
Page 50
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
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
Page 51
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.
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.
Page 52
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
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
Page 53
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
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
Page 54
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.
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.
Page 55
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.
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.
Page 56
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.
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.
Page 57
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
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
Page 58
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.
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.
Page 59
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.
(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.
Page 60
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 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.
Page 61
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.
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.
Page 62
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
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
Page 63
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.
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.
Page 64
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.
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.
Page 65
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 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
Page 66
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.
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.
Page 67
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
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
Page 68
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
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
Page 69
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
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
Page 70
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.
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.
Page 71
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.
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.
Page 72
TABLE I
Martini- Lee- Lee- Krag-
Guedes Mauser
Henry Metford Enfield Jörgensen
Calibre of
.45 in. .314 in. .303 in. .303 in. .276 in. .254 in.
rifle
Number
7 4 7 5 4 4
of grooves
One twist 22 in. to 9.85 in. to 10 in. to 10 in. to 8-11/16 in.
8 in. to left
in right right left left to right
Muzzle 1,300 2,000 2,000
1,988 f.s. 2,262 f.s. 2,309 f.s.
velocity f.s. f.s. f.s.
1,450 2,600 2,800 2,800
Sighted to 2,187 yds. 2,406 yds.
yds. paces yds. yds.
Weight of 758 464.05 416½ 416½
[6] 384.5 grains 372.1 grains
cartridge grains grains grains grains
Weight of 480 215 215
244 grains 173.3 grains 156.4 grains
bullet grains grains grains
Length of 1.250 1.250 1.250
1.250 in. 1 in. 1.250 in.
bullet in. in. in.
Calibre of
.450 in. .315 in. .309 in. .309 in. .280 in. .260 in.
bullet
85 20-23
31½ 31½ 36 grains
Charge of grains (grains 38.0 grains
grains grains (nitro-
powder (black nitro- (smokeless)
(cordite) (cordite) smokeless)
powder) smokeless)
Nature of — Mantle: Cupro- Cupro- Mantle: Mantle: Mild
alloy used Mild steel, nickel nickel Steel with steel coated
for mantle greased alloy of with copper
of bullet copper on nickel, the
surface composition
of the latter
being that of
the cupro-
nickel of the
Martini- Lee- Lee- Krag-
Guedes Mauser
Henry Metford Enfield Jörgensen
Calibre of
.45 in. .314 in. .303 in. .303 in. .276 in. .254 in.
rifle
Number
7 4 7 5 4 4
of grooves
One twist 22 in. to 9.85 in. to 10 in. to 10 in. to 8-11/16 in.
8 in. to left
in right right left left to right
Muzzle 1,300 2,000 2,000
1,988 f.s. 2,262 f.s. 2,309 f.s.
velocity f.s. f.s. f.s.
1,450 2,600 2,800 2,800
Sighted to 2,187 yds. 2,406 yds.
yds. paces yds. yds.
Weight of 758 464.05 416½ 416½
[6] 384.5 grains 372.1 grains
cartridge grains grains grains grains
Weight of 480 215 215
244 grains 173.3 grains 156.4 grains
bullet grains grains grains
Length of 1.250 1.250 1.250
1.250 in. 1 in. 1.250 in.
bullet in. in. in.
Calibre of
.450 in. .315 in. .309 in. .309 in. .280 in. .260 in.
bullet
85 20-23
31½ 31½ 36 grains
Charge of grains (grains 38.0 grains
grains grains (nitro-
powder (black nitro- (smokeless)
(cordite) (cordite) smokeless)
powder) smokeless)
Nature of — Mantle: Cupro- Cupro- Mantle: Mantle: Mild
alloy used Mild steel, nickel nickel Steel with steel coated
for mantle greased alloy of with copper
of bullet copper on nickel, the
surface composition
of the latter
being that of
the cupro-
nickel of the
Page 73
Lee-Enfield
bullet
Thickness Mark II. Mark II.
— — — —
of mantle bullet bullet
Tip — .031 .036 .036 .031 .022
Sides .984
— .011 .015 .015 .015 .015
from tip
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:
15½ in. of 1 in. deal 19 in. of sand containing 15 per
Martini-Henry
boards 1 in. apart cent. of moisture
Lee-Metford
{Mark II. } 42 in. of 1 in. deal 60 in. of sand containing 15 per
Lee-Enfield boards 1 in. apart cent. of moisture
{bullet }
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
Thickness Mark II. Mark II.
— — — —
of mantle bullet bullet
Tip — .031 .036 .036 .031 .022
Sides .984
— .011 .015 .015 .015 .015
from tip
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:
15½ in. of 1 in. deal 19 in. of sand containing 15 per
Martini-Henry
boards 1 in. apart cent. of moisture
Lee-Metford
{Mark II. } 42 in. of 1 in. deal 60 in. of sand containing 15 per
Lee-Enfield boards 1 in. apart cent. of moisture
{bullet }
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
Page 74
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.
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.
Page 75
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.
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.
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.
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.
Page 76
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.
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.
Page 77
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
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
Page 78
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.)
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.)
Page 79
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
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
Page 80
skin is supported by soft tissues alone, or on those of a more resistent nature
such as bone or cartilage.
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
such as bone or cartilage.
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
Page 81
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
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
Page 82
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.
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
ecchymosis half an inch or more in diameter surrounds the original wound.
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
Page 83
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.
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.
resulting from rectangular impact of the bullet, since the distal margin is
really lifted.
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.
Page 84
Fig. 20.
Circular Entry back of arm; exit (bird-like) in anterior elbow crease
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
Circular Entry back of arm; exit (bird-like) in anterior elbow crease
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
Page 85
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.
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.
Page 86
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.
Fig. 23.
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.
Fig. 23.
Page 87
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.
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.
Page 88
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
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
Page 89
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.
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.
Page 90
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
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
Page 91
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
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
Page 92
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
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
Page 93
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.
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.
Page 94
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
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
Page 95
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
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
Page 96
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
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
Page 97
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.
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.
Page 98
PLATE I.
Mauser Wound of Entrance, a little more than 48 hours after
infliction. About 12/1.
G. L. Cheatle.
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
Mauser Wound of Entrance, a little more than 48 hours after
infliction. About 12/1.
G. L. Cheatle.
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
Page 99
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
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
Page 100
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.
Fig. 25 (a).
A. Wound of entry 48 hours after reception. B. Wound of exit, 7½ 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
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.
Fig. 25 (a).
A. Wound of entry 48 hours after reception. B. Wound of exit, 7½ 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
Page 101
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.
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.
Page 102
PLATE II
G. L. Cheatle.
Mauser Wound of Exit, 7½ 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.
G. L. Cheatle.
Mauser Wound of Exit, 7½ 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.
Page 103
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.
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.
Page 104
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
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
Page 105
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
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
Page 106
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
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
Page 107
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.
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.
Page 108
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]
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
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]
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
Page 109
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.
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.
Page 110
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.
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.
Page 111
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.
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
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.
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
Page 112
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.
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.
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.
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.
Page 113
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.
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.
Page 114
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.
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.
Page 115
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
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
Page 116
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.
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
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.
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
Page 117
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.
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.
Page 118
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
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
Page 119
(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.
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
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.
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
Page 120
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]
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.
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]
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.
Page 121
Fig. 37.—
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
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
Page 122
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.
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
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.
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
Page 123
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.
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-
have been very high, and the comminution was slight. If it had passed out, a
large exit wound would, however, have resulted.
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-
Page 124
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.
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.
Page 125
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
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
Page 126
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.
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.
Page 127
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
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
Page 128
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
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
Page 129
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 manœuvre 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.
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 manœuvre 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.
Page 130
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 4½ in. in
length by 1½ in. width. (Fig. 44.)
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 4½ in. in
length by 1½ in. width. (Fig. 44.)
Page 131
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.
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
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.
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
Page 132
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
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
Page 133
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.
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
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.
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
Page 134
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.
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.
Page 135
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
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
Page 136
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.
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).
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.
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).
Page 137
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
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
Page 138
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 4½ 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 2½ 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
composed of a piece of gauze, a pad of flax charpie between layers of gauze,
a gauze bandage 4½ 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 2½ 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
Page 139
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.
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.
Page 140
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,
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,
Page 141
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.
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.
Page 142
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 œdema of the
limb, which was also normal in temperature. The patient was kept at rest in
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 œdema of the
limb, which was also normal in temperature. The patient was kept at rest in
Page 143
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, 2½ 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 œsophagus
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
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, 2½ 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 œsophagus
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
Page 144
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
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
Page 145
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.
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.
Page 146
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
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
Page 147
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
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
Page 148
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.
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.
Page 149
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.
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.
Page 150
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
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
Page 151
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
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
Page 152
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.
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.
Page 153
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, 1½ 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
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, 1½ 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
Page 154
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
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
Page 155
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.
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.
Page 156
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.
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.
Page 157
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
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
Page 158
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 2½ 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
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 2½ 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
Page 159
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
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
Page 160
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 1½ 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
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 1½ 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
Page 161
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
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
Page 162
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
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
Page 163
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
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
Page 164
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.
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.
Page 165
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 1½ 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 1½ broad extending in the line of
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 1½ 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 1½ broad extending in the line of
Page 166
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
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
Page 167
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
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
Page 168
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
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
Page 169
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 œsophagus 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
1½ 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
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 œsophagus 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
1½ 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
Page 170
was still weak and husky, but there was no dysphagia or
dyspnœa. 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 2½ 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 dyspnœa. 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.
dyspnœa. 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 2½ 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 dyspnœa. 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.
Page 171
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.
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.
Page 172
The patient was sent down to the Base, and on the twenty-fourth
day the condition was as follows. A pulsating swelling existed
extending 1¼ 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
day the condition was as follows. A pulsating swelling existed
extending 1¼ 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
Page 173
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 2½ 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 œdema 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
imperfect.
The aneurism had considerably altered in form and outline; its walls were
dense and firm; it extended 2½ 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 œdema 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
Page 174
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
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
Page 175
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.
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.
Page 176
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.
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.
Page 177
(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 1½ inch broad existed along the line of the upper two-
thirds of the axillary artery, and along the subclavian in the neck,
rising some 1½ 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,
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 1½ inch broad existed along the line of the upper two-
thirds of the axillary artery, and along the subclavian in the neck,
rising some 1½ 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,
Page 178
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.
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.
Page 179
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
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
Page 180
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.
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.
Page 181
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.
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.
Page 182
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
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
Page 183
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.
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.
Page 184
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
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
Page 185
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.
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.
Page 186
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.
(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.
Page 187
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.
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.
Page 188
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.
(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.
Page 189
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 ×3½ 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.
'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 ×3½ 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.
Page 190
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
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
Page 191
various wedge-shaped forms were the most strongly characteristic of the
special form of injury in which we are interested.
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.
special form of injury in which we are interested.
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.
Page 192
PLATE III.
(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.
(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.
Page 193
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
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
Page 194
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.
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.
Page 195
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.
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.
Page 196
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
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
Page 197
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
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
Page 198
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.
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.
Page 199
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
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
Page 200
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.
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
clinical evidence in the rarity of subsequent limitation of joint movements
due to bony deformity.
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
Page 201
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
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
Page 202
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 2½ 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.
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 2½ 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.
Page 203
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
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
Page 204
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.
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.
Page 205
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 œdema; 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
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 œdema; 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
Page 206
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
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
Page 207
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
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
Page 208
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.
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.
Page 209
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.
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.
Page 210
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.
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.
Page 211
PLATE IV.
(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.
(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.
Page 212
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.
Fig. 53 a.—Diagram
of "butterfly' type
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
provisional callus. The musculo-spiral nerve was united by
suture some three months later.
Fig. 53 a.—Diagram
of "butterfly' type
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
Page 213
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.
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.
Page 214
PLATE V.
(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.
(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.
Page 215
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.
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.
Page 216
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.
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.
Page 217
PLATE VI.
(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.
(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.
Page 218
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.
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.
Page 219
PLATE VII.
(26a) 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.
(26a) 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.
Page 220
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,
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,
Page 221
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.
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.
Page 222
PLATE VIII.
(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.
(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.
Page 223
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.
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.
Page 224
PLATE IX.
(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
(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
Page 225
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.
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.
Page 226
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 1½ 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
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 1½ 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
Page 227
lateral impact on the part of the bullet; hence the form of injury was nearly
allied to the comminutions of the ilium already described.
PLATE X.
(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
allied to the comminutions of the ilium already described.
PLATE X.
(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
Page 228
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.
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.
Page 229
PLATE XI.
(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.
(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.
Page 230
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
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
Page 231
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.
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.
Page 232
PLATE XII.
(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.
(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.
Page 233
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 1½ 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
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 1½ 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
Page 234
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.
PLATE XIII.
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.
PLATE XIII.
Page 235
(31a) 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
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
Page 236
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.
Fig. 55a.—Diagram
of 'Butterfly' type.
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.
Fig. 55a.—Diagram
of 'Butterfly' type.
Page 237
PLATE XIV.
(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
(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
Page 238
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.
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.
Page 239
PLATE XV.
(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
(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
Page 240
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
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
Page 241
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.
PLATE XVI.
(34) Oblique Fracture of the Shaft of the Femur
Range '300 to 400 yards.'
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.
PLATE XVI.
(34) Oblique Fracture of the Shaft of the Femur
Range '300 to 400 yards.'
Page 242
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.
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.
Page 243
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.
PLATE XVII.
(35) Perforation of the Shaft of the Femur. Flap of bone
raised at the aperture of exit in the popliteal surface of the
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.
PLATE XVII.
(35) Perforation of the Shaft of the Femur. Flap of bone
raised at the aperture of exit in the popliteal surface of the
Page 244
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
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
Page 245
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.
PLATE XVIII.
(36) Obliquely Transverse Fracture of the Patella
Range 'short.'
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.
PLATE XVIII.
(36) Obliquely Transverse Fracture of the Patella
Range 'short.'
Page 246
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.
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.
from loss of substance of the bone was palpable superficial to
the actual cleft of the fracture.
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.
Page 247
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.
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.
Page 248
PLATE XIX.
(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.
(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.
Page 249
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.
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.
Page 250
PLATE XX.
(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.
(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.
Page 251
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
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
Page 252
thigh should be through the fracture, and not at the hip-joint, even if a
subsequent secondary operation is risked.
PLATE XXI.
(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.
subsequent secondary operation is risked.
PLATE XXI.
(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.
Page 253
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
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
Page 254
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.
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.
Page 255
PLATE XXII.
(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
(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
Page 256
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.
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.
Page 257
PLATE XXIII.
(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.
(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.
Page 258
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.
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.
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.
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.
Page 259
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.
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.
Page 260
PLATE XXIV.
(41a) 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
(41a) 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
Page 261
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
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
Page 262
the wounds were small and frequent dressing was not required, nothing was
so good as plaster of Paris, especially when transport was a necessity.
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
so good as plaster of Paris, especially when transport was a necessity.
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
Page 263
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.
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.
Page 264
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.
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.
Page 265
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
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
Page 266
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.
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.
Page 267
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
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
Page 268
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
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
Page 269
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
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
Page 270
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
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
Page 271
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
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
Page 272
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
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
Page 273
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
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
Page 274
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
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
Page 275
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.
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.
Page 276
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
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
Page 277
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.
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
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.
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
Page 278
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,
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,
Page 279
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.
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.
Page 280
Page 281
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
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
Page 282
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
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
Page 283
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,
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,
Page 284
for instance, were less constant in their course and position. The cases as a
whole are best divided into four classes.
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.
whole are best divided into four classes.
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.
Page 285
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.
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
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.
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
Page 286
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
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
Page 287
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 œdema 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
being limited in their extent by the nearest suture.
Over extensive fractures of this nature general œdema 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
Page 288
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.
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.
Page 289
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
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
Page 290
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.
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.
Page 291
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.
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.
Page 292
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.
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.
Page 293
(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.
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.
Page 294
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, 2¼ 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 (122½ 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
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, 2¼ 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 (122½ 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
Page 295
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 1½ 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.
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 1½ 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.
Page 296
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.
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.
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.
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.
Page 297
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.
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.
Page 298
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).
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
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).
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
Page 299
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).
Fig. 67.
Diagrammatic transverse sections of complete Gutter Fracture. A.
External table destroyed, large fragment of internal table depressed.
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).
Fig. 67.
Diagrammatic transverse sections of complete Gutter Fracture. A.
External table destroyed, large fragment of internal table depressed.
Page 300
(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.
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.
Page 301
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.
Fig. 69.
Diagrammatic longitudinal section of Fracture shown in 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.
Fig. 69.
Diagrammatic longitudinal section of Fracture shown in fig. 68
Page 302
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.
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.
Page 303
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.
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.
Page 304
Fig. 71.
Scale of outer table of Frontal Bone and Diploë. Exact size, from
fracture shown in fig. 72
Scale of outer table of Frontal Bone and Diploë. Exact size, from
fracture shown in fig. 72
Page 305
Fig. 72.—Perforating Fracture of Frontal
Bone from within Separation of plate
outer table. (Low velocity.) 1/2
The injury to the cranial contents varied with the degree of bone injury.
Hæmorrhage on the surface of the dura may in rare instances have been the
sole gross lesion; I never met with such a condition, however. In all the
cases in which comminution had occurred, some laceration of the dura,
even if not more than surface damage or a punctiform opening, had
resulted. In the more serious gutter fractures an elongated rent of some
extent usually existed. In the perforating fractures two more or less irregular
openings were the rule. The amount of hæmorrhage, even if the venous
sinuses were implicated, was on the whole surprisingly small, when the
cases were such as to survive the injury long enough to be brought to the
Field hospital. I never saw a typical case of middle meningeal hæmorrhage,
although many fractures crossing the line of distribution of the large
branches came under observation. Case 60, p. 274, illustrated the fact that
the osseous lesions of lesser apparent degree are sometimes the more to be
Bone from within Separation of plate
outer table. (Low velocity.) 1/2
The injury to the cranial contents varied with the degree of bone injury.
Hæmorrhage on the surface of the dura may in rare instances have been the
sole gross lesion; I never met with such a condition, however. In all the
cases in which comminution had occurred, some laceration of the dura,
even if not more than surface damage or a punctiform opening, had
resulted. In the more serious gutter fractures an elongated rent of some
extent usually existed. In the perforating fractures two more or less irregular
openings were the rule. The amount of hæmorrhage, even if the venous
sinuses were implicated, was on the whole surprisingly small, when the
cases were such as to survive the injury long enough to be brought to the
Field hospital. I never saw a typical case of middle meningeal hæmorrhage,
although many fractures crossing the line of distribution of the large
branches came under observation. Case 60, p. 274, illustrated the fact that
the osseous lesions of lesser apparent degree are sometimes the more to be
Page 306
feared in the matter of hæmorrhage, as compression is more readily
developed.
The degree of injury to the brain depended on the depth of the track, the
resistance offered by the bones of any individual skull, the weight of the
patient, but chiefly on the degree of velocity retained by the bullet. It was
sometimes slight and local as far as symptoms would guide us; but in the
majority of cases out of all proportion to the apparent bone lesion, if the
range was at all a short one. Cases illustrative of these injuries are included
under the heading of symptoms.
It will be, of course, appreciated that the coarse brain lesions under the third
heading differed in localisation and in extent alone, and in no wise in
nature, from those observed in the two preceding classes. The damage
consisted in direct superficial laceration and contusion, and beyond the
limits of the area of actual destruction, abundant parenchymatous
hæmorrhages more or less broke up the structure of the brain, such
hæmorrhages decreasing both in size and number as macroscopically
uninjured tissue was reached. No opportunity was ever afforded of
examining a simple wound track in a case in which no obvious cerebral
symptoms had been present.
IV. Fractures of the base.—In addition to the above classes, a few words
ought to be added regarding the gunshot fractures of the base of the skull.
These possessed some striking peculiarities; first in the fact that they might
occur in any position, and hence differed from the typically coursing
'bursting' fractures we are accustomed to in civil life as the consequence of
blows and falls, and consequently were often present without any of the
classical symptoms by which we are accustomed to locate such fissures.
Secondly, the peculiar form was not uncommon in which extensive
mischief was produced from within by direct contact of a passing bullet.
As far as could be judged from clinical symptoms, indirect fractures of the
base such as we are accustomed to meet in civil practice in connection with
fractures of the vault were decidedly rare, and, as has already been
mentioned, ocular evidence of extensive fissures extending from perforating
wounds of the vertex was wanting, except in the extreme cases classed
developed.
The degree of injury to the brain depended on the depth of the track, the
resistance offered by the bones of any individual skull, the weight of the
patient, but chiefly on the degree of velocity retained by the bullet. It was
sometimes slight and local as far as symptoms would guide us; but in the
majority of cases out of all proportion to the apparent bone lesion, if the
range was at all a short one. Cases illustrative of these injuries are included
under the heading of symptoms.
It will be, of course, appreciated that the coarse brain lesions under the third
heading differed in localisation and in extent alone, and in no wise in
nature, from those observed in the two preceding classes. The damage
consisted in direct superficial laceration and contusion, and beyond the
limits of the area of actual destruction, abundant parenchymatous
hæmorrhages more or less broke up the structure of the brain, such
hæmorrhages decreasing both in size and number as macroscopically
uninjured tissue was reached. No opportunity was ever afforded of
examining a simple wound track in a case in which no obvious cerebral
symptoms had been present.
IV. Fractures of the base.—In addition to the above classes, a few words
ought to be added regarding the gunshot fractures of the base of the skull.
These possessed some striking peculiarities; first in the fact that they might
occur in any position, and hence differed from the typically coursing
'bursting' fractures we are accustomed to in civil life as the consequence of
blows and falls, and consequently were often present without any of the
classical symptoms by which we are accustomed to locate such fissures.
Secondly, the peculiar form was not uncommon in which extensive
mischief was produced from within by direct contact of a passing bullet.
As far as could be judged from clinical symptoms, indirect fractures of the
base such as we are accustomed to meet in civil practice in connection with
fractures of the vault were decidedly rare, and, as has already been
mentioned, ocular evidence of extensive fissures extending from perforating
wounds of the vertex was wanting, except in the extreme cases classed
Page 307
under heading I. For these reasons I am inclined to regard them as
uncommon.
Direct fractures of the base, on the other hand, were of common occurrence,
especially in the anterior fossa of the skull. These might be produced either
from within, the most characteristic form of gunshot injury, or from
without. The fractures from within were often simple punctures of the roof
of the orbit or nose.
Punctured fractures of the roof of the orbit caused little trouble as far as the
cranium was concerned, but the orbital structures often suffered severely. I
saw one or two very severe comminutions of the roof of the orbit caused by
bullets which had crossed the interior of the skull; in one case the whole
roof was in small fragments, while the damage in others was not greater
than chipping off some portion of the lesser wing of the sphenoid. The roof
of the orbit again was sometimes very severely damaged by bullets which
first traversed that cavity itself; thus in one case which recovered, the bullet
passed transversely, smashing both globes, and fracturing the roof of both
orbits and the cribriform plate so severely as to lacerate both dura-mater
and brain, portions of the latter being found in the orbit on removal of the
damaged eyes.
Fractures of the middle and posterior fossæ were met with far less
frequently, partly I think because vertical wounds passing from the vertex to
the base in these regions were with few exceptions rapidly fatal, and partly
from the fact that the occipital region, being ordinarily sheltered from the
line of fire, was rarely exposed to the danger of direct fracture from
without. As an odd coincidence I may mention that in my whole experience
during the war I only once saw bleeding from the ear as a sign of fracture of
the base, apart from direct injuries to the tympanum or external auditory
meatus.
Symptoms of fracture of the skull, with concurrent injury to the brain.—
These consisted in various combinations of the groups of signs indicative of
the conditions of concussion, compression, cerebral irritation, or
destruction. Although the symptoms possessed no inherent peculiarities, yet
certain characteristics exhibited served to illustrate the fact that, as a result
of the special mechanism of causation of the injuries, the type deviated in
uncommon.
Direct fractures of the base, on the other hand, were of common occurrence,
especially in the anterior fossa of the skull. These might be produced either
from within, the most characteristic form of gunshot injury, or from
without. The fractures from within were often simple punctures of the roof
of the orbit or nose.
Punctured fractures of the roof of the orbit caused little trouble as far as the
cranium was concerned, but the orbital structures often suffered severely. I
saw one or two very severe comminutions of the roof of the orbit caused by
bullets which had crossed the interior of the skull; in one case the whole
roof was in small fragments, while the damage in others was not greater
than chipping off some portion of the lesser wing of the sphenoid. The roof
of the orbit again was sometimes very severely damaged by bullets which
first traversed that cavity itself; thus in one case which recovered, the bullet
passed transversely, smashing both globes, and fracturing the roof of both
orbits and the cribriform plate so severely as to lacerate both dura-mater
and brain, portions of the latter being found in the orbit on removal of the
damaged eyes.
Fractures of the middle and posterior fossæ were met with far less
frequently, partly I think because vertical wounds passing from the vertex to
the base in these regions were with few exceptions rapidly fatal, and partly
from the fact that the occipital region, being ordinarily sheltered from the
line of fire, was rarely exposed to the danger of direct fracture from
without. As an odd coincidence I may mention that in my whole experience
during the war I only once saw bleeding from the ear as a sign of fracture of
the base, apart from direct injuries to the tympanum or external auditory
meatus.
Symptoms of fracture of the skull, with concurrent injury to the brain.—
These consisted in various combinations of the groups of signs indicative of
the conditions of concussion, compression, cerebral irritation, or
destruction. Although the symptoms possessed no inherent peculiarities, yet
certain characteristics exhibited served to illustrate the fact that, as a result
of the special mechanism of causation of the injuries, the type deviated in
Page 308
many ways from that accompanying the corresponding injuries of civil
practice.
The characters of the external wounds will be first considered, followed by
some remarks concerning the symptoms attendant on the different degrees
and types of lesion, the symptoms special to injuries to different regions of
the head, and on the subsequent complications observed.
In the simplest injuries the type forms of entry and exit wound were found,
and it has already been observed that in these, if symmetrical, considerable
difficulty existed in discriminating between the two apertures. This is to be
explained by the fact that the arrangement and structure of the scalp are
identical in corresponding regions; hence the only difference in the
conditions of production of the entry and exit wounds exists in the absence
of support to the skin in the latter. The granular structure of the hairy scalp
is opposed to the occurrence of the slit forms of exit, hence the openings
were usually irregularly rounded. Any increase of size in the exit wound in
the soft parts due to the passage of bone fragments with the bullet, was
equalised in that of entry by the fact that the latter, as supported by a hard
substratum, was usually larger than those met with in situations where the
skin covers soft parts alone.
In some cases of gutter fracture the wounds of entry were large and
irregular, as a result of upward splintering of the bone at the distal margin of
the aperture of entry in the skull, and consequent laceration of the scalp.
Again, on the forehead very pure types of slit exit wound were often met
with in the position of the vertical or horizontal creases. With higher
degrees of velocity on the part of the bullet and consequent comminution at
the aperture of exit in the bone, the scalp was more extensively lacerated,
and large irregular openings in the soft parts, often occupied by fragments
of bone and brain pulp, were met with. It is well to repeat here, however,
that the presence of brain pulp in a wound by no means necessarily
indicated the aperture of exit, for it was sometimes found in the entry
opening also.
In the most severe cases, such as are included in class I., the exit wound
often possessed in the highest degree the so-called 'explosive' character.
From an opening in the skin with everted margins two or more inches in
practice.
The characters of the external wounds will be first considered, followed by
some remarks concerning the symptoms attendant on the different degrees
and types of lesion, the symptoms special to injuries to different regions of
the head, and on the subsequent complications observed.
In the simplest injuries the type forms of entry and exit wound were found,
and it has already been observed that in these, if symmetrical, considerable
difficulty existed in discriminating between the two apertures. This is to be
explained by the fact that the arrangement and structure of the scalp are
identical in corresponding regions; hence the only difference in the
conditions of production of the entry and exit wounds exists in the absence
of support to the skin in the latter. The granular structure of the hairy scalp
is opposed to the occurrence of the slit forms of exit, hence the openings
were usually irregularly rounded. Any increase of size in the exit wound in
the soft parts due to the passage of bone fragments with the bullet, was
equalised in that of entry by the fact that the latter, as supported by a hard
substratum, was usually larger than those met with in situations where the
skin covers soft parts alone.
In some cases of gutter fracture the wounds of entry were large and
irregular, as a result of upward splintering of the bone at the distal margin of
the aperture of entry in the skull, and consequent laceration of the scalp.
Again, on the forehead very pure types of slit exit wound were often met
with in the position of the vertical or horizontal creases. With higher
degrees of velocity on the part of the bullet and consequent comminution at
the aperture of exit in the bone, the scalp was more extensively lacerated,
and large irregular openings in the soft parts, often occupied by fragments
of bone and brain pulp, were met with. It is well to repeat here, however,
that the presence of brain pulp in a wound by no means necessarily
indicated the aperture of exit, for it was sometimes found in the entry
opening also.
In the most severe cases, such as are included in class I., the exit wound
often possessed in the highest degree the so-called 'explosive' character.
From an opening in the skin with everted margins two or more inches in
Page 309
diameter a mass of brain débris, bone fragments and particles of dura-mater,
skin, and hair, bound together by coagulated blood, protruded as a primary
hernia cerebri if the patient survived the first few hours after the injury. In
other cases of the same class the actual opening was smaller, but the whole
scalp was swollen and œdematous, sometimes crackling when touched from
the presence of extravasated blood in the cellular tissue, while firm
palpation often gave the impression that the head consisted of a bag of
bones over a considerable area.
Gutter fractures of the scalp were sometimes situated beneath an open
furrow, gaping from loss of substance, or beneath a bridge of skin; in the
latter case they were usually palpable. Simple punctures were also usually
palpable, but the smallness of the openings sometimes rendered their
detection more difficult than might be assumed.
I never saw a case in which the skull escaped injury when the bullet struck
the scalp at right angles, but the frequency with which Mauser bullets were
found within the helmets of men would suggest that this must have
sometimes occurred. A case of injury to the external table alone has been
described (p. 243). An illustration of the next degree of injury is afforded by
the following:—A bullet lodged in the centre of the forehead, the point
lying within the cranial cavity, while the base projected from the surface:
this patient suffered but slight immediate trouble, so little, indeed, that he
merely asked his officer to remove the bullet for him, as it was
inconvenient. The bullet was subsequently removed in the Field hospital.
In a few cases the bullet entered the skull and was retained, when only a
single wound was found. Such cases are described in Nos. 54 and 68, where
the position of the bullet was determined by palpable fractures beneath the
skin. With regard to the retention of bullets, however, in small-calibre
wounds, it was always necessary to examine the other parts of the body
with great care, and to ascertain, if possible, the direction from which the
wound was received, as an exit was often found some distance down the
neck or trunk. Again the possibility of the opening having been produced by
glancing contact had to be considered.
In cases which survived the injury on the field, free hæmorrhage, as in
wounds of other regions, was rare, and although general evidence of loss of
skin, and hair, bound together by coagulated blood, protruded as a primary
hernia cerebri if the patient survived the first few hours after the injury. In
other cases of the same class the actual opening was smaller, but the whole
scalp was swollen and œdematous, sometimes crackling when touched from
the presence of extravasated blood in the cellular tissue, while firm
palpation often gave the impression that the head consisted of a bag of
bones over a considerable area.
Gutter fractures of the scalp were sometimes situated beneath an open
furrow, gaping from loss of substance, or beneath a bridge of skin; in the
latter case they were usually palpable. Simple punctures were also usually
palpable, but the smallness of the openings sometimes rendered their
detection more difficult than might be assumed.
I never saw a case in which the skull escaped injury when the bullet struck
the scalp at right angles, but the frequency with which Mauser bullets were
found within the helmets of men would suggest that this must have
sometimes occurred. A case of injury to the external table alone has been
described (p. 243). An illustration of the next degree of injury is afforded by
the following:—A bullet lodged in the centre of the forehead, the point
lying within the cranial cavity, while the base projected from the surface:
this patient suffered but slight immediate trouble, so little, indeed, that he
merely asked his officer to remove the bullet for him, as it was
inconvenient. The bullet was subsequently removed in the Field hospital.
In a few cases the bullet entered the skull and was retained, when only a
single wound was found. Such cases are described in Nos. 54 and 68, where
the position of the bullet was determined by palpable fractures beneath the
skin. With regard to the retention of bullets, however, in small-calibre
wounds, it was always necessary to examine the other parts of the body
with great care, and to ascertain, if possible, the direction from which the
wound was received, as an exit was often found some distance down the
neck or trunk. Again the possibility of the opening having been produced by
glancing contact had to be considered.
In cases which survived the injury on the field, free hæmorrhage, as in
wounds of other regions, was rare, and although general evidence of loss of
Page 310
blood was often noted in patients brought in, progressive bleeding was
seldom observed. Again, when the wounds were explored, the amount of
blood, although considerable, was usually not more than sufficed to fill up
the space consequent on the loss of brain tissue. This was especially striking
when large venous sinuses, as the superior longitudinal, were involved in
the injury. None the less, hæmorrhage at the base of the brain was, I
believe, responsible for early death in many of the severe cases, especially
when the wounds were near the lower regions of the skull.
Escape of cerebro-spinal fluid was not so prominent a feature as might have
been expected, considering how freely the arachnoid space was opened up
in many cases. I think this was usually checked by early coagulation of the
blood, and later by adhesions. It must be remembered also that extensive
wounds were most common on the vertex, or at any rate over the convex
surface of the brain, while fractures of the middle fossa were usually rapidly
fatal.
Concussion.—Cases exhibiting symptoms of pure uncomplicated
concussion were distinctly rare, as would be expected from the mechanism
of the injuries. On the other hand, symptoms of concussion formed the
dominant feature of all severe cases.
The symptoms in many instances consisted in great part in transitory signs
of the so-called 'radiation' type, such as are seen in destructive lesions
where the signs of nervous damage rapidly tend to diminish and localise
themselves.
As to the causation of the 'radiation' symptoms, it is difficult to discriminate
the effects of neighbouring parenchymatous hæmorrhages from those of
local vibratory concussion of the nervous tissue. The local character of the
signs seems, however, to point to causation by molecular disturbance,
resulting from the conduction of forcible mechanical vibration to the brain
tissue rather than to upset in the intra-cranial pressure. Again the limited
nature of the paralysis observed, sharply defines it from the general loss of
power accompanying ordinary cases of concussion of the brain. The
similarity of the phenomena to those described in other parts of the body
under the heading of 'local shock' is sufficiently obvious.
The following instance well exemplifies the condition in question:
seldom observed. Again, when the wounds were explored, the amount of
blood, although considerable, was usually not more than sufficed to fill up
the space consequent on the loss of brain tissue. This was especially striking
when large venous sinuses, as the superior longitudinal, were involved in
the injury. None the less, hæmorrhage at the base of the brain was, I
believe, responsible for early death in many of the severe cases, especially
when the wounds were near the lower regions of the skull.
Escape of cerebro-spinal fluid was not so prominent a feature as might have
been expected, considering how freely the arachnoid space was opened up
in many cases. I think this was usually checked by early coagulation of the
blood, and later by adhesions. It must be remembered also that extensive
wounds were most common on the vertex, or at any rate over the convex
surface of the brain, while fractures of the middle fossa were usually rapidly
fatal.
Concussion.—Cases exhibiting symptoms of pure uncomplicated
concussion were distinctly rare, as would be expected from the mechanism
of the injuries. On the other hand, symptoms of concussion formed the
dominant feature of all severe cases.
The symptoms in many instances consisted in great part in transitory signs
of the so-called 'radiation' type, such as are seen in destructive lesions
where the signs of nervous damage rapidly tend to diminish and localise
themselves.
As to the causation of the 'radiation' symptoms, it is difficult to discriminate
the effects of neighbouring parenchymatous hæmorrhages from those of
local vibratory concussion of the nervous tissue. The local character of the
signs seems, however, to point to causation by molecular disturbance,
resulting from the conduction of forcible mechanical vibration to the brain
tissue rather than to upset in the intra-cranial pressure. Again the limited
nature of the paralysis observed, sharply defines it from the general loss of
power accompanying ordinary cases of concussion of the brain. The
similarity of the phenomena to those described in other parts of the body
under the heading of 'local shock' is sufficiently obvious.
The following instance well exemplifies the condition in question:
Page 311
(55) Wounded at Spion Kop. A scalp wound 3 inches in length crossed the
left parietal bone nearly transversely, starting 1½ and ending 2 inches from
the median line: the centre of the wound corresponded with the position of
the fissure of Rolando. The patient was struck at a distance of fifty yards
while kneeling; he fell and remained unconscious an hour and a half. Right
hemiplegia without aphasia followed. The wound was cleansed and sutured,
and in three days both arm and leg could be moved, after which time the
man improved rapidly. Three weeks later when I saw him at Wynberg there
was still comparative weakness of the right side, but beyond some neuralgia
of the scalp, the man considered himself well. No groove could be detected
on the bone on palpation. (This case offers a good example of the ease with
which bone injury may be overlooked. The man came over to England
'well;' but while on furlough, two pieces of bone came away spontaneously.
He is now again on active service.)
Compression.—Equally rare was it for pure symptoms of compression to be
exhibited. This depended on two circumstances: first, the rarity of injuries
giving rise to meningeal hæmorrhage; secondly, the fact that in nearly every
case a more or less extensive destructive lesion was present, at the margins
of which less completely destroyed tissue remained, capable of giving rise
to symptoms of irritation. Again, as we have seen, free hæmorrhage into, or
from the walls of, the cavities produced in the brain was not a marked
feature, and beyond this the large defect in the cranial parietes was
calculated to render a high degree of compression impossible.
As the most serious head injuries presented a remarkable similarity in their
symptoms, I will shortly summarise their common features.
Every degree of mental stupor up to complete unconsciousness was met
with, but in some instances where the pulse, respiration, and general bodily
condition pointed to speedy dissolution, the patients answered rationally
often between moans or cries indicative of pain.
Widespread paralysis often existed, but this was seldom completely general;
more commonly it was combined with extreme restlessness of the
unparalysed parts, or sometimes, even when the whole of one hemisphere
was tunnelled, and in all probability widely destroyed, restlessness was the
left parietal bone nearly transversely, starting 1½ and ending 2 inches from
the median line: the centre of the wound corresponded with the position of
the fissure of Rolando. The patient was struck at a distance of fifty yards
while kneeling; he fell and remained unconscious an hour and a half. Right
hemiplegia without aphasia followed. The wound was cleansed and sutured,
and in three days both arm and leg could be moved, after which time the
man improved rapidly. Three weeks later when I saw him at Wynberg there
was still comparative weakness of the right side, but beyond some neuralgia
of the scalp, the man considered himself well. No groove could be detected
on the bone on palpation. (This case offers a good example of the ease with
which bone injury may be overlooked. The man came over to England
'well;' but while on furlough, two pieces of bone came away spontaneously.
He is now again on active service.)
Compression.—Equally rare was it for pure symptoms of compression to be
exhibited. This depended on two circumstances: first, the rarity of injuries
giving rise to meningeal hæmorrhage; secondly, the fact that in nearly every
case a more or less extensive destructive lesion was present, at the margins
of which less completely destroyed tissue remained, capable of giving rise
to symptoms of irritation. Again, as we have seen, free hæmorrhage into, or
from the walls of, the cavities produced in the brain was not a marked
feature, and beyond this the large defect in the cranial parietes was
calculated to render a high degree of compression impossible.
As the most serious head injuries presented a remarkable similarity in their
symptoms, I will shortly summarise their common features.
Every degree of mental stupor up to complete unconsciousness was met
with, but in some instances where the pulse, respiration, and general bodily
condition pointed to speedy dissolution, the patients answered rationally
often between moans or cries indicative of pain.
Widespread paralysis often existed, but this was seldom completely general;
more commonly it was combined with extreme restlessness of the
unparalysed parts, or sometimes, even when the whole of one hemisphere
was tunnelled, and in all probability widely destroyed, restlessness was the
Page 312
only symptom. In some cases twitching of the features or the limbs or
severe convulsions were superadded.
The pupils were rarely unequal, and at the stage in which these patients
were first seen were usually moderately contracted. Wide dilatation was
uncommon throughout.
The pulse was with very few exceptions slow, sometimes irregular. In some
instances, when the wounds had been thought suitable for exploration, the
slow pulse was altered after operation to a rapid one, and death usually
quickly supervened.
Respiration was irregular, sometimes sighing; in the late stage often of the
Cheyne-Stokes type; actual stertor was exceptional, but the respiration was
often noisy.
The temperature was often raised from an early stage to 99° or 100°, and if
the patient survived a day or two, it often rose to 103° or 104°. How far the
secondary rise depended on sepsis it was not always easy to determine. The
urine was usually retained.
Cases presenting the above characters were usually those suffering from
lesions such as are described in class I., and mostly died in twenty-four to
forty-eight hours. The correspondence of the train of symptoms with those
due to combined brain destruction and severe concussion is at once
apparent.
To illustrate the nature of the symptoms in patients suffering from the less
extensive forms of injury, such as those included in classes II. and III. under
the heading of anatomical lesion, the relation of a short series of histories
will be advisable. I may first premise, however, that the special
characteristics of these were in some instances the almost entire absence of
primary symptoms of gravity; in others general symptoms of a severity out
of apparent proportion to the external lesion; while in all destructive
lesions, very widely distributed radiation symptoms developed, often
disappearing with great rapidity.
The symptoms consisted in those of concussion, irritation, local pressure,
and actual destruction.
severe convulsions were superadded.
The pupils were rarely unequal, and at the stage in which these patients
were first seen were usually moderately contracted. Wide dilatation was
uncommon throughout.
The pulse was with very few exceptions slow, sometimes irregular. In some
instances, when the wounds had been thought suitable for exploration, the
slow pulse was altered after operation to a rapid one, and death usually
quickly supervened.
Respiration was irregular, sometimes sighing; in the late stage often of the
Cheyne-Stokes type; actual stertor was exceptional, but the respiration was
often noisy.
The temperature was often raised from an early stage to 99° or 100°, and if
the patient survived a day or two, it often rose to 103° or 104°. How far the
secondary rise depended on sepsis it was not always easy to determine. The
urine was usually retained.
Cases presenting the above characters were usually those suffering from
lesions such as are described in class I., and mostly died in twenty-four to
forty-eight hours. The correspondence of the train of symptoms with those
due to combined brain destruction and severe concussion is at once
apparent.
To illustrate the nature of the symptoms in patients suffering from the less
extensive forms of injury, such as those included in classes II. and III. under
the heading of anatomical lesion, the relation of a short series of histories
will be advisable. I may first premise, however, that the special
characteristics of these were in some instances the almost entire absence of
primary symptoms of gravity; in others general symptoms of a severity out
of apparent proportion to the external lesion; while in all destructive
lesions, very widely distributed radiation symptoms developed, often
disappearing with great rapidity.
The symptoms consisted in those of concussion, irritation, local pressure,
and actual destruction.
Page 313
The symptoms of concussion were either general, and then usually
transient, or local paralysis of the radiation variety, which also rapidly
improved.
Signs of irritation consisted in irritability of temper, drowsiness, closure of
the eyes and objection to light, contracted pupils sometimes unequal, a
tendency to the assumption of the flexed position at all the joints,
twitchings, and sometimes convulsions. Sometimes these appeared early as
a direct result of mechanical irritation from bone fragments or blood-clot;
sometimes only in the course of a few days, as a result of irritation of parts
recovering from the radiation effects which had prevented earlier nervous
reaction. Possibly in some cases the symptoms of irritation depended upon
an increase in the amount of hæmorrhage, and in others upon the
development of local inflammatory changes.
Local pressure, or actual destruction of brain tissue, was evidenced by
temporary paralysis in the former, permanent loss of function in the latter,
condition.
Fractures of the anterior fossa of the skull were attended by very marked
evidence of orbital hæmorrhage, as subconjunctival ecchymosis (rarely
pure), increased tension, and proptosis.
Injuries to the cranial nerves at the base, with the single exception of lesion
of the optic nerves, which was not rare, were in my experience uncommon
in the hospitals—a fact pointing to the very fatal nature of direct basal
injuries, except in the anterior fossa of the skull. Signs indicative of injury
to the olfactory lobe were occasionally observed.
I should, perhaps, again insist here on the rarity with which acute diffuse
septic infection occurred in cases of these degrees of severity, also on the
fact that interference with the wounds in the way of secondary exploration,
even when they were manifestly the seat of local infection, was followed
almost without exception by good immediate results; and, lastly, that when
suppuration did occur, it was usually strictly local in character. The
influence of the climate of South Africa and our surroundings has already
been discussed, but whether climate, condition of the patients, or peculiarity
in the nature of causation of the wounds was responsible, in no series of
transient, or local paralysis of the radiation variety, which also rapidly
improved.
Signs of irritation consisted in irritability of temper, drowsiness, closure of
the eyes and objection to light, contracted pupils sometimes unequal, a
tendency to the assumption of the flexed position at all the joints,
twitchings, and sometimes convulsions. Sometimes these appeared early as
a direct result of mechanical irritation from bone fragments or blood-clot;
sometimes only in the course of a few days, as a result of irritation of parts
recovering from the radiation effects which had prevented earlier nervous
reaction. Possibly in some cases the symptoms of irritation depended upon
an increase in the amount of hæmorrhage, and in others upon the
development of local inflammatory changes.
Local pressure, or actual destruction of brain tissue, was evidenced by
temporary paralysis in the former, permanent loss of function in the latter,
condition.
Fractures of the anterior fossa of the skull were attended by very marked
evidence of orbital hæmorrhage, as subconjunctival ecchymosis (rarely
pure), increased tension, and proptosis.
Injuries to the cranial nerves at the base, with the single exception of lesion
of the optic nerves, which was not rare, were in my experience uncommon
in the hospitals—a fact pointing to the very fatal nature of direct basal
injuries, except in the anterior fossa of the skull. Signs indicative of injury
to the olfactory lobe were occasionally observed.
I should, perhaps, again insist here on the rarity with which acute diffuse
septic infection occurred in cases of these degrees of severity, also on the
fact that interference with the wounds in the way of secondary exploration,
even when they were manifestly the seat of local infection, was followed
almost without exception by good immediate results; and, lastly, that when
suppuration did occur, it was usually strictly local in character. The
influence of the climate of South Africa and our surroundings has already
been discussed, but whether climate, condition of the patients, or peculiarity
in the nature of causation of the wounds was responsible, in no series of
Page 314
cases was the absence of acute inflammatory troubles more striking than in
this one of brain injuries.
Frontal injuries were those most frequently unaccompanied by primary
symptoms of severity; slowing of the pulse—this often fell to 40—and
occasional irregularity, were almost the only constant signs of cerebral
damage. Some patients temporarily lost consciousness, others rose at once
and walked to the dressing station, and in few cases was any psychical
disturbance noted in the early stages.
I think, however, it may be affirmed that frontal injuries, accompanied by
trivial signs, resulted without exception from the passage of bullets
travelling at a low rate of velocity. Thus in several of the instances here
related the patients at the time of reception of the wound were under the
impression that they were entirely beyond the range of fire, and in one, in
which well-marked signs of concussion followed, the bullet, which had
traversed the head, retained only sufficient force to perforate the skin of the
neck and bury itself in the posterior triangle without even fracturing the
clavicle, against which it impinged. In men struck at a shorter range, signs
of concussion, often followed by transient radiation signs of injury to the
parietal lobe, were common. These signs were, I think, not as a rule due to
surface hæmorrhage, since they were of a purely paralytic nature and not
irritative. Several cases with partial or complete hemiplegia, hemiplegia and
aphasia, or facial paralysis are recorded below.
(56) Frontal injury.—Wounded at Magersfontein. In prone
position when struck, distance 700 to 800 yards. Entry (Mauser),
at the margin of the hairy scalp above and to the left of the
frontal eminence; course, through anterior third of left frontal
lobe, roof of orbit, obliquely across line of optic nerve, inner
wall of orbit, nose, right superior maxilla piercing alveolar
process, and passing superficial to inferior maxilla: exit, one
inch anterior to angle of jaw. The bullet again entered the
posterior triangle of the neck, struck the right clavicle, and
turned a somersault, so that its base lay deepest in the wound.
The patient was unconscious for a short time, suffered with
general headache and giddiness, and was somewhat irritable. On
this one of brain injuries.
Frontal injuries were those most frequently unaccompanied by primary
symptoms of severity; slowing of the pulse—this often fell to 40—and
occasional irregularity, were almost the only constant signs of cerebral
damage. Some patients temporarily lost consciousness, others rose at once
and walked to the dressing station, and in few cases was any psychical
disturbance noted in the early stages.
I think, however, it may be affirmed that frontal injuries, accompanied by
trivial signs, resulted without exception from the passage of bullets
travelling at a low rate of velocity. Thus in several of the instances here
related the patients at the time of reception of the wound were under the
impression that they were entirely beyond the range of fire, and in one, in
which well-marked signs of concussion followed, the bullet, which had
traversed the head, retained only sufficient force to perforate the skin of the
neck and bury itself in the posterior triangle without even fracturing the
clavicle, against which it impinged. In men struck at a shorter range, signs
of concussion, often followed by transient radiation signs of injury to the
parietal lobe, were common. These signs were, I think, not as a rule due to
surface hæmorrhage, since they were of a purely paralytic nature and not
irritative. Several cases with partial or complete hemiplegia, hemiplegia and
aphasia, or facial paralysis are recorded below.
(56) Frontal injury.—Wounded at Magersfontein. In prone
position when struck, distance 700 to 800 yards. Entry (Mauser),
at the margin of the hairy scalp above and to the left of the
frontal eminence; course, through anterior third of left frontal
lobe, roof of orbit, obliquely across line of optic nerve, inner
wall of orbit, nose, right superior maxilla piercing alveolar
process, and passing superficial to inferior maxilla: exit, one
inch anterior to angle of jaw. The bullet again entered the
posterior triangle of the neck, struck the right clavicle, and
turned a somersault, so that its base lay deepest in the wound.
The patient was unconscious for a short time, suffered with
general headache and giddiness, and was somewhat irritable. On
Page 315
the third day the pulse was 70, temperature normal, and he was
sent to the Base. There was considerable proptosis, œdema and
discoloration of the eyelid, and subconjunctival ecchymosis, but
the movements of the eyeball could be made and light could be
distinguished. The sense of smell was apparently absent. A week
later the headache was gone, the pulse numbered 80 to 90, the
temperature was normal, he slept well, sat up in bed and
smoked, took his food well, and exhibited no cerebral
symptoms. He could detect the smell of tobacco, but not as a
definite odour.
No further symptoms were noted, the sense of smell returned,
the swelling of the eyelid and proptosis decreased, but the upper
lid could not be raised. When the lid was drawn up, there
appeared to be vision at the margins of the field with a large
central blind spot. The patient left for England at the end of a
month apparently well.
(57) Gutter fracture of frontal bone.—Wounded at Paardeberg.
Entry (Mauser), 3/4 of an inch within the margin of hairy scalp
above outer extremity of right eyebrow; gutter fracture; exit, 2
inches nearer middle line, at the same distance from the margin
of the hairy scalp. The patient was knocked head over heels, his
main feeling being a sense of dulness in the right great toe. He
sat up and got a first field dressing applied, then lay down, but
as he was still under fire, he retired 1,000 yards to the collecting
station; here he dressed some patients, and later mounted an
ambulance wagon and was driven to the Field hospital. The next
day he helped with the work of the hospital, amongst other
things controlling the artery during an amputation of the arm.
He then took a three days' and nights' journey to Modder River
in a bullock wagon, during which journey he had a fit, which
was general, the thumbs being turned in and a wedge being
necessary between the teeth to prevent him biting his tongue.
On the sixth day the wound was examined, and between this and
the tenth day he had several fits of the same nature as the first,
accompanied by stertorous breathing and profuse sweating. On
sent to the Base. There was considerable proptosis, œdema and
discoloration of the eyelid, and subconjunctival ecchymosis, but
the movements of the eyeball could be made and light could be
distinguished. The sense of smell was apparently absent. A week
later the headache was gone, the pulse numbered 80 to 90, the
temperature was normal, he slept well, sat up in bed and
smoked, took his food well, and exhibited no cerebral
symptoms. He could detect the smell of tobacco, but not as a
definite odour.
No further symptoms were noted, the sense of smell returned,
the swelling of the eyelid and proptosis decreased, but the upper
lid could not be raised. When the lid was drawn up, there
appeared to be vision at the margins of the field with a large
central blind spot. The patient left for England at the end of a
month apparently well.
(57) Gutter fracture of frontal bone.—Wounded at Paardeberg.
Entry (Mauser), 3/4 of an inch within the margin of hairy scalp
above outer extremity of right eyebrow; gutter fracture; exit, 2
inches nearer middle line, at the same distance from the margin
of the hairy scalp. The patient was knocked head over heels, his
main feeling being a sense of dulness in the right great toe. He
sat up and got a first field dressing applied, then lay down, but
as he was still under fire, he retired 1,000 yards to the collecting
station; here he dressed some patients, and later mounted an
ambulance wagon and was driven to the Field hospital. The next
day he helped with the work of the hospital, amongst other
things controlling the artery during an amputation of the arm.
He then took a three days' and nights' journey to Modder River
in a bullock wagon, during which journey he had a fit, which
was general, the thumbs being turned in and a wedge being
necessary between the teeth to prevent him biting his tongue.
On the sixth day the wound was examined, and between this and
the tenth day he had several fits of the same nature as the first,
accompanied by stertorous breathing and profuse sweating. On
Page 316
the tenth day Mr. Cheatle opened up the wound and removed
numerous fragments of bone, leaving a clean gutter 2 inches by
3/4 of an inch. After the operation no further fits occurred, and
eight days later he was conscious, but was excitable and talked
at random. On the twentieth day he arrived at the Base after 30
hours' railway journey (623 miles). He was then quite rational,
but unable to make any demands on his memory and very
sensitive to noise; at times he wandered in the evenings and his
temperature rose as high as 100°. The wound was open and
granulating, the floor pulsating freely.
Three weeks later the wound was still open, and the skin dipped
in at the lower margin. The mental condition was much
improved, although attempts at giving a history of his case were
obviously tiresome.
The wounds in the leather headband of this patient's helmet were
interesting, the round aperture of entry in the exterior of the
helmet being followed by a starred exit aperture in the leather
band, the second entry opening in the leather band being again
circular, and the external opening in the puggaree a transverse
slit.
(58) Transverse superficial perforating frontal injury.—
Wounded at Graspan. Aperture of entry (Lee-Metford), at upper
and outer part of left frontal eminence; exit, at margin of hairy
scalp over outer third of right eyebrow. On the second day the
patient complained of giddiness and headache; the pulse was 60.
He was then walking about. The wounds were explored and
typical entry and exit apertures discovered in the frontal bone
from which cerebral matter was protruding. Both openings were
enlarged (Mr. S. W. F. Richardson) with Hoffman's forceps, and
a considerable number of splinters of the inner table were
removed from the aperture of entry.
The headache gradually passed off, but there was throbbing
about the scar, and pulsation was visible for some three weeks,
after which no further symptoms were observed.
numerous fragments of bone, leaving a clean gutter 2 inches by
3/4 of an inch. After the operation no further fits occurred, and
eight days later he was conscious, but was excitable and talked
at random. On the twentieth day he arrived at the Base after 30
hours' railway journey (623 miles). He was then quite rational,
but unable to make any demands on his memory and very
sensitive to noise; at times he wandered in the evenings and his
temperature rose as high as 100°. The wound was open and
granulating, the floor pulsating freely.
Three weeks later the wound was still open, and the skin dipped
in at the lower margin. The mental condition was much
improved, although attempts at giving a history of his case were
obviously tiresome.
The wounds in the leather headband of this patient's helmet were
interesting, the round aperture of entry in the exterior of the
helmet being followed by a starred exit aperture in the leather
band, the second entry opening in the leather band being again
circular, and the external opening in the puggaree a transverse
slit.
(58) Transverse superficial perforating frontal injury.—
Wounded at Graspan. Aperture of entry (Lee-Metford), at upper
and outer part of left frontal eminence; exit, at margin of hairy
scalp over outer third of right eyebrow. On the second day the
patient complained of giddiness and headache; the pulse was 60.
He was then walking about. The wounds were explored and
typical entry and exit apertures discovered in the frontal bone
from which cerebral matter was protruding. Both openings were
enlarged (Mr. S. W. F. Richardson) with Hoffman's forceps, and
a considerable number of splinters of the inner table were
removed from the aperture of entry.
The headache gradually passed off, but there was throbbing
about the scar, and pulsation was visible for some three weeks,
after which no further symptoms were observed.
Page 317
(59) Oblique frontal gutter fracture.—Wounded at
Magersfontein. Entry (Mauser), 1/2 an inch to right of median
line of forehead, 3/4 of an inch from the margin of the hairy
scalp; exit, about 3/4 of an inch anterior to the lower extremity
of the right fissure of Rolando. Weakness of left facial muscles,
especially of angle of mouth. No further motor symptoms.
Wounds explored (Mr. Stewart); numerous fragments of bone
and some pulped cerebral matter were removed. Patient
developed no further signs; the paralysis, although improved,
did not completely disappear. The man a year later was still on
active duty, the paralysis almost well, and no further ill effects
of the injury remained.
In the fronto-parietal or parietal regions, signs of damage to the cortical
motor area were seldom absent, sometimes evanescent, at others prolonged.
In some cases the signs were permanent and followed by evidence of local
sclerosis.
The motor area on both sides of the brain was sometimes implicated; thus in
a child shot at Kimberley the bullet entered in the right frontal region, and
emerged to the left of the line connecting bregma and inion a little behind
its centre. Paralysis of both lower extremities resulted, power rapidly
returning in the right, while incomplete paralysis persisted in the left.
In only one instance (see case 73, p. 292) was any permanent sensory defect
observed, and the mental condition of this patient would have certainly
suggested a functional explanation for its presence, had it not been for the
accompanying inequality in the axillary surface temperatures.
In a second case (No. 67) blunting of sensation followed a definite lesion of
the inferior parietal lobule. In this instance an occipital lesion was
associated with the parietal.
(60) Parietal gutter fracture.—Wounded at Magersfontein. A
scalp wound 3 inches in length ran transversely across the right
parietal bone at the level of the lower third of the fissure of
Rolando. A second wound of entry was found crossing the third
dorsal spine; the bullet was retained and was palpable over the
right scapula. There was left facial paralysis, weakness and
Magersfontein. Entry (Mauser), 1/2 an inch to right of median
line of forehead, 3/4 of an inch from the margin of the hairy
scalp; exit, about 3/4 of an inch anterior to the lower extremity
of the right fissure of Rolando. Weakness of left facial muscles,
especially of angle of mouth. No further motor symptoms.
Wounds explored (Mr. Stewart); numerous fragments of bone
and some pulped cerebral matter were removed. Patient
developed no further signs; the paralysis, although improved,
did not completely disappear. The man a year later was still on
active duty, the paralysis almost well, and no further ill effects
of the injury remained.
In the fronto-parietal or parietal regions, signs of damage to the cortical
motor area were seldom absent, sometimes evanescent, at others prolonged.
In some cases the signs were permanent and followed by evidence of local
sclerosis.
The motor area on both sides of the brain was sometimes implicated; thus in
a child shot at Kimberley the bullet entered in the right frontal region, and
emerged to the left of the line connecting bregma and inion a little behind
its centre. Paralysis of both lower extremities resulted, power rapidly
returning in the right, while incomplete paralysis persisted in the left.
In only one instance (see case 73, p. 292) was any permanent sensory defect
observed, and the mental condition of this patient would have certainly
suggested a functional explanation for its presence, had it not been for the
accompanying inequality in the axillary surface temperatures.
In a second case (No. 67) blunting of sensation followed a definite lesion of
the inferior parietal lobule. In this instance an occipital lesion was
associated with the parietal.
(60) Parietal gutter fracture.—Wounded at Magersfontein. A
scalp wound 3 inches in length ran transversely across the right
parietal bone at the level of the lower third of the fissure of
Rolando. A second wound of entry was found crossing the third
dorsal spine; the bullet was retained and was palpable over the
right scapula. There was left facial paralysis, weakness and
Page 318
numbness of both upper extremities, especially of the left, and
some difficulty in swallowing. The man was sent to the Base,
where he arrived on the fourth day. The symptoms had then
become much more marked, consciousness was incomplete, and
articulation slow and imperfect. There was complete left
hemiplegia, and deviation of the tongue to the right. The pulse
was 40. An exploration (Mr. J. J. Day) showed that an oval plate
of the outer table of the parietal bone had been struck off. A
trephine was applied to the exposed diploë and a crown of bone
removed; considerable comminution of the inner table had
occurred, several large fragments having perforated the dura-
mater. The latter did not pulsate; it was therefore freely incised,
and many more fragments of bone and a large quantity of blood-
clot removed.
The first effect of the operation was slight, but ten days later
rapid improvement commenced, the first sign being acceleration
of the pulse, which rose to 70. On the eighteenth day the original
symptoms still remained to a diminished extent, but a fortnight
later there remained traces of the facial weakness only, and there
was little difference in the grip of the two hands. The patient
was shortly afterwards sent home. Ten months later he returned
to South Africa on active service.
(61) Fronto-parietal gutter fracture.—Wounded at Graspan.
Entry (Mauser), 1 inch within the margin of the hairy scalp, 1/2
an inch to the left of the median line; exit, 3½ inches posterior in
same line. Complete right-sided hemiplegia. The wounds were
explored on the fourth day (Major Moffatt, R.A.M.C.) and a
gutter fracture involving the frontal and parietal bones exposed.
The dura-mater was lacerated and brain matter from the frontal
lobe escaped freely. A large number of bone fragments were
removed. On the fourth day after the operation, the patient
became unconscious with right-sided twitchings, but rapidly
improved, and at the end of three weeks, except for slight
headache, he was well, the power of the right side being good.
Ten months later he rejoined his regiment in South Africa, no
apparent ill effects remaining.
some difficulty in swallowing. The man was sent to the Base,
where he arrived on the fourth day. The symptoms had then
become much more marked, consciousness was incomplete, and
articulation slow and imperfect. There was complete left
hemiplegia, and deviation of the tongue to the right. The pulse
was 40. An exploration (Mr. J. J. Day) showed that an oval plate
of the outer table of the parietal bone had been struck off. A
trephine was applied to the exposed diploë and a crown of bone
removed; considerable comminution of the inner table had
occurred, several large fragments having perforated the dura-
mater. The latter did not pulsate; it was therefore freely incised,
and many more fragments of bone and a large quantity of blood-
clot removed.
The first effect of the operation was slight, but ten days later
rapid improvement commenced, the first sign being acceleration
of the pulse, which rose to 70. On the eighteenth day the original
symptoms still remained to a diminished extent, but a fortnight
later there remained traces of the facial weakness only, and there
was little difference in the grip of the two hands. The patient
was shortly afterwards sent home. Ten months later he returned
to South Africa on active service.
(61) Fronto-parietal gutter fracture.—Wounded at Graspan.
Entry (Mauser), 1 inch within the margin of the hairy scalp, 1/2
an inch to the left of the median line; exit, 3½ inches posterior in
same line. Complete right-sided hemiplegia. The wounds were
explored on the fourth day (Major Moffatt, R.A.M.C.) and a
gutter fracture involving the frontal and parietal bones exposed.
The dura-mater was lacerated and brain matter from the frontal
lobe escaped freely. A large number of bone fragments were
removed. On the fourth day after the operation, the patient
became unconscious with right-sided twitchings, but rapidly
improved, and at the end of three weeks, except for slight
headache, he was well, the power of the right side being good.
Ten months later he rejoined his regiment in South Africa, no
apparent ill effects remaining.
Page 319
(62) Fronto-parietal perforating fracture.—Wounded at
Magersfontein. Entry, within the margin of the hairy scalp; exit,
behind and below the left parietal eminence, the track crossing
about the centre of the fissure of Rolando. Right hemiplegia, the
lower half of the face only being involved. The wounds were
explored and a large number of fragments of bone and a quantity
of pulped cerebral matter removed. Six days later the hemiplegia
persisted, speech was slow, headache was troublesome and the
pulse not above 45. After this, gradual improvement took place,
and a month later the lower extremity and face had regained
good power. The upper extremity remained flaccid and
paralysed, except for some slight power of movement of the
shoulder.
(63) Fronto-parietal perforating fracture.—Wounded at
Magersfontein. Entry (Mauser), 2½ inches from the median line,
3½ inches from the occipital protuberance; exit, 3/4 of an inch
from the median line, 4½ inches from the glabella; sanious fluid
escaped from both ears. There was left facial paralysis, complete
paralysis of the left upper extremity, and partial paralysis of the
left lower extremity. The patient was deaf, drowsy, and the pulse
45.
Exploration showed the entry wound to be in the parietal, the
exit to involve both parietal and frontal bones. The openings
were enlarged, and a number of fragments of bone, together
with pulped cerebral matter and blood-clot, were removed. The
wound healed, except at the front part, where a small
prominence suggested a hernia cerebri.
The patient improved slowly; fourteen days after the operation
he could hear well, and the flow from the ears had ceased. The
facial weakness was slight, the upper extremity was still
powerless, but he could move the lower and draw it up in bed.
At the end of six weeks the wound had healed, and he was got
up and dressed.
Magersfontein. Entry, within the margin of the hairy scalp; exit,
behind and below the left parietal eminence, the track crossing
about the centre of the fissure of Rolando. Right hemiplegia, the
lower half of the face only being involved. The wounds were
explored and a large number of fragments of bone and a quantity
of pulped cerebral matter removed. Six days later the hemiplegia
persisted, speech was slow, headache was troublesome and the
pulse not above 45. After this, gradual improvement took place,
and a month later the lower extremity and face had regained
good power. The upper extremity remained flaccid and
paralysed, except for some slight power of movement of the
shoulder.
(63) Fronto-parietal perforating fracture.—Wounded at
Magersfontein. Entry (Mauser), 2½ inches from the median line,
3½ inches from the occipital protuberance; exit, 3/4 of an inch
from the median line, 4½ inches from the glabella; sanious fluid
escaped from both ears. There was left facial paralysis, complete
paralysis of the left upper extremity, and partial paralysis of the
left lower extremity. The patient was deaf, drowsy, and the pulse
45.
Exploration showed the entry wound to be in the parietal, the
exit to involve both parietal and frontal bones. The openings
were enlarged, and a number of fragments of bone, together
with pulped cerebral matter and blood-clot, were removed. The
wound healed, except at the front part, where a small
prominence suggested a hernia cerebri.
The patient improved slowly; fourteen days after the operation
he could hear well, and the flow from the ears had ceased. The
facial weakness was slight, the upper extremity was still
powerless, but he could move the lower and draw it up in bed.
At the end of six weeks the wound had healed, and he was got
up and dressed.
Page 320
At the end of two months he was well enough to be sent home;
there was only a trace of facial weakness; the right upper
extremity, however, was powerless and slightly rigid, occasional
twitchings occurring in it. Considerable power had been
regained in the lower extremity, so that the patient could walk
with help, but foot-drop persisted; the gait was spastic in
character, the reflexes were much exaggerated, and there was
marked clonus. The patient was sensible, but his manner
suggested some mental weakness. Both the openings in the skull
were closed by very firm material, apparently bony.
This patient became a Commissionaire some ten months later.
His mental condition is normal, and loss of memory seems
confined to the events immediately following the injury. The
lower extremity has improved, but the upper is useless.
(64) Parietal injury: retained bullet.—Wounded at Paardeberg.
Aperture of entry (Mauser), 1 inch diagonally below and
anterior to left parietal eminence. No exit. The patient was
trephined by the surgeons of the German ambulance at
Jacobsdal.
Sixteen days later he arrived at the Base. A circular pulsating
trephine opening was then to be felt beneath the flap, but no
information was forthcoming as to the bullet. The patient could
speak, but lost words and the gist of sentences; he could
remember nothing as to himself since the day of the injury.
There was right facial weakness; he could not close the right eye
or whistle, but there was little apparent want of symmetry; there
was weakness in the grip of both hands, more marked on the
right side; both lower extremities could be moved. The reflexes
were normal, although the left limb was slightly rigid. The
pupils were equal, reflex normal; slight nystagmus. Pulse 72,
small and regular. Temperature normal. Rapid improvement
followed.
During the fourth week the temperature rose to 103°, and
remained elevated for six days, but no local or general signs
there was only a trace of facial weakness; the right upper
extremity, however, was powerless and slightly rigid, occasional
twitchings occurring in it. Considerable power had been
regained in the lower extremity, so that the patient could walk
with help, but foot-drop persisted; the gait was spastic in
character, the reflexes were much exaggerated, and there was
marked clonus. The patient was sensible, but his manner
suggested some mental weakness. Both the openings in the skull
were closed by very firm material, apparently bony.
This patient became a Commissionaire some ten months later.
His mental condition is normal, and loss of memory seems
confined to the events immediately following the injury. The
lower extremity has improved, but the upper is useless.
(64) Parietal injury: retained bullet.—Wounded at Paardeberg.
Aperture of entry (Mauser), 1 inch diagonally below and
anterior to left parietal eminence. No exit. The patient was
trephined by the surgeons of the German ambulance at
Jacobsdal.
Sixteen days later he arrived at the Base. A circular pulsating
trephine opening was then to be felt beneath the flap, but no
information was forthcoming as to the bullet. The patient could
speak, but lost words and the gist of sentences; he could
remember nothing as to himself since the day of the injury.
There was right facial weakness; he could not close the right eye
or whistle, but there was little apparent want of symmetry; there
was weakness in the grip of both hands, more marked on the
right side; both lower extremities could be moved. The reflexes
were normal, although the left limb was slightly rigid. The
pupils were equal, reflex normal; slight nystagmus. Pulse 72,
small and regular. Temperature normal. Rapid improvement
followed.
During the fourth week the temperature rose to 103°, and
remained elevated for six days, but no local or general signs
Page 321
appeared; at the end of five weeks there was little evidence of
the paralysis remaining. The patient was discharged from the
service on his return home.
In the upper part of the occipital region glancing or superficial injuries were
comparatively favourable; those near the base, especially if perforating,
were very dangerous. Two such cases are referred to elsewhere. Case 69 is
included as the only example of cerebellar injury I happened to see who
lived any appreciable time after the accident.
The main interest in these cases centres in the defects produced in the area
of the visual field. I am extremely indebted to my colleague, Mr. J. H.
Fisher, who has kindly determined this for me in three of the following
cases. It will be noted that in two instances the injury was to the left
occipital lobe. In these the resulting hemianopsia was of the pure lateral
homonymous character, and in both the visual symptoms were accompanied
by a certain degree of amnesic aphasia (65 and 68).
In 65 the injury was definitely unilateral, and at the time of the operation I
decided that at least an inch and a half of the posterior extremity of the left
occipital lobe was totally destroyed.
In 68 the lesion was probably confined to the left lobe, but it is impossible
to exclude slight injury to the right lobe also. In this instance amnesic
aphasia was a far more marked symptom than in 65, and the position of the
lesion suggested damage both to the visual and auditory word centres.
Cases 66 and 67 are instances of damage to both occipital lobes. In 66,
although the wound was a glancing one, and did not perforate, it was so
near the median line, and accompanied by such severe damage to the bone,
that a symmetrical lesion of the cuneate and precuneate lobules of both
right and left sides is to be inferred. In 67 the great longitudinal fissure was
traversed by the bullet obliquely. It is of great interest to observe that in
each of these cases the lesion of the visual field was a horizontal one and
affected the lower half in place of assuming a lateral distribution.
In all four cases the primary effect of the occipital injury was the same—
viz. absolute blindness—while the return of vision in each was of the nature
of the dawning of light. I regret that I am unable to furnish any detail as to
the paralysis remaining. The patient was discharged from the
service on his return home.
In the upper part of the occipital region glancing or superficial injuries were
comparatively favourable; those near the base, especially if perforating,
were very dangerous. Two such cases are referred to elsewhere. Case 69 is
included as the only example of cerebellar injury I happened to see who
lived any appreciable time after the accident.
The main interest in these cases centres in the defects produced in the area
of the visual field. I am extremely indebted to my colleague, Mr. J. H.
Fisher, who has kindly determined this for me in three of the following
cases. It will be noted that in two instances the injury was to the left
occipital lobe. In these the resulting hemianopsia was of the pure lateral
homonymous character, and in both the visual symptoms were accompanied
by a certain degree of amnesic aphasia (65 and 68).
In 65 the injury was definitely unilateral, and at the time of the operation I
decided that at least an inch and a half of the posterior extremity of the left
occipital lobe was totally destroyed.
In 68 the lesion was probably confined to the left lobe, but it is impossible
to exclude slight injury to the right lobe also. In this instance amnesic
aphasia was a far more marked symptom than in 65, and the position of the
lesion suggested damage both to the visual and auditory word centres.
Cases 66 and 67 are instances of damage to both occipital lobes. In 66,
although the wound was a glancing one, and did not perforate, it was so
near the median line, and accompanied by such severe damage to the bone,
that a symmetrical lesion of the cuneate and precuneate lobules of both
right and left sides is to be inferred. In 67 the great longitudinal fissure was
traversed by the bullet obliquely. It is of great interest to observe that in
each of these cases the lesion of the visual field was a horizontal one and
affected the lower half in place of assuming a lateral distribution.
In all four cases the primary effect of the occipital injury was the same—
viz. absolute blindness—while the return of vision in each was of the nature
of the dawning of light. I regret that I am unable to furnish any detail as to
Page 322
increase of the field of vision in the progress of the cases, but circumstances
rendered continuous observation of the patients impossible.
In each case deafness was apparently the direct result of concussion of the
ear on the side corresponding to the wound. Deafness of the opposite ear
was never noted.
In case 67 some general blunting of sensation was noted in the paralysed
upper extremity, and in this patient, no doubt, injury to the inferior parietal
lobule accompanied the occipital lesion.
(65) Injury to left occipital lobe.—Wounded at Belmont. A
single transverse wound, 2 inches in length, extended across the
occipital bone, 2 inches above the level of the external
protuberance. When seen on the third day the wound was gaping
and pulped cerebral matter was found in it. The patient was very
drowsy, lying with closed eyes, and complaining of great
coronal and frontal headache. He could distinguish light and
darkness, but not persons. Total blindness immediately followed
the injury, persisting some three days, and the patient spoke of
return of sight as of the appearance of dawn. The pupils were
equal, moderately dilated and acted to light, which was
unpleasant to him. He was somewhat irritable and silent, but
apparently rational. Temperature 99°. Pulse 56 full. Tongue
clean. No sickness, no difficulty in micturition.
Fifty-six hours after the injury the wound was opened up and
cleaned, and an oval fractured opening about 3/4 by 1/2 inch
was exposed 3/4 inch to the left, and 2 inches above the
occipital protuberance. The margins of the opening showed
several small fragments of lead attached to the bone. A 3/4-inch
trephine was applied at the left extremity of the opening, and it
was found that about a square inch of the internal table was
comminuted and driven into the brain, together with several
small fragments of lead. On introducing the finger, about 1½
square inches of the occipital lobe were found to be pulped, and
the finger could be swept across the tentorium. There was no
sinus hæmorrhage (nor did the history suggest that hæmorrhage
rendered continuous observation of the patients impossible.
In each case deafness was apparently the direct result of concussion of the
ear on the side corresponding to the wound. Deafness of the opposite ear
was never noted.
In case 67 some general blunting of sensation was noted in the paralysed
upper extremity, and in this patient, no doubt, injury to the inferior parietal
lobule accompanied the occipital lesion.
(65) Injury to left occipital lobe.—Wounded at Belmont. A
single transverse wound, 2 inches in length, extended across the
occipital bone, 2 inches above the level of the external
protuberance. When seen on the third day the wound was gaping
and pulped cerebral matter was found in it. The patient was very
drowsy, lying with closed eyes, and complaining of great
coronal and frontal headache. He could distinguish light and
darkness, but not persons. Total blindness immediately followed
the injury, persisting some three days, and the patient spoke of
return of sight as of the appearance of dawn. The pupils were
equal, moderately dilated and acted to light, which was
unpleasant to him. He was somewhat irritable and silent, but
apparently rational. Temperature 99°. Pulse 56 full. Tongue
clean. No sickness, no difficulty in micturition.
Fifty-six hours after the injury the wound was opened up and
cleaned, and an oval fractured opening about 3/4 by 1/2 inch
was exposed 3/4 inch to the left, and 2 inches above the
occipital protuberance. The margins of the opening showed
several small fragments of lead attached to the bone. A 3/4-inch
trephine was applied at the left extremity of the opening, and it
was found that about a square inch of the internal table was
comminuted and driven into the brain, together with several
small fragments of lead. On introducing the finger, about 1½
square inches of the occipital lobe were found to be pulped, and
the finger could be swept across the tentorium. There was no
sinus hæmorrhage (nor did the history suggest that hæmorrhage
Page 323
had ever been severe). The cavity was carefully sponged out,
and the wound closed with a drainage aperture. Little change
followed in the patient's condition, and on the sixth day he was
sent to the Base hospital.
Three weeks later the wound was firmly healed. The patient still
complained of frontal headache, and wore a shade, as the light
hurt his eyes and made them water freely. The pupils acted, but
were wide; objects could be distinguished, and also persons.
Otherwise, the man's condition was good: he began to get up,
and at the end of six weeks returned to England.
A year later the man was earning his living as a Commissionaire
porter. He complains of giddiness when he stoops, or when he
looks upwards, and at times he suffers much with headache both
in the region of the injury and across the temples.
There is a bony defect and slight pulsation at the site of the
injury, but no prominence. When attempts are made to read the
lines run together, and a dark shadow comes before his eyes. He
speaks of the latter as still terribly weak. Speech is slow and
somewhat simple, but he makes no mistakes as to words.
Memory is bad for recent events.
Mr. Fisher makes the following report as to the eyes: Pupils and
movement of eyes normal in every respect. No changes in fundi.
Vision, R. 5/12 with—0.5 5/6
L. 5/9 with—0.5 5/5
There is therefore practically full direct vision. Though the man chooses a
concave glass he is not really myopic. There is typical right homonymous
hemianopsia; the answers, when tested with the perimeter, are quite certain,
and the fields absolutely reliable.
The man's statements confirm the condition; he is aware of his inability to
see objects to his right-hand side, and is apt to collide with persons or
objects on that side.
and the wound closed with a drainage aperture. Little change
followed in the patient's condition, and on the sixth day he was
sent to the Base hospital.
Three weeks later the wound was firmly healed. The patient still
complained of frontal headache, and wore a shade, as the light
hurt his eyes and made them water freely. The pupils acted, but
were wide; objects could be distinguished, and also persons.
Otherwise, the man's condition was good: he began to get up,
and at the end of six weeks returned to England.
A year later the man was earning his living as a Commissionaire
porter. He complains of giddiness when he stoops, or when he
looks upwards, and at times he suffers much with headache both
in the region of the injury and across the temples.
There is a bony defect and slight pulsation at the site of the
injury, but no prominence. When attempts are made to read the
lines run together, and a dark shadow comes before his eyes. He
speaks of the latter as still terribly weak. Speech is slow and
somewhat simple, but he makes no mistakes as to words.
Memory is bad for recent events.
Mr. Fisher makes the following report as to the eyes: Pupils and
movement of eyes normal in every respect. No changes in fundi.
Vision, R. 5/12 with—0.5 5/6
L. 5/9 with—0.5 5/5
There is therefore practically full direct vision. Though the man chooses a
concave glass he is not really myopic. There is typical right homonymous
hemianopsia; the answers, when tested with the perimeter, are quite certain,
and the fields absolutely reliable.
The man's statements confirm the condition; he is aware of his inability to
see objects to his right-hand side, and is apt to collide with persons or
objects on that side.
Page 324
Fig. 73.
Right Visual Field, in case 65. Injury to left occipital lobe. Field for
white. Test spot 10 mm. Good daylight. Right homonymous
hemianopsia
Right Visual Field, in case 65. Injury to left occipital lobe. Field for
white. Test spot 10 mm. Good daylight. Right homonymous
hemianopsia
Page 325
Fig. 74.—Left Visual Field, case 65
The lesion is one of the left occipital cortex in the cuneate lobe and the
neighbourhood of the calcarine fissure. The speech suggests a slight degree
of aphasia.
(66) Injury to occipital lobes.—Wounded at Magersfontein while in prone
position. Distance, 500 yards. He says he was never unconscious, but for
two days was absolutely blind. His eyesight gradually improved, but
headache was very severe, and sleeplessness nearly absolute. On the eighth
day the wound, which was situated over the right posterior superior angle of
the parietal bone, was opened up, and a number of fragments of bone and a
quantity of pulped brain removed from a depressed punctured fracture,
surrounded by an annular fissure, completely encircling it, 1½ inch from the
opening. The portion of brain destroyed was probably a considerable
portion of the cuneate and precuneate lobules of both sides, as well as a
portion of the first occipital convolution, and the superior parietal lobule of
The lesion is one of the left occipital cortex in the cuneate lobe and the
neighbourhood of the calcarine fissure. The speech suggests a slight degree
of aphasia.
(66) Injury to occipital lobes.—Wounded at Magersfontein while in prone
position. Distance, 500 yards. He says he was never unconscious, but for
two days was absolutely blind. His eyesight gradually improved, but
headache was very severe, and sleeplessness nearly absolute. On the eighth
day the wound, which was situated over the right posterior superior angle of
the parietal bone, was opened up, and a number of fragments of bone and a
quantity of pulped brain removed from a depressed punctured fracture,
surrounded by an annular fissure, completely encircling it, 1½ inch from the
opening. The portion of brain destroyed was probably a considerable
portion of the cuneate and precuneate lobules of both sides, as well as a
portion of the first occipital convolution, and the superior parietal lobule of
Page 326
the right side. There was no evidence of injury to the superior longitudinal
sinus in the way of hæmorrhage.
After the operation the patient slept better, but still complained of headache,
and when he arrived at the Base, the flap became œdematous, and the stitch
holes and also the central part of the wound suppurated. The temperature
rose to 101°. The wound was therefore re-opened, and a number of
additional fragments of bone, some as deeply situated as 2 inches from the
surface, were removed. Steady improvement followed, and at the end of a
further three weeks the wound was healed, the headache had ceased, and
there were no abnormal symptoms, except that light was unpleasant to the
right eye, and the field of vision was manifestly contracted (Mr. Pooley).
A year later the man was employed as a letter-carrier. He complains of
headache at times, and on six occasions has had 'fainting fits.' He says that
the latter commence with tremor, that his legs then give way and he falls. In
a quarter of an hour he gets up, and feels no further inconvenience. Speech
is perfect, there is no deafness. The bone defect is very nearly completely
closed.
Mr. Fisher reports as follows as to the vision. There is a high degree of
hypermetropia in each eye, the R. has nearly 6.0 D and the L. about 5.0 D.
With correction he gets practically full direct vision with each.
sinus in the way of hæmorrhage.
After the operation the patient slept better, but still complained of headache,
and when he arrived at the Base, the flap became œdematous, and the stitch
holes and also the central part of the wound suppurated. The temperature
rose to 101°. The wound was therefore re-opened, and a number of
additional fragments of bone, some as deeply situated as 2 inches from the
surface, were removed. Steady improvement followed, and at the end of a
further three weeks the wound was healed, the headache had ceased, and
there were no abnormal symptoms, except that light was unpleasant to the
right eye, and the field of vision was manifestly contracted (Mr. Pooley).
A year later the man was employed as a letter-carrier. He complains of
headache at times, and on six occasions has had 'fainting fits.' He says that
the latter commence with tremor, that his legs then give way and he falls. In
a quarter of an hour he gets up, and feels no further inconvenience. Speech
is perfect, there is no deafness. The bone defect is very nearly completely
closed.
Mr. Fisher reports as follows as to the vision. There is a high degree of
hypermetropia in each eye, the R. has nearly 6.0 D and the L. about 5.0 D.
With correction he gets practically full direct vision with each.
Page 327
Fig. 75.
Right Visual Field, in case 66. Injury to both occipital lobes. Field for
white. Test spot 10 mm. Good artificial light. Defect in field
complicated by functional symptoms
Right Visual Field, in case 66. Injury to both occipital lobes. Field for
white. Test spot 10 mm. Good artificial light. Defect in field
complicated by functional symptoms
Page 328
Fig. 76.—Left Visual Field, in case 66. Defect in
lower half of field
The patient has been examined before, and has been informed that his
vision quite incapacitates him from further service. He began by stating that
he could not see on either side of him, but only straight in front; that he is
apt to collide with people in walking, was nearly knocked down by a horse,
and that his acquaintances accuse him of passing them unnoticed. The fields
of vision are very small, but the loss is not typically in the temporal half of
either. That of the right eye which we know as the spiral field, becoming
more and more contracted as the perimeter test is continued, is what is
found in functional cases; that of the left, however, shows a characteristic
loss of the lower part of the field of vision, and agrees with the statement of
the man that he can see the upper part of my face but not the lower when he
looks at me. Such a loss agrees with a lesion involving the upper part of the
cuneate lobe above the calcarine fissure.
I feel satisfied that there is considerable loss in the right field also, but the
functional element obscures its exact nature.
lower half of field
The patient has been examined before, and has been informed that his
vision quite incapacitates him from further service. He began by stating that
he could not see on either side of him, but only straight in front; that he is
apt to collide with people in walking, was nearly knocked down by a horse,
and that his acquaintances accuse him of passing them unnoticed. The fields
of vision are very small, but the loss is not typically in the temporal half of
either. That of the right eye which we know as the spiral field, becoming
more and more contracted as the perimeter test is continued, is what is
found in functional cases; that of the left, however, shows a characteristic
loss of the lower part of the field of vision, and agrees with the statement of
the man that he can see the upper part of my face but not the lower when he
looks at me. Such a loss agrees with a lesion involving the upper part of the
cuneate lobe above the calcarine fissure.
I feel satisfied that there is considerable loss in the right field also, but the
functional element obscures its exact nature.
Page 329
The fundi, pupils, and ocular movements are all normal.
(67) Injury to occipital lobes and left motor and sensory areas.—Wounded
outside Lindley (Spitzkop). Range within 1,000 yards. Entry, one inch
within the right lateral angle of the occipital bone, external wound more
than 1/2 an inch in diameter; exit, 2 inches from the median line, over the
upper half of the left fissure of Rolando. Behind the wound of exit
comminution of the parietal bone, extending back to the lambdoid suture,
existed. I attributed this to oblique lateral impact by the bullet on the inner
surface of the skull.
The patient could afterwards remember being struck, but became rapidly
unconscious. When brought into the Field hospital some five hours later the
condition was as follows: Semi-conscious, can speak, apparently blind,
pupils equal, of moderate size, do not react to light. Right hemiplegia. No
sickness. Moans with pain in head. Passes water normally.
Considerable hæmorrhage had occurred from each wound, the scalp was
puffy, and the bones yielded on pressure over the left parietal bone,
indicating considerable comminution.
The night was so cold that no operation could be considered, so the head
was partly shaved, the wounds cleansed, and a dressing applied. The next
morning the Division marched at 5 a.m., and it was considered wise to leave
the man at Lindley in the local hospital.
(67) Injury to occipital lobes and left motor and sensory areas.—Wounded
outside Lindley (Spitzkop). Range within 1,000 yards. Entry, one inch
within the right lateral angle of the occipital bone, external wound more
than 1/2 an inch in diameter; exit, 2 inches from the median line, over the
upper half of the left fissure of Rolando. Behind the wound of exit
comminution of the parietal bone, extending back to the lambdoid suture,
existed. I attributed this to oblique lateral impact by the bullet on the inner
surface of the skull.
The patient could afterwards remember being struck, but became rapidly
unconscious. When brought into the Field hospital some five hours later the
condition was as follows: Semi-conscious, can speak, apparently blind,
pupils equal, of moderate size, do not react to light. Right hemiplegia. No
sickness. Moans with pain in head. Passes water normally.
Considerable hæmorrhage had occurred from each wound, the scalp was
puffy, and the bones yielded on pressure over the left parietal bone,
indicating considerable comminution.
The night was so cold that no operation could be considered, so the head
was partly shaved, the wounds cleansed, and a dressing applied. The next
morning the Division marched at 5 a.m., and it was considered wise to leave
the man at Lindley in the local hospital.
Page 330
Fig. 77.—Right Visual Field, in case 67.
Injury to both occipital lobes. Field for white. Test spot 10 mm. Good
artificial light. Defect in lower half of field
Injury to both occipital lobes. Field for white. Test spot 10 mm. Good
artificial light. Defect in lower half of field
Page 331
Fig. 78.—Left Visual Field, in case 67
No operation was performed there, but I heard later that the man recovered
full consciousness at the end of five days, and at the end of a fortnight he
commenced to see again.
Six weeks later he travelled to Kroonstadt, thence to Bloemfontein, and
thence to Cape Town and home to Netley. The paralytic symptoms
meanwhile steadily improved.
Seven months later his condition is as follows: Scarcely a trace of facial
paralysis. Slight power of movement of arm, forearm, and fingers, but grip
is very weak. Little power of abduction of the shoulder or of straightening
the elbow. The latter movement is made with effort and in jerks. Sensation
over the back of the arm is somewhat lowered, and is 'furry' at the finger
tips. There is very little wasting of the muscles noticeable.
Walks well, but with some foot-drop. Slight increase of patellar reflex. He
says that he does not walk in the street with confidence, as he often feels as
if omnibuses &c. were coming too near him.
No operation was performed there, but I heard later that the man recovered
full consciousness at the end of five days, and at the end of a fortnight he
commenced to see again.
Six weeks later he travelled to Kroonstadt, thence to Bloemfontein, and
thence to Cape Town and home to Netley. The paralytic symptoms
meanwhile steadily improved.
Seven months later his condition is as follows: Scarcely a trace of facial
paralysis. Slight power of movement of arm, forearm, and fingers, but grip
is very weak. Little power of abduction of the shoulder or of straightening
the elbow. The latter movement is made with effort and in jerks. Sensation
over the back of the arm is somewhat lowered, and is 'furry' at the finger
tips. There is very little wasting of the muscles noticeable.
Walks well, but with some foot-drop. Slight increase of patellar reflex. He
says that he does not walk in the street with confidence, as he often feels as
if omnibuses &c. were coming too near him.
Page 332
He is absolutely deaf in the right ear.
The openings in the skull are closed, the occipital lies about halfway
between the external auditory meatus and the external occipital
protuberance, while the parietal still affords evidence of the earlier
comminution, one fissure passing backwards as far as the lambda, and the
whole surface is lumpy and uneven.
The track through the brain no doubt involved a considerable extent of the
outer aspect of the right occipital lobe and the cuneate lobule. It must also
have crossed the great longitudinal fissure, and penetrated the left Rolandic
region, just above its centre, probably involving the precuneate lobule, and
a portion of the internal capsular fibres as well as the cortex on the left side.
The deafness was probably due to concussion of the internal ear.
Mr. Fisher has kindly furnished the following note regarding the vision. The
pupils, movements, and fundi are quite healthy. There is good direct vision
R. or L. 5/5 fairly, and together 5/5. The man complains he has lost his side
sight, also the lower; he demonstrates the latter quite obviously with his
hand, and says he has to repeatedly look down when walking. He thinks no
improvement has taken place during the last month. The accompanying
fields of vision show the loss quite characteristically.
(68) Injury to left occipital lobe.—Wounded at Paardeberg. Entry (Mauser),
through the lambdoid suture on the right side of the mid line. Bullet
retained, but a palpable prominence behind the left ear suggested its
localisation.
The patient became at once unconscious and remained so for several days.
He was completely blind; vision returned later, but only to a limited degree.
There was complete loss of memory as to the events of the day.
When admitted at Rondebosch into No. 3 General Hospital the condition
was as follows: The field of vision is limited, and examination shows right
homonymous hemianopsia. When any one comes into the tent the patient
sees a shadow only until his bed is reached.
When spoken to the patient 'thinks and thinks,' and then apologises for not
answering, saying he will remember at some future time. He is absolutely
unable to remember times, names, or localities, but places his hand to his
The openings in the skull are closed, the occipital lies about halfway
between the external auditory meatus and the external occipital
protuberance, while the parietal still affords evidence of the earlier
comminution, one fissure passing backwards as far as the lambda, and the
whole surface is lumpy and uneven.
The track through the brain no doubt involved a considerable extent of the
outer aspect of the right occipital lobe and the cuneate lobule. It must also
have crossed the great longitudinal fissure, and penetrated the left Rolandic
region, just above its centre, probably involving the precuneate lobule, and
a portion of the internal capsular fibres as well as the cortex on the left side.
The deafness was probably due to concussion of the internal ear.
Mr. Fisher has kindly furnished the following note regarding the vision. The
pupils, movements, and fundi are quite healthy. There is good direct vision
R. or L. 5/5 fairly, and together 5/5. The man complains he has lost his side
sight, also the lower; he demonstrates the latter quite obviously with his
hand, and says he has to repeatedly look down when walking. He thinks no
improvement has taken place during the last month. The accompanying
fields of vision show the loss quite characteristically.
(68) Injury to left occipital lobe.—Wounded at Paardeberg. Entry (Mauser),
through the lambdoid suture on the right side of the mid line. Bullet
retained, but a palpable prominence behind the left ear suggested its
localisation.
The patient became at once unconscious and remained so for several days.
He was completely blind; vision returned later, but only to a limited degree.
There was complete loss of memory as to the events of the day.
When admitted at Rondebosch into No. 3 General Hospital the condition
was as follows: The field of vision is limited, and examination shows right
homonymous hemianopsia. When any one comes into the tent the patient
sees a shadow only until his bed is reached.
When spoken to the patient 'thinks and thinks,' and then apologises for not
answering, saying he will remember at some future time. He is absolutely
unable to remember times, names, or localities, but places his hand to his
Page 333
head and appears to think deeply in the effort to recall them. Occasionally
when you go into his tent he suddenly remembers something he has been
trying to think of for some days, and will tell you.
A fortnight later after an attack of influenza the patient was not so well, and
vision was apparently becoming more impaired.
An incision was made (Mr. J. E. Ker) so as to raise a flap the centre of the
convexity of which was 2½ inches behind the left external auditory meatus.
A slight prominence and a fissure was discovered in the temporal bone, and
over this a trephine was applied. On removal of the crown of bone the bullet
was discovered with the point turned backwards (having evidently
undergone a partial ricochet turn) on the upper surface of the petrous bone,
just above the lateral sinus. The dura-mater was healed but thickened, and
some clot upon its surface was removed.
The wound healed per primam, and a rapid recovery was made. Ten days
later a running water-tap was able to be detected 120 yards from the tent
door. The hemianopsia however persisted.
The following letter, dictated by the patient to his wife, and sent to me,
gives a clear account of his condition ten months later:—
I am pleased to say my memory is better than it was some time
ago, though at times I am entirely lost and really forget all that I
was speaking about. I also find that I often call things and places
by their wrong names. I sometimes try to read a paper or book
which I have to read letter by letter, sometimes calling out the
wrong letter, such as B for D &c., and by the time I have read
almost halfway through, I have forgotten the commencement.
My sight is about the same. There is no improvement in the right
eye, and the doctor at Stoke said that the left eye was not as it
ought to be and might get worse.
I ofttimes go to take up a thing, but find I am not near to it,
though it appears to me so.
I have no pain to speak of in the head, though at times a
shooting pain.
when you go into his tent he suddenly remembers something he has been
trying to think of for some days, and will tell you.
A fortnight later after an attack of influenza the patient was not so well, and
vision was apparently becoming more impaired.
An incision was made (Mr. J. E. Ker) so as to raise a flap the centre of the
convexity of which was 2½ inches behind the left external auditory meatus.
A slight prominence and a fissure was discovered in the temporal bone, and
over this a trephine was applied. On removal of the crown of bone the bullet
was discovered with the point turned backwards (having evidently
undergone a partial ricochet turn) on the upper surface of the petrous bone,
just above the lateral sinus. The dura-mater was healed but thickened, and
some clot upon its surface was removed.
The wound healed per primam, and a rapid recovery was made. Ten days
later a running water-tap was able to be detected 120 yards from the tent
door. The hemianopsia however persisted.
The following letter, dictated by the patient to his wife, and sent to me,
gives a clear account of his condition ten months later:—
I am pleased to say my memory is better than it was some time
ago, though at times I am entirely lost and really forget all that I
was speaking about. I also find that I often call things and places
by their wrong names. I sometimes try to read a paper or book
which I have to read letter by letter, sometimes calling out the
wrong letter, such as B for D &c., and by the time I have read
almost halfway through, I have forgotten the commencement.
My sight is about the same. There is no improvement in the right
eye, and the doctor at Stoke said that the left eye was not as it
ought to be and might get worse.
I ofttimes go to take up a thing, but find I am not near to it,
though it appears to me so.
I have no pain to speak of in the head, though at times a
shooting pain.
Page 334
I have a continual noise in the left ear as if of a locomotive
blowing off steam, and a deafness in the left ear which I had not
before being wounded.
I am extremely indebted to my friend Mr. J. Errington Ker for the notes of
the above case, so successfully treated by him.
(69) Injury to occipital lobe.—Wounded at Modder River. Scalp
wound in occipital region. Two days later on arrival at the Base
the patient was extremely restless and in a condition of noisy
delirium. The wound was explored (Mr. J. J. Day) and a vertical
gutter fracture discovered 1/2 an inch above and to the left of the
occipital protuberance. The gutter was 1½ inch in length and
finely comminuted, the dura wounded, and the left occipital lobe
pulped. A number of fragments of bone (one lodged in the wall
of, but not penetrating, the lateral sinus) and pulped brain were
removed. No improvement took place in the general condition,
but the patient lived twenty-two days, during which time he
coughed up a large quantity of gangrenous lung tissue and foul
pus.
At the post-mortem examination a wound track was found
extending to the crest of the left ilium, where the bullet was
lodged. The patient was no doubt lying with his head dipped
into a hole scooped out in the sand (a common custom) when
struck; the bullet then traversed the muscles of the neck, entered
the upper opening of the thorax, where it struck the bodies of the
second and third dorsal vertebræ, one third of the bodies of each
of which were driven into an extensive laceration of the lung; it
then grooved the inner surfaces of the eighth and ninth ribs,
fractured the tenth and eleventh, and passing the twelfth
traversed the deep muscles of the back to the pelvis. Beyond the
injury to the occipital lobe, the cerebellum was found to be
lacerated and extensively bruised and ecchymosed.
Complications.—Hernia cerebri as a primary feature has already been
mentioned as one of the peculiarities of some explosive wounds. In the later
stages of the cases in which primary union did not take place the
blowing off steam, and a deafness in the left ear which I had not
before being wounded.
I am extremely indebted to my friend Mr. J. Errington Ker for the notes of
the above case, so successfully treated by him.
(69) Injury to occipital lobe.—Wounded at Modder River. Scalp
wound in occipital region. Two days later on arrival at the Base
the patient was extremely restless and in a condition of noisy
delirium. The wound was explored (Mr. J. J. Day) and a vertical
gutter fracture discovered 1/2 an inch above and to the left of the
occipital protuberance. The gutter was 1½ inch in length and
finely comminuted, the dura wounded, and the left occipital lobe
pulped. A number of fragments of bone (one lodged in the wall
of, but not penetrating, the lateral sinus) and pulped brain were
removed. No improvement took place in the general condition,
but the patient lived twenty-two days, during which time he
coughed up a large quantity of gangrenous lung tissue and foul
pus.
At the post-mortem examination a wound track was found
extending to the crest of the left ilium, where the bullet was
lodged. The patient was no doubt lying with his head dipped
into a hole scooped out in the sand (a common custom) when
struck; the bullet then traversed the muscles of the neck, entered
the upper opening of the thorax, where it struck the bodies of the
second and third dorsal vertebræ, one third of the bodies of each
of which were driven into an extensive laceration of the lung; it
then grooved the inner surfaces of the eighth and ninth ribs,
fractured the tenth and eleventh, and passing the twelfth
traversed the deep muscles of the back to the pelvis. Beyond the
injury to the occipital lobe, the cerebellum was found to be
lacerated and extensively bruised and ecchymosed.
Complications.—Hernia cerebri as a primary feature has already been
mentioned as one of the peculiarities of some explosive wounds. In the later
stages of the cases in which primary union did not take place the
Page 335
development of granulation tumours was often seen, sometimes in
connection with slight local suppuration, sometimes over a cerebral abscess.
In some cases a wound which had once closed reopened and a hernia
developed. This sequence was chiefly of prognostic significance as an
indication of intra-cranial inflammation, usually of a chronic character, and
affecting rather the lowly organised granulation tissue formed in the cavity
than the brain itself. When primary union of the skin flap and wound failed,
the process of definitive closure of the subjacent cavity was always a very
prolonged one, and it was in such cases that a great proportion of the so-
called herniæ developed.
Abscess of the brain.—Local abscesses formed in a considerable proportion
of the cases where serious damage to the brain had occurred, in whatever
region this happened to be. I never saw one develop in cases where primary
union had taken place, even when bone fragments had not been removed;
neither did I ever see an abscess situated at a distance from the original
injury. I take it that the latter is to be explained by the early date of the
suppuration, and the fact that in the great majority of small-calibre wounds
the exit opening exists in the situation of the contre-coup damages of civil
practice.
The main feature in the symptoms when abscesses developed was the
insidious mode of their appearance, usually at the end of fourteen to twenty-
one days, and their comparative mildness.
Very slight evidences of compression were observed; thus, varying degrees
of headache, drowsiness, irritability of temper or depression, twitchings, or
in some cases Jacksonian seizures, combined with slow pulse and slight
rises of temperature. I never happened to see complete unconsciousness.
The slight evidence of compression was perhaps explained in most cases by
the large bony defect in the skull, which acted as a kind of safety-valve.
Again the firm nature of the cicatricial tissue which formed at the periphery
of the injury and extended up to the skull and there formed a more or less
firm attachment, also preserved the actual brain tissue to some degree from
either pressure or direct irritation. After evacuation of the pus, the usual
difficulty was experienced in ensuring free drainage, and definitive healing
and closure of the cavities was very slow. The following two cases will
illustrate the character of the cases of cerebral abscess we met with:—
connection with slight local suppuration, sometimes over a cerebral abscess.
In some cases a wound which had once closed reopened and a hernia
developed. This sequence was chiefly of prognostic significance as an
indication of intra-cranial inflammation, usually of a chronic character, and
affecting rather the lowly organised granulation tissue formed in the cavity
than the brain itself. When primary union of the skin flap and wound failed,
the process of definitive closure of the subjacent cavity was always a very
prolonged one, and it was in such cases that a great proportion of the so-
called herniæ developed.
Abscess of the brain.—Local abscesses formed in a considerable proportion
of the cases where serious damage to the brain had occurred, in whatever
region this happened to be. I never saw one develop in cases where primary
union had taken place, even when bone fragments had not been removed;
neither did I ever see an abscess situated at a distance from the original
injury. I take it that the latter is to be explained by the early date of the
suppuration, and the fact that in the great majority of small-calibre wounds
the exit opening exists in the situation of the contre-coup damages of civil
practice.
The main feature in the symptoms when abscesses developed was the
insidious mode of their appearance, usually at the end of fourteen to twenty-
one days, and their comparative mildness.
Very slight evidences of compression were observed; thus, varying degrees
of headache, drowsiness, irritability of temper or depression, twitchings, or
in some cases Jacksonian seizures, combined with slow pulse and slight
rises of temperature. I never happened to see complete unconsciousness.
The slight evidence of compression was perhaps explained in most cases by
the large bony defect in the skull, which acted as a kind of safety-valve.
Again the firm nature of the cicatricial tissue which formed at the periphery
of the injury and extended up to the skull and there formed a more or less
firm attachment, also preserved the actual brain tissue to some degree from
either pressure or direct irritation. After evacuation of the pus, the usual
difficulty was experienced in ensuring free drainage, and definitive healing
and closure of the cavities was very slow. The following two cases will
illustrate the character of the cases of cerebral abscess we met with:—
Page 336
(70) Fronto-parietal abscess.—Wounded at Magersfontein
(Mauser). Entry, 1¾ inch above the line from the lower margin
of the orbit to the external auditory meatus, and 1¾ inch behind
the external angular process; exit, a little posterior to the left
parietal eminence. There was right hemiplegia. The wounds
were explored, and a large number of fragments of bone and
pulped brain were removed, especially from the anterior wound.
No great improvement followed, and the patient was sent to the
Base. At this time there was a large hernia cerebri at the anterior
wound which was suppurating.
A further operation was here performed (Mr. J. J. Day). The
hernia cerebri was removed, also several fragments of bone
which were found deeply imbedded in the brain. The patient
then improved, but a month later his temperature rose, and on
exploration an abscess was discovered in the frontal lobe and
drained.
Subsequently the patient suffered with Jacksonian seizures,
sometimes starting spontaneously, sometimes following
interference with the wound. The convulsions commenced in the
muscles of the face, and the twitchings then became general.
Meanwhile the right upper extremity remained weak, although
the fist could be clenched, and all movements of the limb made
in some degree.
Some difficulty was experienced in maintaining a free exit for
the pus, which was however overcome by the use of a silver
tube. All twitchings ceased about a month after the opening of
the abscess, the man improved steadily, and he left for England
fifteen weeks after the reception of the injury, walking well,
with a firm hand-grip, and the wounds soundly healed.
(71) Frontal injury. Secondary abscess.—Wounded at Modder
River. Aperture of entry (Mauser), just external to the centre of
the right eyebrow; exit, above the centre of the right zygoma.
The wound did not render the man immediately unconscious,
but he lost all recollection of what had happened to him for the
(Mauser). Entry, 1¾ inch above the line from the lower margin
of the orbit to the external auditory meatus, and 1¾ inch behind
the external angular process; exit, a little posterior to the left
parietal eminence. There was right hemiplegia. The wounds
were explored, and a large number of fragments of bone and
pulped brain were removed, especially from the anterior wound.
No great improvement followed, and the patient was sent to the
Base. At this time there was a large hernia cerebri at the anterior
wound which was suppurating.
A further operation was here performed (Mr. J. J. Day). The
hernia cerebri was removed, also several fragments of bone
which were found deeply imbedded in the brain. The patient
then improved, but a month later his temperature rose, and on
exploration an abscess was discovered in the frontal lobe and
drained.
Subsequently the patient suffered with Jacksonian seizures,
sometimes starting spontaneously, sometimes following
interference with the wound. The convulsions commenced in the
muscles of the face, and the twitchings then became general.
Meanwhile the right upper extremity remained weak, although
the fist could be clenched, and all movements of the limb made
in some degree.
Some difficulty was experienced in maintaining a free exit for
the pus, which was however overcome by the use of a silver
tube. All twitchings ceased about a month after the opening of
the abscess, the man improved steadily, and he left for England
fifteen weeks after the reception of the injury, walking well,
with a firm hand-grip, and the wounds soundly healed.
(71) Frontal injury. Secondary abscess.—Wounded at Modder
River. Aperture of entry (Mauser), just external to the centre of
the right eyebrow; exit, above the centre of the right zygoma.
The wound did not render the man immediately unconscious,
but he lost all recollection of what had happened to him for the
Page 337
next three or four days. The wounds were explored on the
second day, at which time the patient was in a semi-conscious
drowsy state, the pupils contracted and the pulse slow. A number
of fragments of bone and pulped brain matter were removed.
Subsequently to the operation the patient showed more signs of
cerebral irritation than usual, lying in a semi-conscious state and
more or less curled up. He answered questions on being
bothered. He improved somewhat, and was sent to the Base,
where the improvement continued, but he suffered much from
headache.
Later the headache became much more severe, and eleven
weeks after the injury the man complained of great pain both
locally and over the whole right hemisphere; he lay moaning,
with the temperature subnormal, and the pulse very slow. At
times there was nocturnal delirium.
The wound had remained closed and apparently normal, but
now a small fluctuating pulsating nipple-like swelling developed
in the situation of the aperture of entry. This was incised, and
two ounces of sweet pus evacuated (Professor Dunlop). A tube
was introduced, and removed later on the cessation of discharge.
Removal of the tube was followed by a recurrence of the same
symptoms, and this occurred on no fewer than six occasions
whenever the wound closed.
At the end of twenty weeks the patient appeared quite well, the
wound had been closed six weeks, the previously irritable
mental state was replaced by placidity, and he was sent home.
Diagnosis.—The importance of proper exploration of scalp wounds to
determine the condition of the bone has already been insisted upon. The
localisation of the position and extent of the injury to the cranial contents
depended simply on attention to the symptoms, and needs no further
mention here.
Prognosis.—This subject can only be very imperfectly considered at the
present time, since only the more or less immediate results of the injuries
second day, at which time the patient was in a semi-conscious
drowsy state, the pupils contracted and the pulse slow. A number
of fragments of bone and pulped brain matter were removed.
Subsequently to the operation the patient showed more signs of
cerebral irritation than usual, lying in a semi-conscious state and
more or less curled up. He answered questions on being
bothered. He improved somewhat, and was sent to the Base,
where the improvement continued, but he suffered much from
headache.
Later the headache became much more severe, and eleven
weeks after the injury the man complained of great pain both
locally and over the whole right hemisphere; he lay moaning,
with the temperature subnormal, and the pulse very slow. At
times there was nocturnal delirium.
The wound had remained closed and apparently normal, but
now a small fluctuating pulsating nipple-like swelling developed
in the situation of the aperture of entry. This was incised, and
two ounces of sweet pus evacuated (Professor Dunlop). A tube
was introduced, and removed later on the cessation of discharge.
Removal of the tube was followed by a recurrence of the same
symptoms, and this occurred on no fewer than six occasions
whenever the wound closed.
At the end of twenty weeks the patient appeared quite well, the
wound had been closed six weeks, the previously irritable
mental state was replaced by placidity, and he was sent home.
Diagnosis.—The importance of proper exploration of scalp wounds to
determine the condition of the bone has already been insisted upon. The
localisation of the position and extent of the injury to the cranial contents
depended simply on attention to the symptoms, and needs no further
mention here.
Prognosis.—This subject can only be very imperfectly considered at the
present time, since only the more or less immediate results of the injuries
Page 338
are known to us, while the more important after consequences remain to be
followed up.
As to life the immediate prognosis has been already foreshadowed in the
section on the anatomical lesions. It is there shown that the first point of
general importance is the range of fire at which the injury has been
received. At short ranges, as evidenced by the history, the characters of the
wounds, and the severity of the symptoms, the immediate prognosis was
uniformly bad, a very great majority of the patients dying, and that at the
end of a few hours or days.
The rapidity with which death followed depended in part on the actual
severity of the wound, and still more on the region it affected; the nearer the
base and the longer the track the more rapidly the patients died, and this
always with signs of failure of the functions of the heart and lungs due to
general concussion, pressure from basal hæmorrhage, or rapid intracranial
œdema. In my experience no patients survived direct fracture of the base in
any region but the frontal, although many, no doubt, got well in whom
fissures merely spread into the middle or posterior fossa. Patients with very
extensive injuries at a higher level, on the other hand, often survived days,
or even a week, then usually dying of sepsis.
The actual relative mortality of these injuries I can give little idea of, but it
was a high one both on the field and in the Field hospitals; thus of 10 cases
treated in one Field hospital, after the battle at Paardeberg Drift, no less
than 8 died; while of 61 cases from various battles who survived to be sent
down to the Base during a period of some months, only 4 or 6.55 per cent.
died. Many of the latter, as is seen from the cases here recorded which were
among the number, were none the less of a very serious nature. The early
causes of death in patients dying during the first forty-eight hours have been
already mentioned; the later one was almost always sepsis.
As in civil practice the best immediate results were seen in injuries to the
frontal lobes, and after these in injuries to the occipital region. In the latter
permanent lesions of vision were, however, common. The above injuries
apart, the prognosis depended on the severity and depth of the lesion. The
frequency and extent of radiation symptoms often made it possible to give a
more hopeful prognosis than the immediate conditions seemed to warrant, if
followed up.
As to life the immediate prognosis has been already foreshadowed in the
section on the anatomical lesions. It is there shown that the first point of
general importance is the range of fire at which the injury has been
received. At short ranges, as evidenced by the history, the characters of the
wounds, and the severity of the symptoms, the immediate prognosis was
uniformly bad, a very great majority of the patients dying, and that at the
end of a few hours or days.
The rapidity with which death followed depended in part on the actual
severity of the wound, and still more on the region it affected; the nearer the
base and the longer the track the more rapidly the patients died, and this
always with signs of failure of the functions of the heart and lungs due to
general concussion, pressure from basal hæmorrhage, or rapid intracranial
œdema. In my experience no patients survived direct fracture of the base in
any region but the frontal, although many, no doubt, got well in whom
fissures merely spread into the middle or posterior fossa. Patients with very
extensive injuries at a higher level, on the other hand, often survived days,
or even a week, then usually dying of sepsis.
The actual relative mortality of these injuries I can give little idea of, but it
was a high one both on the field and in the Field hospitals; thus of 10 cases
treated in one Field hospital, after the battle at Paardeberg Drift, no less
than 8 died; while of 61 cases from various battles who survived to be sent
down to the Base during a period of some months, only 4 or 6.55 per cent.
died. Many of the latter, as is seen from the cases here recorded which were
among the number, were none the less of a very serious nature. The early
causes of death in patients dying during the first forty-eight hours have been
already mentioned; the later one was almost always sepsis.
As in civil practice the best immediate results were seen in injuries to the
frontal lobes, and after these in injuries to the occipital region. In the latter
permanent lesions of vision were, however, common. The above injuries
apart, the prognosis depended on the severity and depth of the lesion. The
frequency and extent of radiation symptoms often made it possible to give a
more hopeful prognosis than the immediate conditions seemed to warrant, if
Page 339
the exact situation of the lesion, and the probable velocity at which the
bullet was travelling, were taken into account; since the actual destructive
lesion, when the velocity had been insufficient to cause damage of a general
nature, was often very strictly localised.
Another very important point in the immediate prognosis was the primary
union of the scalp wound; if this could only be ensured, few cases went
wrong afterwards. Such remote effects as I witnessed were mainly the
results of the actual destructive lesion, such as paralyses and contraction. I
know of only one case in which early maniacal symptoms closely followed
on a frontal injury, and here the symptoms accompanied the development of
an abscess. Some patients were depressed and irritable, and some were
blind or deaf, probably from gross lesion; in one patient the mental faculties
generally were lowered.
In spite of the surprising immediate recoveries which occurred, and the
small amount of experience I am able to record as to remote ill effects of
these injuries, I feel certain that a long roll of secondary troubles from the
contraction of cicatricial tissue, irritation from distant remaining bone
fragments, as well as mental troubles from actual brain destruction, await
record in the near future.
Since my return to England I have heard of four cases of injury to the head,
which died on their return, as the result of the formation of secondary
residual abscesses; and of one who died suddenly, soon after his return to
active service in South Africa apparently well. These occurrences are
sufficiently suggestive.
It may be of interest to add here two cases of secondary traumatic epilepsy
of differing degree:—
(72) Gutter fracture over left temporo-sphenoidal lobe.
Traumatic epilepsy.—A trooper in Brabant's Horse was
wounded at Aliwal North, in March, in several places. A Mauser
bullet entered the head 1½ inch above the junction of the
anterior border of the left pinna with the side of the head. The
exit wound was situated just below and behind the left parietal
eminence. The patient stated that the shot was fired by a man he
recognised in a laager 150 yards distant from him.
bullet was travelling, were taken into account; since the actual destructive
lesion, when the velocity had been insufficient to cause damage of a general
nature, was often very strictly localised.
Another very important point in the immediate prognosis was the primary
union of the scalp wound; if this could only be ensured, few cases went
wrong afterwards. Such remote effects as I witnessed were mainly the
results of the actual destructive lesion, such as paralyses and contraction. I
know of only one case in which early maniacal symptoms closely followed
on a frontal injury, and here the symptoms accompanied the development of
an abscess. Some patients were depressed and irritable, and some were
blind or deaf, probably from gross lesion; in one patient the mental faculties
generally were lowered.
In spite of the surprising immediate recoveries which occurred, and the
small amount of experience I am able to record as to remote ill effects of
these injuries, I feel certain that a long roll of secondary troubles from the
contraction of cicatricial tissue, irritation from distant remaining bone
fragments, as well as mental troubles from actual brain destruction, await
record in the near future.
Since my return to England I have heard of four cases of injury to the head,
which died on their return, as the result of the formation of secondary
residual abscesses; and of one who died suddenly, soon after his return to
active service in South Africa apparently well. These occurrences are
sufficiently suggestive.
It may be of interest to add here two cases of secondary traumatic epilepsy
of differing degree:—
(72) Gutter fracture over left temporo-sphenoidal lobe.
Traumatic epilepsy.—A trooper in Brabant's Horse was
wounded at Aliwal North, in March, in several places. A Mauser
bullet entered the head 1½ inch above the junction of the
anterior border of the left pinna with the side of the head. The
exit wound was situated just below and behind the left parietal
eminence. The patient stated that the shot was fired by a man he
recognised in a laager 150 yards distant from him.
Page 340
The man remained unconscious eleven days, and when he came
round paralysis of the right upper extremity, and weakness of
both lower extremities, were noted. There was also ataxic
aphasia.
The wounds healed, but two months later the man began to
suffer from fits every few days. He spoke of them as fainting
fits, but they were accompanied by general twitchings.
The patient was shown to me in July by Major Woodhouse,
R.A.M.C. The strength of the right upper extremity was then
good, and he walked well. Speech was slow, but correct. The
pupils were equal, and acted normally.
The mental condition was weak, and the temper irritable. The
man had hallucinations, and was very obstinate: there was
complete deafness of the left ear. He refused surgical treatment,
but was really hardly a responsible individual.
(73) Gutter fracture in right frontal region. Traumatic epilepsy.
—Wounded at Pieter's Hill. Gutter fracture crossing the outer
aspect of the frontal lobe, immediately above the level of the
right Sylvian fissure. The wound was perforating at the central
part, but only reached as far back as the lower end of the
ascending frontal convolution. The patient was rendered
unconscious and was removed to Mooi River. He was there seen
by Sir William MacCormac, who removed a number of
fragments of bone. The patient rapidly recovered consciousness
after the operation, but was completely hemiplegic. After a
month he suddenly found he was able to move his lower
extremity, and later the paralysis became steadily less.
On his return home the man obtained employment as a
Commissionaire, but nine months after the injury, while his wife
was helping him on with his coat one morning, he was suddenly
seized with a fit; the paralysed arm was jerked up, and
convulsions became general, a wedge needing to be inserted to
prevent the tongue suffering injury.
round paralysis of the right upper extremity, and weakness of
both lower extremities, were noted. There was also ataxic
aphasia.
The wounds healed, but two months later the man began to
suffer from fits every few days. He spoke of them as fainting
fits, but they were accompanied by general twitchings.
The patient was shown to me in July by Major Woodhouse,
R.A.M.C. The strength of the right upper extremity was then
good, and he walked well. Speech was slow, but correct. The
pupils were equal, and acted normally.
The mental condition was weak, and the temper irritable. The
man had hallucinations, and was very obstinate: there was
complete deafness of the left ear. He refused surgical treatment,
but was really hardly a responsible individual.
(73) Gutter fracture in right frontal region. Traumatic epilepsy.
—Wounded at Pieter's Hill. Gutter fracture crossing the outer
aspect of the frontal lobe, immediately above the level of the
right Sylvian fissure. The wound was perforating at the central
part, but only reached as far back as the lower end of the
ascending frontal convolution. The patient was rendered
unconscious and was removed to Mooi River. He was there seen
by Sir William MacCormac, who removed a number of
fragments of bone. The patient rapidly recovered consciousness
after the operation, but was completely hemiplegic. After a
month he suddenly found he was able to move his lower
extremity, and later the paralysis became steadily less.
On his return home the man obtained employment as a
Commissionaire, but nine months after the injury, while his wife
was helping him on with his coat one morning, he was suddenly
seized with a fit; the paralysed arm was jerked up, and
convulsions became general, a wedge needing to be inserted to
prevent the tongue suffering injury.
Page 341
When admitted into the hospital, the cicatrix of the wound was
considerably depressed, and the central part was evidently
continuously attached to the surface of the brain. Pulsation was
both visible and palpable, there was little or no tenderness on
examination, and the patient did not complain of pain.
Little trace of the left facial paralysis remained. The man walked
well, but with foot-drop. The left upper extremity was rigid, but
chiefly from the elbow downwards. The fingers were flexed, but
a slight increase of grip could be effected. No other active
movements of hand. The elbow was held flexed, but could be
straightened to about 3/4 range on effort. The shoulder could be
slightly abducted, but wide movements were made by the
scapular muscles.
Sensation was dull over the left side of the face, also over the
left side of the neck. There was complete loss of cutaneous
sensibility over the lower half of the forearm and hand, and a
similar patch in the left axilla. Over the rest of the extremity the
sensation was better on the flexor than on the extensor aspects.
There was little alteration in the common sensation elsewhere,
except that the contrast between that of the dorsum and sole of
the foot was somewhat more marked than usual. The
temperature of the insensitive axilla was one degree higher than
that of the right.
The left knee jerk was somewhat exaggerated.
On December 15 an incision was made through the old cicatrix
directly over the defect in the skull. On separating the skin it
was found directly adherent to the cicatrised dura, and when this
was incised a large vicarious arachnoid space was opened up.
The space was crossed by a number of strands of connective
tissue, and the cavity had no epithelial lining. The fluid ran out
freely, and the space was evidently in free communication with
the general arachnoid cavity. A trephine crown was taken out at
the posterior end of the gutter, and the surface of the brain
explored, but no fragments of bone were found. I therefore
considerably depressed, and the central part was evidently
continuously attached to the surface of the brain. Pulsation was
both visible and palpable, there was little or no tenderness on
examination, and the patient did not complain of pain.
Little trace of the left facial paralysis remained. The man walked
well, but with foot-drop. The left upper extremity was rigid, but
chiefly from the elbow downwards. The fingers were flexed, but
a slight increase of grip could be effected. No other active
movements of hand. The elbow was held flexed, but could be
straightened to about 3/4 range on effort. The shoulder could be
slightly abducted, but wide movements were made by the
scapular muscles.
Sensation was dull over the left side of the face, also over the
left side of the neck. There was complete loss of cutaneous
sensibility over the lower half of the forearm and hand, and a
similar patch in the left axilla. Over the rest of the extremity the
sensation was better on the flexor than on the extensor aspects.
There was little alteration in the common sensation elsewhere,
except that the contrast between that of the dorsum and sole of
the foot was somewhat more marked than usual. The
temperature of the insensitive axilla was one degree higher than
that of the right.
The left knee jerk was somewhat exaggerated.
On December 15 an incision was made through the old cicatrix
directly over the defect in the skull. On separating the skin it
was found directly adherent to the cicatrised dura, and when this
was incised a large vicarious arachnoid space was opened up.
The space was crossed by a number of strands of connective
tissue, and the cavity had no epithelial lining. The fluid ran out
freely, and the space was evidently in free communication with
the general arachnoid cavity. A trephine crown was taken out at
the posterior end of the gutter, and the surface of the brain
explored, but no fragments of bone were found. I therefore
Page 342
replaced the crown, and closed the bony defect in the floor of
the gutter with a plate of platinum fitted into a groove made in
the bony margin. The wound was then sutured. Primary union
took place, and there was no constitutional disturbance beyond
one temperature of 100° on the evening of the second day;
otherwise the temperature remained normal, and the pulse did
not rise above 75.
On the second evening a fit occurred, coming on while the
patient was apparently asleep. It lasted about a quarter of an
hour and was general, the patient becoming for a short time
unconscious, and passing water involuntarily.
On the third morning two similar fits occurred, the first a severe
one, during which the patient passed a motion involuntarily. The
commencement of all three fits was observed by the nurse only,
but in each the convulsions apparently commenced in the face
and then became general.
Three months later no further fits had occurred, and the patient,
who throughout had said he felt remarkably well, complained of
nothing. The upper extremity was apparently slightly less rigid
than before the exploration, and the patient said he walked
somewhat better than before. The closure of the skull was
perfect.
Treatment.—The treatment of fractures of the skull possesses a degree of
surgical interest that attaches to no other class of gunshot injury, since
operative interference is necessary in every case in which recovery is
judged possible. The injuries are, without exception, of the nature of
punctured wounds of the skull, and the ordinary rule of surgery should
under no circumstances be deviated from. An expectant attitude, although it
often appears immediately satisfactory, exposes the patient to future risks
which are incalculable, but none the less serious. Happily the operations
needed may be included amongst the most simple as well as the most
successful, and expose the patient with ordinary precautions to no increase
of risk beyond that dependent on the original injury.
the gutter with a plate of platinum fitted into a groove made in
the bony margin. The wound was then sutured. Primary union
took place, and there was no constitutional disturbance beyond
one temperature of 100° on the evening of the second day;
otherwise the temperature remained normal, and the pulse did
not rise above 75.
On the second evening a fit occurred, coming on while the
patient was apparently asleep. It lasted about a quarter of an
hour and was general, the patient becoming for a short time
unconscious, and passing water involuntarily.
On the third morning two similar fits occurred, the first a severe
one, during which the patient passed a motion involuntarily. The
commencement of all three fits was observed by the nurse only,
but in each the convulsions apparently commenced in the face
and then became general.
Three months later no further fits had occurred, and the patient,
who throughout had said he felt remarkably well, complained of
nothing. The upper extremity was apparently slightly less rigid
than before the exploration, and the patient said he walked
somewhat better than before. The closure of the skull was
perfect.
Treatment.—The treatment of fractures of the skull possesses a degree of
surgical interest that attaches to no other class of gunshot injury, since
operative interference is necessary in every case in which recovery is
judged possible. The injuries are, without exception, of the nature of
punctured wounds of the skull, and the ordinary rule of surgery should
under no circumstances be deviated from. An expectant attitude, although it
often appears immediately satisfactory, exposes the patient to future risks
which are incalculable, but none the less serious. Happily the operations
needed may be included amongst the most simple as well as the most
successful, and expose the patient with ordinary precautions to no increase
of risk beyond that dependent on the original injury.
Page 343
Cases of a general character, or in which the base has been directly
fractured other than in the frontal region, are seldom suitable for operation,
since surgical skill is in these of no avail; but in all others an exploration is
indicated. I use the word 'exploration' advisedly, since what may be called
the formal operation of trephining is seldom necessary except in the case of
the small openings due to wounds received from a very long range of fire;
in all others there is no difficulty, but very great advantage, in making such
enlargement of the bone opening as is necessary with Hoffman's forceps.
The scalp should be first shaved and cleansed; if for any reason an
operation is impossible, this procedure at least should be carried out, with a
view to ensuring, as far as possible, future asepsis, infection in head injuries
being almost the only danger to be feared. The shaving may need to be
complete, but local clearance of the hair suffices in many cases. The hair
having been removed, the scalp is cleansed with all care, a flap is raised of
which the bullet opening forms the central point, and the wound explored.
In slight cases the entry opening is the one of chief importance, and the exit
may be simply cleansed and dressed. In some instances, as in direct fracture
of the roof of the orbit from above, the exit should not be touched.
The flap having been raised, if the wound be a small perforation, a 1/2-inch
trephine crown may be taken from one side; but it is rare for the opening to
be so small that the tip of a pair of Hoffman's forceps cannot be inserted.
The trephine is more often useful in cases of non-penetrating gutter
fractures where space is needed for exploration, and the elevation or
removal of fragments of the inner-table. Loose fragments may need to be
removed from beneath the scalp, but the important ones are those within the
cranium. These may either be of some size, or fine comminuted splinters of
either table, often at as great a distance as 2 inches or more from the
surface. The cavity must be thoroughly explored and all splinters removed.
I have seen more than fifty extracted in one case of open gutter fracture.
The brain pulp and clot should then be gently removed or washed away, and
the wound closed without drainage. Fragments of bone, as a rule, are better
not replaced, but complete suture of the skin flap is always advisable in
view of the great importance of primary union, and the fact that a drainage
opening exists at the original wound of entry, and that the wound is readily
re-opened to its whole extent, should such a step be advisable.
fractured other than in the frontal region, are seldom suitable for operation,
since surgical skill is in these of no avail; but in all others an exploration is
indicated. I use the word 'exploration' advisedly, since what may be called
the formal operation of trephining is seldom necessary except in the case of
the small openings due to wounds received from a very long range of fire;
in all others there is no difficulty, but very great advantage, in making such
enlargement of the bone opening as is necessary with Hoffman's forceps.
The scalp should be first shaved and cleansed; if for any reason an
operation is impossible, this procedure at least should be carried out, with a
view to ensuring, as far as possible, future asepsis, infection in head injuries
being almost the only danger to be feared. The shaving may need to be
complete, but local clearance of the hair suffices in many cases. The hair
having been removed, the scalp is cleansed with all care, a flap is raised of
which the bullet opening forms the central point, and the wound explored.
In slight cases the entry opening is the one of chief importance, and the exit
may be simply cleansed and dressed. In some instances, as in direct fracture
of the roof of the orbit from above, the exit should not be touched.
The flap having been raised, if the wound be a small perforation, a 1/2-inch
trephine crown may be taken from one side; but it is rare for the opening to
be so small that the tip of a pair of Hoffman's forceps cannot be inserted.
The trephine is more often useful in cases of non-penetrating gutter
fractures where space is needed for exploration, and the elevation or
removal of fragments of the inner-table. Loose fragments may need to be
removed from beneath the scalp, but the important ones are those within the
cranium. These may either be of some size, or fine comminuted splinters of
either table, often at as great a distance as 2 inches or more from the
surface. The cavity must be thoroughly explored and all splinters removed.
I have seen more than fifty extracted in one case of open gutter fracture.
The brain pulp and clot should then be gently removed or washed away, and
the wound closed without drainage. Fragments of bone, as a rule, are better
not replaced, but complete suture of the skin flap is always advisable in
view of the great importance of primary union, and the fact that a drainage
opening exists at the original wound of entry, and that the wound is readily
re-opened to its whole extent, should such a step be advisable.
Page 344
The detection of fragments is easiest and most satisfactorily done with the
finger, and in all but simple punctures the opening should be large enough
to allow thoroughly effective digital exploration; the remarks already made
as to the factors determining the size of fragments are of interest in this
connection. The determination of the amount of brain pulp which should be
removed is somewhat more difficult; one can only say that all that washes
readily away should be removed, and its place is usually taken up by blood.
Few fractures of the base are suitable for treatment; the only ones I saw
were those of direct fracture of the roof of the orbit or nose, produced by
bullets passing across the orbits; here the advisability of interference with
the injured eye led to opening of the orbit, and sometimes exposed the
fracture. Some patients recovered, even when the damage had been
sufficient to cause escape of pulped brain into the orbit.
The after treatment simply consisted in keeping the patients as quiet as
circumstances would permit, and the administration of a fluid diet. In some
cases recurring symptoms pointed to the continued presence of bone
fragments; these were usually indicated by signs of irritation, or often of
local inflammation, in the latter case infection taking the greater share in the
causation. Such cases needed secondary exploration, and the wonderful
success of this operation, even when the wound was evidently infected, was
perhaps one of the most striking experiences of the surgery in general.
I should add a word here as to the most satisfactory time for the
performance of these operations; as in all cases the earlier they could be
undertaken the better, but in the head injuries the advantages of early
interference were more evident than in any other region. This depended on
the fact that, as in civil practice, the scalp is one of the most dangerous
regions as far as auto-infection of the wound is concerned, and one of the
most difficult to cleanse, except by thorough shaving. Beyond this the
extreme simplicity of the operative procedure needed, called for few
precautions beyond those for asepsis, and very little armament in the way of
instruments, &c.
When on the march from Winberg to Heilbron with the Highland Brigade
we had some five days' continuous fighting, and on this occasion several
perforating fractures of the skull were brought in. The coldness of the nights
finger, and in all but simple punctures the opening should be large enough
to allow thoroughly effective digital exploration; the remarks already made
as to the factors determining the size of fragments are of interest in this
connection. The determination of the amount of brain pulp which should be
removed is somewhat more difficult; one can only say that all that washes
readily away should be removed, and its place is usually taken up by blood.
Few fractures of the base are suitable for treatment; the only ones I saw
were those of direct fracture of the roof of the orbit or nose, produced by
bullets passing across the orbits; here the advisability of interference with
the injured eye led to opening of the orbit, and sometimes exposed the
fracture. Some patients recovered, even when the damage had been
sufficient to cause escape of pulped brain into the orbit.
The after treatment simply consisted in keeping the patients as quiet as
circumstances would permit, and the administration of a fluid diet. In some
cases recurring symptoms pointed to the continued presence of bone
fragments; these were usually indicated by signs of irritation, or often of
local inflammation, in the latter case infection taking the greater share in the
causation. Such cases needed secondary exploration, and the wonderful
success of this operation, even when the wound was evidently infected, was
perhaps one of the most striking experiences of the surgery in general.
I should add a word here as to the most satisfactory time for the
performance of these operations; as in all cases the earlier they could be
undertaken the better, but in the head injuries the advantages of early
interference were more evident than in any other region. This depended on
the fact that, as in civil practice, the scalp is one of the most dangerous
regions as far as auto-infection of the wound is concerned, and one of the
most difficult to cleanse, except by thorough shaving. Beyond this the
extreme simplicity of the operative procedure needed, called for few
precautions beyond those for asepsis, and very little armament in the way of
instruments, &c.
When on the march from Winberg to Heilbron with the Highland Brigade
we had some five days' continuous fighting, and on this occasion several
perforating fractures of the skull were brought in. The coldness of the nights
Page 345
at that time made evening operations an impossibility; hence the operations
on these men were performed at the first dressing station, in the open air, at
the side of the ambulance wagons, often during the progress of fighting
around. Of several cases so operated on, all healed by primary union
without a bad symptom of any kind, except one (see p. 249), in whom a
very large entrance opening over the right cortical motor area led down to
an extensive destruction of the brain, complicated by a fracture of the base
in the middle fossa. This wound, from the first considered hopeless, became
septic during the four days' travelling in an ambulance wagon that was
necessary, and the man died at the end of fourteen days. As the whole
cortical motor area was destroyed, death was, perhaps, the end most to be
desired; but the fight that this man made for recovery, and the fact that his
death, after all, was due to general infection and not to any local extension
of the injury, very strongly impressed me with the possibility of recovery,
even in such extensive cases, if only an aseptic condition can be
maintained. I saw many other cases of the same nature, particularly in men
who, as a result of unfortunate circumstances, were necessarily left out on
the field for more than twenty-four hours. In some of these maggots were
found in the wounds only thirty-six hours after the infliction of the injury.
I have said nothing as to the treatment of the large primary herniæ cerebri in
wounds of an explosive nature, since these were rarely subjects suitable for
operation; but in the instances of minor severity they were treated as the
other cases where the pulped brain lay mostly within the skull.
In cases where the wounds were in the frontal or fronto-parietal regions,
and hemiplegia existed, the rapid improvement in the paralytic symptoms,
after operation, was very marked, showing that the signs were mainly, or
entirely, due to 'radiation' injury. I am inclined to think that temporary
injury of this kind from vibratory disturbance and small parenchymatous
hæmorrhages, were far more often the cause of the paralysis than surface
hæmorrhage, since the latter was rarely found in large quantity. Large clots,
however, no doubt growing in both size and firmness, occasionally
occupied the area of destroyed brain, and these sometimes manifestly
exercised pressure that was at once relieved by their evacuation.
In cases where inflammatory hernia cerebri developed, a secondary
exploration was often indicated for the removal of fragments of bone or the
on these men were performed at the first dressing station, in the open air, at
the side of the ambulance wagons, often during the progress of fighting
around. Of several cases so operated on, all healed by primary union
without a bad symptom of any kind, except one (see p. 249), in whom a
very large entrance opening over the right cortical motor area led down to
an extensive destruction of the brain, complicated by a fracture of the base
in the middle fossa. This wound, from the first considered hopeless, became
septic during the four days' travelling in an ambulance wagon that was
necessary, and the man died at the end of fourteen days. As the whole
cortical motor area was destroyed, death was, perhaps, the end most to be
desired; but the fight that this man made for recovery, and the fact that his
death, after all, was due to general infection and not to any local extension
of the injury, very strongly impressed me with the possibility of recovery,
even in such extensive cases, if only an aseptic condition can be
maintained. I saw many other cases of the same nature, particularly in men
who, as a result of unfortunate circumstances, were necessarily left out on
the field for more than twenty-four hours. In some of these maggots were
found in the wounds only thirty-six hours after the infliction of the injury.
I have said nothing as to the treatment of the large primary herniæ cerebri in
wounds of an explosive nature, since these were rarely subjects suitable for
operation; but in the instances of minor severity they were treated as the
other cases where the pulped brain lay mostly within the skull.
In cases where the wounds were in the frontal or fronto-parietal regions,
and hemiplegia existed, the rapid improvement in the paralytic symptoms,
after operation, was very marked, showing that the signs were mainly, or
entirely, due to 'radiation' injury. I am inclined to think that temporary
injury of this kind from vibratory disturbance and small parenchymatous
hæmorrhages, were far more often the cause of the paralysis than surface
hæmorrhage, since the latter was rarely found in large quantity. Large clots,
however, no doubt growing in both size and firmness, occasionally
occupied the area of destroyed brain, and these sometimes manifestly
exercised pressure that was at once relieved by their evacuation.
In cases where inflammatory hernia cerebri developed, a secondary
exploration was often indicated for the removal of fragments of bone or the
Page 346
evacuation of pus, otherwise the condition was best treated by dry dressings
and gentle support.
Abscess of the brain was treated by simple evacuation and drainage by
metal or rubber tubes: the operations were always of extreme simplicity,
since the abscess in every case I saw was in the direct line of the wound
track, and was readily opened by the insertion of a director or blunt knife.
The only trouble in the after treatment was that already referred to, of
preventing premature closure of the drainage opening.
I have made no special reference to the method of dressing, since it was of
the ordinary routine kind. The most important factor in success was the
efficient primary disinfection of the scalp; a piece of antiseptic gauze and
some absorbent wool, efficiently secured, was all that was needed later.
As usual the consideration of the treatment of cases in which the bullet was
retained may be considered last. Such accidents were distinctly rare. I
operated in only one (No. 54, p. 260) in whom the indications both for
localisation and interference were obvious, since the bullet had palpably
fractured the bone, although it had not retained sufficient force to enable it
to leave the skull. In two other cases that I saw, in one the bullet was lodged
in the zygomatic fossa, in the second just below the mastoid process. The
former patient died; the latter exhibited symptoms indicative of injury to the
occipital lobe (No. 68), and was successfully treated by Mr. J. E. Ker. I
never happened to see a case in which a retained bullet in the skull was
localised by the X rays, but such might have been possible in case No. 64,
p. 275. In no case is primary interference indicated, unless a fracture exists
where the bullet has tried to escape, or secondary symptoms develop
pointing to irritation.
Under ordinary circumstances, moreover, the indications for removal of a
bullet are not likely to be sufficiently imperative to necessitate the operation
being undertaken until the patient can be placed under the best conditions
that can be secured. This is the more advisable since such operations need
the infliction of an additional wound, require great delicacy, and may be
very prolonged in performance. The experience of civil practice has already
sufficiently proved the small amount of inconvenience likely to follow the
retention of a bullet in the skull.
and gentle support.
Abscess of the brain was treated by simple evacuation and drainage by
metal or rubber tubes: the operations were always of extreme simplicity,
since the abscess in every case I saw was in the direct line of the wound
track, and was readily opened by the insertion of a director or blunt knife.
The only trouble in the after treatment was that already referred to, of
preventing premature closure of the drainage opening.
I have made no special reference to the method of dressing, since it was of
the ordinary routine kind. The most important factor in success was the
efficient primary disinfection of the scalp; a piece of antiseptic gauze and
some absorbent wool, efficiently secured, was all that was needed later.
As usual the consideration of the treatment of cases in which the bullet was
retained may be considered last. Such accidents were distinctly rare. I
operated in only one (No. 54, p. 260) in whom the indications both for
localisation and interference were obvious, since the bullet had palpably
fractured the bone, although it had not retained sufficient force to enable it
to leave the skull. In two other cases that I saw, in one the bullet was lodged
in the zygomatic fossa, in the second just below the mastoid process. The
former patient died; the latter exhibited symptoms indicative of injury to the
occipital lobe (No. 68), and was successfully treated by Mr. J. E. Ker. I
never happened to see a case in which a retained bullet in the skull was
localised by the X rays, but such might have been possible in case No. 64,
p. 275. In no case is primary interference indicated, unless a fracture exists
where the bullet has tried to escape, or secondary symptoms develop
pointing to irritation.
Under ordinary circumstances, moreover, the indications for removal of a
bullet are not likely to be sufficiently imperative to necessitate the operation
being undertaken until the patient can be placed under the best conditions
that can be secured. This is the more advisable since such operations need
the infliction of an additional wound, require great delicacy, and may be
very prolonged in performance. The experience of civil practice has already
sufficiently proved the small amount of inconvenience likely to follow the
retention of a bullet in the skull.
Page 347
I may again mention the fact that in explorations for the removal of bone
fragments, fragments of lead, from breaking or setting up of the bullet, are
sometimes found.
Taken as a whole, the operations on the head were extremely satisfactory
from a technical point of view; the large depressed pulsating cicatrix so
often left was the chief defect observed. The circumstances under which
many of the operations had to be performed militated strongly, however,
against the successful replacement of separated bone fragments, which
might have rendered the defects less serious.
Secondary operations for traumatic epilepsy scarcely come within the scope
of these experiences. In case 73, p. 292, it is of interest to note the manner
in which the cavity due to loss of brain substance was filled up. No doubt a
similar vicarious arachnoid space develops in all cases in which a soft
pulsating swelling fills an aperture in the bones of the skull.
Wounds of the Head not Involving the Brain
Mastoid process.—The most important wound of the cranium not already
mentioned was that involving the mastoid process and the bony capsule of
the ear. Wounds of the mastoid process obtained their chief interest in
connection with paralysis of the seventh nerve. This nerve rarely or never
escaped, and, as far as my experience went, the facial paralysis was
permanent (see cases 111-114, p. 355). I think the same prognosis holds
good with regard to the deafness resulting from these injuries, and it is
difficult to believe, with our experience of the effect of vibration on other
nerve centres and organs, that the internal ear could ever escape permanent
damage.
In a number of cases the tympanum itself, or the external auditory meatus,
was directly implicated in tracks; in these, also, loss of hearing was the rule.
Wounds of the pinna when produced by undeformed bullets were usually of
the same slitlike nature remarked in perforations of the cartilages of the
nose, and healed with equal rapidity.
Wounds of the orbit.—Injuries to the orbit were very numerous and serious
in their results, both to the globe of the eye and the surrounding structures.
fragments, fragments of lead, from breaking or setting up of the bullet, are
sometimes found.
Taken as a whole, the operations on the head were extremely satisfactory
from a technical point of view; the large depressed pulsating cicatrix so
often left was the chief defect observed. The circumstances under which
many of the operations had to be performed militated strongly, however,
against the successful replacement of separated bone fragments, which
might have rendered the defects less serious.
Secondary operations for traumatic epilepsy scarcely come within the scope
of these experiences. In case 73, p. 292, it is of interest to note the manner
in which the cavity due to loss of brain substance was filled up. No doubt a
similar vicarious arachnoid space develops in all cases in which a soft
pulsating swelling fills an aperture in the bones of the skull.
Wounds of the Head not Involving the Brain
Mastoid process.—The most important wound of the cranium not already
mentioned was that involving the mastoid process and the bony capsule of
the ear. Wounds of the mastoid process obtained their chief interest in
connection with paralysis of the seventh nerve. This nerve rarely or never
escaped, and, as far as my experience went, the facial paralysis was
permanent (see cases 111-114, p. 355). I think the same prognosis holds
good with regard to the deafness resulting from these injuries, and it is
difficult to believe, with our experience of the effect of vibration on other
nerve centres and organs, that the internal ear could ever escape permanent
damage.
In a number of cases the tympanum itself, or the external auditory meatus,
was directly implicated in tracks; in these, also, loss of hearing was the rule.
Wounds of the pinna when produced by undeformed bullets were usually of
the same slitlike nature remarked in perforations of the cartilages of the
nose, and healed with equal rapidity.
Wounds of the orbit.—Injuries to the orbit were very numerous and serious
in their results, both to the globe of the eye and the surrounding structures.
Page 348
Anatomical lesions.—The wound tracks, with regard to the injuries
produced, may be well classified according to the direction they took; thus
—vertical, transverse, and oblique.
Vertical wound tracks were on the whole the least serious, but this mainly
from the fact of limitation of the injury to one orbital cavity. They were
usually produced by bullets passing from above downwards through the
frontal region of the cranium, and were received by the patients while in the
prone position.
Transverse and oblique wounds owed their greater importance to the fact
that both eyes were more likely to be implicated.
Besides these tracks, which actually crossed the cavities, a number involved
the bony boundaries, producing almost as severe lesions in the globe of the
eye, many of the patients being rendered permanently blind. The only
difference in nature of such cases was the escape of orbital structures, and
this was of minor importance in the presence of the graver lesion to vision.
The following is an illustrative case:—
(74) Wounded at Colenso. Entry (Mauser), 1 inch below the
centre of the margin of the right orbit; exit, behind the right
angle of the mandible. Fracture of lower jaw, and development
of a diffuse traumatic aneurism of the external carotid artery.
The common carotid artery was tied for secondary hæmorrhage
(Mr. Jameson) some three weeks later.
Vision was affected at the time of the accident; the fingers could
be seen, but not counted. After ligation of the carotid the
condition was possibly worse, and this needs mention as
transitory loss of power in the left upper extremity also followed
the operation.
Fractures of the bony wall were of every degree. The most severe that I saw
were two in which lateral impact by a bullet crossing the cranial cavity
caused general comminution of the whole orbital roof. Fissures of the roof
were common in connection with 'explosive' exit apertures in the frontal
region of the skull. Pure perforations usually accompanied the vertical or
produced, may be well classified according to the direction they took; thus
—vertical, transverse, and oblique.
Vertical wound tracks were on the whole the least serious, but this mainly
from the fact of limitation of the injury to one orbital cavity. They were
usually produced by bullets passing from above downwards through the
frontal region of the cranium, and were received by the patients while in the
prone position.
Transverse and oblique wounds owed their greater importance to the fact
that both eyes were more likely to be implicated.
Besides these tracks, which actually crossed the cavities, a number involved
the bony boundaries, producing almost as severe lesions in the globe of the
eye, many of the patients being rendered permanently blind. The only
difference in nature of such cases was the escape of orbital structures, and
this was of minor importance in the presence of the graver lesion to vision.
The following is an illustrative case:—
(74) Wounded at Colenso. Entry (Mauser), 1 inch below the
centre of the margin of the right orbit; exit, behind the right
angle of the mandible. Fracture of lower jaw, and development
of a diffuse traumatic aneurism of the external carotid artery.
The common carotid artery was tied for secondary hæmorrhage
(Mr. Jameson) some three weeks later.
Vision was affected at the time of the accident; the fingers could
be seen, but not counted. After ligation of the carotid the
condition was possibly worse, and this needs mention as
transitory loss of power in the left upper extremity also followed
the operation.
Fractures of the bony wall were of every degree. The most severe that I saw
were two in which lateral impact by a bullet crossing the cranial cavity
caused general comminution of the whole orbital roof. Fissures of the roof
were common in connection with 'explosive' exit apertures in the frontal
region of the skull. Pure perforations usually accompanied the vertical or
Page 349
transverse wounds of the cavity, fragments at the aperture of entry then
being projected into the orbit, sometimes penetrating the muscles.
Occasionally the margin of the cavity was merely notched.
The ocular muscles were often divided more or less completely, and
occasionally some difficulty arose in determining whether loss of
movement of the globe in any definite direction depended on injury to the
muscle itself, or to the nerve supplying the muscle. The following case
illustrates this point:—
(75) Entry (Mauser), 2 inches behind the right external canthus;
the bullet pierced the external wall and traversed the floor of the
right orbit beneath the globe, crossed the nasal cavity, and a part
of the left orbit; exit, at the lower margin of the left orbit,
beneath the centre of the globe of the eye.
Complete loss of sight followed the injury, and persisted for one
week. Modified vision then returned.
Three weeks later there was diplopia; loss of function of the
right external and inferior recti, although the ball could be
turned downward to some extent by the superior oblique when
the internal rectus was in action. Movements of the left globe
were not seriously affected.
The pupils were immobile and moderately dilated, but atropine
had been employed two days previously.
A year later the condition was as follows: There is some
weakness of the right seventh nerve, as evidenced by want of
symmetry in all the folds of the face, and in narrowing of the
palpebral fissure.
When at rest the right eye is somewhat raised and turned
outwards. Active movements outwards or downwards are
restricted. There is diplopia, and the vision of the right eye is
much impaired; the man can see persons, but cannot count
fingers with certainty, although he sees the hand. Putting on one
being projected into the orbit, sometimes penetrating the muscles.
Occasionally the margin of the cavity was merely notched.
The ocular muscles were often divided more or less completely, and
occasionally some difficulty arose in determining whether loss of
movement of the globe in any definite direction depended on injury to the
muscle itself, or to the nerve supplying the muscle. The following case
illustrates this point:—
(75) Entry (Mauser), 2 inches behind the right external canthus;
the bullet pierced the external wall and traversed the floor of the
right orbit beneath the globe, crossed the nasal cavity, and a part
of the left orbit; exit, at the lower margin of the left orbit,
beneath the centre of the globe of the eye.
Complete loss of sight followed the injury, and persisted for one
week. Modified vision then returned.
Three weeks later there was diplopia; loss of function of the
right external and inferior recti, although the ball could be
turned downward to some extent by the superior oblique when
the internal rectus was in action. Movements of the left globe
were not seriously affected.
The pupils were immobile and moderately dilated, but atropine
had been employed two days previously.
A year later the condition was as follows: There is some
weakness of the right seventh nerve, as evidenced by want of
symmetry in all the folds of the face, and in narrowing of the
palpebral fissure.
When at rest the right eye is somewhat raised and turned
outwards. Active movements outwards or downwards are
restricted. There is diplopia, and the vision of the right eye is
much impaired; the man can see persons, but cannot count
fingers with certainty, although he sees the hand. Putting on one
Page 350
side the loss of free movement, there is no obvious external
appearance of injury to the eye.
Mr. J. H. Fisher reported as follows:
Ophthalmoscopic examination shows the left eye and fundus to
be normal. The right disc is not atrophied, but the whole of the
lower half of the fundus is coated with masses of black retinal
pigment. There is atrophy in spots of the capillary layer of the
choroid, and the larger vessels of the deeper layer are exposed
between the interstices of the pigment masses. There is no
definite choroidal rupture. The lesion encroaches upon and
implicates the macular region.
The injury is a concussion one, not necessarily resulting from
contact, and certainly not due to a perforation. The loss of
movement and faulty position are the result of injury to the
muscles, and not to nerve implication.
The man complained that when he blew his nose the left eye
filled with water and air came out. The left nasal duct was
however shown to be intact, as water injected by the canaliculus
passed freely into the nose.
Intra-orbital bleeding, subconjunctival hæmorrhage with proptosis and
ecchymosis of the lids were usually well marked. The latter was sometimes
extreme.
Injury to the nerves was naturally of a very mixed character. In many
instances the branches of the first two divisions of the fifth nerve were
obviously implicated and regional anæsthesia was common. This was often
transitory when the result of vibratory concussion, contusion, or pressure
from hæmorrhage. In other cases it was more prolonged as a result of actual
division of the nerve. As is usually the case, when a small area of
distribution only was affected, sensation was rapidly regained from
vicarious sources, even when section had been complete.
As individual injuries, those to the optic nerve were the most frequently
diagnosed. I am sorry to be unable to attempt a discrimination of injuries to
the nerve alone from those in which both nerve and globe suffered, but the
appearance of injury to the eye.
Mr. J. H. Fisher reported as follows:
Ophthalmoscopic examination shows the left eye and fundus to
be normal. The right disc is not atrophied, but the whole of the
lower half of the fundus is coated with masses of black retinal
pigment. There is atrophy in spots of the capillary layer of the
choroid, and the larger vessels of the deeper layer are exposed
between the interstices of the pigment masses. There is no
definite choroidal rupture. The lesion encroaches upon and
implicates the macular region.
The injury is a concussion one, not necessarily resulting from
contact, and certainly not due to a perforation. The loss of
movement and faulty position are the result of injury to the
muscles, and not to nerve implication.
The man complained that when he blew his nose the left eye
filled with water and air came out. The left nasal duct was
however shown to be intact, as water injected by the canaliculus
passed freely into the nose.
Intra-orbital bleeding, subconjunctival hæmorrhage with proptosis and
ecchymosis of the lids were usually well marked. The latter was sometimes
extreme.
Injury to the nerves was naturally of a very mixed character. In many
instances the branches of the first two divisions of the fifth nerve were
obviously implicated and regional anæsthesia was common. This was often
transitory when the result of vibratory concussion, contusion, or pressure
from hæmorrhage. In other cases it was more prolonged as a result of actual
division of the nerve. As is usually the case, when a small area of
distribution only was affected, sensation was rapidly regained from
vicarious sources, even when section had been complete.
As individual injuries, those to the optic nerve were the most frequently
diagnosed. I am sorry to be unable to attempt a discrimination of injuries to
the nerve alone from those in which both nerve and globe suffered, but the
Page 351
globe can rarely have escaped injury, either direct or indirect, when the
bullet actually traversed the orbital cavity. (A few further remarks
concerning injuries to the optic nerve will be found in Chapter IX.)
Injuries to the globe of the eye, either direct or indirect, accompanied most
of the orbital wounds.
In some the lesion was of the nature of concussion. In such the bone injury
was usually at the periphery of the orbit, or to the bones of the face in the
neighbourhood. The loss of vision might then be temporary, persisting from
two to ten days, then returning, often with some deficiencies.
In other similar external injuries, the lesion of the globe was more severe,
and permanent blindness followed.
In variability of degree of completeness, these lesions of the globe
corresponded exactly with those produced in other parts of the nervous
system by bullets striking the bones in their vicinity, and they were no
doubt the result of a similar transmission of vibratory force.
In a third series of cases the globe suffered direct contusion, and in a fourth
was perforated and destroyed.
In cases in which permanent blindness was produced without solution of
continuity of the sclerotic coat, the nature of the lesion was probably in
most cases vibratory concussion and the development of multiple
hæmorrhages from choroidal ruptures of a similar nature to those seen in
the brain and spinal cord. The actual hæmorrhagic areæ varied in size; but,
as far as my experience went, gross hæmorrhages into the anterior chamber
did not occur without severe direct contact of the bullet.
In the vast majority of the cases blindness, whether transitory or permanent,
developed immediately on the reception of the injury, and was possibly in
its initial stage the result of primary concussion.
Cases were, however, seen occasionally in which the symptoms were less
sudden, of which the following is an example. I did not think that the mode
of progress seen here could be referred to simple orbital hæmorrhage,
although this existed, but rather to intravaginal hæmorrhage into the sheath
of the optic nerve. On external inspection the globes appeared normal.
bullet actually traversed the orbital cavity. (A few further remarks
concerning injuries to the optic nerve will be found in Chapter IX.)
Injuries to the globe of the eye, either direct or indirect, accompanied most
of the orbital wounds.
In some the lesion was of the nature of concussion. In such the bone injury
was usually at the periphery of the orbit, or to the bones of the face in the
neighbourhood. The loss of vision might then be temporary, persisting from
two to ten days, then returning, often with some deficiencies.
In other similar external injuries, the lesion of the globe was more severe,
and permanent blindness followed.
In variability of degree of completeness, these lesions of the globe
corresponded exactly with those produced in other parts of the nervous
system by bullets striking the bones in their vicinity, and they were no
doubt the result of a similar transmission of vibratory force.
In a third series of cases the globe suffered direct contusion, and in a fourth
was perforated and destroyed.
In cases in which permanent blindness was produced without solution of
continuity of the sclerotic coat, the nature of the lesion was probably in
most cases vibratory concussion and the development of multiple
hæmorrhages from choroidal ruptures of a similar nature to those seen in
the brain and spinal cord. The actual hæmorrhagic areæ varied in size; but,
as far as my experience went, gross hæmorrhages into the anterior chamber
did not occur without severe direct contact of the bullet.
In the vast majority of the cases blindness, whether transitory or permanent,
developed immediately on the reception of the injury, and was possibly in
its initial stage the result of primary concussion.
Cases were, however, seen occasionally in which the symptoms were less
sudden, of which the following is an example. I did not think that the mode
of progress seen here could be referred to simple orbital hæmorrhage,
although this existed, but rather to intravaginal hæmorrhage into the sheath
of the optic nerve. On external inspection the globes appeared normal.
Page 352
(76) Wounded at Paardeberg. Entry (Mauser), over the centre of
the right zygoma; the bullet traversed the right orbit, nose, and
left orbit. Exit, immediately above the outer extremity of the left
eyebrow.
The patient stated that he could 'see' for thirty minutes with the
right eye and for an hour with the left, immediately after the
injury. He then became totally blind, and has since remained so.
During the next three weeks there were occasional 'flashes of
light' experienced, but these then ceased.
At the end of three weeks the condition was as follows: Ocular
movements good in every direction except that of elevation of
the globe. The levator palpebræ superioris acted very slightly;
the right, however, better than the left.
There were marked right proptosis, less left proptosis, and slight
patchy subconjunctival hæmorrhage of both eyes. The pupils
were dilated, motionless, and not concentric.
The patient was invalided as totally blind (November, 1900).
Mr. Lang, who saw this patient on his return to England, kindly furnishes
me with the following note as to the condition. There was extensive damage
to both eyes, hæmorrhage, and probably retinal detachment as well as
choroidal changes.
The quotation of a few illustrative examples typical of the ordinary orbital
injuries may be of interest:—
(77) Vertical wound.—Entry, into left orbit in roof posterior to
globe, and internal to optic nerve; exit, from orbit through
junction of inner wall and floor into nose.
Complete blindness followed the injury, but upon the second
day light was perceived on lifting the upper lid. There was
marked proptosis, subconjunctival ecchymosis, swelling and
ecchymosis of the upper lid, and ptosis. Anæsthesia in the whole
area of distribution of the frontal nerve.
the right zygoma; the bullet traversed the right orbit, nose, and
left orbit. Exit, immediately above the outer extremity of the left
eyebrow.
The patient stated that he could 'see' for thirty minutes with the
right eye and for an hour with the left, immediately after the
injury. He then became totally blind, and has since remained so.
During the next three weeks there were occasional 'flashes of
light' experienced, but these then ceased.
At the end of three weeks the condition was as follows: Ocular
movements good in every direction except that of elevation of
the globe. The levator palpebræ superioris acted very slightly;
the right, however, better than the left.
There were marked right proptosis, less left proptosis, and slight
patchy subconjunctival hæmorrhage of both eyes. The pupils
were dilated, motionless, and not concentric.
The patient was invalided as totally blind (November, 1900).
Mr. Lang, who saw this patient on his return to England, kindly furnishes
me with the following note as to the condition. There was extensive damage
to both eyes, hæmorrhage, and probably retinal detachment as well as
choroidal changes.
The quotation of a few illustrative examples typical of the ordinary orbital
injuries may be of interest:—
(77) Vertical wound.—Entry, into left orbit in roof posterior to
globe, and internal to optic nerve; exit, from orbit through
junction of inner wall and floor into nose.
Complete blindness followed the injury, but upon the second
day light was perceived on lifting the upper lid. There was
marked proptosis, subconjunctival ecchymosis, swelling and
ecchymosis of the upper lid, and ptosis. Anæsthesia in the whole
area of distribution of the frontal nerve.
Page 353
At the end of three weeks, fingers could be recognised, but a
large blind spot existed in the centre of the field of vision. The
general movements of the globe were fair, but the upper lid
could not be raised. The proptosis and subconjunctival
hæmorrhage cleared up.
Little further improvement occurred; six months later the patient
could only count the fingers excentrically. A very extensive
scotoma was present. The optic disc was much atrophied, the
calibre of the arteries diminished and the veins full (Mr.
Critchett). The ptosis persisted. It was doubtful in this case
whether the ptosis depended on injury to the nerve of supply, or
on laceration and fixation of the levator palpebræ superioris.
The latter seemed the more probable, as the superior rectus
acted. The absence of any sign of gross bleeding into the
anterior chamber is opposed to the existence of a perforating
lesion of the globe in this case.
(78) Entry (Mauser), from cranial cavity, just within the centre
of the roof of the right orbit; exit, from the orbit by a notch in
the lower orbital margin internal to the infra-orbital foramen;
track thence beneath the soft parts of the face to emerge from
the margin of the upper lip near the left angle of the mouth.
Collapse of globe, proptosis, subconjunctival hæmorrhage,
œdema and ecchymosis of lids.
Shrunken ball removed on twenty-fourth day (Major Burton,
R.A.M.C.).
(79) Entry (Mauser), at the posterior border of the left mastoid
process, 3/4 inch above the tip; exit, in the inner third of the left
upper eyelid. Globe excised at end of seven days. Facial
paralysis and deafness.
(80) Entry (Mauser), from cranial cavity through centre of roof
of orbit; exit, through maxillary antrum. Total blindness.
Movements of ball good, no loss of tension. Proptosis,
subconjunctival hæmorrhage, ecchymosis of eyelids. No
improvement in sight followed. One month later the globe
large blind spot existed in the centre of the field of vision. The
general movements of the globe were fair, but the upper lid
could not be raised. The proptosis and subconjunctival
hæmorrhage cleared up.
Little further improvement occurred; six months later the patient
could only count the fingers excentrically. A very extensive
scotoma was present. The optic disc was much atrophied, the
calibre of the arteries diminished and the veins full (Mr.
Critchett). The ptosis persisted. It was doubtful in this case
whether the ptosis depended on injury to the nerve of supply, or
on laceration and fixation of the levator palpebræ superioris.
The latter seemed the more probable, as the superior rectus
acted. The absence of any sign of gross bleeding into the
anterior chamber is opposed to the existence of a perforating
lesion of the globe in this case.
(78) Entry (Mauser), from cranial cavity, just within the centre
of the roof of the right orbit; exit, from the orbit by a notch in
the lower orbital margin internal to the infra-orbital foramen;
track thence beneath the soft parts of the face to emerge from
the margin of the upper lip near the left angle of the mouth.
Collapse of globe, proptosis, subconjunctival hæmorrhage,
œdema and ecchymosis of lids.
Shrunken ball removed on twenty-fourth day (Major Burton,
R.A.M.C.).
(79) Entry (Mauser), at the posterior border of the left mastoid
process, 3/4 inch above the tip; exit, in the inner third of the left
upper eyelid. Globe excised at end of seven days. Facial
paralysis and deafness.
(80) Entry (Mauser), from cranial cavity through centre of roof
of orbit; exit, through maxillary antrum. Total blindness.
Movements of ball good, no loss of tension. Proptosis,
subconjunctival hæmorrhage, ecchymosis of eyelids. No
improvement in sight followed. One month later the globe
Page 354
suppurated and was removed. The bullet had divided the optic
nerve and contused the ball.
Prognosis and treatment of wounds of the orbit.—Except in those cases in
which return of vision was rapid, the prognosis was consistently bad in the
injuries to the globe. When the globe was ruptured it, as a rule, rapidly
shrank. The case (80) quoted above is the only one in which I saw
secondary suppuration.
With regard to active treatment, the majority of the cases were complicated
by fracture of the roof of the orbit, and in many instances concurrent brain
injury was present. In all of these, as a general rule, it was advisable to
await the closure of the wound in the orbital roof prior to removal of the
injured eye, if that was considered necessary. The only exception to this rule
was offered by instances in which the bullet passed from the orbit into the
cranium; in these primary removal of fragments projecting into the frontal
lobe was preferable. As already indicated, such wounds were comparatively
rare except in the case of bullets coursing transversely or obliquely.
The wounds were, as a rule, followed by considerable matting of the orbital
structures.
Wounds of the nose.—I will pass by the external parts, with the remark that
perforating wounds of the cartilages were remarkable for their sharp
limitation and simple nature. I remember one case shown to me in the Irish
Hospital in Bloemfontein by Sir W. Thomson, in which at the end of the
third day small symmetrical vertical slits in each ala already healed were
scarcely visible. This case very strongly impressed one with the doctrine of
chances, since on the same morning I was asked to see a patient in whom a
similar transverse shot had crossed both orbits, destroying both globes and
injuring the brain.
A retained bullet in the upper portion of the nasal cavity has already been
referred to (fig. 60). This accident was naturally a rare one; in that instance
the bullet had only retained sufficient force to insert itself neatly between
the bones.
Wounds crossing the nasal fossæ were comparatively common. The
interference with the sense of smell often resulting is discussed in Chapter
nerve and contused the ball.
Prognosis and treatment of wounds of the orbit.—Except in those cases in
which return of vision was rapid, the prognosis was consistently bad in the
injuries to the globe. When the globe was ruptured it, as a rule, rapidly
shrank. The case (80) quoted above is the only one in which I saw
secondary suppuration.
With regard to active treatment, the majority of the cases were complicated
by fracture of the roof of the orbit, and in many instances concurrent brain
injury was present. In all of these, as a general rule, it was advisable to
await the closure of the wound in the orbital roof prior to removal of the
injured eye, if that was considered necessary. The only exception to this rule
was offered by instances in which the bullet passed from the orbit into the
cranium; in these primary removal of fragments projecting into the frontal
lobe was preferable. As already indicated, such wounds were comparatively
rare except in the case of bullets coursing transversely or obliquely.
The wounds were, as a rule, followed by considerable matting of the orbital
structures.
Wounds of the nose.—I will pass by the external parts, with the remark that
perforating wounds of the cartilages were remarkable for their sharp
limitation and simple nature. I remember one case shown to me in the Irish
Hospital in Bloemfontein by Sir W. Thomson, in which at the end of the
third day small symmetrical vertical slits in each ala already healed were
scarcely visible. This case very strongly impressed one with the doctrine of
chances, since on the same morning I was asked to see a patient in whom a
similar transverse shot had crossed both orbits, destroying both globes and
injuring the brain.
A retained bullet in the upper portion of the nasal cavity has already been
referred to (fig. 60). This accident was naturally a rare one; in that instance
the bullet had only retained sufficient force to insert itself neatly between
the bones.
Wounds crossing the nasal fossæ were comparatively common. The
interference with the sense of smell often resulting is discussed in Chapter
Page 355
IX.
Wounds of the malar bone were not infrequent. The small amount of
splintering was somewhat remarkable considering the density of structure
of the bone. In this particular the behaviour of the malar corresponded with
what was observed in the flat bones in general. A case quoted in Chapter III.
p. 87, illustrates the capacity of the hard edge of the bone to check the
course of a bullet, and cause considerable deformity and fissuring of the
mantle.
Wounds of the jaws. Upper jaw.—A large number of tracks crossing the
antrum transversely, obliquely, or vertically were observed. In the first case
the nasal cavity, in the others the orbital or buccal cavity, were generally
concurrently involved. It was somewhat striking that I never observed any
trouble, immediate or remote, from these perforations of the antrum. If
hæmorrhage into the cavity occurred, it gave rise to no ultimate trouble. I
never saw an instance of secondary suppuration even in cases where the
bullet entered or escaped through the alveolar process with considerable
local comminution. The branches of the second division of the fifth nerve
were sometimes implicated. In one instance a bullet traversed and cut away
a longitudinal groove in the bones, extending from the posterior margin of
the hard palate, and terminating by a wide notch in the alveolar process.
A good example of a troublesome transverse wound of the bones of the face
is afforded by the following instance:—
(81) Entry (Mauser), through the left malar eminence, 1 inch
below and external to the external canthus; exit, a slightly
curved tranverse slit in the lobe of the right ear.
The injury was followed by no signs of orbital concussion, and
no loss of consciousness. There was free bleeding from both
external wounds and from the nose. The sense of smell was
unaffected, but taste was impaired, and there was loss of tactile
sensation in the teeth on the left side also on the hard palate.
There was no evidence of fracture of the neck of the mandible,
nor of the external auditory meatus, but there was considerable
difficulty in opening the mouth widely or protruding the teeth.
Wounds of the malar bone were not infrequent. The small amount of
splintering was somewhat remarkable considering the density of structure
of the bone. In this particular the behaviour of the malar corresponded with
what was observed in the flat bones in general. A case quoted in Chapter III.
p. 87, illustrates the capacity of the hard edge of the bone to check the
course of a bullet, and cause considerable deformity and fissuring of the
mantle.
Wounds of the jaws. Upper jaw.—A large number of tracks crossing the
antrum transversely, obliquely, or vertically were observed. In the first case
the nasal cavity, in the others the orbital or buccal cavity, were generally
concurrently involved. It was somewhat striking that I never observed any
trouble, immediate or remote, from these perforations of the antrum. If
hæmorrhage into the cavity occurred, it gave rise to no ultimate trouble. I
never saw an instance of secondary suppuration even in cases where the
bullet entered or escaped through the alveolar process with considerable
local comminution. The branches of the second division of the fifth nerve
were sometimes implicated. In one instance a bullet traversed and cut away
a longitudinal groove in the bones, extending from the posterior margin of
the hard palate, and terminating by a wide notch in the alveolar process.
A good example of a troublesome transverse wound of the bones of the face
is afforded by the following instance:—
(81) Entry (Mauser), through the left malar eminence, 1 inch
below and external to the external canthus; exit, a slightly
curved tranverse slit in the lobe of the right ear.
The injury was followed by no signs of orbital concussion, and
no loss of consciousness. There was free bleeding from both
external wounds and from the nose. The sense of smell was
unaffected, but taste was impaired, and there was loss of tactile
sensation in the teeth on the left side also on the hard palate.
There was no evidence of fracture of the neck of the mandible,
nor of the external auditory meatus, but there was considerable
difficulty in opening the mouth widely or protruding the teeth.
Page 356
The latter difficulty persisted for some time, and was still
present when I last saw the patient.
Mandible.—Fractures of the lower jaw were frequent and offered some
peculiarities, the chief of which were the liability of any part of the bone to
be damaged, and the absence of the obliquity between the cleft in the outer
and inner tables so common in the fractures seen in civil practice.
The neck of the condyle I three times saw fractured; in each instance
permanent stiffness and inability to open the mouth resulted. This stiffness
was of a degree sufficient to raise the question whether the best course in
such cases would not be to cut down primarily and remove a considerable
number of loose fragments, and thus diminish the amount of callus likely to
be thrown out.
Fractures of the ascending ramus and body were more frequent. They were
accompanied by considerable comminution, but all that I observed healed
remarkably well, and in good position, in spite of the fact that many of the
patients objected to wear any form of splint.
The most special feature was the occurrence of notched fractures,
corresponding to the type wedges described in Chapter V. When these
fractures were at the lower margin of the bone, the buccal cavity
occasionally escaped in spite of considerable comminution, the latter
confining itself to the basal portion of the bone.
When the base of the teeth, or the alveolus, was struck, a wedge was often
broken away, and from the apex of the resulting gap a fracture extended to
the lower margin of the bone.
When fractures of the latter nature resulted from vertically coursing bullets,
much trouble often ensued. I will quote two cases in illustration:—
(82) Wounded at Rooipoort. Entry (Mauser), through the lower
lip; the bullet struck the base of the right lateral incisor and
canine teeth, knocked out a wedge, and becoming slightly
deflected, cut a vertical groove to the base of the mandible; exit,
in left submaxillary triangle. The bullet subsequently re-entered
the chest wall just below the clavicle, and escaped at the anterior
axillary fold. The appearance of these second wounds suggested
present when I last saw the patient.
Mandible.—Fractures of the lower jaw were frequent and offered some
peculiarities, the chief of which were the liability of any part of the bone to
be damaged, and the absence of the obliquity between the cleft in the outer
and inner tables so common in the fractures seen in civil practice.
The neck of the condyle I three times saw fractured; in each instance
permanent stiffness and inability to open the mouth resulted. This stiffness
was of a degree sufficient to raise the question whether the best course in
such cases would not be to cut down primarily and remove a considerable
number of loose fragments, and thus diminish the amount of callus likely to
be thrown out.
Fractures of the ascending ramus and body were more frequent. They were
accompanied by considerable comminution, but all that I observed healed
remarkably well, and in good position, in spite of the fact that many of the
patients objected to wear any form of splint.
The most special feature was the occurrence of notched fractures,
corresponding to the type wedges described in Chapter V. When these
fractures were at the lower margin of the bone, the buccal cavity
occasionally escaped in spite of considerable comminution, the latter
confining itself to the basal portion of the bone.
When the base of the teeth, or the alveolus, was struck, a wedge was often
broken away, and from the apex of the resulting gap a fracture extended to
the lower margin of the bone.
When fractures of the latter nature resulted from vertically coursing bullets,
much trouble often ensued. I will quote two cases in illustration:—
(82) Wounded at Rooipoort. Entry (Mauser), through the lower
lip; the bullet struck the base of the right lateral incisor and
canine teeth, knocked out a wedge, and becoming slightly
deflected, cut a vertical groove to the base of the mandible; exit,
in left submaxillary triangle. The bullet subsequently re-entered
the chest wall just below the clavicle, and escaped at the anterior
axillary fold. The appearance of these second wounds suggested
Page 357
only slight setting up of the bullet; the original impact was no
doubt of an oblique or lateral character.
The injury was followed by free hæmorrhage and remarkably
abundant salivation (I was inclined to think that the latter
symptom was particularly well marked in gunshot fractures of
the body of the mandible), and very great swelling of the floor
of the mouth.
The patient could not bear any form of apparatus, but was
assiduous in washing out his mouth, and made a good recovery,
the fragments being in good apposition.
(83) Entry (Mauser), over the right malar eminence; the bullet
carried away all the right upper and lower molars, fractured the
mandible, and was retained in the neck.
A fortnight later an abscess formed in the lower part of the neck,
which was opened (Mr. Pooley), and portions of the mantle and
leaden core, together with numerous fragments of the teeth,
were removed. The bullet had undergone fragmentation on
impact, probably on the last one (teeth of mandible), and still
retained sufficient force to enter the neck.
This case affords an interesting example of transmission of force from the
bullet to the teeth, and bears on the theory of explosive action.
In the treatment of fractures of the upper jaw, interference was rarely
needed. In the case of the mandible, a remark has already been made as to
the advisability of removing fragments when the neck of the condyle has
suffered comminution. The removal of loose fragments is necessary in all
cases in which the buccal cavity is involved. Experience in fracture of the
limbs has shown a tendency to quiet necrosis when comminution was
severe, in spite of primary union. This is no doubt dependent on the very
free separation of fragments on the entry and exit aspects from their
enveloping periosteum. In the case of the mandible, considerable necrosis is
inevitable, and much time is saved by the primary removal of all actually
loose fragments.
doubt of an oblique or lateral character.
The injury was followed by free hæmorrhage and remarkably
abundant salivation (I was inclined to think that the latter
symptom was particularly well marked in gunshot fractures of
the body of the mandible), and very great swelling of the floor
of the mouth.
The patient could not bear any form of apparatus, but was
assiduous in washing out his mouth, and made a good recovery,
the fragments being in good apposition.
(83) Entry (Mauser), over the right malar eminence; the bullet
carried away all the right upper and lower molars, fractured the
mandible, and was retained in the neck.
A fortnight later an abscess formed in the lower part of the neck,
which was opened (Mr. Pooley), and portions of the mantle and
leaden core, together with numerous fragments of the teeth,
were removed. The bullet had undergone fragmentation on
impact, probably on the last one (teeth of mandible), and still
retained sufficient force to enter the neck.
This case affords an interesting example of transmission of force from the
bullet to the teeth, and bears on the theory of explosive action.
In the treatment of fractures of the upper jaw, interference was rarely
needed. In the case of the mandible, a remark has already been made as to
the advisability of removing fragments when the neck of the condyle has
suffered comminution. The removal of loose fragments is necessary in all
cases in which the buccal cavity is involved. Experience in fracture of the
limbs has shown a tendency to quiet necrosis when comminution was
severe, in spite of primary union. This is no doubt dependent on the very
free separation of fragments on the entry and exit aspects from their
enveloping periosteum. In the case of the mandible, considerable necrosis is
inevitable, and much time is saved by the primary removal of all actually
loose fragments.
Page 358
A splint of the ordinary chin-cap type with a four-tailed bandage meets all
further requirements, but the patients often object to them. Cases in which
the fragments could be fixed by wiring the teeth were not common, as the
latter had so frequently been carried away. The usual precautions as to
maintaining oral asepsis were especially necessary.
The results of fractures of the mandible were, in so far as my experience
went, remarkably good, as deformity was seldom considerable. The absence
of obliquity and the effect of primary local shock were no doubt favourable
elements, little primary displacement from muscular action occurring.
Wounds of the cheek healed readily, and the same was noticeable of the
lips. Wounds of the tongue healed with remarkable rapidity when of the
simple perforating type, often with little or no swelling or evidence of
contusion. At the end of a few days it was often difficult to localise them.
In connection with this subject a remarkable case which occurred at the
fighting at Koodoosberg Drift is worthy of mention, although the projectile
was a shell fragment and not a bullet of small calibre.
(84) A Highlander was the unfortunate possessor of an entire set
of upper teeth set in a gold plate. A small fragment of a shell
perforated the upper lip by an irregular aperture, and struck the
teeth in such a manner as to turn the posterior edge of the plate
towards the tongue, which latter was cut into two halves
transversely through to the base.
The patient asserted that the plate had been driven down his
throat, but nothing was palpable either in the fauces or on
external examination of the neck. He spoke distinctly, but there
was dysphagia as far as solids were concerned.
On the second day swelling of the neck due to early cellulitis
developed, especially on the left side, and signs of laryngeal
obstruction became prominent. Chloroform was administered,
but on the introduction of the finger into the fauces, respiration
failed and a hasty tracheotomy had to be performed. No foreign
body was palpable with the finger in the pharynx.
further requirements, but the patients often object to them. Cases in which
the fragments could be fixed by wiring the teeth were not common, as the
latter had so frequently been carried away. The usual precautions as to
maintaining oral asepsis were especially necessary.
The results of fractures of the mandible were, in so far as my experience
went, remarkably good, as deformity was seldom considerable. The absence
of obliquity and the effect of primary local shock were no doubt favourable
elements, little primary displacement from muscular action occurring.
Wounds of the cheek healed readily, and the same was noticeable of the
lips. Wounds of the tongue healed with remarkable rapidity when of the
simple perforating type, often with little or no swelling or evidence of
contusion. At the end of a few days it was often difficult to localise them.
In connection with this subject a remarkable case which occurred at the
fighting at Koodoosberg Drift is worthy of mention, although the projectile
was a shell fragment and not a bullet of small calibre.
(84) A Highlander was the unfortunate possessor of an entire set
of upper teeth set in a gold plate. A small fragment of a shell
perforated the upper lip by an irregular aperture, and struck the
teeth in such a manner as to turn the posterior edge of the plate
towards the tongue, which latter was cut into two halves
transversely through to the base.
The patient asserted that the plate had been driven down his
throat, but nothing was palpable either in the fauces or on
external examination of the neck. He spoke distinctly, but there
was dysphagia as far as solids were concerned.
On the second day swelling of the neck due to early cellulitis
developed, especially on the left side, and signs of laryngeal
obstruction became prominent. Chloroform was administered,
but on the introduction of the finger into the fauces, respiration
failed and a hasty tracheotomy had to be performed. No foreign
body was palpable with the finger in the pharynx.
Page 359
Tracheitis and septic pneumonia developed, and the man died of
acute septicæmia thirty-six hours later. Death occurred just as
the Division received marching orders, and no post-mortem
examination was made. As a result of palpation at the time of
the tracheotomy, the probabilities seemed against the presence
of the tooth plate in the pharynx, but the absence of positive
evidence scarcely allows the case to be certainly classed as one
of cellulitis and septicæmia secondary to wound of the tongue.
Wounds of the Neck
Wounds of the neck were not unfrequent and were of the gravest
importance; there can be little doubt that they accounted for a considerable
proportion of the deaths on the field. On the other hand, the neck as a region
offered some of the most striking examples of hairbreadth escape of
important structures. Consideration of a number of the vascular lesions (see
cervical aneurisms, p. 135) also shows conclusively that in no region did
the small size of the bullet more materially influence the result, since no
doubt can exist that all these wounds would have proved immediately fatal
if produced by projectiles of larger calibre.
In this place only a few general considerations will be entered into, as most
of the important cases are dealt with under the general headings of vessels,
nerves, and spine; but it is convenient to include here the few remarks that
have to be made concerning the cervical viscera.
The wounds of the soft parts might course in any direction, but vertical
tracks from above downwards were rare. In point of fact, these occurred
only in connection with perforations of the head, and as vertical wounds of
the latter were received in the prone position, usually when the head was
raised, the necessary conditions for longitudinal tracks were seldom offered.
One case of a complete vertical track in the muscles of the back of the neck
has been already quoted (No. 69, p. 286).
Tracks coursing upwards from the trunk were somewhat more frequent in
occurrence; thus a considerable number traversing the thorax were seen. In
such instances the aperture of exit was generally situated in the posterior
triangle, and some of the brachial nerves often suffered.
acute septicæmia thirty-six hours later. Death occurred just as
the Division received marching orders, and no post-mortem
examination was made. As a result of palpation at the time of
the tracheotomy, the probabilities seemed against the presence
of the tooth plate in the pharynx, but the absence of positive
evidence scarcely allows the case to be certainly classed as one
of cellulitis and septicæmia secondary to wound of the tongue.
Wounds of the Neck
Wounds of the neck were not unfrequent and were of the gravest
importance; there can be little doubt that they accounted for a considerable
proportion of the deaths on the field. On the other hand, the neck as a region
offered some of the most striking examples of hairbreadth escape of
important structures. Consideration of a number of the vascular lesions (see
cervical aneurisms, p. 135) also shows conclusively that in no region did
the small size of the bullet more materially influence the result, since no
doubt can exist that all these wounds would have proved immediately fatal
if produced by projectiles of larger calibre.
In this place only a few general considerations will be entered into, as most
of the important cases are dealt with under the general headings of vessels,
nerves, and spine; but it is convenient to include here the few remarks that
have to be made concerning the cervical viscera.
The wounds of the soft parts might course in any direction, but vertical
tracks from above downwards were rare. In point of fact, these occurred
only in connection with perforations of the head, and as vertical wounds of
the latter were received in the prone position, usually when the head was
raised, the necessary conditions for longitudinal tracks were seldom offered.
One case of a complete vertical track in the muscles of the back of the neck
has been already quoted (No. 69, p. 286).
Tracks coursing upwards from the trunk were somewhat more frequent in
occurrence; thus a considerable number traversing the thorax were seen. In
such instances the aperture of exit was generally situated in the posterior
triangle, and some of the brachial nerves often suffered.
Page 360
The commonest forms of wound were the transverse or the oblique. A large
number of cases with such tracks will be found among the cases of injury to
the cervical vessels and nerves. In some instances the course was restricted
to the neck alone, in others the trunk or upper extremity was also
implicated.
The favourable influence of the arrangement of the structures of the neck,
which allows of the ordinary displacement excursions necessary for
deglutition, respiration, and their cognate movements, was very strongly
marked. Thus in several cases the bullet traversed the neck behind the
pharynx and œsophagus without injuring either viscus, and the escape of
the main vessels and nerves was equally striking. In such wounds the
wedge-like bullet without doubt separated and displaced all these structures,
causing mere superficial contusion.
In connection with the latter statement, the rarity of direct sagittal wounds
in the hospitals should be mentioned. This is probably to be explained by
the facts that wounds in the mid-line of the neck implicated the cervical
spinal cord, and that sagittal wounds implicating the vessels were apt to
lead more directly to the surface, and thus external hæmorrhage was
favoured. A few examples of cervical tracks will suffice to illustrate these
remarks:—
(85) Entry (Lee-Metford), below angle of scapula; exit, centre of
posterior triangle. Injury to the lung, and hæmothorax. No
damage to neck structures.
(86) Entry (Mauser), over Pomum Adami; exit, below right
scapular spine. Median and musculo-spiral paralysis.
(87) Entry, a large oval aperture through ninth right rib, 1/2 an
inch external to scapular angle; exit, anterior border of sterno-
mastoid opposite Pomum Adami. Second entry, opposite angle
of mandible; exit, in centre of cheek.
Wound of lung. Musculo-spiral paralysis still persisting at the
end of nine months.
(88) Entry (Mauser), 2 inches above left clavicle at margin of
trapezius; exit, 1 inch from sternum in left first intercostal space.
number of cases with such tracks will be found among the cases of injury to
the cervical vessels and nerves. In some instances the course was restricted
to the neck alone, in others the trunk or upper extremity was also
implicated.
The favourable influence of the arrangement of the structures of the neck,
which allows of the ordinary displacement excursions necessary for
deglutition, respiration, and their cognate movements, was very strongly
marked. Thus in several cases the bullet traversed the neck behind the
pharynx and œsophagus without injuring either viscus, and the escape of
the main vessels and nerves was equally striking. In such wounds the
wedge-like bullet without doubt separated and displaced all these structures,
causing mere superficial contusion.
In connection with the latter statement, the rarity of direct sagittal wounds
in the hospitals should be mentioned. This is probably to be explained by
the facts that wounds in the mid-line of the neck implicated the cervical
spinal cord, and that sagittal wounds implicating the vessels were apt to
lead more directly to the surface, and thus external hæmorrhage was
favoured. A few examples of cervical tracks will suffice to illustrate these
remarks:—
(85) Entry (Lee-Metford), below angle of scapula; exit, centre of
posterior triangle. Injury to the lung, and hæmothorax. No
damage to neck structures.
(86) Entry (Mauser), over Pomum Adami; exit, below right
scapular spine. Median and musculo-spiral paralysis.
(87) Entry, a large oval aperture through ninth right rib, 1/2 an
inch external to scapular angle; exit, anterior border of sterno-
mastoid opposite Pomum Adami. Second entry, opposite angle
of mandible; exit, in centre of cheek.
Wound of lung. Musculo-spiral paralysis still persisting at the
end of nine months.
(88) Entry (Mauser), 2 inches above left clavicle at margin of
trapezius; exit, 1 inch from sternum in left first intercostal space.
Page 361
Contusion of brachial plexus, with mixed signs, which
disappeared in two months. No signs of vascular injury.
See also cases of cervical aneurism, &c.
Wounds of the pharynx.—I saw only three cases of wound of the pharynx;
in each the injury was in the nasal or buccal segment of the cavity, and in
each the soft palate was injured, in two instances the wound being a small
perforation.
All three cases belong to the somewhat miraculous class. The first (89) was
the only one in which the wound gave rise to subsequent trouble. The
second was under the charge of Mr. Bowlby, and will no doubt be more
fully recounted by him, as interesting signs of injury to the cervical cord
were present. In the third the occipital neuralgia was the only troublesome
symptom.
In both cases 90 and 91 the high position of the wound in the fixed portion
of the pharynx no doubt accounted for the absence of any infective trouble.
(89) Wounds of the pharynx.—Entry (Lee-Metford),
immediately below the tip of right mastoid process; the bullet
traversed the neck, entering the pharynx close to the right tonsil,
crossed the cavity of the pharynx and the mouth, emerging
through the left cheek. Great swelling of the fauces and
dysphagia persisted for some days after the injury, and there was
considerable hæmorrhage.
Infection of the posterior portion of the track from the pharynx
resulted, and suppuration continued for some weeks: a small
sequestrum eventually needed to be removed from the tip of the
transverse process of the atlas.
(90) Entry (Mauser), through mouth; the bullet pierced the soft
palate and the posterior wall of the pharynx, and passed out
between the transverse process of atlas and the occiput. No
serious pharyngeal symptoms.
(91) Entry (Mauser), through the mouth, knocking out the left
upper canine and bicuspid teeth. Perforation of the soft palate
disappeared in two months. No signs of vascular injury.
See also cases of cervical aneurism, &c.
Wounds of the pharynx.—I saw only three cases of wound of the pharynx;
in each the injury was in the nasal or buccal segment of the cavity, and in
each the soft palate was injured, in two instances the wound being a small
perforation.
All three cases belong to the somewhat miraculous class. The first (89) was
the only one in which the wound gave rise to subsequent trouble. The
second was under the charge of Mr. Bowlby, and will no doubt be more
fully recounted by him, as interesting signs of injury to the cervical cord
were present. In the third the occipital neuralgia was the only troublesome
symptom.
In both cases 90 and 91 the high position of the wound in the fixed portion
of the pharynx no doubt accounted for the absence of any infective trouble.
(89) Wounds of the pharynx.—Entry (Lee-Metford),
immediately below the tip of right mastoid process; the bullet
traversed the neck, entering the pharynx close to the right tonsil,
crossed the cavity of the pharynx and the mouth, emerging
through the left cheek. Great swelling of the fauces and
dysphagia persisted for some days after the injury, and there was
considerable hæmorrhage.
Infection of the posterior portion of the track from the pharynx
resulted, and suppuration continued for some weeks: a small
sequestrum eventually needed to be removed from the tip of the
transverse process of the atlas.
(90) Entry (Mauser), through mouth; the bullet pierced the soft
palate and the posterior wall of the pharynx, and passed out
between the transverse process of atlas and the occiput. No
serious pharyngeal symptoms.
(91) Entry (Mauser), through the mouth, knocking out the left
upper canine and bicuspid teeth. Perforation of the soft palate
Page 362
just to the right of the base of the uvula and the posterior wall of
the pharynx; exit, 1½ inch internal to and 1/2 an inch below the
tip of the right mastoid process. Hæmorrhage persisted for half
an hour, and the patient could not swallow solids for a week.
Great occipital neuralgia followed the wound.
Wounds of the larynx.—I saw only one wound of the larynx (see No. 10, p.
135). In this instance the thyroid cartilage was wounded on either side at the
level of the Pomum Adami. Transitory hæmorrhage and signs of œdema
were the only signs referable to the wound, but in addition the bullet
contused the left vagus and gave rise to temporary laryngeal paralysis. The
same course was observed in a second case of perforation of the larynx of
which I was told.
Wounds of the trachea.—The two cases recounted below are the only
tracheal injuries I met with; in one the œsophagus was also implicated. This
patient died from mediastinal emphysema. In the second case the wide
development of emphysema was prevented by the early introduction of a
tracheotomy tube.
(92) Entry (Mauser), on the outer side of the right arm, 3½
inches below the acromion; exit, 3 inches below the tip of the
left mastoid process, through the sterno-mastoid. Thirty six
hours later there was very free hæmorrhage into the right
posterior triangle, emphysema at the episternal notch,
dysphagia, and complete obliteration of the cardiac area of
dulness. Respiration was rapid (40) and extremely noisy. Pulse
130, small and weak.
A tracheotomy was performed (Mr. Stewart), but the patient
died an hour later. When the operation was performed a
considerable amount of mucus from the œsophagus was
discovered in the wound. The bullet had passed obliquely
between trachea and œsophagus, wounding both tubes.
(93) Entry, at the centre of the margin of the left trapezius; exit,
in mid line of the neck over the trachea. Dyspnœa was noted the
next morning, which increased during a journey in a wagon. On
the third day the dyspnœa was more troublesome and
the pharynx; exit, 1½ inch internal to and 1/2 an inch below the
tip of the right mastoid process. Hæmorrhage persisted for half
an hour, and the patient could not swallow solids for a week.
Great occipital neuralgia followed the wound.
Wounds of the larynx.—I saw only one wound of the larynx (see No. 10, p.
135). In this instance the thyroid cartilage was wounded on either side at the
level of the Pomum Adami. Transitory hæmorrhage and signs of œdema
were the only signs referable to the wound, but in addition the bullet
contused the left vagus and gave rise to temporary laryngeal paralysis. The
same course was observed in a second case of perforation of the larynx of
which I was told.
Wounds of the trachea.—The two cases recounted below are the only
tracheal injuries I met with; in one the œsophagus was also implicated. This
patient died from mediastinal emphysema. In the second case the wide
development of emphysema was prevented by the early introduction of a
tracheotomy tube.
(92) Entry (Mauser), on the outer side of the right arm, 3½
inches below the acromion; exit, 3 inches below the tip of the
left mastoid process, through the sterno-mastoid. Thirty six
hours later there was very free hæmorrhage into the right
posterior triangle, emphysema at the episternal notch,
dysphagia, and complete obliteration of the cardiac area of
dulness. Respiration was rapid (40) and extremely noisy. Pulse
130, small and weak.
A tracheotomy was performed (Mr. Stewart), but the patient
died an hour later. When the operation was performed a
considerable amount of mucus from the œsophagus was
discovered in the wound. The bullet had passed obliquely
between trachea and œsophagus, wounding both tubes.
(93) Entry, at the centre of the margin of the left trapezius; exit,
in mid line of the neck over the trachea. Dyspnœa was noted the
next morning, which increased during a journey in a wagon. On
the third day the dyspnœa was more troublesome and
Page 363
emphysema began to develop in the neck. A tracheotomy was
performed (Mr. Hunter), and the tube was kept in for four days.
No further trouble was experienced, and the wound shortly
closed, and the patient, a surgeon, returned to his duties.
Temporary signs of median nerve concussion and contusion
were noted.
performed (Mr. Hunter), and the tube was kept in for four days.
No further trouble was experienced, and the wound shortly
closed, and the patient, a surgeon, returned to his duties.
Temporary signs of median nerve concussion and contusion
were noted.
Page 364
CHAPTER VIII
INJURIES TO THE VERTEBRAL COLUMN AND SPINAL
CORD
Every degree of local injury to the constituent vertebræ and the contents of
the spinal canal was met with considerable frequency. Pure uncomplicated
fractures of the bones were of minor importance, except in so far as they
exemplified the general tendency to localised injury in small-calibre bullet
wounds. Injuries implicating the spinal medulla, on the other hand, were
proportionately the most fatal of any in the whole body to the wounded who
left the field of battle or Field hospital alive, and these cases formed one of
the most painful and distressing features of the surgery of the campaign.
The prognostic gravity of any spinal injury depended upon two factors:
first, the obvious one of relative contiguity or direct implication of the cord
or nerves in the wound track; secondly, the degree of velocity retained by
the bullet at the moment of impact with the spine. Observation of the
serious ill effects produced by bullets passing in the immediate proximity of
large strongly ensheathed peripheral nerves surrounded by soft tissue, such
as those of the arm or thigh, would lead one to expect that a comparatively
thin-clad bundle of delicate nerve tissue like the spinal cord, enclosed in a
bony canal so well disposed for the conveyance of vibrations, would suffer
severely, and such proved to be the case.
Fractures in their relation to nerve injury will be first dealt with, and
secondly injuries to the cord itself.
Isolated fractures of the processes were not uncommon, the determination
of the injury to anyone being naturally dependent on the position and
direction taken by the wound track.
For implication of the transverse processes sagittal wounds coursing in
varying degrees of obliquity were mainly responsible. Such injuries might
be unaccompanied by any nerve lesion. Thus a Boer received a Lee-
INJURIES TO THE VERTEBRAL COLUMN AND SPINAL
CORD
Every degree of local injury to the constituent vertebræ and the contents of
the spinal canal was met with considerable frequency. Pure uncomplicated
fractures of the bones were of minor importance, except in so far as they
exemplified the general tendency to localised injury in small-calibre bullet
wounds. Injuries implicating the spinal medulla, on the other hand, were
proportionately the most fatal of any in the whole body to the wounded who
left the field of battle or Field hospital alive, and these cases formed one of
the most painful and distressing features of the surgery of the campaign.
The prognostic gravity of any spinal injury depended upon two factors:
first, the obvious one of relative contiguity or direct implication of the cord
or nerves in the wound track; secondly, the degree of velocity retained by
the bullet at the moment of impact with the spine. Observation of the
serious ill effects produced by bullets passing in the immediate proximity of
large strongly ensheathed peripheral nerves surrounded by soft tissue, such
as those of the arm or thigh, would lead one to expect that a comparatively
thin-clad bundle of delicate nerve tissue like the spinal cord, enclosed in a
bony canal so well disposed for the conveyance of vibrations, would suffer
severely, and such proved to be the case.
Fractures in their relation to nerve injury will be first dealt with, and
secondly injuries to the cord itself.
Isolated fractures of the processes were not uncommon, the determination
of the injury to anyone being naturally dependent on the position and
direction taken by the wound track.
For implication of the transverse processes sagittal wounds coursing in
varying degrees of obliquity were mainly responsible. Such injuries might
be unaccompanied by any nerve lesion. Thus a Boer received a Lee-
Page 365
Metford wound at Belmont which passed from just below the tip of the
right mastoid process across the pharynx and through the opposite cheek.
No bone damage was at first suspected; suppuration in the neck, however,
followed infection from the pharynx, and when a sinus which persisted was
opened up later, a number of small comminuted fragments were found
detached from the transverse process of the axis. In other cases more or less
severe symptoms of nerve lesion were observed, varying from transient
hyperæsthesia, due to implication of the issuing nerves, to symptoms of
spinal hæmorrhage, such as are portrayed in the following:—
(94) A private in the Black Watch was wounded at
Magersfontein from within a distance of 1,000 yards. Among
other wounds, one track entered 1 inch to the right of the second
lumbar spinous process, and emerged 1 inch internal to the right
anterior superior iliac spine. There were signs of wound of the
kidney, and in addition, retention of urine, incontinence of
fæces, complete motor and sensory paralysis of the right lower
extremity, and total absence of all reflexes. Anæsthesia existed
over the whole area of skin supplied by the nerves of the sacral
plexus, hyperæsthesia over that supplied by the lumbar nerves.
On the tenth day subsequent to the injury, the hyperæsthesia in
the area of lumbar supply was replaced by normal sensation,
motor power began to be slowly regained in the muscles
supplied by the anterior crural and obturator nerves, and the
patellar reflex returned. At this time lowered sensation returned
in the area supplied by the sacral plexus, but no improvement in
motor power took place, and no control was regained over the
bladder and rectum.
During the succeeding week some sciatic hyperæsthesia
developed, but on the twenty-eighth day the patient developed
secondary peritonitis from other causes and died on the thirty-
first. A fracture of the transverse process existed, but
unfortunately the spinal canal was not opened for examination
and no details can be given as to the condition of the cord. (See
case 201, p. 463.)
right mastoid process across the pharynx and through the opposite cheek.
No bone damage was at first suspected; suppuration in the neck, however,
followed infection from the pharynx, and when a sinus which persisted was
opened up later, a number of small comminuted fragments were found
detached from the transverse process of the axis. In other cases more or less
severe symptoms of nerve lesion were observed, varying from transient
hyperæsthesia, due to implication of the issuing nerves, to symptoms of
spinal hæmorrhage, such as are portrayed in the following:—
(94) A private in the Black Watch was wounded at
Magersfontein from within a distance of 1,000 yards. Among
other wounds, one track entered 1 inch to the right of the second
lumbar spinous process, and emerged 1 inch internal to the right
anterior superior iliac spine. There were signs of wound of the
kidney, and in addition, retention of urine, incontinence of
fæces, complete motor and sensory paralysis of the right lower
extremity, and total absence of all reflexes. Anæsthesia existed
over the whole area of skin supplied by the nerves of the sacral
plexus, hyperæsthesia over that supplied by the lumbar nerves.
On the tenth day subsequent to the injury, the hyperæsthesia in
the area of lumbar supply was replaced by normal sensation,
motor power began to be slowly regained in the muscles
supplied by the anterior crural and obturator nerves, and the
patellar reflex returned. At this time lowered sensation returned
in the area supplied by the sacral plexus, but no improvement in
motor power took place, and no control was regained over the
bladder and rectum.
During the succeeding week some sciatic hyperæsthesia
developed, but on the twenty-eighth day the patient developed
secondary peritonitis from other causes and died on the thirty-
first. A fracture of the transverse process existed, but
unfortunately the spinal canal was not opened for examination
and no details can be given as to the condition of the cord. (See
case 201, p. 463.)
Page 366
Fractures of the spinous processes, or those involving both the process and
laminæ, were not uncommon. Isolated separation of the spinous process
was usually the result of wounds crossing the back obliquely or
transversely. Examples of this injury were numerous, especially in the
dorsal region, as being the most prominent, particularly when the patients
assumed the prone position when advancing on the enemy.
Cervical injuries, owing to the comparatively sheltered position of the more
deeply sunk spines, and from the fact that the head was usually under cover
of a stone or ant-heap, were less common; in one instance hyperæsthesia
was noted in one upper extremity as the result of a crossing bullet having
struck the fourth cervical spine. In a man wounded at Paardeberg Drift the
bullet entered at the centre of the buttock, traversed the bones of the pelvis,
and, leaving that cavity above the crest of the ilium, crossed the spine to
emerge in the opposite loin. Suppuration occurred, and when the wound
was laid open the third and fourth lumbar spinous processes were found to
be loosened, but still connected to the surrounding soft parts. There were no
nerve symptoms in this case; these would not have been expected, since by
the time that the bullet had traversed the bones of the pelvis its velocity
must have been considerably lessened, even if high at the moment of
primary impact. In another case a dorsal spine, together with its lamina, was
separated and moveable; the only nerve symptoms were slight pain and a
crop of herpes on the line of distribution of the corresponding intercostal
nerve, the bullet having probably struck the nerve in passing across the
intercostal space. In one instance of a retained bullet lying beneath the skin
of the back, its passage between two contiguous dorsal spines without
fracture of either was determined during an extraction operation.
When the prone position was assumed by the men, more or less longitudinal
wounds in the course of the spine were naturally liable to occur. These
tracks assumed somewhat greater importance than the transverse ones,
because the injury to bone was more often multiple, and the laminæ were
frequently implicated. The relative importance of such injuries was
dependent on the velocity of the bullet and the depth at which it travelled.
As an instance of a more serious character the following may be given:—
(95) In a Highlander wounded at Magersfontein, probably at a
range within 1,000 yards, the bullet entered at the right side of
laminæ, were not uncommon. Isolated separation of the spinous process
was usually the result of wounds crossing the back obliquely or
transversely. Examples of this injury were numerous, especially in the
dorsal region, as being the most prominent, particularly when the patients
assumed the prone position when advancing on the enemy.
Cervical injuries, owing to the comparatively sheltered position of the more
deeply sunk spines, and from the fact that the head was usually under cover
of a stone or ant-heap, were less common; in one instance hyperæsthesia
was noted in one upper extremity as the result of a crossing bullet having
struck the fourth cervical spine. In a man wounded at Paardeberg Drift the
bullet entered at the centre of the buttock, traversed the bones of the pelvis,
and, leaving that cavity above the crest of the ilium, crossed the spine to
emerge in the opposite loin. Suppuration occurred, and when the wound
was laid open the third and fourth lumbar spinous processes were found to
be loosened, but still connected to the surrounding soft parts. There were no
nerve symptoms in this case; these would not have been expected, since by
the time that the bullet had traversed the bones of the pelvis its velocity
must have been considerably lessened, even if high at the moment of
primary impact. In another case a dorsal spine, together with its lamina, was
separated and moveable; the only nerve symptoms were slight pain and a
crop of herpes on the line of distribution of the corresponding intercostal
nerve, the bullet having probably struck the nerve in passing across the
intercostal space. In one instance of a retained bullet lying beneath the skin
of the back, its passage between two contiguous dorsal spines without
fracture of either was determined during an extraction operation.
When the prone position was assumed by the men, more or less longitudinal
wounds in the course of the spine were naturally liable to occur. These
tracks assumed somewhat greater importance than the transverse ones,
because the injury to bone was more often multiple, and the laminæ were
frequently implicated. The relative importance of such injuries was
dependent on the velocity of the bullet and the depth at which it travelled.
As an instance of a more serious character the following may be given:—
(95) In a Highlander wounded at Magersfontein, probably at a
range within 1,000 yards, the bullet entered at the right side of
Page 367
the sixth cervical vertebra; tracking downwards, it loosened the
laminæ of the fifth and sixth dorsal vertebræ from the pedicles,
and separated the tip of the seventh spine. The bullet was
extracted from beneath the skin at the latter spot, its force
having been no doubt exhausted by the resistance of the firm
neural arches supported by the weight of the man's body.
Symptoms of total transverse lesion of the cord followed, and
the patient died at the end of fifty-four days. The bone had not
apparently been sufficiently depressed to exert continuous
pressure, but the cord was diffluent and actually destroyed over
an area corresponding with the fourth, fifth, sixth, and seventh
dorsal segments.
I saw no instance of wound of the neural arch from a direct shot in the back
in any of our men, neither was I ever able to detect an injury to the articular
processes as a localised lesion.
Injuries to the centra were very frequent, but differed extraordinarily in
their importance. Perforation by bullets travelling at a relatively low grade
of velocity, but still one sufficient to allow them to pass through the body,
produced in many instances no symptoms whatever when the track did not
lie in immediate contiguity to the spinal canal or perforate it.
In all the wounds which I had the opportunity of examining post mortem,
the fracture was of the nature of a pure perforation of the cancellous tissue
of the centrum, with no comminution beyond slight splintering of the
compact tissue at the aperture of exit. In one instance the bullet passed in a
coronal direction so close to the back of the centrum as to leave a septum of
only the thickness of stout paper between the track and the spinal canal. In
this case signs of total transverse lesion were present. I never happened to
meet with a case in which the canal was encroached upon from the front by
displaced bone. In some cases at the end of six weeks there was difficulty in
determining the position of the openings, and section of the bone was
necessary in order to assure oneself as to the direction of the track.
In some instances the centra were pierced in the coronal direction with
varying degrees of obliquity; in others the direction was more sagittal; in
two of the latter the bullet was retained in the spinal canal. The tracks were
laminæ of the fifth and sixth dorsal vertebræ from the pedicles,
and separated the tip of the seventh spine. The bullet was
extracted from beneath the skin at the latter spot, its force
having been no doubt exhausted by the resistance of the firm
neural arches supported by the weight of the man's body.
Symptoms of total transverse lesion of the cord followed, and
the patient died at the end of fifty-four days. The bone had not
apparently been sufficiently depressed to exert continuous
pressure, but the cord was diffluent and actually destroyed over
an area corresponding with the fourth, fifth, sixth, and seventh
dorsal segments.
I saw no instance of wound of the neural arch from a direct shot in the back
in any of our men, neither was I ever able to detect an injury to the articular
processes as a localised lesion.
Injuries to the centra were very frequent, but differed extraordinarily in
their importance. Perforation by bullets travelling at a relatively low grade
of velocity, but still one sufficient to allow them to pass through the body,
produced in many instances no symptoms whatever when the track did not
lie in immediate contiguity to the spinal canal or perforate it.
In all the wounds which I had the opportunity of examining post mortem,
the fracture was of the nature of a pure perforation of the cancellous tissue
of the centrum, with no comminution beyond slight splintering of the
compact tissue at the aperture of exit. In one instance the bullet passed in a
coronal direction so close to the back of the centrum as to leave a septum of
only the thickness of stout paper between the track and the spinal canal. In
this case signs of total transverse lesion were present. I never happened to
meet with a case in which the canal was encroached upon from the front by
displaced bone. In some cases at the end of six weeks there was difficulty in
determining the position of the openings, and section of the bone was
necessary in order to assure oneself as to the direction of the track.
In some instances the centra were pierced in the coronal direction with
varying degrees of obliquity; in others the direction was more sagittal; in
two of the latter the bullet was retained in the spinal canal. The tracks were
Page 368
sometimes confined to one vertebra, but often implicated two. In others the
bullet passed longitudinally through the thorax, grooving or perforating one
or more centra.
The accompanying evidences of nerve injury varied from nil to those of
pressure or irritation of the nerve roots, transient signs of spinal concussion,
signs of contusion and hæmorrhage, or to evidence of total transverse
lesion. Instances of all these conditions will be quoted under the heading of
injuries to the cord or nerves.
Signs of injury to the vertebræ.—Separation of the spinous processes was
often indicated by slight deformity, either evident or palpable, local pain,
tenderness, mobility, and crepitus. In some cases these local signs were
reinforced by evidence of cord injury. Fractures involving the laminæ
differed merely in the degree to which the above signs were developed.
Fractures of the transverse processes were generally only to be assumed
from the position and direction of the wounds, the assumption being
sometimes strengthened in probability by evidence of injury to the cord and
nerves.
Fractures of the centra were also frequently only to be assumed from the
direction of the wound tracks, and possibly from evidence of nerve injury.
When no paralysis supervened, interference with the movements of the
back, or pain, was so slight as to be inappreciable, especially in the
presence of concurrent injury to other parts, which was seldom absent. I
only once saw any angular deformity from this injury, and that slight, and
not apparent before the end of three weeks. In this particular a very striking
difference exists between injuries from small-calibre bullets and larger ones
such as the Martini-Henry. In the only instance of Martini-Henry fracture of
the spine that came under my notice, the centrum was severely comminuted
and deformity was obvious. Still, as in so many particulars, the difference
was only one of degree, since comminution of the centra in gunshot wounds
has always been observed to be slight in nature compared with what is met
with in the compression fractures of civil life.
A few words will suffice to dismiss the questions of diagnosis, prognosis,
and treatment of the above injuries. The diagnosis depended on attention to
the signs above indicated, the prognosis almost entirely on the concurrent
bullet passed longitudinally through the thorax, grooving or perforating one
or more centra.
The accompanying evidences of nerve injury varied from nil to those of
pressure or irritation of the nerve roots, transient signs of spinal concussion,
signs of contusion and hæmorrhage, or to evidence of total transverse
lesion. Instances of all these conditions will be quoted under the heading of
injuries to the cord or nerves.
Signs of injury to the vertebræ.—Separation of the spinous processes was
often indicated by slight deformity, either evident or palpable, local pain,
tenderness, mobility, and crepitus. In some cases these local signs were
reinforced by evidence of cord injury. Fractures involving the laminæ
differed merely in the degree to which the above signs were developed.
Fractures of the transverse processes were generally only to be assumed
from the position and direction of the wounds, the assumption being
sometimes strengthened in probability by evidence of injury to the cord and
nerves.
Fractures of the centra were also frequently only to be assumed from the
direction of the wound tracks, and possibly from evidence of nerve injury.
When no paralysis supervened, interference with the movements of the
back, or pain, was so slight as to be inappreciable, especially in the
presence of concurrent injury to other parts, which was seldom absent. I
only once saw any angular deformity from this injury, and that slight, and
not apparent before the end of three weeks. In this particular a very striking
difference exists between injuries from small-calibre bullets and larger ones
such as the Martini-Henry. In the only instance of Martini-Henry fracture of
the spine that came under my notice, the centrum was severely comminuted
and deformity was obvious. Still, as in so many particulars, the difference
was only one of degree, since comminution of the centra in gunshot wounds
has always been observed to be slight in nature compared with what is met
with in the compression fractures of civil life.
A few words will suffice to dismiss the questions of diagnosis, prognosis,
and treatment of the above injuries. The diagnosis depended on attention to
the signs above indicated, the prognosis almost entirely on the concurrent
Page 369
injury to the nervous system, which will be considered later, and the
treatment consisted in enforcing rest alone.
Injuries to the Spinal Cord accompanying Small-calibre
Bullet Wounds of the Vertebræ
Anatomical lesions.—In introducing the subject of the nature of the lesions
of the spinal cord and membranes, I should again enforce the statement that
their character and degree, in comparison with the slight accompanying
bone damage, are pathognomonic of gunshot wounds, and that these
characters find their completest exemplification in injuries produced by
bullets of small calibre, endowed with a high grade of velocity. Again, that
the varying degrees of damage depend comparatively slightly on the
position of the bone lesion, apart from actual encroachment on the canal,
while the degree of velocity retained by the bullet at the moment of impact
is all-important. In no other way are the divergent results to be explained
which follow an apparently identical injury, in so far as extent, position, and
external evidence of damage to the spinal column are concerned.
Injuries to the nerve roots of the nature of concussion and contusion, are
dealt with in Chapter IX.
Pure concussion of the spinal cord may, I believe, be studied from a better
standpoint in the case of small-calibre bullet injuries than in any others,
since in many instances it is, I think, possible to exclude any complications
such as wrenches and strains of the vertebral column, and ascribe the
symptoms to the pure effect of extreme vibratory force communicated to
the cord by its enveloping bony canal. The condition must be considered
under the two headings of slight and severe.
In slight concussion the usually transient effects of the injury, and its happy
tendency not to destroy life, place us in a state of uncertainty as to the
occurrence of anatomical changes, since no opportunity of post-mortem
examination occurred. The clinical condition included under this term
corresponds with that implied in 'spinal concussion' in civil practice. One
point of extreme interest, whether the subjects of small-calibre bullet spinal
concussion will in the future suffer from the remote effects common to
similar sufferers in civil life from other causes such as railway collisions,
treatment consisted in enforcing rest alone.
Injuries to the Spinal Cord accompanying Small-calibre
Bullet Wounds of the Vertebræ
Anatomical lesions.—In introducing the subject of the nature of the lesions
of the spinal cord and membranes, I should again enforce the statement that
their character and degree, in comparison with the slight accompanying
bone damage, are pathognomonic of gunshot wounds, and that these
characters find their completest exemplification in injuries produced by
bullets of small calibre, endowed with a high grade of velocity. Again, that
the varying degrees of damage depend comparatively slightly on the
position of the bone lesion, apart from actual encroachment on the canal,
while the degree of velocity retained by the bullet at the moment of impact
is all-important. In no other way are the divergent results to be explained
which follow an apparently identical injury, in so far as extent, position, and
external evidence of damage to the spinal column are concerned.
Injuries to the nerve roots of the nature of concussion and contusion, are
dealt with in Chapter IX.
Pure concussion of the spinal cord may, I believe, be studied from a better
standpoint in the case of small-calibre bullet injuries than in any others,
since in many instances it is, I think, possible to exclude any complications
such as wrenches and strains of the vertebral column, and ascribe the
symptoms to the pure effect of extreme vibratory force communicated to
the cord by its enveloping bony canal. The condition must be considered
under the two headings of slight and severe.
In slight concussion the usually transient effects of the injury, and its happy
tendency not to destroy life, place us in a state of uncertainty as to the
occurrence of anatomical changes, since no opportunity of post-mortem
examination occurred. The clinical condition included under this term
corresponds with that implied in 'spinal concussion' in civil practice. One
point of extreme interest, whether the subjects of small-calibre bullet spinal
concussion will in the future suffer from the remote effects common to
similar sufferers in civil life from other causes such as railway collisions,
Page 370
still remains for future determination. An ample field for such observations
has at any rate been created by the present war.
In severe concussion a far more highly destructive action is exerted. This
condition may be followed by complete disorganisation of the cord,
accompanied or not by multiple parenchymatous hæmorrhages into its
substance. Either or both of these pathological conditions are produced by
the impact of the bullet with the spine, given a sufficiently high degree of
velocity, and it is difficult to separate clinically the resulting symptoms.
This is a matter perhaps of less importance, since it stands to reason that a
vibratory force, capable of rupturing the spinal capillaries, would at the
same time damage the nervous tissue.
In speaking of concussion of this degree, it should be clearly recognised
that a general condition, such as is indicated by the use of the term
'concussion of the brain,' is in no wise implied. The condition is really far
more nearly allied to one of contusion, a strictly localised portion of the
spinal cord undergoing the destructive process which affects the segments
below only in so far as it interrupts the normal channels of communication
with the higher centres.
Case 102 is an instance of such a lesion, the post-mortem examination
showing clearly that the spinal canal was not encroached upon by the bullet.
The cord in this instance appeared little changed macroscopically, and this
fact was observed in other instances, both during operations and post
mortem.
Contusion.—This condition is very closely allied to the last. In cases 101
and 103 the spinal canal was as little encroached upon as in 102, but the
bullet struck the somewhat elastic neural arch in each case, and post
mortem an adhesion between the cord and the enveloping dura opposite the
point at which impact of the bullet was closest suggests that, in spite of the
escape of the bone from fracture, it may have been momentarily depressed
to a sufficient degree to contuse the cord, or the latter may have suffered a
contre-coup injury. For these reasons the inclusion of the cases as instances
of pure concussion is not warranted. In both Nos. 99 and 100 the neural
arch had actually suffered fracture, and although the bone was not
has at any rate been created by the present war.
In severe concussion a far more highly destructive action is exerted. This
condition may be followed by complete disorganisation of the cord,
accompanied or not by multiple parenchymatous hæmorrhages into its
substance. Either or both of these pathological conditions are produced by
the impact of the bullet with the spine, given a sufficiently high degree of
velocity, and it is difficult to separate clinically the resulting symptoms.
This is a matter perhaps of less importance, since it stands to reason that a
vibratory force, capable of rupturing the spinal capillaries, would at the
same time damage the nervous tissue.
In speaking of concussion of this degree, it should be clearly recognised
that a general condition, such as is indicated by the use of the term
'concussion of the brain,' is in no wise implied. The condition is really far
more nearly allied to one of contusion, a strictly localised portion of the
spinal cord undergoing the destructive process which affects the segments
below only in so far as it interrupts the normal channels of communication
with the higher centres.
Case 102 is an instance of such a lesion, the post-mortem examination
showing clearly that the spinal canal was not encroached upon by the bullet.
The cord in this instance appeared little changed macroscopically, and this
fact was observed in other instances, both during operations and post
mortem.
Contusion.—This condition is very closely allied to the last. In cases 101
and 103 the spinal canal was as little encroached upon as in 102, but the
bullet struck the somewhat elastic neural arch in each case, and post
mortem an adhesion between the cord and the enveloping dura opposite the
point at which impact of the bullet was closest suggests that, in spite of the
escape of the bone from fracture, it may have been momentarily depressed
to a sufficient degree to contuse the cord, or the latter may have suffered a
contre-coup injury. For these reasons the inclusion of the cases as instances
of pure concussion is not warranted. In both Nos. 99 and 100 the neural
arch had actually suffered fracture, and although the bone was not
Page 371
depressed or exercising pressure at the time of the autopsies, it was no
doubt driven in temporarily at the moment of impact of the bullet.
At the post-mortem examinations of injuries of this nature it was common
to find one to four segments of the spinal cord completely disorganised. At
the end of some five weeks, the common duration of life, the structure of
the cord was represented by a semi-diffluent yellowish material, the
consistence of which was so deficient in firmness as to allow the partial
collapse of the membranes covering the affected portion, so as to exhibit a
definite narrowing when the whole was held up (see fig. 79). In such cases
traces of extra- or intra-dural hæmorrhage sometimes still persisted.
Hæmorrhage.—This occurred as surface extravasation and in the form of
parenchymatous hæmorrhages. I saw the former both in the extra-dural and
peri-pial forms, but never in sufficient quantity to exert a degree of pressure
calculated to produce symptoms of total transverse lesion. Here again,
however, it is difficult to speak with confidence since the conditions which
regulate the tension within the normal spinal canal are so complicated and
liable to variation, that it is very difficult to estimate the effect of any given
hæmorrhage discovered.
My friend Mr. R. H. Mills-Roberts described to me one fatal case under his
care in the Welsh Hospital in which extra-dural hæmorrhage was so
abundant as, in his opinion, to have taken a prominent part in the production
of the paralytic symptoms.
Examples of both extra- and intra-dural (peri-pial) hæmorrhage are afforded
by cases 99, 102, and 103; in none was it large in amount or widely
distributed. The condition was probably also frequently associated in
varying degree with that to be immediately described below.
Intra-medullary hæmorrhage (hæmato-myelia).—The importance of this
condition is lessened in small-calibre bullet injuries by the fact already
alluded to, that it is almost invariably accompanied by concussion changes.
In one instance in which death took place at the end of eight days, partly as
the result of concurrent injury, in a man in whom signs of total transverse
lesion of the cord were present, the substance of the cord was found to be
closely scattered over with hæmorrhages of various sizes and extending for
a longitudinal area of some three inches.
doubt driven in temporarily at the moment of impact of the bullet.
At the post-mortem examinations of injuries of this nature it was common
to find one to four segments of the spinal cord completely disorganised. At
the end of some five weeks, the common duration of life, the structure of
the cord was represented by a semi-diffluent yellowish material, the
consistence of which was so deficient in firmness as to allow the partial
collapse of the membranes covering the affected portion, so as to exhibit a
definite narrowing when the whole was held up (see fig. 79). In such cases
traces of extra- or intra-dural hæmorrhage sometimes still persisted.
Hæmorrhage.—This occurred as surface extravasation and in the form of
parenchymatous hæmorrhages. I saw the former both in the extra-dural and
peri-pial forms, but never in sufficient quantity to exert a degree of pressure
calculated to produce symptoms of total transverse lesion. Here again,
however, it is difficult to speak with confidence since the conditions which
regulate the tension within the normal spinal canal are so complicated and
liable to variation, that it is very difficult to estimate the effect of any given
hæmorrhage discovered.
My friend Mr. R. H. Mills-Roberts described to me one fatal case under his
care in the Welsh Hospital in which extra-dural hæmorrhage was so
abundant as, in his opinion, to have taken a prominent part in the production
of the paralytic symptoms.
Examples of both extra- and intra-dural (peri-pial) hæmorrhage are afforded
by cases 99, 102, and 103; in none was it large in amount or widely
distributed. The condition was probably also frequently associated in
varying degree with that to be immediately described below.
Intra-medullary hæmorrhage (hæmato-myelia).—The importance of this
condition is lessened in small-calibre bullet injuries by the fact already
alluded to, that it is almost invariably accompanied by concussion changes.
In one instance in which death took place at the end of eight days, partly as
the result of concurrent injury, in a man in whom signs of total transverse
lesion of the cord were present, the substance of the cord was found to be
closely scattered over with hæmorrhages of various sizes and extending for
a longitudinal area of some three inches.
Page 372
As to the frequency with which hæmorrhage into the substance of the cord
occurred, I regret to be unable to give an opinion. In the late post-mortem
examinations I witnessed, a yellow discoloration of the softened cord was
the only macroscopic evidence of hæmorrhage.
Hæmorrhages of this nature may, however, account for the grave paralytic
symptoms in some cases of partial or total transverse lesion not due to
direct compression or laceration.
The conditions of concussion, contusion, or hæmatomyelia were, I believe,
responsible for at least nine-tenths of the cases in which a total transverse
lesion was indicated by the symptoms. The extreme importance of realising
this fact and the rarity of the production of symptoms by continuing
compression both from the prognostic and the therapeutic point of view is
obvious.
The analogous injuries termed generally in Chapter IX. nerve contusion,
although frequently accompanied by tissue destruction, may be followed by
reparative change, and are capable of complete or almost complete
spontaneous recovery; while the lesions in the spinal cord are permanent,
and complete recovery is only witnessed in the parts affected by the remote
pressure or irritation from blood extravasation, or in those influenced by
concussion.
I include below short abstracts of all the cases of lesion of the spinal cord
which terminated fatally, in which I had the opportunity of witnessing the
post-mortem conditions. In a considerable proportion of the cases at the end
of six weeks the spinal cord was softened over an area of from two to four
segments in such degree as to have practically lost all continuity. Although
the autopsies were made on patients who had died slowly and in summer
weather, often twelve to sixteen hours after death, I think it can be but fair
to assume, when the consistency of the remaining portion of the spinal cord
is considered, that the softening was only in slight degree if at all
exaggerated by post-mortem change. Again symptoms of secondary
myelitis and meningitis had been observed in some of the fatal cases prior
to death.
I had but one opportunity of observing a case in which a retained bullet
exercised compression, and none in which this was due to displaced bone
occurred, I regret to be unable to give an opinion. In the late post-mortem
examinations I witnessed, a yellow discoloration of the softened cord was
the only macroscopic evidence of hæmorrhage.
Hæmorrhages of this nature may, however, account for the grave paralytic
symptoms in some cases of partial or total transverse lesion not due to
direct compression or laceration.
The conditions of concussion, contusion, or hæmatomyelia were, I believe,
responsible for at least nine-tenths of the cases in which a total transverse
lesion was indicated by the symptoms. The extreme importance of realising
this fact and the rarity of the production of symptoms by continuing
compression both from the prognostic and the therapeutic point of view is
obvious.
The analogous injuries termed generally in Chapter IX. nerve contusion,
although frequently accompanied by tissue destruction, may be followed by
reparative change, and are capable of complete or almost complete
spontaneous recovery; while the lesions in the spinal cord are permanent,
and complete recovery is only witnessed in the parts affected by the remote
pressure or irritation from blood extravasation, or in those influenced by
concussion.
I include below short abstracts of all the cases of lesion of the spinal cord
which terminated fatally, in which I had the opportunity of witnessing the
post-mortem conditions. In a considerable proportion of the cases at the end
of six weeks the spinal cord was softened over an area of from two to four
segments in such degree as to have practically lost all continuity. Although
the autopsies were made on patients who had died slowly and in summer
weather, often twelve to sixteen hours after death, I think it can be but fair
to assume, when the consistency of the remaining portion of the spinal cord
is considered, that the softening was only in slight degree if at all
exaggerated by post-mortem change. Again symptoms of secondary
myelitis and meningitis had been observed in some of the fatal cases prior
to death.
I had but one opportunity of observing a case in which a retained bullet
exercised compression, and none in which this was due to displaced bone
Page 373
fragments. I also only once came across a case of complete section, but no
doubt both bone pressure and section may have occurred with greater
frequency amongst patients dying on the field or shortly after. The case of
section is illustrated in fig. 80. It will be noted that, although the section is
complete, the bullet lies to one side of the canal, and hence the bullet, as
fixed in its course by the bone of the centrum, directly struck but half of the
whole width of the cord.
It was striking how little secondary change in the cord had occurred in the
neighbourhood of the spot of division. This well illustrates the
comparatively slight vibratory effect of a bullet travelling with a degree of
velocity insufficient to completely perforate the vertebral column.
Symptoms of injury to the spinal cord.—In slight spinal concussion these
exactly resembled those of the more severe lesions, except in their
transitory nature. They consisted in loss of cutaneous sensibility, motor
paralysis, and vesical and rectal incompetence. The phenomena persisted
from periods of a few hours to two or three days, return of function being
first noticeable in the sensory nerves, and often with modification in the
way of lowered acuteness, or minor signs of irritation, such as formication,
slight hyperæsthesia or pain, pointing to a combination with the least
extensive degrees of hæmorrhage; later, motor power was rapidly regained.
The subjects of such symptoms often suffered from weakness and
unsteadiness in movement for some days or weeks; a sharp line of
discrimination between such cases and those described in the next
paragraphs is manifestly impossible.
Spinal hæmorrhage.—The symptoms of this condition developed
differently according to whether concurrent concussion existed.
Occasionally very typical instances of pure hæmorrhage were observed
with transient symptoms:—
doubt both bone pressure and section may have occurred with greater
frequency amongst patients dying on the field or shortly after. The case of
section is illustrated in fig. 80. It will be noted that, although the section is
complete, the bullet lies to one side of the canal, and hence the bullet, as
fixed in its course by the bone of the centrum, directly struck but half of the
whole width of the cord.
It was striking how little secondary change in the cord had occurred in the
neighbourhood of the spot of division. This well illustrates the
comparatively slight vibratory effect of a bullet travelling with a degree of
velocity insufficient to completely perforate the vertebral column.
Symptoms of injury to the spinal cord.—In slight spinal concussion these
exactly resembled those of the more severe lesions, except in their
transitory nature. They consisted in loss of cutaneous sensibility, motor
paralysis, and vesical and rectal incompetence. The phenomena persisted
from periods of a few hours to two or three days, return of function being
first noticeable in the sensory nerves, and often with modification in the
way of lowered acuteness, or minor signs of irritation, such as formication,
slight hyperæsthesia or pain, pointing to a combination with the least
extensive degrees of hæmorrhage; later, motor power was rapidly regained.
The subjects of such symptoms often suffered from weakness and
unsteadiness in movement for some days or weeks; a sharp line of
discrimination between such cases and those described in the next
paragraphs is manifestly impossible.
Spinal hæmorrhage.—The symptoms of this condition developed
differently according to whether concurrent concussion existed.
Occasionally very typical instances of pure hæmorrhage were observed
with transient symptoms:—
Page 374
(96) A private in the Yorkshire Light Infantry was wounded at
Modder River; the bullet entered between the eleventh and
twelfth ribs, just posterior to the left mid-axillary line, emerging
in the posterior axillary fold, at its junction with the right side of
the trunk. On the second day after the injury the lower
extremities became drawn up, the knees and hips assuming a
flexed position, and this was followed shortly by the advent of
complete motor and sensory paraplegia, accompanied by
retention of urine. Two days later, the patient again passed water
normally, and gradual and rapid return of both sensation and
motor power took place. At the end of fourteen days no trace of
the condition remained, and the patient was shortly after sent
home.
The symptoms, however, were rarely so simple as in this example; it was
very much more common to meet with an admixture of signs of primary
concussion, or at any rate symptoms of radiation. The following is an
extreme but excellent example of more complicated and prolonged effects:
(97) A lance-corporal of the Black Watch was wounded at
Magersfontein at a range of from 400 to 500 yards. The bullet
entered over the left malar bone 2½ inches from the outer
canthus, while the aperture of exit was 2¼ inches above the
inferior angle of the right scapula, 3/4 of an inch anterior to its
axillary margin.
Very shortly after the injury complete motor and sensory
paralysis developed in both upper extremities, followed by the
development of a similar condition in the left lower limb, and
retention of urine and fæces, but the latter unaccompanied by
the marked abdominal intestinal distension so characteristic in
cases of total transverse lesion. The right side of the chest
continued to work well, but the intercostals of the left side were
paralysed. No disturbance of the normal action or condition of
the pupils was noted. After the first few days the condition
began to improve.
Modder River; the bullet entered between the eleventh and
twelfth ribs, just posterior to the left mid-axillary line, emerging
in the posterior axillary fold, at its junction with the right side of
the trunk. On the second day after the injury the lower
extremities became drawn up, the knees and hips assuming a
flexed position, and this was followed shortly by the advent of
complete motor and sensory paraplegia, accompanied by
retention of urine. Two days later, the patient again passed water
normally, and gradual and rapid return of both sensation and
motor power took place. At the end of fourteen days no trace of
the condition remained, and the patient was shortly after sent
home.
The symptoms, however, were rarely so simple as in this example; it was
very much more common to meet with an admixture of signs of primary
concussion, or at any rate symptoms of radiation. The following is an
extreme but excellent example of more complicated and prolonged effects:
(97) A lance-corporal of the Black Watch was wounded at
Magersfontein at a range of from 400 to 500 yards. The bullet
entered over the left malar bone 2½ inches from the outer
canthus, while the aperture of exit was 2¼ inches above the
inferior angle of the right scapula, 3/4 of an inch anterior to its
axillary margin.
Very shortly after the injury complete motor and sensory
paralysis developed in both upper extremities, followed by the
development of a similar condition in the left lower limb, and
retention of urine and fæces, but the latter unaccompanied by
the marked abdominal intestinal distension so characteristic in
cases of total transverse lesion. The right side of the chest
continued to work well, but the intercostals of the left side were
paralysed. No disturbance of the normal action or condition of
the pupils was noted. After the first few days the condition
began to improve.
Page 375
Three weeks later, the chest was moving symmetrically and
well, sensation and motor power had returned in considerable
degree in the left lower extremity, with marked increase in both
the plantar and patellar reflexes; sensation had returned in both
upper extremities, a slight amount of motor power was regained
in the right, but the left remained entirely flaccid and incapable
of movement.
At the end of a month power was regained over both bladder
and rectum, some slight movement of the left thumb was
possible, and a certain degree of hyperæsthesia developed over
the back of the forearm.
At the end of six weeks there was little further alteration, but
that in the direction of improvement. There was some wasting of
the muscles of the left upper extremity, and this was most
marked in the muscles supplied by the ulnar nerve.
At the end of ten weeks the patient had been up some days; he
could stand and walk, but was unable to rise from the sitting
posture without help. The plantar and patellar reflexes were
much exaggerated, and there was ankle clonus, most marked in
the left limb. The right upper extremity was normal, but weak;
there was wrist-drop on the left side and the deltoid was wasted
and powerless; on the other hand the fingers could be flexed,
and although the elbow could not be, there were signs of
returning power in the biceps, and some movements of the
shoulder could be performed by the capsular muscles. It was
remarkable that common sensation was more acute in the left
than the right lower extremity, but I attributed this to the remains
of hyperæsthesia on the left side. The patient left for home
shortly after the last note.
In both these cases the absence of marked hyperæsthesia or pain points to
medullary hæmorrhage (hæmato-myelia) as the pathological condition
produced by the injury. In this particular they contrast well with case 94
quoted on page 315, where the degree of both hyperæsthesia and pain
indicated a combination of pressure and irritation of the nerve roots by
well, sensation and motor power had returned in considerable
degree in the left lower extremity, with marked increase in both
the plantar and patellar reflexes; sensation had returned in both
upper extremities, a slight amount of motor power was regained
in the right, but the left remained entirely flaccid and incapable
of movement.
At the end of a month power was regained over both bladder
and rectum, some slight movement of the left thumb was
possible, and a certain degree of hyperæsthesia developed over
the back of the forearm.
At the end of six weeks there was little further alteration, but
that in the direction of improvement. There was some wasting of
the muscles of the left upper extremity, and this was most
marked in the muscles supplied by the ulnar nerve.
At the end of ten weeks the patient had been up some days; he
could stand and walk, but was unable to rise from the sitting
posture without help. The plantar and patellar reflexes were
much exaggerated, and there was ankle clonus, most marked in
the left limb. The right upper extremity was normal, but weak;
there was wrist-drop on the left side and the deltoid was wasted
and powerless; on the other hand the fingers could be flexed,
and although the elbow could not be, there were signs of
returning power in the biceps, and some movements of the
shoulder could be performed by the capsular muscles. It was
remarkable that common sensation was more acute in the left
than the right lower extremity, but I attributed this to the remains
of hyperæsthesia on the left side. The patient left for home
shortly after the last note.
In both these cases the absence of marked hyperæsthesia or pain points to
medullary hæmorrhage (hæmato-myelia) as the pathological condition
produced by the injury. In this particular they contrast well with case 94
quoted on page 315, where the degree of both hyperæsthesia and pain
indicated a combination of pressure and irritation of the nerve roots by
Page 376
surface hæmorrhage on the affected side. In case 97 the persistence for four
weeks of paralysis of the bladder and rectum suggested medullary
hæmorrhage in addition, while the return of patellar reflex in the paralysed
limb negatived the occurrence of an extensive destructive lesion.
In view of the extreme interest of these cases I will shortly detail one other
in which the cauda equina alone was affected.
I must confess my inability to place the case definitely in the category either
of concussion or medullary hæmorrhage. As so often happened, both
conditions probably took part in the lesion. The immediate development of
the primary symptoms is no doubt to be referred to concussion, while the
patchy nature of the prolonged lesion and gradual recession of the
symptoms point to the presence of hæmorrhages. We find here the link most
nearly connecting the spinal cord and the peripheral systemic nerves. Such
a case goes far to show that the condition which I have in the next chapter
often referred to as nerve contusion may in fact be produced by an injury
far short of actual contact.
(98) A trooper in the Imperial Yeomanry, while advancing in the
crouching attitude, was struck by a bullet from his left front, at
an estimated distance of 300 yards. The bullet traversed the right
arm anteriorly to the humerus, entered the trunk in the line of
the posterior axillary fold, 1½ inch below the level of the nipple,
crossed the thoracic and abdominal cavities, deeply striking the
lumbar spine, and finally lodged beneath the skin over the
venter of the left ilium. The skin was broken, but the force of the
bullet was not sufficient to cause it to pass through, and it was
later expressed from the wound by the surgeon. The bullet was a
Mauser, and not in any way deformed, although it must at any
rate have struck the spine and perforated the ilium.
Immediate paraplegia resulted, both sensation and motor power
were completely abolished, but there was no trouble either with
the bladder or rectum. No symptoms of injury to either thoracic
or abdominal viscera were noted.
Three days after the injury sensation and some return of motor
power were observed in the left extremity, and some power of
weeks of paralysis of the bladder and rectum suggested medullary
hæmorrhage in addition, while the return of patellar reflex in the paralysed
limb negatived the occurrence of an extensive destructive lesion.
In view of the extreme interest of these cases I will shortly detail one other
in which the cauda equina alone was affected.
I must confess my inability to place the case definitely in the category either
of concussion or medullary hæmorrhage. As so often happened, both
conditions probably took part in the lesion. The immediate development of
the primary symptoms is no doubt to be referred to concussion, while the
patchy nature of the prolonged lesion and gradual recession of the
symptoms point to the presence of hæmorrhages. We find here the link most
nearly connecting the spinal cord and the peripheral systemic nerves. Such
a case goes far to show that the condition which I have in the next chapter
often referred to as nerve contusion may in fact be produced by an injury
far short of actual contact.
(98) A trooper in the Imperial Yeomanry, while advancing in the
crouching attitude, was struck by a bullet from his left front, at
an estimated distance of 300 yards. The bullet traversed the right
arm anteriorly to the humerus, entered the trunk in the line of
the posterior axillary fold, 1½ inch below the level of the nipple,
crossed the thoracic and abdominal cavities, deeply striking the
lumbar spine, and finally lodged beneath the skin over the
venter of the left ilium. The skin was broken, but the force of the
bullet was not sufficient to cause it to pass through, and it was
later expressed from the wound by the surgeon. The bullet was a
Mauser, and not in any way deformed, although it must at any
rate have struck the spine and perforated the ilium.
Immediate paraplegia resulted, both sensation and motor power
were completely abolished, but there was no trouble either with
the bladder or rectum. No symptoms of injury to either thoracic
or abdominal viscera were noted.
Three days after the injury sensation and some return of motor
power were observed in the left extremity, and some power of
Page 377
movement in the toes of the right foot.
During the next eight weeks steady but slow improvement took
place; during the last three weeks of this period he made the
voyage to England. Ever since the injury some elevation of
temperature was noted, a rise at night to 100° or at times to
102°; for this no definite cause was discovered. In the tenth
week the condition was as follows: The temperature has become
normal. The patient has lost flesh to a considerable extent since
the reception of the injury. The lower extremities are much
wasted, especially the peroneal muscles. Patellar reflexes can be
obtained, but the knee jerks are uncertain. Unevenly distributed
paralysis exists in both lower extremities. Left—Sensation fairly
good throughout. Quadriceps very weak; does not react to
electrical stimulation. Calf muscles act fairly. Anterior tibial and
musculo-cutaneous groups are paralysed. Right—Quadriceps
acts better than on left, muscles below the knee paralysed, and
in the same area there is complete absence of sensation. The
patient complains of shooting pains in both legs, and there is
some deep muscular tenderness.
Three weeks later an abundant crop of vesicles appeared over
the front of the right thigh and leg, above and below the knee.
Sensation in the limb at the same time returned to a considerable
degree, anæsthesia persisting on the outer aspect of the thigh
only.
At the end of four months very considerable improvement had
taken place, but there was no return of motor power in the right
leg, or the muscles supplied by the peroneal nerve in the left leg.
There was some general œdema of the legs, especially of the
right, possibly in connection with the herpetic eruption which
was now disappearing. Muscular tenderness had disappeared.
There was also definite improvement in the size and tone of the
peroneal muscles, although no motor power was regained.
At the end of five months, slight gradual improvement was still
taking place, but the loss of power was nearly as extensive as
During the next eight weeks steady but slow improvement took
place; during the last three weeks of this period he made the
voyage to England. Ever since the injury some elevation of
temperature was noted, a rise at night to 100° or at times to
102°; for this no definite cause was discovered. In the tenth
week the condition was as follows: The temperature has become
normal. The patient has lost flesh to a considerable extent since
the reception of the injury. The lower extremities are much
wasted, especially the peroneal muscles. Patellar reflexes can be
obtained, but the knee jerks are uncertain. Unevenly distributed
paralysis exists in both lower extremities. Left—Sensation fairly
good throughout. Quadriceps very weak; does not react to
electrical stimulation. Calf muscles act fairly. Anterior tibial and
musculo-cutaneous groups are paralysed. Right—Quadriceps
acts better than on left, muscles below the knee paralysed, and
in the same area there is complete absence of sensation. The
patient complains of shooting pains in both legs, and there is
some deep muscular tenderness.
Three weeks later an abundant crop of vesicles appeared over
the front of the right thigh and leg, above and below the knee.
Sensation in the limb at the same time returned to a considerable
degree, anæsthesia persisting on the outer aspect of the thigh
only.
At the end of four months very considerable improvement had
taken place, but there was no return of motor power in the right
leg, or the muscles supplied by the peroneal nerve in the left leg.
There was some general œdema of the legs, especially of the
right, possibly in connection with the herpetic eruption which
was now disappearing. Muscular tenderness had disappeared.
There was also definite improvement in the size and tone of the
peroneal muscles, although no motor power was regained.
At the end of five months, slight gradual improvement was still
taking place, but the loss of power was nearly as extensive as
Page 378
when the last note was taken. The skin of the right leg was
glossy, that of the left apparently normal. At times some
hyperæsthesia of the soles was noted, and the plantar reflex was
very brisk.
The right anterior tibial and musculo-cutaneous groups of
muscles reacted to the strongest faradic current, not to any
galvanic current below 20-25 m.a., contraction very sluggish.
The same muscles in the left leg also reacted to the strongest
faradic current, but only locally, with no sort of effect on the
tendons. Similar contractions could be induced in the right
quadriceps, but none in the left (Dr. Turney).
Appreciation of heat and cold applied to the skin was fair, but, in
the case of heat, distinctly slow in the right leg and foot.
At the end of seven months improvement was still taking place;
the patient could now stand, walk a little with crutches, and even
ascend and descend a staircase.
Severe concussion, contusion, or medullary hæmorrhage producing signs of
total transverse lesion, and complete transverse section.—The symptoms of
these conditions will be taken together, because, with very slight variations,
they may be considered as lesions of equal degree as to severity, bad
prognosis, and unsuitability for active interference.
All were characterised by the exhibition of the same essential phenomena,
symmetrical abolition of sensation and motor power on either side of the
body, absence of any signs of irritation in the paralysed area, and loss of
patellar reflex. In a small number of the cases of medullary hæmorrhage
some return of sensation was observed prior to death; in a still smaller,
traces of motor power, and in one or two irritability of the muscles or feeble
reflexes pointed to the fact that destruction of the cord was not absolute. As
abstracts of a series of cases are appended on page 330, it is only necessary
to add a few remarks as to any slight peculiarities which seemed directly
dependent on the mode of causation.
It may be first stated that these severe injuries were accompanied by signs
of a very high degree of shock. In fact, the shock observed in them was
glossy, that of the left apparently normal. At times some
hyperæsthesia of the soles was noted, and the plantar reflex was
very brisk.
The right anterior tibial and musculo-cutaneous groups of
muscles reacted to the strongest faradic current, not to any
galvanic current below 20-25 m.a., contraction very sluggish.
The same muscles in the left leg also reacted to the strongest
faradic current, but only locally, with no sort of effect on the
tendons. Similar contractions could be induced in the right
quadriceps, but none in the left (Dr. Turney).
Appreciation of heat and cold applied to the skin was fair, but, in
the case of heat, distinctly slow in the right leg and foot.
At the end of seven months improvement was still taking place;
the patient could now stand, walk a little with crutches, and even
ascend and descend a staircase.
Severe concussion, contusion, or medullary hæmorrhage producing signs of
total transverse lesion, and complete transverse section.—The symptoms of
these conditions will be taken together, because, with very slight variations,
they may be considered as lesions of equal degree as to severity, bad
prognosis, and unsuitability for active interference.
All were characterised by the exhibition of the same essential phenomena,
symmetrical abolition of sensation and motor power on either side of the
body, absence of any signs of irritation in the paralysed area, and loss of
patellar reflex. In a small number of the cases of medullary hæmorrhage
some return of sensation was observed prior to death; in a still smaller,
traces of motor power, and in one or two irritability of the muscles or feeble
reflexes pointed to the fact that destruction of the cord was not absolute. As
abstracts of a series of cases are appended on page 330, it is only necessary
to add a few remarks as to any slight peculiarities which seemed directly
dependent on the mode of causation.
It may be first stated that these severe injuries were accompanied by signs
of a very high degree of shock. In fact, the shock observed in them was
Page 379
more severe than in any other small-calibre bullet injuries that I witnessed.
The patients lay still with the eyes closed, great pallor of surface,
sometimes moaning with pain, the sensorium much benumbed, or
occasionally early delirium was noted. The pulse was small, often slow and
irregular, and the respiration shallow. The originally quiet state was often
changed to one of great restlessness of the unparalysed part of the body,
with the appearance of reaction.
The degree of primary pain varied greatly, but as a rule it was considerable;
in some cases it was excruciating in the parts above the level of the totally
destructive lesion, and commonly of the zonal variety. A hyperæsthetic zone
at the lower limit of sensation usually existed.
In the majority of the cases pain must have depended on meningeal
hæmorrhage. In one of the cases related, positive evidence was offered as to
this particular by the autopsy, although this was made as long as six weeks
after the original injury, since no other source of pressure or irritation was
discovered. When I first saw this patient some twenty-four hours after the
injury he was moaning with pain, although a strong and plucky man; I
hastened to give him an injection of morphia, and assured him that it would
relieve his suffering: as I left I heard him say to his neighbour: 'That is no
use; they gave me three last night, and I was no better,' and his remark
proved true.
In high dorsal and cervical injuries the temperature rose high, in one case to
108° F.; I had no opportunity, however, of observing the temperature in any
case immediately before and after death. During the hot weather the profuse
sweating of the upper part of the body contrasted very strongly with the dry
skin of the paralysed part.
The heart's action was often particularly irregular in the dorsal injuries, and
the respiration slow and irregular; as these cases, however, were often
complicated by severe concurrent injuries to internal organs, the
irregularities could hardly be ascribed to the spinal-cord lesion alone. In
cases of pure diaphragmatic respiration, the rate did not as a rule exceed the
normal of 16 or 20 to the minute, and it was quite regular; this was noted
soon after the injury and persisted throughout the course of the cases. As is
usually the case, both respiration and the heart's action were most
The patients lay still with the eyes closed, great pallor of surface,
sometimes moaning with pain, the sensorium much benumbed, or
occasionally early delirium was noted. The pulse was small, often slow and
irregular, and the respiration shallow. The originally quiet state was often
changed to one of great restlessness of the unparalysed part of the body,
with the appearance of reaction.
The degree of primary pain varied greatly, but as a rule it was considerable;
in some cases it was excruciating in the parts above the level of the totally
destructive lesion, and commonly of the zonal variety. A hyperæsthetic zone
at the lower limit of sensation usually existed.
In the majority of the cases pain must have depended on meningeal
hæmorrhage. In one of the cases related, positive evidence was offered as to
this particular by the autopsy, although this was made as long as six weeks
after the original injury, since no other source of pressure or irritation was
discovered. When I first saw this patient some twenty-four hours after the
injury he was moaning with pain, although a strong and plucky man; I
hastened to give him an injection of morphia, and assured him that it would
relieve his suffering: as I left I heard him say to his neighbour: 'That is no
use; they gave me three last night, and I was no better,' and his remark
proved true.
In high dorsal and cervical injuries the temperature rose high, in one case to
108° F.; I had no opportunity, however, of observing the temperature in any
case immediately before and after death. During the hot weather the profuse
sweating of the upper part of the body contrasted very strongly with the dry
skin of the paralysed part.
The heart's action was often particularly irregular in the dorsal injuries, and
the respiration slow and irregular; as these cases, however, were often
complicated by severe concurrent injuries to internal organs, the
irregularities could hardly be ascribed to the spinal-cord lesion alone. In
cases of pure diaphragmatic respiration, the rate did not as a rule exceed the
normal of 16 or 20 to the minute, and it was quite regular; this was noted
soon after the injury and persisted throughout the course of the cases. As is
usually the case, both respiration and the heart's action were most
Page 380
embarrassed in the cases in which abdominal distension was a prominent
feature. In some of the neck cases the Cheyne-Stokes type of respiration
was very strongly marked.
In cases of low dorsal injury intestinal distension was extreme, and I think
more troublesome than the same condition as seen in civil practice. The
distension was accompanied by most persistent vomiting, continuing for
days, and in the cases that lived for some time severe gastric crises of the
same type occurred in some instances.
Priapism was a common symptom; but, as is seen from the cases quoted,
was rarely due to any gross direct laceration of the cord.
Trophic sores were both early to develop, and extensive; primary decubitus
occurred in all the cases I saw, and steady extension followed. In one case a
remarkable symmetrical serpiginous ulceration developed in the area of
distribution of the cutaneous branches of the external popliteal nerve on the
outer side of the leg.
The paralysis in nearly every case was of the utterly flaccid type, and
wasting of the muscles was early and extreme. This was occasionally
accentuated by the supervention of myelitis.
Opportunities for making observations on the quantity of urine secreted
were not great, and I can offer no remark as to the occurrence of polyuria.
In one rapidly fatal case, however, suppression of urine occurred.
(99) Lumbar region. Transverse lesion.—Range under 1,000
yards. Wound of entry (Mauser), over the seventh rib 1 inch
from the left posterior axillary fold; exit, over the centre of the
right iliac crest. Complete symmetrical motor and sensory
paralysis of lower extremities, entire abolition of reflexes,
retention of urine.
On the ninth day there was some return of sensation in the lower
extremities, and a cremasteric reflex was to be obtained. A large
bedsore had developed over the sacrum. No further change
occurred in the lower extremities. The patient became
progressively emaciated and exhausted, cystitis persisted, the
bedsore deepened. The man eventually developed signs of a
feature. In some of the neck cases the Cheyne-Stokes type of respiration
was very strongly marked.
In cases of low dorsal injury intestinal distension was extreme, and I think
more troublesome than the same condition as seen in civil practice. The
distension was accompanied by most persistent vomiting, continuing for
days, and in the cases that lived for some time severe gastric crises of the
same type occurred in some instances.
Priapism was a common symptom; but, as is seen from the cases quoted,
was rarely due to any gross direct laceration of the cord.
Trophic sores were both early to develop, and extensive; primary decubitus
occurred in all the cases I saw, and steady extension followed. In one case a
remarkable symmetrical serpiginous ulceration developed in the area of
distribution of the cutaneous branches of the external popliteal nerve on the
outer side of the leg.
The paralysis in nearly every case was of the utterly flaccid type, and
wasting of the muscles was early and extreme. This was occasionally
accentuated by the supervention of myelitis.
Opportunities for making observations on the quantity of urine secreted
were not great, and I can offer no remark as to the occurrence of polyuria.
In one rapidly fatal case, however, suppression of urine occurred.
(99) Lumbar region. Transverse lesion.—Range under 1,000
yards. Wound of entry (Mauser), over the seventh rib 1 inch
from the left posterior axillary fold; exit, over the centre of the
right iliac crest. Complete symmetrical motor and sensory
paralysis of lower extremities, entire abolition of reflexes,
retention of urine.
On the ninth day there was some return of sensation in the lower
extremities, and a cremasteric reflex was to be obtained. A large
bedsore had developed over the sacrum. No further change
occurred in the lower extremities. The patient became
progressively emaciated and exhausted, cystitis persisted, the
bedsore deepened. The man eventually developed signs of a
Page 381
large basal abscess in the left lung, and died on the forty-second
day.
At the post-mortem a fracture of the first lumbar lamina was
discovered, with some splintering of the bone; the lumbar
spinous process was attached and in its normal position.
Opposite the centre of the cauda equina were the remains of a
considerable hæmorrhage, both extra- and intra-dural, the nerves
appearing somewhat compressed, but of normal consistency.
The muscles of the back were infiltrated with putrid pus on both
sides. A pulmonary abscess cavity the size of a hen's egg
occupied the upper part of the lower lobe of the left lung. The
kidneys were congested, and the bladder thickened and
chronically inflamed.
(100) Cervico-dorsal region. Total transverse lesion.—Wound
of entry (Mauser), to the right of the sixth cervical vertebra: the
bullet was removed on the field from the left of the seventh
dorsal spinous process, which was somewhat prominent.
Complete motor and sensory paralysis extended upwards to the
third intercostal space; the breathing was almost entirely
diaphragmatic. Retention of urine. Entire abolition of reflexes in
lower limbs and trunk. Hyperæsthesia was present in both upper
extremities, with a zone of hyperæsthesia around the chest. The
patient suffered greatly for some weeks from pain in the
hyperæsthetic area, he developed severe cystitis and later
incontinence of urine. A large trophic sacral bed-sore steadily
increased in depth and size.
About ten days before death, which occurred on the fifty-third
day from exhaustion and septicæmia, the patient complained of
pains in his legs; but there was no return of sensation, motion, or
reflexes.
At the post-mortem, the seventh dorsal spinous process was
found to be loose and the laminæ of the fifth, sixth, and seventh
vertebræ were separated from the pedicles, and somewhat
depressed on the left side. These laminæ were adherent to the
day.
At the post-mortem a fracture of the first lumbar lamina was
discovered, with some splintering of the bone; the lumbar
spinous process was attached and in its normal position.
Opposite the centre of the cauda equina were the remains of a
considerable hæmorrhage, both extra- and intra-dural, the nerves
appearing somewhat compressed, but of normal consistency.
The muscles of the back were infiltrated with putrid pus on both
sides. A pulmonary abscess cavity the size of a hen's egg
occupied the upper part of the lower lobe of the left lung. The
kidneys were congested, and the bladder thickened and
chronically inflamed.
(100) Cervico-dorsal region. Total transverse lesion.—Wound
of entry (Mauser), to the right of the sixth cervical vertebra: the
bullet was removed on the field from the left of the seventh
dorsal spinous process, which was somewhat prominent.
Complete motor and sensory paralysis extended upwards to the
third intercostal space; the breathing was almost entirely
diaphragmatic. Retention of urine. Entire abolition of reflexes in
lower limbs and trunk. Hyperæsthesia was present in both upper
extremities, with a zone of hyperæsthesia around the chest. The
patient suffered greatly for some weeks from pain in the
hyperæsthetic area, he developed severe cystitis and later
incontinence of urine. A large trophic sacral bed-sore steadily
increased in depth and size.
About ten days before death, which occurred on the fifty-third
day from exhaustion and septicæmia, the patient complained of
pains in his legs; but there was no return of sensation, motion, or
reflexes.
At the post-mortem, the seventh dorsal spinous process was
found to be loose and the laminæ of the fifth, sixth, and seventh
vertebræ were separated from the pedicles, and somewhat
depressed on the left side. These laminæ were adherent to the
Page 382
dura, as were also a few small separated bony spiculæ. There
was no sign of old hæmorrhage. The spinal cord was practically
gone between the levels of the fourth and seventh dorsal
vertebræ, and diffluent from myelitis up to the third cervical.
(101) Dorsal region; total transverse lesion.—Wound of entry
(Mauser), in the left supra-spinous fossa of the scapula; exit,
between the eleventh and twelfth ribs of the right side. Complete
motor and sensory paralysis, with absence of reflexes from mid-
dorsal region downwards. Upper intercostals working. Retention
of urine, penis turgid. Sensation perfect to lower extremity of
sternum. Early trophic sacral bed-sores developed and steadily
increased in depth and extent, slighter ones developed on the
heels. The paralysis was flaccid throughout. The patient
gradually emaciated with fever, and died on the seventy-eighth
day.
At the post-mortem the wound proved not to have penetrated the
thorax, and both the vertebral spines and laminæ were intact, no
trace of bony injury being discoverable. Opposite the sixth
dorsal vertebra, for a distance of 1½ inch, the cord and dura
were adherent, and over the same area the cord was represented
by soft custard-like material. There was no sign of old
hæmorrhage.
(102) Dorsal region; total transverse lesion; slight extra-dural
hæmorrhage.—Wound of entry (Mauser), at the posterior aspect
of the right shoulder; exit, 2 inches to the left of the spine below
the ninth rib.
Complete motor and sensory paralysis below the site of the
lesion, with absence of superficial and deep reflexes. Retention
of urine. Great abdominal distension, pain, and vomiting. Bed-
sores over the sacrum developed on the third day; meanwhile
the vomiting continued on and off for a week, and very severe
girdle pain persisted.
One month later when seen at the Base hospital considerable
improvement had occurred. Sensation had returned in both
was no sign of old hæmorrhage. The spinal cord was practically
gone between the levels of the fourth and seventh dorsal
vertebræ, and diffluent from myelitis up to the third cervical.
(101) Dorsal region; total transverse lesion.—Wound of entry
(Mauser), in the left supra-spinous fossa of the scapula; exit,
between the eleventh and twelfth ribs of the right side. Complete
motor and sensory paralysis, with absence of reflexes from mid-
dorsal region downwards. Upper intercostals working. Retention
of urine, penis turgid. Sensation perfect to lower extremity of
sternum. Early trophic sacral bed-sores developed and steadily
increased in depth and extent, slighter ones developed on the
heels. The paralysis was flaccid throughout. The patient
gradually emaciated with fever, and died on the seventy-eighth
day.
At the post-mortem the wound proved not to have penetrated the
thorax, and both the vertebral spines and laminæ were intact, no
trace of bony injury being discoverable. Opposite the sixth
dorsal vertebra, for a distance of 1½ inch, the cord and dura
were adherent, and over the same area the cord was represented
by soft custard-like material. There was no sign of old
hæmorrhage.
(102) Dorsal region; total transverse lesion; slight extra-dural
hæmorrhage.—Wound of entry (Mauser), at the posterior aspect
of the right shoulder; exit, 2 inches to the left of the spine below
the ninth rib.
Complete motor and sensory paralysis below the site of the
lesion, with absence of superficial and deep reflexes. Retention
of urine. Great abdominal distension, pain, and vomiting. Bed-
sores over the sacrum developed on the third day; meanwhile
the vomiting continued on and off for a week, and very severe
girdle pain persisted.
One month later when seen at the Base hospital considerable
improvement had occurred. Sensation had returned in both
Page 383
lower limbs; but flaccid paralysis persisted and both were
wasted, especially the left. There was no return of reflexes in the
lower limbs, the urine was passed in gushes, and the patient was
cognisant when these occurred. The sacral bed-sores were,
however, very extensive and becoming larger and deeper.
At the end of the fifth week slight power was regained in the
flexors and abductors of the right thigh, and the same muscles of
the left limb could be made to contract feebly. Meanwhile the
patient suffered with severe fever, accompanied by frequent
rigors and profuse sweats; the bed-sore continued to extend, and
the urine was foul and contained pus.
The patient continued in a similar condition, progressive
emaciation and exhaustion taking place, and at the end of six
weeks he died.
At the post-mortem the bullet was found to have tracked beneath
the right scapula, entering the chest by the fifth intercostal space
and lacerating the right lung; thence it entered the eighth dorsal
centrum and tunnelled both this and the ninth diagonally, to
escape beneath the ninth rib. On opening the spinal canal the
tunnel was found to be separated only by the compact tissue of
the centrum from the cavity, while a thin extra-dural
hæmorrhage separated the dura from the bones anteriorly. The
spinal cord exhibited no sign of pressure and was firm and
continuous, but up to the lower limit of the dorsal region there
was septic myelitis and meningitis, the result of pus having
tracked up the canal from the sacral bedsore. Suppurative
cystitis and pyelitis were present. The patient was the subject of
an old urethral stricture which had given rise to trouble during
treatment.
(103) Dorsal region; total transverse lesion; slight intra-dural
hæmorrhage.—Wound of entry (Mauser), below spine of
scapula, close to right axilla; exit, 2½ inches to left of tenth
dorsal spinous process.
wasted, especially the left. There was no return of reflexes in the
lower limbs, the urine was passed in gushes, and the patient was
cognisant when these occurred. The sacral bed-sores were,
however, very extensive and becoming larger and deeper.
At the end of the fifth week slight power was regained in the
flexors and abductors of the right thigh, and the same muscles of
the left limb could be made to contract feebly. Meanwhile the
patient suffered with severe fever, accompanied by frequent
rigors and profuse sweats; the bed-sore continued to extend, and
the urine was foul and contained pus.
The patient continued in a similar condition, progressive
emaciation and exhaustion taking place, and at the end of six
weeks he died.
At the post-mortem the bullet was found to have tracked beneath
the right scapula, entering the chest by the fifth intercostal space
and lacerating the right lung; thence it entered the eighth dorsal
centrum and tunnelled both this and the ninth diagonally, to
escape beneath the ninth rib. On opening the spinal canal the
tunnel was found to be separated only by the compact tissue of
the centrum from the cavity, while a thin extra-dural
hæmorrhage separated the dura from the bones anteriorly. The
spinal cord exhibited no sign of pressure and was firm and
continuous, but up to the lower limit of the dorsal region there
was septic myelitis and meningitis, the result of pus having
tracked up the canal from the sacral bedsore. Suppurative
cystitis and pyelitis were present. The patient was the subject of
an old urethral stricture which had given rise to trouble during
treatment.
(103) Dorsal region; total transverse lesion; slight intra-dural
hæmorrhage.—Wound of entry (Mauser), below spine of
scapula, close to right axilla; exit, 2½ inches to left of tenth
dorsal spinous process.
Page 384
Complete motor and sensory paralysis below ensiform cartilage,
with well-marked hyperæsthetic zone around trunk. All reflexes
absent. Retention of urine. Incontinence of fæces. Bed-sores in
sacral region developed during the first two days, and seventeen
days later well-developed serpiginous trophic sores developed
on the outer side of each leg and continued to increase slowly
until death. The paralysis remained of the absolutely flaccid
variety. Great emaciation occurred, accompanied by hectic
fever, the temperature ranging from normal to 102.5°. During
the third week double pleurisy developed.
At the post-mortem no bone injury could be detected. The cord
and dura-mater were adherent over an area corresponding to the
fifth to the eighth dorsal vertebræ, and opposite the seventh the
cord was soft and of the consistence of butter. A small intra-
dural hæmorrhage was still evident below the main lesion, not
extensive enough to give rise to serious compression. General
adhesions in each pleura. Cystitis.
with well-marked hyperæsthetic zone around trunk. All reflexes
absent. Retention of urine. Incontinence of fæces. Bed-sores in
sacral region developed during the first two days, and seventeen
days later well-developed serpiginous trophic sores developed
on the outer side of each leg and continued to increase slowly
until death. The paralysis remained of the absolutely flaccid
variety. Great emaciation occurred, accompanied by hectic
fever, the temperature ranging from normal to 102.5°. During
the third week double pleurisy developed.
At the post-mortem no bone injury could be detected. The cord
and dura-mater were adherent over an area corresponding to the
fifth to the eighth dorsal vertebræ, and opposite the seventh the
cord was soft and of the consistence of butter. A small intra-
dural hæmorrhage was still evident below the main lesion, not
extensive enough to give rise to serious compression. General
adhesions in each pleura. Cystitis.
Page 385
Fig. 79.
Appearance of Spinal Cord enclosed in membranes in case 103 after
removal from the canal. When the membranes were opened a white
custard-like substance took the place of the cord. Slight evidence of
extra-dural hæmorrhage existed
(104) Dorsal region; section of cord; retained bullet.—Wound
of entry (Mauser), in seventh right intercostal space, 4½ inches
from the dorsal spinous processes, oval in outline; bullet
retained.
Complete motor and sensory paralysis, with absence of reflexes
below umbilicus. Retention of urine, incontinence of fæces.
Large sacral bed-sore developed rapidly. Right hæmothorax.
The patient emaciated rapidly, and for the last fourteen days the
temperature ranged to 104°, the bed-sore steadily increasing in
size. Death occurred on the forty-second day.
At the post-mortem a Mauser bullet was found embedded in the
centrum of the twelfth dorsal vertebra. The bullet was slightly
curved; its anterior extremity had passed across the spinal canal,
and wounding the dura posteriorly rested against the left lamina.
The plating of the mantle of the bullet was stripped from half the
area of the tip. The dura was not adherent, and the cord was
softened for half an inch above the point of section; above this it
was normal, the vessels coursing normally to the softened spot.
Below the point of section the cord was blanched, but offered no
other macroscopic evidence of disease. No evidence of either
intra- or extra-dural hæmorrhage was detectible.
Appearance of Spinal Cord enclosed in membranes in case 103 after
removal from the canal. When the membranes were opened a white
custard-like substance took the place of the cord. Slight evidence of
extra-dural hæmorrhage existed
(104) Dorsal region; section of cord; retained bullet.—Wound
of entry (Mauser), in seventh right intercostal space, 4½ inches
from the dorsal spinous processes, oval in outline; bullet
retained.
Complete motor and sensory paralysis, with absence of reflexes
below umbilicus. Retention of urine, incontinence of fæces.
Large sacral bed-sore developed rapidly. Right hæmothorax.
The patient emaciated rapidly, and for the last fourteen days the
temperature ranged to 104°, the bed-sore steadily increasing in
size. Death occurred on the forty-second day.
At the post-mortem a Mauser bullet was found embedded in the
centrum of the twelfth dorsal vertebra. The bullet was slightly
curved; its anterior extremity had passed across the spinal canal,
and wounding the dura posteriorly rested against the left lamina.
The plating of the mantle of the bullet was stripped from half the
area of the tip. The dura was not adherent, and the cord was
softened for half an inch above the point of section; above this it
was normal, the vessels coursing normally to the softened spot.
Below the point of section the cord was blanched, but offered no
other macroscopic evidence of disease. No evidence of either
intra- or extra-dural hæmorrhage was detectible.
Page 386
Fig. 80.
Complete division of Spinal Cord. The bullet is retained, and from its
position can be seen to have struck the right half of the cord only. The
nickel plating of half of the tip of the bullet is stripped off. Case No. 104
The right pleura contained a large quantity of dark cocoa-like
fluid. Extensive adhesions were present in both pleural cavities.
The spleen was much enlarged. At the base of the bladder a
large submucous hæmorrhage had occurred, the blood-clot had
assumed a dark orange colour, and on first opening the viscus
the appearance was that of a mass of fæces. The mucous lining
elsewhere was slaty grey, with small hæmorrhages. The kidneys
were large, but no abscesses or pyelitis were present.
(105) Cervico-dorsal region; total transverse lesion.—Wound
of entry (Mauser), opposite right sixth cervical transverse
process; exit, on left side of third dorsal spinous process. Slight
Complete division of Spinal Cord. The bullet is retained, and from its
position can be seen to have struck the right half of the cord only. The
nickel plating of half of the tip of the bullet is stripped off. Case No. 104
The right pleura contained a large quantity of dark cocoa-like
fluid. Extensive adhesions were present in both pleural cavities.
The spleen was much enlarged. At the base of the bladder a
large submucous hæmorrhage had occurred, the blood-clot had
assumed a dark orange colour, and on first opening the viscus
the appearance was that of a mass of fæces. The mucous lining
elsewhere was slaty grey, with small hæmorrhages. The kidneys
were large, but no abscesses or pyelitis were present.
(105) Cervico-dorsal region; total transverse lesion.—Wound
of entry (Mauser), opposite right sixth cervical transverse
process; exit, on left side of third dorsal spinous process. Slight
Page 387
grasping power was present in the hands, and the patient could
hold his arms across his chest. Complete motor and sensory
paralysis, with absence of all reflexes below. The pupils were
moderately contracted. Retention of urine. On the second day
blebs appeared on each buttock, and the patient complained of
very severe pain in the neck: the temperature rose to 103°, and
on the third day he died suddenly. No post-mortem examination
was made.
I observed two similar cases in the Field Hospital at Orange River, the
patients dying on the third day; pain and high temperature were prominent
symptoms in both. In one patient early delirium was present.
(106) Dorsal region; Martini-Henry wound.—Wound of entry,
oval, 1 inch ×3¼ inches; long axis obliquely crossing infra-
spinous fossa of right scapula; bullet retained (Martini-Henry).
Spine of third dorsal vertebra loose, and a distinct thickening to
its right side. Complete symmetrical paralysis extending up to
upper extremities. No sensation on surface of trunk below
cervical area. Respiration entirely diaphragmatic. Retention of
urine, penis turgid. Total absence of reflexes, superficial and
deep. Reddening of buttocks, but no bullæ.
General hyperæsthesia of upper extremities, with severe
spasmodic attacks of pain.
On the third day an exploration was decided upon, in view of
the local deformity, and the severe pain in the upper extremities.
The third dorsal spine was found to be loose, as a result of
bilateral fracture of the neural arch; the bullet had crossed the
right limit of the spinal canal, and destroyed the body of the
vertebra, and passing onwards had entered the left pleural cavity,
into which air entered freely from the operation wound.
The patient was relieved from his pain by the exploration, and
lived four days. On the second day after operation, however, the
temperature rose to 107°, while on the last two days the
temperature was normal in the mornings, rising to 105° in the
evenings. No alteration resulted in the trunk symptoms.
hold his arms across his chest. Complete motor and sensory
paralysis, with absence of all reflexes below. The pupils were
moderately contracted. Retention of urine. On the second day
blebs appeared on each buttock, and the patient complained of
very severe pain in the neck: the temperature rose to 103°, and
on the third day he died suddenly. No post-mortem examination
was made.
I observed two similar cases in the Field Hospital at Orange River, the
patients dying on the third day; pain and high temperature were prominent
symptoms in both. In one patient early delirium was present.
(106) Dorsal region; Martini-Henry wound.—Wound of entry,
oval, 1 inch ×3¼ inches; long axis obliquely crossing infra-
spinous fossa of right scapula; bullet retained (Martini-Henry).
Spine of third dorsal vertebra loose, and a distinct thickening to
its right side. Complete symmetrical paralysis extending up to
upper extremities. No sensation on surface of trunk below
cervical area. Respiration entirely diaphragmatic. Retention of
urine, penis turgid. Total absence of reflexes, superficial and
deep. Reddening of buttocks, but no bullæ.
General hyperæsthesia of upper extremities, with severe
spasmodic attacks of pain.
On the third day an exploration was decided upon, in view of
the local deformity, and the severe pain in the upper extremities.
The third dorsal spine was found to be loose, as a result of
bilateral fracture of the neural arch; the bullet had crossed the
right limit of the spinal canal, and destroyed the body of the
vertebra, and passing onwards had entered the left pleural cavity,
into which air entered freely from the operation wound.
The patient was relieved from his pain by the exploration, and
lived four days. On the second day after operation, however, the
temperature rose to 107°, while on the last two days the
temperature was normal in the mornings, rising to 105° in the
evenings. No alteration resulted in the trunk symptoms.
Page 388
Diagnosis.—The pure question of the fact of injury of the spinal cord needs
no discussion; but it is necessary to make some remarks on the
discrimination between concussion, contusion and hæmorrhage, meningeal
and medullary hæmorrhage, the latter condition and compression, and on
partial and complete severance of the cord.
The sharp discrimination of cases of concussion from those of slight
medullary hæmorrhage was necessarily impossible. I think the only points
of any importance in diagnosing pure concussion were the transitory nature
of the symptoms, and the uniformity of recovery, without persistence of any
signs of minor destructive lesion. In medullary hæmorrhage the tendency
for a certain period was towards increase in gravity in the signs. It goes
almost without saying that the latter point was seldom accurately
determined in patients struck on the field of battle; these perhaps lay out for
hours before they were brought in, and when they were placed in the Field
hospital the rush of work did not usually allow the careful observation
necessary to clear up this difference in the development of the symptoms.
Nevertheless it is preferable to consider the cases in which transitory
symptoms persist for a period of hours, or even a couple of days, as
instances of pure concussion, unless the existence of this condition can be
disproved by actual observation.
Extra-medullary hæmorrhage, accompanied by only slight encroachment on
the spinal canal, certainly results with some frequency from small-calibre
wounds. Some of the quoted cases show this decisively by post-mortem
evidence, others by such clinical signs of irritation as pain and
hyperæsthesia. I think its presence may also be assumed in cases of total
transverse lesion due to medullary hæmorrhage or severe concussion,
accompanied by well-marked pain and hyperæsthesia above the level of
paralysis. As affecting treatment, however, determination of its presence is
of small importance.
The important conditions for discriminative diagnosis are those of local
compression, actual destructive lesion, whether from concussion changes,
contusion, or medullary hæmorrhage, and partial and total section of the
cord.
no discussion; but it is necessary to make some remarks on the
discrimination between concussion, contusion and hæmorrhage, meningeal
and medullary hæmorrhage, the latter condition and compression, and on
partial and complete severance of the cord.
The sharp discrimination of cases of concussion from those of slight
medullary hæmorrhage was necessarily impossible. I think the only points
of any importance in diagnosing pure concussion were the transitory nature
of the symptoms, and the uniformity of recovery, without persistence of any
signs of minor destructive lesion. In medullary hæmorrhage the tendency
for a certain period was towards increase in gravity in the signs. It goes
almost without saying that the latter point was seldom accurately
determined in patients struck on the field of battle; these perhaps lay out for
hours before they were brought in, and when they were placed in the Field
hospital the rush of work did not usually allow the careful observation
necessary to clear up this difference in the development of the symptoms.
Nevertheless it is preferable to consider the cases in which transitory
symptoms persist for a period of hours, or even a couple of days, as
instances of pure concussion, unless the existence of this condition can be
disproved by actual observation.
Extra-medullary hæmorrhage, accompanied by only slight encroachment on
the spinal canal, certainly results with some frequency from small-calibre
wounds. Some of the quoted cases show this decisively by post-mortem
evidence, others by such clinical signs of irritation as pain and
hyperæsthesia. I think its presence may also be assumed in cases of total
transverse lesion due to medullary hæmorrhage or severe concussion,
accompanied by well-marked pain and hyperæsthesia above the level of
paralysis. As affecting treatment, however, determination of its presence is
of small importance.
The important conditions for discriminative diagnosis are those of local
compression, actual destructive lesion, whether from concussion changes,
contusion, or medullary hæmorrhage, and partial and total section of the
cord.
Page 389
First, with regard to compression of the cord, the possible sources are three;
(i) extra-dural hæmorrhage, which may, I think, be dismissed with mention
as rarely capable of producing severe symptoms. (ii) The displacement of
bone fragments. This is of less importance than in civil practice, because an
injury by a bullet of small calibre, capable of seriously displacing
fragments, has probably at the same time produced grave changes in the
cord. In the presence of severe immediate symptoms we may tentatively
assume that a simultaneous destructive lesion has been produced. In such
injuries pain, combined with a tendency to improvement in the paralytic
symptoms and return of reflexes, is the only point in favour of bone
pressure, unless considerable deformity of the spinal column can be
detected by palpation or examination with the X-rays.
(iii) Pressure from the bullet. This is the most important form of
compression, because the mere fact of retention of the bullet is evidence of
a low degree of velocity, and therefore opposed to the existence of the most
severe form of intramedullary lesion. In a case of apparent transverse lesion
with retained bullet, shown to me at No. 3 General Hospital by Mr. J. E.
Ker, the pain was very severe, and so greatly aggravated by movement that
an anæsthetic had to be administered prior to the renewal of some necessary
dressings. The general condition of this patient precluded a projected
operation, and after death the bullet was found to be pressing laterally upon
a cord not materially altered on macroscopic inspection. In the case of
retained bullet recorded (No. 104), the slight degree to which the severed
ends of the cord appeared altered has been already remarked upon.
Beyond this we are helped by the position of the aperture of entry, and its
shape, as evidence of the direction in which the bullet passed, the presence
of pain, and positive proof may be obtained by examination with the X-
rays.
Lastly, we come to the discrimination of total or partial section, destruction
by vibratory concussion or contusion, and severe intramedullary
hæmorrhage. Except in the case of partial section with localised symptoms,
which must be rare, I believe this to be impossible from the primary
symptoms, although some indication of possible encroachment on the canal
may be obtained from careful consideration of the course of the wound, as
evidenced by the position and shape of the openings, the position of the
(i) extra-dural hæmorrhage, which may, I think, be dismissed with mention
as rarely capable of producing severe symptoms. (ii) The displacement of
bone fragments. This is of less importance than in civil practice, because an
injury by a bullet of small calibre, capable of seriously displacing
fragments, has probably at the same time produced grave changes in the
cord. In the presence of severe immediate symptoms we may tentatively
assume that a simultaneous destructive lesion has been produced. In such
injuries pain, combined with a tendency to improvement in the paralytic
symptoms and return of reflexes, is the only point in favour of bone
pressure, unless considerable deformity of the spinal column can be
detected by palpation or examination with the X-rays.
(iii) Pressure from the bullet. This is the most important form of
compression, because the mere fact of retention of the bullet is evidence of
a low degree of velocity, and therefore opposed to the existence of the most
severe form of intramedullary lesion. In a case of apparent transverse lesion
with retained bullet, shown to me at No. 3 General Hospital by Mr. J. E.
Ker, the pain was very severe, and so greatly aggravated by movement that
an anæsthetic had to be administered prior to the renewal of some necessary
dressings. The general condition of this patient precluded a projected
operation, and after death the bullet was found to be pressing laterally upon
a cord not materially altered on macroscopic inspection. In the case of
retained bullet recorded (No. 104), the slight degree to which the severed
ends of the cord appeared altered has been already remarked upon.
Beyond this we are helped by the position of the aperture of entry, and its
shape, as evidence of the direction in which the bullet passed, the presence
of pain, and positive proof may be obtained by examination with the X-
rays.
Lastly, we come to the discrimination of total or partial section, destruction
by vibratory concussion or contusion, and severe intramedullary
hæmorrhage. Except in the case of partial section with localised symptoms,
which must be rare, I believe this to be impossible from the primary
symptoms, although some indication of possible encroachment on the canal
may be obtained from careful consideration of the course of the wound, as
evidenced by the position and shape of the openings, the position of the
Page 390
patient's body at the time of reception of the injury being taken into
consideration. Later we may get some aid from the possible improvement in
the symptoms in the case of hæmorrhage. In cases with signs of total
transverse lesion, however, the discrimination of the conditions is of little
practical importance, since either is equally unfavourable and unsuitable for
surgical treatment.
In closing these remarks reference must be made to the occasional
occurrence of paraplegic symptoms of an apparently purely functional
nature. I saw these on one or two occasions, of which the following is a fair
example. A man was wounded in the lower extremity and fell. When
brought into the hospital he complained of loss of power in the legs and
inability to straighten his back. No very definite evidence was present of
serious impairment either of motor or sensory nerves, and the man was got
up and walked with crutches. While moving about the hospital camp,
another man pushed him down, and the patient then became completely
paraplegic. He was placed in bed, and the next day moved his limbs without
any difficulty, and gave rise to no further anxiety.
Prognosis.—In slight concussion the importance of prognosis is as to
remote effects, and upon this no opinion can be given at the present time.
The same may be said concerning cases in which transient symptoms
followed the slighter degrees of surface and medullary hæmorrhage. In the
case of the latter, however, I think it would be rash to give a too confident
opinion as to the future non-occurrence of secondary changes.
Severe concussion is probably irrecoverable.
Meningeal hæmorrhage of either form is one of the slighter lesions, and less
dangerous, both as an immediate condition and as to the probabilities of
after trouble. None the less the possibilities of secondary chronic
meningitis, or chronic trouble from adhesions, must be kept in mind.
Cases of medullary hæmorrhage with incomplete signs are favourable in
prognosis, as far as life is concerned; as to complete recovery, however, this
is hardly possible; in many cases serious functional deficiency at any rate
will remain, while in others the healing of the lacerated tissue and
subsequent contraction can scarcely fail to influence unfavourably an
already imperfect recovery.
consideration. Later we may get some aid from the possible improvement in
the symptoms in the case of hæmorrhage. In cases with signs of total
transverse lesion, however, the discrimination of the conditions is of little
practical importance, since either is equally unfavourable and unsuitable for
surgical treatment.
In closing these remarks reference must be made to the occasional
occurrence of paraplegic symptoms of an apparently purely functional
nature. I saw these on one or two occasions, of which the following is a fair
example. A man was wounded in the lower extremity and fell. When
brought into the hospital he complained of loss of power in the legs and
inability to straighten his back. No very definite evidence was present of
serious impairment either of motor or sensory nerves, and the man was got
up and walked with crutches. While moving about the hospital camp,
another man pushed him down, and the patient then became completely
paraplegic. He was placed in bed, and the next day moved his limbs without
any difficulty, and gave rise to no further anxiety.
Prognosis.—In slight concussion the importance of prognosis is as to
remote effects, and upon this no opinion can be given at the present time.
The same may be said concerning cases in which transient symptoms
followed the slighter degrees of surface and medullary hæmorrhage. In the
case of the latter, however, I think it would be rash to give a too confident
opinion as to the future non-occurrence of secondary changes.
Severe concussion is probably irrecoverable.
Meningeal hæmorrhage of either form is one of the slighter lesions, and less
dangerous, both as an immediate condition and as to the probabilities of
after trouble. None the less the possibilities of secondary chronic
meningitis, or chronic trouble from adhesions, must be kept in mind.
Cases of medullary hæmorrhage with incomplete signs are favourable in
prognosis, as far as life is concerned; as to complete recovery, however, this
is hardly possible; in many cases serious functional deficiency at any rate
will remain, while in others the healing of the lacerated tissue and
subsequent contraction can scarcely fail to influence unfavourably an
already imperfect recovery.
Page 391
I think it must be a rare occurrence for pressure from bone fragments to be
able to be regarded as a favourable prognostic condition, since in the very
large majority of cases the velocity of the bullet causing the injury will have
been such as to inflict irreparable damage on the cord. Still, cases may
occasionally be met with where the velocity has been sufficiently low, or
contact with the bone slight enough, to allow of the comparative escape of
the cord. In this relation cases in which the bullet is retained, especially if
the symptoms of transverse lesion are incomplete, may be regarded as
relatively favourable.
Cervical and high dorsal injuries, as in civil practice, offered the worst
prognosis. In cases in which symptoms of total transverse lesion were
present, as far as my experience went, it was, however, only a matter of
importance as to the prolongation of a miserable existence. All the patients
eventually died; those with higher lesions at the end of a few days; the
lower ones, at the completion on an average of six weeks of suffering.
The actual causes of death resembled exactly those met with in civil
practice, except in so far as it was more often influenced or determined by
concurrent injuries, a complication so characteristic of modern gunshot
wounds. Thus exhaustion, septicæmia from absorption from suppurating
bed-sores or from severe cystitis, secondary myelitis, and pulmonary
complications, carried off most of the patients.
Treatment.—The general treatment of the cases demanded nothing special
to military surgery, except in so far as it was modified by the disadvantage
to the patient of necessarily having to be transported, often for some
distance. The ill effects of this, particularly in cases of hæmorrhage, are
obvious, but in so far as fracture was concerned the question of transport
did not acquire the importance that it does in civil practice, since the nature
of the fractures and their strict localisation did not render movement either
painful or particularly hurtful. It was indeed striking how little pain
movement, made for the purposes of examination, caused these patients.
The treatment of bed-sores, cystitis, or other secondary complications
possessed no special features.
The importance of insuring rest in the early stages of the cases of
hæmorrhage is self-evident; hence, if the possibility exists of not moving
able to be regarded as a favourable prognostic condition, since in the very
large majority of cases the velocity of the bullet causing the injury will have
been such as to inflict irreparable damage on the cord. Still, cases may
occasionally be met with where the velocity has been sufficiently low, or
contact with the bone slight enough, to allow of the comparative escape of
the cord. In this relation cases in which the bullet is retained, especially if
the symptoms of transverse lesion are incomplete, may be regarded as
relatively favourable.
Cervical and high dorsal injuries, as in civil practice, offered the worst
prognosis. In cases in which symptoms of total transverse lesion were
present, as far as my experience went, it was, however, only a matter of
importance as to the prolongation of a miserable existence. All the patients
eventually died; those with higher lesions at the end of a few days; the
lower ones, at the completion on an average of six weeks of suffering.
The actual causes of death resembled exactly those met with in civil
practice, except in so far as it was more often influenced or determined by
concurrent injuries, a complication so characteristic of modern gunshot
wounds. Thus exhaustion, septicæmia from absorption from suppurating
bed-sores or from severe cystitis, secondary myelitis, and pulmonary
complications, carried off most of the patients.
Treatment.—The general treatment of the cases demanded nothing special
to military surgery, except in so far as it was modified by the disadvantage
to the patient of necessarily having to be transported, often for some
distance. The ill effects of this, particularly in cases of hæmorrhage, are
obvious, but in so far as fracture was concerned the question of transport
did not acquire the importance that it does in civil practice, since the nature
of the fractures and their strict localisation did not render movement either
painful or particularly hurtful. It was indeed striking how little pain
movement, made for the purposes of examination, caused these patients.
The treatment of bed-sores, cystitis, or other secondary complications
possessed no special features.
The importance of insuring rest in the early stages of the cases of
hæmorrhage is self-evident; hence, if the possibility exists of not moving
Page 392
the patient, its advantage cannot be too strongly insisted upon. Again, if
transport is inevitable, the shorter distance that can be arranged for the
better. It should be borne in mind, also, that from the peculiar nature of
causation of the injuries, stretcher or wagon transport for short distances is
preferable to the vibratory movements of a long railway journey. Beyond
this the administration of opium, and in some cases the assumption of the
prone position, are both useful in the recent or possibly progressive stage of
hæmorrhage.
Lastly, as to active surgical treatment by operation. In no form of spinal
injury is this less often indicated, or less likely to be useful. It is useless in
the cases of severe concussion, contusion, or medullary hæmorrhage which
form such a very large proportion of those exhibiting total tranverse lesion,
and equally unsuited to cases of partial lesion of the same character. Extra-
medullary hæmorrhage can rarely be extensive enough to produce signs
calling for the mechanical relief of pressure; the section of the cord cannot
be remedied. In one case with signs of total transverse lesion, in which a
laminectomy was performed, no apparent lesion was discovered, and this
would frequently be the case, since the damage is parenchymatous. The
experience was indeed exactly comparable to that which followed early
exposure of the peripheral nerves.
Only three indications for operation exist. 1. Excessive pain in the area of
the body above the paralysed segment; operation is here of doubtful
practical use, except in so far as it relieves the immediate sufferings of the
patient.
2. An incomplete or recovering lesion, when such is accompanied by
evidence furnished by the position of the wounds, pain, and signs of
irritation of pressure from without, or possibly palpable displacement of
parts of the vertebra, that the spinal canal is encroached upon by fragments
of bone.
3. Retention of the bullet, accompanied by similar signs to those detailed
under 2.
In both the latter cases the aid of the X-rays should be invoked before
resorting to exploration.
transport is inevitable, the shorter distance that can be arranged for the
better. It should be borne in mind, also, that from the peculiar nature of
causation of the injuries, stretcher or wagon transport for short distances is
preferable to the vibratory movements of a long railway journey. Beyond
this the administration of opium, and in some cases the assumption of the
prone position, are both useful in the recent or possibly progressive stage of
hæmorrhage.
Lastly, as to active surgical treatment by operation. In no form of spinal
injury is this less often indicated, or less likely to be useful. It is useless in
the cases of severe concussion, contusion, or medullary hæmorrhage which
form such a very large proportion of those exhibiting total tranverse lesion,
and equally unsuited to cases of partial lesion of the same character. Extra-
medullary hæmorrhage can rarely be extensive enough to produce signs
calling for the mechanical relief of pressure; the section of the cord cannot
be remedied. In one case with signs of total transverse lesion, in which a
laminectomy was performed, no apparent lesion was discovered, and this
would frequently be the case, since the damage is parenchymatous. The
experience was indeed exactly comparable to that which followed early
exposure of the peripheral nerves.
Only three indications for operation exist. 1. Excessive pain in the area of
the body above the paralysed segment; operation is here of doubtful
practical use, except in so far as it relieves the immediate sufferings of the
patient.
2. An incomplete or recovering lesion, when such is accompanied by
evidence furnished by the position of the wounds, pain, and signs of
irritation of pressure from without, or possibly palpable displacement of
parts of the vertebra, that the spinal canal is encroached upon by fragments
of bone.
3. Retention of the bullet, accompanied by similar signs to those detailed
under 2.
In both the latter cases the aid of the X-rays should be invoked before
resorting to exploration.
Page 393
Operation, if decided upon, in either of the two latter circumstances, may be
performed at any date up to six weeks; but if pressure be the actual source
of trouble, it is obvious that the more promptly operation is undertaken the
better for early relief and ulterior prognostic chances.
In only one case of the whole series I observed did it seem possible to regret
the omission of an exploration.
performed at any date up to six weeks; but if pressure be the actual source
of trouble, it is obvious that the more promptly operation is undertaken the
better for early relief and ulterior prognostic chances.
In only one case of the whole series I observed did it seem possible to regret
the omission of an exploration.
Page 394
CHAPTER IX
INJURIES TO THE PERIPHERAL NERVE TRUNKS
The occurrence of these injuries has undoubtedly increased in frequency
with the employment of bullets of small calibre, and no other class of case
more strikingly illustrates the localised nature of the lesions produced by
small projectiles of high velocity. Again, no other series of injuries affords
such obvious indications of the firm and resistent nature of the cicatricial
tissue formed in the process of repair of small-calibre wounds, and in none
is the advantage of a conservative and expectant attitude so forcibly
impressed upon the surgeon. Implication of the nerves may be primary, or
secondary to an injury which left them originally unscathed.
Nature of the anatomical lesions.—In degree these vary in mathematical
progression, but the extent of the lesion is not always readily differentiated
by the early clinical manifestations, and again the actual damage is not to be
estimated by the gross apparent anatomical lesion alone; but, in addition,
consists in part in changes of a less easily demonstrable nature, varying
with the velocity with which the bullet was travelling and the consequent
comparative degree of vibratory force to which the nerve has been
subjected. In these injuries, as in those of every part of the nervous system,
the degree of velocity appears to gain especial importance both in regard to
the general symptoms and the local effect on the functional capacity of the
nerve.
This is perhaps a fitting place for the introduction of a few further remarks
as to the significance of the term 'concussion' in connection with the injuries
produced by bullets of small calibre, since the most striking exemplification
of the results following the transmission of the vibratory force of the
projectile is afforded by the behaviour of the comparatively densely
ensheathed and supported peripheral nerves.
As already pointed out in Chapters VII. and VIII. the chief concussion
effects on the nervous tissue of the brain and spinal cord are of a destructive
INJURIES TO THE PERIPHERAL NERVE TRUNKS
The occurrence of these injuries has undoubtedly increased in frequency
with the employment of bullets of small calibre, and no other class of case
more strikingly illustrates the localised nature of the lesions produced by
small projectiles of high velocity. Again, no other series of injuries affords
such obvious indications of the firm and resistent nature of the cicatricial
tissue formed in the process of repair of small-calibre wounds, and in none
is the advantage of a conservative and expectant attitude so forcibly
impressed upon the surgeon. Implication of the nerves may be primary, or
secondary to an injury which left them originally unscathed.
Nature of the anatomical lesions.—In degree these vary in mathematical
progression, but the extent of the lesion is not always readily differentiated
by the early clinical manifestations, and again the actual damage is not to be
estimated by the gross apparent anatomical lesion alone; but, in addition,
consists in part in changes of a less easily demonstrable nature, varying
with the velocity with which the bullet was travelling and the consequent
comparative degree of vibratory force to which the nerve has been
subjected. In these injuries, as in those of every part of the nervous system,
the degree of velocity appears to gain especial importance both in regard to
the general symptoms and the local effect on the functional capacity of the
nerve.
This is perhaps a fitting place for the introduction of a few further remarks
as to the significance of the term 'concussion' in connection with the injuries
produced by bullets of small calibre, since the most striking exemplification
of the results following the transmission of the vibratory force of the
projectile is afforded by the behaviour of the comparatively densely
ensheathed and supported peripheral nerves.
As already pointed out in Chapters VII. and VIII. the chief concussion
effects on the nervous tissue of the brain and spinal cord are of a destructive
Page 395
nature, far exceeding those accompanying the injuries designated by the
same term seen in the ordinary accidents met with in civil practice, and this
damage is comparatively localised in extent.
In the case of the peripheral nerves I have still employed the terms
'concussion' and 'contusion' to designate certain groups of symptoms and
clinical phenomena, but any sharp distinction between the two conditions
on a morbid anatomical basis is impossible. The results of severe vibratory
concussion may, in fact, be more generally destructive than those of
contusion, and the subsequent effects more prolonged. A certain length of
the affected nerve is apparently completely destroyed as a conductor of
impulses, the connective-tissue element alone remaining intact. Under these
circumstances a nerve, the subject of the most serious degree of vibratory
concussion, which, if cut down upon, may exhibit no macroscopic change,
may take a longer period to recover than one in which the presence of
considerable local thickening points to direct contact with the bullet, with
resulting hæmorrhage into the nerve sheath and perhaps partial gross
rupture of nerve fibres.
The therapeutic and prognostic importance of the above remarks, if correct,
is obvious. The course of the nerve is preserved by its intact connective-
tissue framework, and ultimate recovery by a regeneration of the nerve
fibres is more likely to be complete, and will be just as rapid, if nature be
relied on and the nerve be left untouched by the hand of the surgeon.
It is, I think, undeniable that nerve trunks may escape severe or
irrecoverable injury by lateral displacement. The mere fact that the trunk
itself may be perforated by a slit in its long axis would suggest the
possibility of displacement of the whole structure, and this no doubt
occurred with some frequency. Displacement would naturally be most
frequent in the case of nerves, such as those of the arm, which run long
courses in comparatively loose tissue. In a remarkable case already
narrated, an exploratory operation showed the musculo-spiral nerve in the
upper part of the arm to have been driven into a loop which projected into,
and provisionally closed, an opening in the brachial artery.
I. Simple concussion.—Anatomically, or histologically, no information
exists as to the changes which give rise to the often transitory symptoms
same term seen in the ordinary accidents met with in civil practice, and this
damage is comparatively localised in extent.
In the case of the peripheral nerves I have still employed the terms
'concussion' and 'contusion' to designate certain groups of symptoms and
clinical phenomena, but any sharp distinction between the two conditions
on a morbid anatomical basis is impossible. The results of severe vibratory
concussion may, in fact, be more generally destructive than those of
contusion, and the subsequent effects more prolonged. A certain length of
the affected nerve is apparently completely destroyed as a conductor of
impulses, the connective-tissue element alone remaining intact. Under these
circumstances a nerve, the subject of the most serious degree of vibratory
concussion, which, if cut down upon, may exhibit no macroscopic change,
may take a longer period to recover than one in which the presence of
considerable local thickening points to direct contact with the bullet, with
resulting hæmorrhage into the nerve sheath and perhaps partial gross
rupture of nerve fibres.
The therapeutic and prognostic importance of the above remarks, if correct,
is obvious. The course of the nerve is preserved by its intact connective-
tissue framework, and ultimate recovery by a regeneration of the nerve
fibres is more likely to be complete, and will be just as rapid, if nature be
relied on and the nerve be left untouched by the hand of the surgeon.
It is, I think, undeniable that nerve trunks may escape severe or
irrecoverable injury by lateral displacement. The mere fact that the trunk
itself may be perforated by a slit in its long axis would suggest the
possibility of displacement of the whole structure, and this no doubt
occurred with some frequency. Displacement would naturally be most
frequent in the case of nerves, such as those of the arm, which run long
courses in comparatively loose tissue. In a remarkable case already
narrated, an exploratory operation showed the musculo-spiral nerve in the
upper part of the arm to have been driven into a loop which projected into,
and provisionally closed, an opening in the brachial artery.
I. Simple concussion.—Anatomically, or histologically, no information
exists as to the changes which give rise to the often transitory symptoms
Page 396
dependent on this condition. We are reduced to the same theories of
molecular disturbance and change which have been invoked to account for
similar affections of the central nervous system. The causation of
concussion is, however, materially influenced in its degree by the velocity
of flight of the bullet and consequent severity of the vibratory force exerted.
Hence actual contact of the bullet with the nerves is not necessary for its
production, as is seen in the temporary complete loss of functional capacity
in the limbs in many cases of fracture, where the vibrations are rendered
still more far-reaching and effective as the result of their wider distribution
from the larger solid resistance afforded by the bone. The relative density
and resistance offered by the different parts of the bone acquire great
significance in this relation, since local shock due to nerve concussion is far
more profound when the shafts are struck than when the cancellous ends
furnish the point of impact.
The form of concussion which most nearly interests us in this chapter is that
affecting single nerve trunks in wounds of the soft parts alone, and here the
passage of the bullet is, as a rule, so contiguous to the nerve that there is
difficulty in drawing a strict line of demarcation between such cases and
those dealt with in the next paragraph.
II. Contusion.—Clinically this was the form of nerve injury both of greatest
comparative frequency and of interest from the points of view both of
diagnosis and prognosis.
The seriousness of a contusion depends on two factors: first, the relative
degree of violence exerted upon the nerve, which is dependent on the force
still retained by the travelling bullet; and, secondly, on the extent of tissue
actually implicated. The range of fire at which the injury was received
determines the importance of the first factor; the second varies with the
degree of exactness with which the nerve is struck, and on the direction
taken by the bullet. Naturally transverse wounds affect a small area; while
an oblique or longitudinal direction of the track may indefinitely increase
the extent of injury to the nerve trunk, and hence acquire prognostic
significance in direct ratio to the amount of tissue which needs to be
regenerated.
molecular disturbance and change which have been invoked to account for
similar affections of the central nervous system. The causation of
concussion is, however, materially influenced in its degree by the velocity
of flight of the bullet and consequent severity of the vibratory force exerted.
Hence actual contact of the bullet with the nerves is not necessary for its
production, as is seen in the temporary complete loss of functional capacity
in the limbs in many cases of fracture, where the vibrations are rendered
still more far-reaching and effective as the result of their wider distribution
from the larger solid resistance afforded by the bone. The relative density
and resistance offered by the different parts of the bone acquire great
significance in this relation, since local shock due to nerve concussion is far
more profound when the shafts are struck than when the cancellous ends
furnish the point of impact.
The form of concussion which most nearly interests us in this chapter is that
affecting single nerve trunks in wounds of the soft parts alone, and here the
passage of the bullet is, as a rule, so contiguous to the nerve that there is
difficulty in drawing a strict line of demarcation between such cases and
those dealt with in the next paragraph.
II. Contusion.—Clinically this was the form of nerve injury both of greatest
comparative frequency and of interest from the points of view both of
diagnosis and prognosis.
The seriousness of a contusion depends on two factors: first, the relative
degree of violence exerted upon the nerve, which is dependent on the force
still retained by the travelling bullet; and, secondly, on the extent of tissue
actually implicated. The range of fire at which the injury was received
determines the importance of the first factor; the second varies with the
degree of exactness with which the nerve is struck, and on the direction
taken by the bullet. Naturally transverse wounds affect a small area; while
an oblique or longitudinal direction of the track may indefinitely increase
the extent of injury to the nerve trunk, and hence acquire prognostic
significance in direct ratio to the amount of tissue which needs to be
regenerated.
Page 397
As to the actual anatomical lesion resulting in the cases which we
designated clinically as contusion I can give no information. On many
occasions when the symptoms were considered of such a nature as to render
an exploration advisable, no macroscopic evidence of gross injury was
obtained. It was therefore impossible to draw a definite line of demarcation
between such cases and those which we considered merely concussion. It
could only be assumed that the vibration transmitted to the nerve had
occasioned such changes as to destroy its capacity as a conductor of
impressions.
In some cases the presence of a certain amount of interstitial blood
extravasation was suggested clinically by early hyperæsthesia and signs of
irritation; in others the paralysis was of such a degree as to lead to the
inference that a complete regeneration of the existing nerve would be
necessary prior to the restitution of functional capacity.
In a certain proportion of the injuries the development of a distinct fusiform
swelling in the course of the nerve pointed to the existence of considerable
tissue damage, while in others this was evidenced clinically by early signs
of neuritis.
III. Division or laceration.—The varying mechanical conditions affecting
the last class of injury play a similar rôle here. Thus the degree of laceration
depends on the direction of the wound track, and as all lacerations are
accompanied by contusion, the relative velocity retained by the travelling
bullet assumes the same importance.
I saw every degree of injury to the trunks, from notching to complete
solution of continuity, and in some cases destruction and disappearance of
pieces from one to two or more inches in length. Such lesions as the latter
were most common in the forearm. In this segment of the limbs tracks of
varying degrees of longitudinal obliquity are readily produced, whether the
patient be in the upright or prone position, since the upper extremities are
commonly in forward action whichever position is assumed.
The most peculiar form of injury consisted in perforation of the trunk
without gross destruction of its fibres, and without in many cases prolonged
or permanent loss of functional capacity. I cannot speak with any
confidence as to the comparative frequency of occurrence of this form of
designated clinically as contusion I can give no information. On many
occasions when the symptoms were considered of such a nature as to render
an exploration advisable, no macroscopic evidence of gross injury was
obtained. It was therefore impossible to draw a definite line of demarcation
between such cases and those which we considered merely concussion. It
could only be assumed that the vibration transmitted to the nerve had
occasioned such changes as to destroy its capacity as a conductor of
impressions.
In some cases the presence of a certain amount of interstitial blood
extravasation was suggested clinically by early hyperæsthesia and signs of
irritation; in others the paralysis was of such a degree as to lead to the
inference that a complete regeneration of the existing nerve would be
necessary prior to the restitution of functional capacity.
In a certain proportion of the injuries the development of a distinct fusiform
swelling in the course of the nerve pointed to the existence of considerable
tissue damage, while in others this was evidenced clinically by early signs
of neuritis.
III. Division or laceration.—The varying mechanical conditions affecting
the last class of injury play a similar rôle here. Thus the degree of laceration
depends on the direction of the wound track, and as all lacerations are
accompanied by contusion, the relative velocity retained by the travelling
bullet assumes the same importance.
I saw every degree of injury to the trunks, from notching to complete
solution of continuity, and in some cases destruction and disappearance of
pieces from one to two or more inches in length. Such lesions as the latter
were most common in the forearm. In this segment of the limbs tracks of
varying degrees of longitudinal obliquity are readily produced, whether the
patient be in the upright or prone position, since the upper extremities are
commonly in forward action whichever position is assumed.
The most peculiar form of injury consisted in perforation of the trunk
without gross destruction of its fibres, and without in many cases prolonged
or permanent loss of functional capacity. I cannot speak with any
confidence as to the comparative frequency of occurrence of this form of
Page 398
injury, but judging by the analogous perforations of the vessels, it is
probably not uncommon in trunks large enough to allow of its production.
The trunk nerves of the arm, and the great sciatic nerve, were probably the
most frequent seats of such wounds. As, however, a very short experience
of the futility of early interference in the case of nerve lesions warned me
against exploration before a date at which observations of this nature were
unsatisfactory, I gained less experience on this point than I could have
wished.
In the case of completely divided nerves the development of a bulbous
enlargement on the proximal end was constant, and very marked in degree.
I saw few cases in which primary effects could be certainly referred to
pressure or laceration by bone spicules, excepting in some fractures of the
humerus, and perhaps some injuries of the seventh nerve accompanying
perforating wounds of the mastoid process.
IV. Secondary implication of the nerves.—This was a striking characteristic
in many at first apparently simple wounds of the soft parts. In such cases it
was due to implication of the contiguous trunk in the process of
cicatrisation, and its importance varied with the size of the nerve in
question. In the smaller sensory trunks it was often evidenced by the
occurrence of neuralgic pain, especially liable to be influenced by climatic
changes; in the larger, by signs of more or less severe motor, sensory, and
trophic disturbance. Musculo-spiral paralysis from implication in, or
pressure from, callus in cases of fracture of the humerus was very frequent.
This would naturally be expected from the extreme degree the comminution
of the bone often reached, and the consequently large amount of callus
developed.
The effect of cicatrisation of the tissues surrounding the nerves varied
somewhat according to the degree of fixation of the individual nerve
implicated. Thus if a nerve lay in a fixed bed some form of circular
constriction resulted; if, on the other hand, the nerve was readily
displaceable, the cicatrix often drew it considerably out of its course; in
either case symptoms corresponding with those of pressure resulted.
Symptoms of nerve lesion.—These differed little in character from those
common to such injuries in civil practice, except in the relative frequency
probably not uncommon in trunks large enough to allow of its production.
The trunk nerves of the arm, and the great sciatic nerve, were probably the
most frequent seats of such wounds. As, however, a very short experience
of the futility of early interference in the case of nerve lesions warned me
against exploration before a date at which observations of this nature were
unsatisfactory, I gained less experience on this point than I could have
wished.
In the case of completely divided nerves the development of a bulbous
enlargement on the proximal end was constant, and very marked in degree.
I saw few cases in which primary effects could be certainly referred to
pressure or laceration by bone spicules, excepting in some fractures of the
humerus, and perhaps some injuries of the seventh nerve accompanying
perforating wounds of the mastoid process.
IV. Secondary implication of the nerves.—This was a striking characteristic
in many at first apparently simple wounds of the soft parts. In such cases it
was due to implication of the contiguous trunk in the process of
cicatrisation, and its importance varied with the size of the nerve in
question. In the smaller sensory trunks it was often evidenced by the
occurrence of neuralgic pain, especially liable to be influenced by climatic
changes; in the larger, by signs of more or less severe motor, sensory, and
trophic disturbance. Musculo-spiral paralysis from implication in, or
pressure from, callus in cases of fracture of the humerus was very frequent.
This would naturally be expected from the extreme degree the comminution
of the bone often reached, and the consequently large amount of callus
developed.
The effect of cicatrisation of the tissues surrounding the nerves varied
somewhat according to the degree of fixation of the individual nerve
implicated. Thus if a nerve lay in a fixed bed some form of circular
constriction resulted; if, on the other hand, the nerve was readily
displaceable, the cicatrix often drew it considerably out of its course; in
either case symptoms corresponding with those of pressure resulted.
Symptoms of nerve lesion.—These differed little in character from those
common to such injuries in civil practice, except in the relative frequency
Page 399
with which they assumed a serious aspect. After all in civil practice nerve
concussion is most familiar to us in the degree common after knocking the
elbow against a hard object, and the same may be said in regard to the allied
injury of contusion. It is in small-calibre bullet wounds alone that the
occurrence of such severe and sharply localised injury to deep parts as was
observed is possible.
Concussion.—Temporary loss of function was often observed in the limbs,
corresponding to the distribution of one or more nerve trunks when wound
tracks had passed in their vicinity. Interference with function sometimes
amounted to loss of sensation alone: in others to loss of both sensation and
motor power. Such symptoms were of a transitory character, lasting for a
few days or a week; if both sensation and motion were impaired, sensation
was usually the first to be regained. In these cases secondary trouble was
not uncommon, since the near proximity of the track to the originally
affected nerve offered every chance for implication of the latter in the
resulting cicatrix. This sequence was often observed, and its symptoms are
described under the heading of secondary implication below. Equally
striking were the instances of concussion in the case of the nerves of special
sense and their end organs, temporary loss of smell, vision, or hearing being
not uncommon, often passing off in the course of a few days with no
apparent ulterior ill-effect.
One of the most interesting illustrations of the occurrence of concussion
was furnished by cases in which complete paralysis of a limb rapidly
cleared up with the exception of that corresponding to a single individual
nerve of the complex apparently originally implicated. Instances of severe
contusion or division of one nerve of the arm, for instance, accompanied by
transient signs of concussion of varying degrees of severity in all the others,
were by no means uncommon.
Contusion.—The symptoms of contusion were somewhat less simple, since,
in addition to lowering or loss of function, signs of irritation were often
observed. In the slighter cases irritation was often a marked feature, as was
evidenced by hyperæsthesia and pain combined with loss of power. In cases
in which pain and hyperæsthesia were primary symptoms, these were often
transitory. I will quote an illustrative case which, though affecting the nerve
concussion is most familiar to us in the degree common after knocking the
elbow against a hard object, and the same may be said in regard to the allied
injury of contusion. It is in small-calibre bullet wounds alone that the
occurrence of such severe and sharply localised injury to deep parts as was
observed is possible.
Concussion.—Temporary loss of function was often observed in the limbs,
corresponding to the distribution of one or more nerve trunks when wound
tracks had passed in their vicinity. Interference with function sometimes
amounted to loss of sensation alone: in others to loss of both sensation and
motor power. Such symptoms were of a transitory character, lasting for a
few days or a week; if both sensation and motion were impaired, sensation
was usually the first to be regained. In these cases secondary trouble was
not uncommon, since the near proximity of the track to the originally
affected nerve offered every chance for implication of the latter in the
resulting cicatrix. This sequence was often observed, and its symptoms are
described under the heading of secondary implication below. Equally
striking were the instances of concussion in the case of the nerves of special
sense and their end organs, temporary loss of smell, vision, or hearing being
not uncommon, often passing off in the course of a few days with no
apparent ulterior ill-effect.
One of the most interesting illustrations of the occurrence of concussion
was furnished by cases in which complete paralysis of a limb rapidly
cleared up with the exception of that corresponding to a single individual
nerve of the complex apparently originally implicated. Instances of severe
contusion or division of one nerve of the arm, for instance, accompanied by
transient signs of concussion of varying degrees of severity in all the others,
were by no means uncommon.
Contusion.—The symptoms of contusion were somewhat less simple, since,
in addition to lowering or loss of function, signs of irritation were often
observed. In the slighter cases irritation was often a marked feature, as was
evidenced by hyperæsthesia and pain combined with loss of power. In cases
in which pain and hyperæsthesia were primary symptoms, these were often
transitory. I will quote an illustrative case which, though affecting the nerve
Page 400
roots, is characteristic of the effects of slight contusion in the case of the
nerve trunks in any part of their course:—
(107) Contusion of cervical nerve roots.—Range probably about
1,000 yards. Wounded at Belmont. Aperture of entry (Lee-
Metford), immediately posterior to the right fifth cervical
transverse process; exit, immediately anterior to the space
between the third and fourth left cervical transverse processes.
The movements of the neck were perfect, there was neither pain
nor difficulty in swallowing. Extreme hyperæsthesia was present
in both palms and down the front of the forearms. The grip in
either hand was weak, this being possibly explained in part by
the hyperæsthesia of the palms, as all movements of the upper
extremities could be made, although not with full power. On the
fourth day the condition was much improved on the left side,
and at the end of a week the left upper extremity was normal;
the right (side of entry, and therefore exposed to greater force
from the bullet) improved more slowly, becoming normal only
at the end of three weeks.
I observed an identical case of injury to the cervical roots, and many similar
instances in injuries of the nerve trunks of the limbs in which the course
was exactly parallel. In the more severe, pain was often added to
hyperæsthesia.
In the most severe cases the signs corresponded in all particulars, except in
the early entire loss of reaction of the muscles to electricity, with those of
complete section. Loss of sensation and motion was immediate, complete,
and prolonged, the limbs being lowered in temperature, flaccid, and
powerless. General systemic shock was also severe. In the case either of
plexus or multiple contusions, or where the injury was more local,
correspondingly complete signs were present in the area supplied by the
affected nerves.
In the cases in which the contusion was not of extreme degree,
hyperæsthesia often developed as a later sign, and was probably due to the
irritation of hæmorrhage, when the sensory portion of the nerve began to
regain functional capacity. The date of appearance of the hyperæsthesia
nerve trunks in any part of their course:—
(107) Contusion of cervical nerve roots.—Range probably about
1,000 yards. Wounded at Belmont. Aperture of entry (Lee-
Metford), immediately posterior to the right fifth cervical
transverse process; exit, immediately anterior to the space
between the third and fourth left cervical transverse processes.
The movements of the neck were perfect, there was neither pain
nor difficulty in swallowing. Extreme hyperæsthesia was present
in both palms and down the front of the forearms. The grip in
either hand was weak, this being possibly explained in part by
the hyperæsthesia of the palms, as all movements of the upper
extremities could be made, although not with full power. On the
fourth day the condition was much improved on the left side,
and at the end of a week the left upper extremity was normal;
the right (side of entry, and therefore exposed to greater force
from the bullet) improved more slowly, becoming normal only
at the end of three weeks.
I observed an identical case of injury to the cervical roots, and many similar
instances in injuries of the nerve trunks of the limbs in which the course
was exactly parallel. In the more severe, pain was often added to
hyperæsthesia.
In the most severe cases the signs corresponded in all particulars, except in
the early entire loss of reaction of the muscles to electricity, with those of
complete section. Loss of sensation and motion was immediate, complete,
and prolonged, the limbs being lowered in temperature, flaccid, and
powerless. General systemic shock was also severe. In the case either of
plexus or multiple contusions, or where the injury was more local,
correspondingly complete signs were present in the area supplied by the
affected nerves.
In the cases in which the contusion was not of extreme degree,
hyperæsthesia often developed as a later sign, and was probably due to the
irritation of hæmorrhage, when the sensory portion of the nerve began to
regain functional capacity. The date of appearance of the hyperæsthesia
Page 401
varied from a few days to a week or later. It might then persist for weeks or
many months.
In a few instances large blebs rose on the back of the hand, or patches of
vesicles appeared over the terminal distribution of the nerve, pointing to
early trophic changes.
The period of recovery varied greatly; in some instances of very complete
paralysis, function was regained and became apparently normal at the end
of three or four weeks; in others, even after severe wasting of muscles for
weeks, rapid improvement occurred often suddenly, while in some there
was no apparent recovery at the end of months. In cases of long-deferred
improvement, wasting of the muscles became a very prominent feature; but
this without complete loss of reaction of the muscles to electrical
stimulation.
Recovery of sensation usually preceded by some time that of motion, the
former often reappearing in some degree at an early date, and, even if very
modified in character, it formed a most useful and valuable aid both in
diagnosis and prognosis.
When in a position allowing of direct examination, the contused portion of
the nerve sometimes developed a palpable fusiform thickening,
manipulation of which might give rise to formication in the area of
distribution—a favourable prognostic sign.
Many of the cases bore a very marked resemblance in character to those in
which paralysis results from tight constriction of the limb, as in the arm
after the application of an Esmarch's tourniquet.
Laceration.—If incomplete, the signs corresponded very nearly to those of
severe contusion, since partial section is impossible without the occurrence
of the latter. The condition indeed was only to be distinguished by the
partial nature of the recovery, and even this latter might be only more
prolonged.
The same remarks hold good with regard to perforation of the nerve trunks;
but, as regards function, these injuries are not so serious in prognosis as
very much more limited transverse divisions or mere notching, and in some
cases the disturbance of function was by no means profound or prolonged.
many months.
In a few instances large blebs rose on the back of the hand, or patches of
vesicles appeared over the terminal distribution of the nerve, pointing to
early trophic changes.
The period of recovery varied greatly; in some instances of very complete
paralysis, function was regained and became apparently normal at the end
of three or four weeks; in others, even after severe wasting of muscles for
weeks, rapid improvement occurred often suddenly, while in some there
was no apparent recovery at the end of months. In cases of long-deferred
improvement, wasting of the muscles became a very prominent feature; but
this without complete loss of reaction of the muscles to electrical
stimulation.
Recovery of sensation usually preceded by some time that of motion, the
former often reappearing in some degree at an early date, and, even if very
modified in character, it formed a most useful and valuable aid both in
diagnosis and prognosis.
When in a position allowing of direct examination, the contused portion of
the nerve sometimes developed a palpable fusiform thickening,
manipulation of which might give rise to formication in the area of
distribution—a favourable prognostic sign.
Many of the cases bore a very marked resemblance in character to those in
which paralysis results from tight constriction of the limb, as in the arm
after the application of an Esmarch's tourniquet.
Laceration.—If incomplete, the signs corresponded very nearly to those of
severe contusion, since partial section is impossible without the occurrence
of the latter. The condition indeed was only to be distinguished by the
partial nature of the recovery, and even this latter might be only more
prolonged.
The same remarks hold good with regard to perforation of the nerve trunks;
but, as regards function, these injuries are not so serious in prognosis as
very much more limited transverse divisions or mere notching, and in some
cases the disturbance of function was by no means profound or prolonged.
Page 402
Absolute loss of reaction to electrical stimulus from above was the only
pathognomonic sign of actual section, unless the position of the nerve was
such as to allow of palpation, when the presence of a bulbous end at once
settled the difficulty. In many cases of superficial tracks with division of
such nerves as the long or short saphenous, the early development of bulbs
in the course of the trunks gave positive information, and these were often
observed.
Traumatic neuritis.—This was a common sequence of contusion of the
nerve itself, or of its subsequent inclusion in a cicatrix or callus. It was
evidenced by hyperæsthesia both superficial and deep, pain, contracture,
wasting of the muscles, local sweating, and the development of glossy skin.
Examples of this condition were seen in the case of nearly every nerve in
the body. In frequency of occurrence, degree of severity, and in its selection
of individual nerves considerable variation was met with. With regard to the
two former points, personal idiosyncrasy, and degree of or peculiarity in the
nature of the injury, are the only explanations I can suggest. Perhaps in
some instances exposure to wet or cold in the early stages of the injury was
of some import. Thus, I saw several severe cases of musculo-spiral neuritis
in men who were wounded during the trying and wet march on
Bloemfontein. I did not observe that suppuration or wound complications
seemed important explanatory moments, as most of the cases occurred in
wounds that healed rapidly.
With regard to the question of selection; the same nerves that appear
particularly liable to suffer from idiopathic inflammations, toxic influences,
or to be the seat of ascending changes (e.g. ulnar, musculo-spiral, and
external popliteal), were those most often affected by secondary neuritis.
Many of the most severe cases I saw were in the musculo-spiral nerve.
Scar implication.—The signs of this most commonly commenced with
neuralgia, or painful sensations when such movements were made as to put
the cicatrix on the stretch. Although such neuralgia might not be constant, it
was often observed to be troublesome when the patients were exposed to
cold in sleeping out at night, or to extra fatigue, as in long marches. The
results in many cases stopped at this point, but the size and wide
distribution of certain nerves rendered even such slight symptoms of
pathognomonic sign of actual section, unless the position of the nerve was
such as to allow of palpation, when the presence of a bulbous end at once
settled the difficulty. In many cases of superficial tracks with division of
such nerves as the long or short saphenous, the early development of bulbs
in the course of the trunks gave positive information, and these were often
observed.
Traumatic neuritis.—This was a common sequence of contusion of the
nerve itself, or of its subsequent inclusion in a cicatrix or callus. It was
evidenced by hyperæsthesia both superficial and deep, pain, contracture,
wasting of the muscles, local sweating, and the development of glossy skin.
Examples of this condition were seen in the case of nearly every nerve in
the body. In frequency of occurrence, degree of severity, and in its selection
of individual nerves considerable variation was met with. With regard to the
two former points, personal idiosyncrasy, and degree of or peculiarity in the
nature of the injury, are the only explanations I can suggest. Perhaps in
some instances exposure to wet or cold in the early stages of the injury was
of some import. Thus, I saw several severe cases of musculo-spiral neuritis
in men who were wounded during the trying and wet march on
Bloemfontein. I did not observe that suppuration or wound complications
seemed important explanatory moments, as most of the cases occurred in
wounds that healed rapidly.
With regard to the question of selection; the same nerves that appear
particularly liable to suffer from idiopathic inflammations, toxic influences,
or to be the seat of ascending changes (e.g. ulnar, musculo-spiral, and
external popliteal), were those most often affected by secondary neuritis.
Many of the most severe cases I saw were in the musculo-spiral nerve.
Scar implication.—The signs of this most commonly commenced with
neuralgia, or painful sensations when such movements were made as to put
the cicatrix on the stretch. Although such neuralgia might not be constant, it
was often observed to be troublesome when the patients were exposed to
cold in sleeping out at night, or to extra fatigue, as in long marches. The
results in many cases stopped at this point, but the size and wide
distribution of certain nerves rendered even such slight symptoms of
Page 403
importance; while in others well-marked signs of neuritis declared
themselves, such as glossy skin, pain, muscular wasting, and paralysis.
Ascending neuritis.—In a few cases I observed very remarkable instances
of ascending neuritis, after comparatively slight wounds. I will quote three
of these as illustrations and make no further remarks as to the symptoms. It
will be observed that one is a case of ulnar, both the others of external
popliteal, neuritis:—
(108) Ulnar nerve: secondary ascending neuritis.—Boer
wounded at Elandslaagte. Wound of hand, implicating anterior
two-thirds of third metacarpal bone. This bone, together with the
middle finger, was removed, and healing took place by
granulation slowly.
The resulting gap allowed considerable overlapping of the
fingers, and shortening of the corresponding digit; the index
finger also became flexed as a result of destruction of the
extensor tendons. Three months later the man was still in
hospital in consequence of the tardiness with which the wound
had healed: at this time pain was noted, which became very
severe in the whole course of the ulnar nerve; superficial
hyperæsthesia and deep muscular tenderness developed, but no
wasting. Several crops of herpetic vesicles also developed over
the distribution of the radial nerve in the hand. This pain was
followed by spastic contracture, first of the ulnar fingers and
later of the wrist and elbow, which could only be straightened by
the application of considerable force. The limb was, therefore,
kept straight by the application of a splint; and warm baths, and
a blister applied over the course of the ulnar nerve, were
resorted to: under this treatment the condition improved until the
patient was well enough to be transferred as a prisoner, and I
saw him no more.
(109) Peroneal nerve branches.—Wounded at Colenso. Entry, at
the anterior margin of the fibula 5 inches above the external
malleolus; the track crossed the anterior aspect of the leg
obliquely, to its exit 1 inch above the centre of the ankle joint.
themselves, such as glossy skin, pain, muscular wasting, and paralysis.
Ascending neuritis.—In a few cases I observed very remarkable instances
of ascending neuritis, after comparatively slight wounds. I will quote three
of these as illustrations and make no further remarks as to the symptoms. It
will be observed that one is a case of ulnar, both the others of external
popliteal, neuritis:—
(108) Ulnar nerve: secondary ascending neuritis.—Boer
wounded at Elandslaagte. Wound of hand, implicating anterior
two-thirds of third metacarpal bone. This bone, together with the
middle finger, was removed, and healing took place by
granulation slowly.
The resulting gap allowed considerable overlapping of the
fingers, and shortening of the corresponding digit; the index
finger also became flexed as a result of destruction of the
extensor tendons. Three months later the man was still in
hospital in consequence of the tardiness with which the wound
had healed: at this time pain was noted, which became very
severe in the whole course of the ulnar nerve; superficial
hyperæsthesia and deep muscular tenderness developed, but no
wasting. Several crops of herpetic vesicles also developed over
the distribution of the radial nerve in the hand. This pain was
followed by spastic contracture, first of the ulnar fingers and
later of the wrist and elbow, which could only be straightened by
the application of considerable force. The limb was, therefore,
kept straight by the application of a splint; and warm baths, and
a blister applied over the course of the ulnar nerve, were
resorted to: under this treatment the condition improved until the
patient was well enough to be transferred as a prisoner, and I
saw him no more.
(109) Peroneal nerve branches.—Wounded at Colenso. Entry, at
the anterior margin of the fibula 5 inches above the external
malleolus; the track crossed the anterior aspect of the leg
obliquely, to its exit 1 inch above the centre of the ankle joint.
Page 404
Incomplete paralysis of the peronei muscles followed, combined
with progressive wasting of the whole limb, which at the end of
a month was marked, and then commenced to improve.
(110) In a second case the wound took a similar course in the
centre of the leg, crossing the line of the branches of the
musculo-cutaneous nerve. Motor paralysis of the peronei
followed, together with general lowering of tactile sensation in
the musculo-cutaneous area.
Traumatic neurosis.—In connection with the cases just quoted, mention
must be made of the fact that the functional element was often somewhat
prominent. The influence of this factor was not to be neglected in case 108;
again, its presence was a feature in cases 132 and 134, of injury to the
sciatic nerve and of peripheral injury to the seventh nerve (p. 355). A
remark has been made as to the occurrence of functional paraplegia on p.
337. Again, in the case of the organs of special sense. Case 66, of injury to
the occipital lobes, showed that a mixture of organic and functional
phenomena might be a source of error, even in the determination of the
visual field in the subject of an undoubted destructive lesion. On more than
one occasion an injury was accompanied by loss of the power of speech;
thus a patient who received a slight wound of the neck did not speak again
until the application of a battery by my colleague, Mr. H. B. Robinson. A
patient was also for a short time an inmate of No. 1 General Hospital,
Wynberg, who had become deaf and dumb as a result of the explosion of a
shrapnel shell over his head. This patient also did not recover his powers
until he returned to the mother-country.
In many other cases of nerve concussion or contusion, the recovery of
power and sensation, or the disappearance of neuralgia or contractures, was
so sudden and rapid after prolonged continuance of the symptoms, as to
suggest a very strong functional element in their origin. The influence of the
general shock to the nervous system received by the patients had an
important bearing on these phenomena, and their interest from a prognostic
point of view was very great.
Injuries to Special Nerves
with progressive wasting of the whole limb, which at the end of
a month was marked, and then commenced to improve.
(110) In a second case the wound took a similar course in the
centre of the leg, crossing the line of the branches of the
musculo-cutaneous nerve. Motor paralysis of the peronei
followed, together with general lowering of tactile sensation in
the musculo-cutaneous area.
Traumatic neurosis.—In connection with the cases just quoted, mention
must be made of the fact that the functional element was often somewhat
prominent. The influence of this factor was not to be neglected in case 108;
again, its presence was a feature in cases 132 and 134, of injury to the
sciatic nerve and of peripheral injury to the seventh nerve (p. 355). A
remark has been made as to the occurrence of functional paraplegia on p.
337. Again, in the case of the organs of special sense. Case 66, of injury to
the occipital lobes, showed that a mixture of organic and functional
phenomena might be a source of error, even in the determination of the
visual field in the subject of an undoubted destructive lesion. On more than
one occasion an injury was accompanied by loss of the power of speech;
thus a patient who received a slight wound of the neck did not speak again
until the application of a battery by my colleague, Mr. H. B. Robinson. A
patient was also for a short time an inmate of No. 1 General Hospital,
Wynberg, who had become deaf and dumb as a result of the explosion of a
shrapnel shell over his head. This patient also did not recover his powers
until he returned to the mother-country.
In many other cases of nerve concussion or contusion, the recovery of
power and sensation, or the disappearance of neuralgia or contractures, was
so sudden and rapid after prolonged continuance of the symptoms, as to
suggest a very strong functional element in their origin. The influence of the
general shock to the nervous system received by the patients had an
important bearing on these phenomena, and their interest from a prognostic
point of view was very great.
Injuries to Special Nerves
Page 405
Cranial nerves.—It will be convenient first to make a few remarks
concerning the nerves of special sense.
Olfactory.—I observed temporary loss of smell on three occasions. In two
instances this accompanied transverse wounds of the bones of the face in
which the upper third of the nasal cavities was crossed; in the third a track
passing obliquely downwards from the frontal region passed through the
inner wall of the orbit, and crossed the nose at a lower level. In view of the
small area of the olfactory distribution which was directly implicated, I was
at first inclined to regard the loss of smell as dependent on the presence of
dried blood on the surface of the mucous membrane, or on obstruction of
the cavities from the same cause. Further observation, however, appeared to
show that it was due to concussion of the branches of the olfactory nerve,
since the loss of function persisted when the cavities were manifestly clear.
In all these cases we were confronted with the same difficulty which was
experienced both in lesions of sight and hearing, the determination as to
whether the concussion was of the branches or of the olfactory bulb. When
the symptom was the accompaniment of a fracture of the roof of the orbit,
the possibility of concussion of the olfactory lobe was manifest. In all,
again, it was difficult to say what part the accompanying concussion of the
branches of the fifth nerve took in the production of the symptom. In all
three cases mentioned the return of function was gradual, but apparently
fairly complete at the end of three weeks. In one it was noted that at first the
patient was conscious of an odour before he was able to discriminate its
actual nature; later he could determine the latter readily.
Optic.—Some remarks concerning lesions of the optic nerve have already
been made under the heading of wounds of the orbit. Concussion and
contusion of the nerve both occurred, but I was unable to differentiate
between the effects of these on the nerve itself, apart from the effects on the
globe of the eye, which usually accompanied wounds of the orbit.
In some cases the nerve was directly divided in orbital wounds, and either
pressure on or division of the nerve in the intra-cranial portion of its course,
or as it traversed the optic foramen, was not uncommon.
Auditory.—Loss of hearing was also not infrequent; thus it accompanied all
three wounds of the mastoid process quoted under the heading of the
concerning the nerves of special sense.
Olfactory.—I observed temporary loss of smell on three occasions. In two
instances this accompanied transverse wounds of the bones of the face in
which the upper third of the nasal cavities was crossed; in the third a track
passing obliquely downwards from the frontal region passed through the
inner wall of the orbit, and crossed the nose at a lower level. In view of the
small area of the olfactory distribution which was directly implicated, I was
at first inclined to regard the loss of smell as dependent on the presence of
dried blood on the surface of the mucous membrane, or on obstruction of
the cavities from the same cause. Further observation, however, appeared to
show that it was due to concussion of the branches of the olfactory nerve,
since the loss of function persisted when the cavities were manifestly clear.
In all these cases we were confronted with the same difficulty which was
experienced both in lesions of sight and hearing, the determination as to
whether the concussion was of the branches or of the olfactory bulb. When
the symptom was the accompaniment of a fracture of the roof of the orbit,
the possibility of concussion of the olfactory lobe was manifest. In all,
again, it was difficult to say what part the accompanying concussion of the
branches of the fifth nerve took in the production of the symptom. In all
three cases mentioned the return of function was gradual, but apparently
fairly complete at the end of three weeks. In one it was noted that at first the
patient was conscious of an odour before he was able to discriminate its
actual nature; later he could determine the latter readily.
Optic.—Some remarks concerning lesions of the optic nerve have already
been made under the heading of wounds of the orbit. Concussion and
contusion of the nerve both occurred, but I was unable to differentiate
between the effects of these on the nerve itself, apart from the effects on the
globe of the eye, which usually accompanied wounds of the orbit.
In some cases the nerve was directly divided in orbital wounds, and either
pressure on or division of the nerve in the intra-cranial portion of its course,
or as it traversed the optic foramen, was not uncommon.
Auditory.—Loss of hearing was also not infrequent; thus it accompanied all
three wounds of the mastoid process quoted under the heading of the
Page 406
seventh nerve, also two cases of fracture of the occipital bone near the ear
quoted on p. 278. In all these instances it was impossible to attribute the
deafness to lesion of the nerve alone, as the causative injury equally
affected the internal ear, and in at least two the bullet implicated the
tympanum as well in its course. The deafness was absolute in each case,
and in none had any improvement occurred at the end of nine months.
Deafness was a symptom in a certain number of the more severe cerebral
injuries in which the course of the bullet was not so near to the internal ear:
probably some of these were central in origin.
I only once observed any interference with the sense of taste.
Remaining cranial nerves.—I have little to say regarding the third, fourth,
and sixth nerves. In the case of the third nerve, ptosis was occasionally seen
in wounds of the skull involving the roof of the orbit, but the relative parts
taken by injury to nerve and laceration or fixation of muscle respectively,
were usually hard to determine. Again, the fourth and sixth nerves may
have been damaged in some of the more extensive orbital wounds,
especially those in which the globe suffered injury, but the signs under such
circumstances were difficult to discriminate, and the injury was of slight
practical importance, in view of the major injury to the globe itself.
Fifth nerve.—Concussion, contusion, or laceration of the different branches
of the three divisions of the fifth nerve were common in wounds of the
head, but most frequent in fractures of the upper or lower jaws. Localised
anæsthesia was common from one or other of these causes, but for the most
part transitory in the cases of contusion or concussion. I saw no case of
entire loss of function in any one division, symptoms being mostly confined
to certain branches, as the supra-orbital, the temporo-malar, the dental
branches of the second division, the auriculo-temporal nerve, and the
lingual, dental, and mental branches of the third division. I did not observe
any cases in which modification of the special senses accompanied these
injuries beyond those mentioned in the remarks already made on the subject
of anosmia, and one case in which some modification of the sense of taste
accompanied an injury to the floor of the mouth. It was a matter of surprise,
considering the frequency with which subsequent neuritis was met with in
the nerves generally, that trifacial neuralgia in some form was not more
often met with. I never observed any serious case. Perhaps this is one of the
quoted on p. 278. In all these instances it was impossible to attribute the
deafness to lesion of the nerve alone, as the causative injury equally
affected the internal ear, and in at least two the bullet implicated the
tympanum as well in its course. The deafness was absolute in each case,
and in none had any improvement occurred at the end of nine months.
Deafness was a symptom in a certain number of the more severe cerebral
injuries in which the course of the bullet was not so near to the internal ear:
probably some of these were central in origin.
I only once observed any interference with the sense of taste.
Remaining cranial nerves.—I have little to say regarding the third, fourth,
and sixth nerves. In the case of the third nerve, ptosis was occasionally seen
in wounds of the skull involving the roof of the orbit, but the relative parts
taken by injury to nerve and laceration or fixation of muscle respectively,
were usually hard to determine. Again, the fourth and sixth nerves may
have been damaged in some of the more extensive orbital wounds,
especially those in which the globe suffered injury, but the signs under such
circumstances were difficult to discriminate, and the injury was of slight
practical importance, in view of the major injury to the globe itself.
Fifth nerve.—Concussion, contusion, or laceration of the different branches
of the three divisions of the fifth nerve were common in wounds of the
head, but most frequent in fractures of the upper or lower jaws. Localised
anæsthesia was common from one or other of these causes, but for the most
part transitory in the cases of contusion or concussion. I saw no case of
entire loss of function in any one division, symptoms being mostly confined
to certain branches, as the supra-orbital, the temporo-malar, the dental
branches of the second division, the auriculo-temporal nerve, and the
lingual, dental, and mental branches of the third division. I did not observe
any cases in which modification of the special senses accompanied these
injuries beyond those mentioned in the remarks already made on the subject
of anosmia, and one case in which some modification of the sense of taste
accompanied an injury to the floor of the mouth. It was a matter of surprise,
considering the frequency with which subsequent neuritis was met with in
the nerves generally, that trifacial neuralgia in some form was not more
often met with. I never observed any serious case. Perhaps this is one of the
Page 407
fields in which a longer after-period may increase our knowledge. Lastly, I
never observed motor paralysis in the case of the third division, although
sensory symptoms in some of the branches were common, evident proof
that injuries to the trunk were rare.
Seventh nerve.—Facial paralysis was most commonly observed in cases of
wound of the mastoid process, apart from central cortical facial paralyses,
of which several are quoted in the chapter on injuries of the head. All the
wounds of the mastoid process were, in addition, accompanied by absolute
deafness. I am sorry to be unable to give any details as to the electrical
condition of the muscles in these cases, but I believe that in the great
majority the paralysis was mainly the result of nerve concussion, since the
perforations were clean in character and not obviously accompanied by
comminution. Pressure from hæmorrhage into the Fallopian canal may, of
course, have been present, and in some instances, particularly those in
which the bullet traversed the tympanic cavity, spicules of bone may have
caused laceration. In every case, however, all the branches were equally
affected; the paralysis was absolute, and in none did any improvement
occur while the cases were under my observation.
The following are a few illustrative examples:—
(111) Boer wounded at Belmont. Entry, immediately above
zygoma; the bullet passed through the temporal fossa, fractured
the neck of the mandible, traversed the mastoid process, and
emerged at the lower margin of the hairy scalp, 1 inch from the
median line. Facial paralysis was complete, and there was no
improvement at the end of ten weeks.
(112) Wounded at Magersfontein. Entry, at the posterior border
of the left mastoid process, 1/2 an inch above the tip; exit,
through the right upper lip at the junction of the middle and
outer thirds. There was considerable hæmorrhage from the left
ear. The injury was followed by complete deafness, and facial
paralysis, which showed no sign of improvement.
There was complete anæsthesia over the area of distribution of
the third division of the fifth nerve; this improved rapidly, and at
the end of five weeks was hardly to be detected; neither at that
never observed motor paralysis in the case of the third division, although
sensory symptoms in some of the branches were common, evident proof
that injuries to the trunk were rare.
Seventh nerve.—Facial paralysis was most commonly observed in cases of
wound of the mastoid process, apart from central cortical facial paralyses,
of which several are quoted in the chapter on injuries of the head. All the
wounds of the mastoid process were, in addition, accompanied by absolute
deafness. I am sorry to be unable to give any details as to the electrical
condition of the muscles in these cases, but I believe that in the great
majority the paralysis was mainly the result of nerve concussion, since the
perforations were clean in character and not obviously accompanied by
comminution. Pressure from hæmorrhage into the Fallopian canal may, of
course, have been present, and in some instances, particularly those in
which the bullet traversed the tympanic cavity, spicules of bone may have
caused laceration. In every case, however, all the branches were equally
affected; the paralysis was absolute, and in none did any improvement
occur while the cases were under my observation.
The following are a few illustrative examples:—
(111) Boer wounded at Belmont. Entry, immediately above
zygoma; the bullet passed through the temporal fossa, fractured
the neck of the mandible, traversed the mastoid process, and
emerged at the lower margin of the hairy scalp, 1 inch from the
median line. Facial paralysis was complete, and there was no
improvement at the end of ten weeks.
(112) Wounded at Magersfontein. Entry, at the posterior border
of the left mastoid process, 1/2 an inch above the tip; exit,
through the right upper lip at the junction of the middle and
outer thirds. There was considerable hæmorrhage from the left
ear. The injury was followed by complete deafness, and facial
paralysis, which showed no sign of improvement.
There was complete anæsthesia over the area of distribution of
the third division of the fifth nerve; this improved rapidly, and at
the end of five weeks was hardly to be detected; neither at that
Page 408
time could any impairment of power on the part of the muscles
of mastication be detected. No impairment of the sense of taste
was noted.
(113) Entry, above the anterior extremity of the zygoma, bullet
retained. Primary hæmorrhage from ear. Complete facial
paralysis and deafness. Anæsthesia over distribution of temporal
branch of temporo-malar nerve, part of supra-orbital area,
auriculo-temporal nerve, and small occipital cervical nerve. The
muscles of mastication acted well. Ecchymosis below the right
mastoid process.
(114) Wounded at Paardeberg. 300 yards. Entry, at the posterior
border of the right mastoid process, 3/4 of an inch above the tip;
exit, the inner third of the left upper eyelid. (Eye destroyed.)
Complete right facial paralysis; deaf, on right side cannot hear
tick of watch either held close or in contact. Purulent otitis
media.
In this place I might mention two other cases of lesion of the seventh nerve
secondary to wound of peripheral branches. In one a patient was struck by
several fragments of lead from a bullet which broke up against a
neighbouring stone. These for the most part lodged in the skin over the left
orbicularis muscle, but one also lodged in the conjunctiva and was
removed. Some ten days later the patient complained that he could not lift
the upper lid. The levator palpebræ was normal, but spasm of the orbicularis
held the eye firmly closed. The condition did not improve, and the patient
was invalided home. He recovered later.
In another patient a bullet entered above the right zygoma and traversed the
orbits, without wounding the globes. At the time no want of power of the
muscles of the face was noted, but a year later there was evident weakness
of the whole of the muscles of the right side of the face, with loss of
symmetry.
In the former case the functional element was strong, but in both an
ascending neuritis was probably present.
of mastication be detected. No impairment of the sense of taste
was noted.
(113) Entry, above the anterior extremity of the zygoma, bullet
retained. Primary hæmorrhage from ear. Complete facial
paralysis and deafness. Anæsthesia over distribution of temporal
branch of temporo-malar nerve, part of supra-orbital area,
auriculo-temporal nerve, and small occipital cervical nerve. The
muscles of mastication acted well. Ecchymosis below the right
mastoid process.
(114) Wounded at Paardeberg. 300 yards. Entry, at the posterior
border of the right mastoid process, 3/4 of an inch above the tip;
exit, the inner third of the left upper eyelid. (Eye destroyed.)
Complete right facial paralysis; deaf, on right side cannot hear
tick of watch either held close or in contact. Purulent otitis
media.
In this place I might mention two other cases of lesion of the seventh nerve
secondary to wound of peripheral branches. In one a patient was struck by
several fragments of lead from a bullet which broke up against a
neighbouring stone. These for the most part lodged in the skin over the left
orbicularis muscle, but one also lodged in the conjunctiva and was
removed. Some ten days later the patient complained that he could not lift
the upper lid. The levator palpebræ was normal, but spasm of the orbicularis
held the eye firmly closed. The condition did not improve, and the patient
was invalided home. He recovered later.
In another patient a bullet entered above the right zygoma and traversed the
orbits, without wounding the globes. At the time no want of power of the
muscles of the face was noted, but a year later there was evident weakness
of the whole of the muscles of the right side of the face, with loss of
symmetry.
In the former case the functional element was strong, but in both an
ascending neuritis was probably present.
Page 409
Tenth nerve.—The pneumogastric was implicated in many wounds of the
neck. I never observed an uncomplicated case, but laryngeal paralysis was
temporarily present in two of the cases of cervical aneurism in which the
wound crossed above the level of origin of the recurrent laryngeal branch,
while in two others the recurrent branch itself was in close contact with the
wall of the aneurism (p. 135). In all such cases signs of concussion or
contusion of the nerve would be expected, judging from the similar results
observed in the brachial nerves when the neighbouring artery was
implicated. The only obvious symptoms occurring, however, were laryngeal
paralysis and acceleration of the pulse. As the latter symptom was often
observed in the cases of arterio-venous communication, wherever situated,
and as the sympathetic nerve also lay in close contiguity to the wound track,
it was difficult to ascribe it with certainty solely to the vagus lesion. In the
two cases of high vagus injury the laryngeal paralysis steadily improved,
and at the end of six months was apparently well; in the two others it
persisted at the end of three months and a year respectively.
The nerve must have been very frequently damaged in wounds of the neck;
it is possible that this injury may have been an important factor in the death
of some of the patients with cervical wounds upon the field.
Eleventh nerve.—I append the only case of localised spinal accessory
paralysis I observed. This was one of my earliest experiences, and when I
examined the neck, in the Field hospital, I assumed from the completeness
of the sterno-mastoid and trapezius paralysis that the nerve was severed.
The patient, however, made such a rapid recovery that it became evident
that the nerve had been contused only, and that the recovery of function was
not due, as is so often the case, to vicarious compensation by the cervical
supply to the muscles.
(115) Entry, immediately to the right of the fourth cervical
spinous process; exit, at the anterior border of the left sterno-
mastoid opposite the angle of the mandible. The left shoulder
was depressed, the head inclined to the injured side. There was
evident spinal accessory paralysis, and marked hyperæsthesia of
the whole left upper extremity, most severe in the circumflex
area. The hyperæsthesia gradually disappeared in a few days,
and was clearly due to concussion and possibly slight contusion
neck. I never observed an uncomplicated case, but laryngeal paralysis was
temporarily present in two of the cases of cervical aneurism in which the
wound crossed above the level of origin of the recurrent laryngeal branch,
while in two others the recurrent branch itself was in close contact with the
wall of the aneurism (p. 135). In all such cases signs of concussion or
contusion of the nerve would be expected, judging from the similar results
observed in the brachial nerves when the neighbouring artery was
implicated. The only obvious symptoms occurring, however, were laryngeal
paralysis and acceleration of the pulse. As the latter symptom was often
observed in the cases of arterio-venous communication, wherever situated,
and as the sympathetic nerve also lay in close contiguity to the wound track,
it was difficult to ascribe it with certainty solely to the vagus lesion. In the
two cases of high vagus injury the laryngeal paralysis steadily improved,
and at the end of six months was apparently well; in the two others it
persisted at the end of three months and a year respectively.
The nerve must have been very frequently damaged in wounds of the neck;
it is possible that this injury may have been an important factor in the death
of some of the patients with cervical wounds upon the field.
Eleventh nerve.—I append the only case of localised spinal accessory
paralysis I observed. This was one of my earliest experiences, and when I
examined the neck, in the Field hospital, I assumed from the completeness
of the sterno-mastoid and trapezius paralysis that the nerve was severed.
The patient, however, made such a rapid recovery that it became evident
that the nerve had been contused only, and that the recovery of function was
not due, as is so often the case, to vicarious compensation by the cervical
supply to the muscles.
(115) Entry, immediately to the right of the fourth cervical
spinous process; exit, at the anterior border of the left sterno-
mastoid opposite the angle of the mandible. The left shoulder
was depressed, the head inclined to the injured side. There was
evident spinal accessory paralysis, and marked hyperæsthesia of
the whole left upper extremity, most severe in the circumflex
area. The hyperæsthesia gradually disappeared in a few days,
and was clearly due to concussion and possibly slight contusion
Page 410
of the cervical nerve roots. The spinal accessory paralysis
improved, so that the patient returned to the front at the end of a
month: when I saw him some four months later the shoulders
were held quite symmetrically.
The twelfth nerve was occasionally damaged in wounds of the floor of the
mouth. I saw no case of permanent paralysis.
Injury to the systemic nerves. Cervical plexus.—Evidence of injury to the
superficial branches of the cervical plexus was not rare; thus I saw cases of
small occipital anæsthesia, and great occipital neuralgia, but none of motor
paralysis from injury to the deeper muscular branches. I take it that the
smallness of the branches, and the multiple supply possessed by many of
the muscles of the neck, would both take part in rendering certain evidence
of the injury of an individual motor nerve rare.
Brachial plexus.—Injury to this plexus in the neck was common; the main
peculiarity observed was the partial nature of the damage inflicted.
Thus injury to a single nerve, or to a complex of two or more, was far more
common than one implicating the whole plexus. Again, while complete
paralysis might affect one set of nerves, another might simply exhibit signs
of irritation in the form of hyperæsthesia or pain.
The wounds producing these injuries varied much in direction; thus some
crossed the neck transversely, some were obliquely transverse, while others
took a more or less vertical course.
These same remarks hold good in the case of the nerves of the arm. In the
upper half, especially, complex injury was not rare, while in the lower third
affection of individual nerves was more common. Another important
difference must be mentioned in regard to the upper and lower segments of
the course of the brachial nerves; they are not only more widely distributed
below, but also more fixed in position, a fact antagonistic to the escape of
the nerve by displacement and liable to expose it to more severe contusion.
The latter point holds good in the forearm also; here, individual injuries
often occurred.
improved, so that the patient returned to the front at the end of a
month: when I saw him some four months later the shoulders
were held quite symmetrically.
The twelfth nerve was occasionally damaged in wounds of the floor of the
mouth. I saw no case of permanent paralysis.
Injury to the systemic nerves. Cervical plexus.—Evidence of injury to the
superficial branches of the cervical plexus was not rare; thus I saw cases of
small occipital anæsthesia, and great occipital neuralgia, but none of motor
paralysis from injury to the deeper muscular branches. I take it that the
smallness of the branches, and the multiple supply possessed by many of
the muscles of the neck, would both take part in rendering certain evidence
of the injury of an individual motor nerve rare.
Brachial plexus.—Injury to this plexus in the neck was common; the main
peculiarity observed was the partial nature of the damage inflicted.
Thus injury to a single nerve, or to a complex of two or more, was far more
common than one implicating the whole plexus. Again, while complete
paralysis might affect one set of nerves, another might simply exhibit signs
of irritation in the form of hyperæsthesia or pain.
The wounds producing these injuries varied much in direction; thus some
crossed the neck transversely, some were obliquely transverse, while others
took a more or less vertical course.
These same remarks hold good in the case of the nerves of the arm. In the
upper half, especially, complex injury was not rare, while in the lower third
affection of individual nerves was more common. Another important
difference must be mentioned in regard to the upper and lower segments of
the course of the brachial nerves; they are not only more widely distributed
below, but also more fixed in position, a fact antagonistic to the escape of
the nerve by displacement and liable to expose it to more severe contusion.
The latter point holds good in the forearm also; here, individual injuries
often occurred.
Page 411
While at work in the Field hospital alone I gained the impression that the
musculo-spiral nerve would not retain the unenviable character of being the
most vulnerable nerve of the upper extremity, since the chances of each
individual nerve seemed about equal, putting the question of the long
course of the musculo-spiral nerve against the humerus out of question.
This expectation was, however, not confirmed, since the musculo-spiral
itself, if not primarily affected, was so often the seat of secondary mischief
in fractures of the humerus. The posterior interosseous branch seemed to
exhibit a similar vulnerability to slight injuries, to be referred to later under
the external popliteal of the lower extremity. Again, in complex injuries of
the brachial plexus, or nerve trunks, the musculo-spiral branch rarely
escaped being a member, if not individually singled out.
Of the thoracic nerves I have little to say. They must have been often
injured in the thoracic wounds, yet, as far as my experience went,
intercostal neuralgia was uncommon, or at any rate not a special feature.
One observation of interest, however, does exist; in the cases in which the
ribs were fractured by bullets travelling across them within the thorax, pain
was distinctly a prominent feature. This was no doubt referable to the facts
that in such instances the intercostal nerves were especially liable to direct
injury, and that this was often multiple. On one occasion a crop of herpetic
vesicles developed along the course of a dorsal nerve in an injury
implicating a single intercostal space posteriorly.
Lumbar plexus.—Although not quite so well arranged to escape bullet
wounds as the thoracic nerves, the lumbar, by reason of their deep position
and the comparatively wide area they cover, together with the rarity of
wounds taking a sufficiently longitudinal direction to cross the course of
more than one or two branches, were also comparatively rarely damaged. I
never saw an uncomplicated case of anterior crural paralysis, and rarely
cruralgia. I think this is to be explained in two ways: first, that the trunk
course of the nerve is short; secondly, that it lies in the inguinal fossa. The
second fact is of importance, since wounds in this region were in my
experience responsible for a considerable percentage of the deaths on the
field or shortly afterwards. Such deaths probably occurred from internal
hæmorrhage from the iliac arteries, and it was in such cases that the anterior
crural nerve stood in greatest danger of injury. I also never saw a case of
localised obturator paralysis. On the other hand, anæsthesia or
musculo-spiral nerve would not retain the unenviable character of being the
most vulnerable nerve of the upper extremity, since the chances of each
individual nerve seemed about equal, putting the question of the long
course of the musculo-spiral nerve against the humerus out of question.
This expectation was, however, not confirmed, since the musculo-spiral
itself, if not primarily affected, was so often the seat of secondary mischief
in fractures of the humerus. The posterior interosseous branch seemed to
exhibit a similar vulnerability to slight injuries, to be referred to later under
the external popliteal of the lower extremity. Again, in complex injuries of
the brachial plexus, or nerve trunks, the musculo-spiral branch rarely
escaped being a member, if not individually singled out.
Of the thoracic nerves I have little to say. They must have been often
injured in the thoracic wounds, yet, as far as my experience went,
intercostal neuralgia was uncommon, or at any rate not a special feature.
One observation of interest, however, does exist; in the cases in which the
ribs were fractured by bullets travelling across them within the thorax, pain
was distinctly a prominent feature. This was no doubt referable to the facts
that in such instances the intercostal nerves were especially liable to direct
injury, and that this was often multiple. On one occasion a crop of herpetic
vesicles developed along the course of a dorsal nerve in an injury
implicating a single intercostal space posteriorly.
Lumbar plexus.—Although not quite so well arranged to escape bullet
wounds as the thoracic nerves, the lumbar, by reason of their deep position
and the comparatively wide area they cover, together with the rarity of
wounds taking a sufficiently longitudinal direction to cross the course of
more than one or two branches, were also comparatively rarely damaged. I
never saw an uncomplicated case of anterior crural paralysis, and rarely
cruralgia. I think this is to be explained in two ways: first, that the trunk
course of the nerve is short; secondly, that it lies in the inguinal fossa. The
second fact is of importance, since wounds in this region were in my
experience responsible for a considerable percentage of the deaths on the
field or shortly afterwards. Such deaths probably occurred from internal
hæmorrhage from the iliac arteries, and it was in such cases that the anterior
crural nerve stood in greatest danger of injury. I also never saw a case of
localised obturator paralysis. On the other hand, anæsthesia or
Page 412
hyperæsthesia in the area of distribution of the lumbar nerves in the groin,
the external cutaneous and the long saphenous in the thigh, were not
uncommon. Hyperæsthesia developed in more than one case in which
injury to the psoas had led to hæmorrhage into the muscle sheath.
Sacral plexus.—The sacral plexus is far more liable to extensive direct
injury than either of the two preceding. Its cords are larger, gathered up into
a much smaller space, and more liable to injury, from the fact that the slope
in which they lie is more readily followed by a bullet track. Again, the cords
rest for a considerable portion of their course on a bony bed, a particularly
dangerous position in gunshot wounds, since the nerves are not only
exposed to the danger of direct wound, or pressure from bony spicules, but
also readily receive transmitted vibrations secondary to impact of the bullet
with the bone.
None the less I had few occasions to observe extensive injuries of the
plexus. In one instance damage particularly affecting the lumbo-sacral cord
occurred, but this was complicated by signs of irritation of the anterior
crural and obturator nerves, as the result of retro-peritoneal hæmorrhage
and injury to the psoas muscle. Two cases in which the sacro-coccygeal
plexus suffered isolated injury on account of their characteristic nature as
gunshot injuries will be shortly quoted:
(116) Sacro-coccygeal plexus.—Entry, at the junction of the
middle and posterior thirds of the left iliac crest; the bullet
passed obliquely downwards through the pelvis to lodge 3
inches below the right trochanter major. Incontinence of soft
fæces persisted for five weeks, and retention of urine during
three weeks.
This patient subsequently died on the homeward voyage, but I
am unable to say from what cause.
(117) Entry, over third sacral vertebra; exit, 2 inches from the
median line, and 1½ inch above Poupart's ligament on the
anterior abdominal wall. Incontinence, with involuntary passage
of fæces, persisted during the first twenty-four hours, and for
two days the urine had to be withdrawn with a catheter. No
further signs of nerve injury were noted.
the external cutaneous and the long saphenous in the thigh, were not
uncommon. Hyperæsthesia developed in more than one case in which
injury to the psoas had led to hæmorrhage into the muscle sheath.
Sacral plexus.—The sacral plexus is far more liable to extensive direct
injury than either of the two preceding. Its cords are larger, gathered up into
a much smaller space, and more liable to injury, from the fact that the slope
in which they lie is more readily followed by a bullet track. Again, the cords
rest for a considerable portion of their course on a bony bed, a particularly
dangerous position in gunshot wounds, since the nerves are not only
exposed to the danger of direct wound, or pressure from bony spicules, but
also readily receive transmitted vibrations secondary to impact of the bullet
with the bone.
None the less I had few occasions to observe extensive injuries of the
plexus. In one instance damage particularly affecting the lumbo-sacral cord
occurred, but this was complicated by signs of irritation of the anterior
crural and obturator nerves, as the result of retro-peritoneal hæmorrhage
and injury to the psoas muscle. Two cases in which the sacro-coccygeal
plexus suffered isolated injury on account of their characteristic nature as
gunshot injuries will be shortly quoted:
(116) Sacro-coccygeal plexus.—Entry, at the junction of the
middle and posterior thirds of the left iliac crest; the bullet
passed obliquely downwards through the pelvis to lodge 3
inches below the right trochanter major. Incontinence of soft
fæces persisted for five weeks, and retention of urine during
three weeks.
This patient subsequently died on the homeward voyage, but I
am unable to say from what cause.
(117) Entry, over third sacral vertebra; exit, 2 inches from the
median line, and 1½ inch above Poupart's ligament on the
anterior abdominal wall. Incontinence, with involuntary passage
of fæces, persisted during the first twenty-four hours, and for
two days the urine had to be withdrawn with a catheter. No
further signs of nerve injury were noted.
Page 413
The same explanation of the comparative rarity of injuries to the sacral
plexus that has been already given in the case of the anterior crural nerve
holds good—viz. that in a great many of the pelvic wounds involving the
plexus early death followed from the severity of the concurrent injuries.
Injuries to the great sciatic nerve outside the pelvis, or to one of its
constituent elements, on the other hand, formed one of the most familiar of
the nerve lesions. The wounds giving rise to these were of the most diverse
character; some crossed the buttock in a vertical, transverse, or oblique
direction; others travelled through the thigh in corresponding directions,
while a third series involved both buttock and thigh.
The size of the great sciatic nerve renders complete laceration by a bullet of
small calibre a matter almost of impossibility; hence complete division may
almost be left out of consideration in the case of this nerve. On the other
hand, partial division, perforation, and severe contusion are each and all
favoured by the same factor.
With an extended thigh the nerve is in a state of comparatively slight
tension, and this may be still lessened if the knee be flexed. This factor,
together with the density of the sheath of the nerve, favours the possibility
of displacement, and this occurrence is more likely in the lower segment
than in the upper, which is comparatively fixed in position.
Clinical experience appeared to illustrate the importance of these
anatomical factors, as the worst cases of sciatic injury that I saw were in
connection with wounds of the buttock or the junction of that segment of
the trunk with the thigh.
The most striking observation with regard to the injuries of the great sciatic
nerve was the comparatively frequent escape of the popliteal element and
the severe lesion of the peroneal. This was so pronounced as to amount to
as high a proportion of peroneal symptoms as 90 per cent., and often when
the whole nerve was implicated the popliteal signs were of the irritative, the
peroneal of the paralytic type. When bullets crossed the popliteal space,
given wounds of equal severity in corresponding degrees of contiguity to
the respective nerves, the peroneal element always suffered in greater
degree. Again, the peroneal nerve symptoms were more obstinate and
prolonged, and instances of ascending neuritis were more common than in
plexus that has been already given in the case of the anterior crural nerve
holds good—viz. that in a great many of the pelvic wounds involving the
plexus early death followed from the severity of the concurrent injuries.
Injuries to the great sciatic nerve outside the pelvis, or to one of its
constituent elements, on the other hand, formed one of the most familiar of
the nerve lesions. The wounds giving rise to these were of the most diverse
character; some crossed the buttock in a vertical, transverse, or oblique
direction; others travelled through the thigh in corresponding directions,
while a third series involved both buttock and thigh.
The size of the great sciatic nerve renders complete laceration by a bullet of
small calibre a matter almost of impossibility; hence complete division may
almost be left out of consideration in the case of this nerve. On the other
hand, partial division, perforation, and severe contusion are each and all
favoured by the same factor.
With an extended thigh the nerve is in a state of comparatively slight
tension, and this may be still lessened if the knee be flexed. This factor,
together with the density of the sheath of the nerve, favours the possibility
of displacement, and this occurrence is more likely in the lower segment
than in the upper, which is comparatively fixed in position.
Clinical experience appeared to illustrate the importance of these
anatomical factors, as the worst cases of sciatic injury that I saw were in
connection with wounds of the buttock or the junction of that segment of
the trunk with the thigh.
The most striking observation with regard to the injuries of the great sciatic
nerve was the comparatively frequent escape of the popliteal element and
the severe lesion of the peroneal. This was so pronounced as to amount to
as high a proportion of peroneal symptoms as 90 per cent., and often when
the whole nerve was implicated the popliteal signs were of the irritative, the
peroneal of the paralytic type. When bullets crossed the popliteal space,
given wounds of equal severity in corresponding degrees of contiguity to
the respective nerves, the peroneal element always suffered in greater
degree. Again, the peroneal nerve symptoms were more obstinate and
prolonged, and instances of ascending neuritis were more common than in
Page 414
the case of any other nerve of the lower extremity, and the trophic wasting
of muscles was more marked.
The peroneal nerve, therefore, acquires the same unenviable degree of
importance in the lower extremity enjoyed by the musculo-spiral in the
upper. Here, again, we are confronted with the fact that the peroneal
element of the great sciatic nerve is the more prone to idiopathic
inflammations or toxic influences, and hence we can only assume it to
possess a special vulnerability. The peroneal element is of course somewhat
the more exposed, as lying posterior; but it seems unreasonable to assume
that so large a proportion of the injuries can implicate the posterior segment
of the nerve as to make the startling difference in the incidence of
degeneration explicable. In this relation we may bear in mind that the
muscles supplied by this nerve suffer most in the degeneration subsequent
to anterior polio-myelitis, and again that in cerebral hemiplegia or spinal-
cord injuries they are the last to recover. Unfortunately no explanation of
these remarkable facts, so forcibly impressed by the large series of cases
with peroneal symptoms seen in a short time, is forthcoming.
I may dismiss the other branches of the sacral plexus in a few words. The
small sciatic was occasionally injured in its course in the buttock, and the
small saphenous in the leg. When either element of the latter was injured, it
was surprising how sharply the imperfections in the anæsthesia
corresponded with the composite character of the nerve.
Cases of Nerve Injury
The following cases are added mainly to give some idea of the comparative
frequency with which the individual nerves were injured, and also to
exemplify the more common forms of complex injury met with.
Circumstances, unfortunately, did not always allow of extended observation
at the time, and I have not been very fortunate in my attempts to obtain
subsequent information on this series since my return. A certain amount of
prognostic information is, however, furnished by some of the records, and I
am very much indebted to my colleague, Dr. Turney, for help in this matter.
(118) Brachial plexus.—Entry, 2 inches above the clavicle at the
anterior margin of the trapezius; exit, first intercostal space, 1
of muscles was more marked.
The peroneal nerve, therefore, acquires the same unenviable degree of
importance in the lower extremity enjoyed by the musculo-spiral in the
upper. Here, again, we are confronted with the fact that the peroneal
element of the great sciatic nerve is the more prone to idiopathic
inflammations or toxic influences, and hence we can only assume it to
possess a special vulnerability. The peroneal element is of course somewhat
the more exposed, as lying posterior; but it seems unreasonable to assume
that so large a proportion of the injuries can implicate the posterior segment
of the nerve as to make the startling difference in the incidence of
degeneration explicable. In this relation we may bear in mind that the
muscles supplied by this nerve suffer most in the degeneration subsequent
to anterior polio-myelitis, and again that in cerebral hemiplegia or spinal-
cord injuries they are the last to recover. Unfortunately no explanation of
these remarkable facts, so forcibly impressed by the large series of cases
with peroneal symptoms seen in a short time, is forthcoming.
I may dismiss the other branches of the sacral plexus in a few words. The
small sciatic was occasionally injured in its course in the buttock, and the
small saphenous in the leg. When either element of the latter was injured, it
was surprising how sharply the imperfections in the anæsthesia
corresponded with the composite character of the nerve.
Cases of Nerve Injury
The following cases are added mainly to give some idea of the comparative
frequency with which the individual nerves were injured, and also to
exemplify the more common forms of complex injury met with.
Circumstances, unfortunately, did not always allow of extended observation
at the time, and I have not been very fortunate in my attempts to obtain
subsequent information on this series since my return. A certain amount of
prognostic information is, however, furnished by some of the records, and I
am very much indebted to my colleague, Dr. Turney, for help in this matter.
(118) Brachial plexus.—Entry, 2 inches above the clavicle at the
anterior margin of the trapezius; exit, first intercostal space, 1
Page 415
inch from the sternal margin. Heavy dull pain developed at
once, extending down the upper extremity. A fortnight later this
pain still persisted; there was lowered sensation in the ulnar area
with formication, also lowered sensation in the internal
cutaneous area of distribution; sensation in the lesser internal
cutaneous area was normal. The patient went home with the
nerve symptoms well at the end of a month.
(119) Brachial plexus injury.—Wounded at Magersfontein.
Entry, at the anterior border of the sterno-mastoid opposite the
pomum Adami; exit, through the ninth rib below and 1/2 an inch
external to the scapular angle. Emphysema and considerable
blood extravasation developed in the posterior triangle of the
neck, also loss of power in the musculo-spiral distribution, but
no anæsthesia. At the end of the first fortnight there was evident
wasting of the muscles, but some power was returning in the
triceps. At the end of a month the man left for England, with fair
power in the triceps, but well-marked wrist-drop. A year later
the wrist-drop still persisted.
(120) Plexus injury.—Wound of entry, over pomum Adami; exit,
below scapular spine, about centre. Complete median and
musculo-spiral paralysis.
(121) Median, musculo-cutaneous, and musculo-spiral nerves.
—The wound traversed the axilla from just beneath the anterior
fold; three weeks later a firm mass in the axilla corresponded to
the wound track. Hyperæsthesia developed in the area of median
distribution, with deep pain in the muscles. There was rigidity of
the biceps cubiti and slight wasting in the radial extensors. The
patient improved slowly, and eventually was discharged and
passed out of sight.
(122) Brachial nerves.—Wounded at Paardeberg. Range 500
yards. Entry, at the front of the arm, 2 inches below the junction
of the anterior axillary fold; exit, a little lower, at the back of the
arm, in the line of junction of the posterior axillary fold.
once, extending down the upper extremity. A fortnight later this
pain still persisted; there was lowered sensation in the ulnar area
with formication, also lowered sensation in the internal
cutaneous area of distribution; sensation in the lesser internal
cutaneous area was normal. The patient went home with the
nerve symptoms well at the end of a month.
(119) Brachial plexus injury.—Wounded at Magersfontein.
Entry, at the anterior border of the sterno-mastoid opposite the
pomum Adami; exit, through the ninth rib below and 1/2 an inch
external to the scapular angle. Emphysema and considerable
blood extravasation developed in the posterior triangle of the
neck, also loss of power in the musculo-spiral distribution, but
no anæsthesia. At the end of the first fortnight there was evident
wasting of the muscles, but some power was returning in the
triceps. At the end of a month the man left for England, with fair
power in the triceps, but well-marked wrist-drop. A year later
the wrist-drop still persisted.
(120) Plexus injury.—Wound of entry, over pomum Adami; exit,
below scapular spine, about centre. Complete median and
musculo-spiral paralysis.
(121) Median, musculo-cutaneous, and musculo-spiral nerves.
—The wound traversed the axilla from just beneath the anterior
fold; three weeks later a firm mass in the axilla corresponded to
the wound track. Hyperæsthesia developed in the area of median
distribution, with deep pain in the muscles. There was rigidity of
the biceps cubiti and slight wasting in the radial extensors. The
patient improved slowly, and eventually was discharged and
passed out of sight.
(122) Brachial nerves.—Wounded at Paardeberg. Range 500
yards. Entry, at the front of the arm, 2 inches below the junction
of the anterior axillary fold; exit, a little lower, at the back of the
arm, in the line of junction of the posterior axillary fold.
Page 416
Considerable shock attended the primary injury; when reaction
had taken place, complete motor and sensory paralysis was
noted of the whole upper extremity, with the exception of some
power of movement of the posterior interosseous group of
muscles. Three weeks later the patient could extend the wrist,
but sensation was imperfect in the arm, and completely absent in
the forearm and hand. The track was now hard and palpable, but
there was no hyperæsthesia in any area; when the track was
manipulated slight formication in the hand was experienced. The
biceps and triceps were equally paralysed. There was no wasting
in any of the muscles.
(123) Brachial nerves.—Wounded at Modder River. Entry,
through the anterior axillary fold at its junction with the arm;
exit, on the posterior wall of the thorax, 1/2 an inch from the
median line at a level with the angle of the scapula. Complete
musculo-spiral paralysis; hæmothorax. Three weeks later, radial
sensation returned; but the triceps was very weak, and wrist-
drop was complete. There was some wasting of the muscles
supplied by the median and ulnar nerves, and complete
obliteration of the radial pulse. A year later the musculo-spiral
paralysis still persisted.
(124) Musculo-spiral and median.—Wounded at Magersfontein.
Entry, 3 inches below the anterior axillary fold, on the inner
aspect of the arm; track passed obliquely downwards behind the
humerus to a point on the outer aspect of the arm 1½ inch below
the level of the entry. The humerus escaped injury. Musculo-
spiral paralysis was complete; hyperæsthesia in the distribution
of the median followed some days later. One month
subsequently radial sensation had returned, and a feeling of
numbness had taken the place of the median hyperæsthesia. The
triceps and marginal muscles were much wasted, and only
interosseous extension was possible in the fingers.
(125) Brachial nerves.—Wounded at Magersfontein. Entry and
exit, in the upper third of the arm internal to the humerus.
Complete median paralysis, anæsthesia in the ulnar area, and in
had taken place, complete motor and sensory paralysis was
noted of the whole upper extremity, with the exception of some
power of movement of the posterior interosseous group of
muscles. Three weeks later the patient could extend the wrist,
but sensation was imperfect in the arm, and completely absent in
the forearm and hand. The track was now hard and palpable, but
there was no hyperæsthesia in any area; when the track was
manipulated slight formication in the hand was experienced. The
biceps and triceps were equally paralysed. There was no wasting
in any of the muscles.
(123) Brachial nerves.—Wounded at Modder River. Entry,
through the anterior axillary fold at its junction with the arm;
exit, on the posterior wall of the thorax, 1/2 an inch from the
median line at a level with the angle of the scapula. Complete
musculo-spiral paralysis; hæmothorax. Three weeks later, radial
sensation returned; but the triceps was very weak, and wrist-
drop was complete. There was some wasting of the muscles
supplied by the median and ulnar nerves, and complete
obliteration of the radial pulse. A year later the musculo-spiral
paralysis still persisted.
(124) Musculo-spiral and median.—Wounded at Magersfontein.
Entry, 3 inches below the anterior axillary fold, on the inner
aspect of the arm; track passed obliquely downwards behind the
humerus to a point on the outer aspect of the arm 1½ inch below
the level of the entry. The humerus escaped injury. Musculo-
spiral paralysis was complete; hyperæsthesia in the distribution
of the median followed some days later. One month
subsequently radial sensation had returned, and a feeling of
numbness had taken the place of the median hyperæsthesia. The
triceps and marginal muscles were much wasted, and only
interosseous extension was possible in the fingers.
(125) Brachial nerves.—Wounded at Magersfontein. Entry and
exit, in the upper third of the arm internal to the humerus.
Complete median paralysis, anæsthesia in the ulnar area, and in
Page 417
the radial supply to the dorsum of the middle and ring fingers.
Could flex, extend, and adduct and abduct the wrist; some
power of flexion in index finger, in others none. The flexion of
the wrist was dependent on the ulnar supply to the muscles of
the forearm. No wasting of the interossei, skin normal except for
a large trophic blister on the dorsum of the hand. Little
improvement had taken place in this patient at the end of a year.
(126) Brachial nerves.—Wounded at Magersfontein. The wound
traversed the lower part of the upper third of the arm, fracturing
the humerus. Immediate complete loss of power in the arm was
experienced, together with loss of all sensation. Three weeks
later the humerus was united; the fracture was evidently the
result of passing contact, and not of direct impact. The paralysis
was still complete in the distribution of the median, ulnar, and
musculo-spiral nerves. There was considerable wasting of the
hand and forearm, and a good deal of thickening in the lower
third of the arm.
Four months after the original injury, the nerves were explored
by Mr. Eve, who kindly gives me the following information. All
the nerves and vessels of the arm were united into one firm
bundle by cicatricial tissue. When dissected clear, the median
nerve was found to be thickened and enlarged for about 1½ inch
of its length; the ulnar was not completely freed, but was found
to be continuous and indurated; the musculo-spiral was also
intact, but at its entrance into the humeral groove a mass of
callus was felt. A sclerosed and thickened portion of the median
nerve 3½ inches in length was resected, also 1 inch of sclerosed
ulnar nerve, and both were sutured. The musculo-spiral nerve
was left for future exploration. A small traumatic aneurism was
found on the brachial artery, and the vessel was ligatured above
it.
Ten months later no improvement in the median or ulnar nerves.
Electrical reaction present in musculo-spiral group of muscles.
Could flex, extend, and adduct and abduct the wrist; some
power of flexion in index finger, in others none. The flexion of
the wrist was dependent on the ulnar supply to the muscles of
the forearm. No wasting of the interossei, skin normal except for
a large trophic blister on the dorsum of the hand. Little
improvement had taken place in this patient at the end of a year.
(126) Brachial nerves.—Wounded at Magersfontein. The wound
traversed the lower part of the upper third of the arm, fracturing
the humerus. Immediate complete loss of power in the arm was
experienced, together with loss of all sensation. Three weeks
later the humerus was united; the fracture was evidently the
result of passing contact, and not of direct impact. The paralysis
was still complete in the distribution of the median, ulnar, and
musculo-spiral nerves. There was considerable wasting of the
hand and forearm, and a good deal of thickening in the lower
third of the arm.
Four months after the original injury, the nerves were explored
by Mr. Eve, who kindly gives me the following information. All
the nerves and vessels of the arm were united into one firm
bundle by cicatricial tissue. When dissected clear, the median
nerve was found to be thickened and enlarged for about 1½ inch
of its length; the ulnar was not completely freed, but was found
to be continuous and indurated; the musculo-spiral was also
intact, but at its entrance into the humeral groove a mass of
callus was felt. A sclerosed and thickened portion of the median
nerve 3½ inches in length was resected, also 1 inch of sclerosed
ulnar nerve, and both were sutured. The musculo-spiral nerve
was left for future exploration. A small traumatic aneurism was
found on the brachial artery, and the vessel was ligatured above
it.
Ten months later no improvement in the median or ulnar nerves.
Electrical reaction present in musculo-spiral group of muscles.
Page 418
(127) Musculo-spiral.—Transverse wound through arm
posterior to humerus. Slight suppuration. Triceps weakened
only, complete paralysis of radial extensors and posterior
interosseous group. Radial sensation lowered only.
(128) Musculo-spiral.—Entry, 2 inches above and 1/2 an inch
behind the external humeral condyle; exit, at the inner edge of
the biceps, 1/2 an inch lower in the arm than the entry. It is
doubtful whether the paralysis was noted at first, but a few days
later complete posterior interosseous paralysis and lowered
radial sensation were remarked. No change except a deepening
of the anæsthesia, and the development of formication on
manipulation of the wound occurred, and at the end of three
weeks the nerve was exposed (Mr. Watson), and it was found
that a notch had been cut in its outer border, which had opened
out into a V shape. The margins of this notch were refreshed and
the gap closed. Ten days later radial sensation was fairly good,
but the motor symptoms remained unchanged. Nine months
later steady but very slow improvement was reported.
(129) Ulnar and musculo-cutaneous nerves.—Entry, back of
forearm; the bullet passed between the bones and was retained at
the posterior aspect of the arm. Three weeks later the hand was
glossy and stiff, the fingers extended and adducted, the thumb
was held stiffly in the palm with no power of extension. The
forearm was held semiprone, and the elbow flexed by a rigid
biceps. Six months later the same position was maintained, but
the contracture disappeared under an anæsthetic.
(130) Median and posterior interosseous.—Entry, over the
external margin of the radius at the centre of the forearm; exit, at
the inner margin of the olecranon 1½ inch below the tip.
Lowered cutaneous sensation in median distribution, and loss of
median flexion of wrist and fingers. Complete wrist-drop. The
triceps supinator longus and extensor carpi radialis longior were
perfect. Twelve days later the wrist could be raised into a direct
line with forearm, but there was no change in the median
symptoms. A week after this the anæsthetic median area became
posterior to humerus. Slight suppuration. Triceps weakened
only, complete paralysis of radial extensors and posterior
interosseous group. Radial sensation lowered only.
(128) Musculo-spiral.—Entry, 2 inches above and 1/2 an inch
behind the external humeral condyle; exit, at the inner edge of
the biceps, 1/2 an inch lower in the arm than the entry. It is
doubtful whether the paralysis was noted at first, but a few days
later complete posterior interosseous paralysis and lowered
radial sensation were remarked. No change except a deepening
of the anæsthesia, and the development of formication on
manipulation of the wound occurred, and at the end of three
weeks the nerve was exposed (Mr. Watson), and it was found
that a notch had been cut in its outer border, which had opened
out into a V shape. The margins of this notch were refreshed and
the gap closed. Ten days later radial sensation was fairly good,
but the motor symptoms remained unchanged. Nine months
later steady but very slow improvement was reported.
(129) Ulnar and musculo-cutaneous nerves.—Entry, back of
forearm; the bullet passed between the bones and was retained at
the posterior aspect of the arm. Three weeks later the hand was
glossy and stiff, the fingers extended and adducted, the thumb
was held stiffly in the palm with no power of extension. The
forearm was held semiprone, and the elbow flexed by a rigid
biceps. Six months later the same position was maintained, but
the contracture disappeared under an anæsthetic.
(130) Median and posterior interosseous.—Entry, over the
external margin of the radius at the centre of the forearm; exit, at
the inner margin of the olecranon 1½ inch below the tip.
Lowered cutaneous sensation in median distribution, and loss of
median flexion of wrist and fingers. Complete wrist-drop. The
triceps supinator longus and extensor carpi radialis longior were
perfect. Twelve days later the wrist could be raised into a direct
line with forearm, but there was no change in the median
symptoms. A week after this the anæsthetic median area became
Page 419
hyperæsthetic both as to skin and on deep pressure over the
muscles.
(131) Sacral plexus. Great sciatic nerve.—Wounded at Modder
River. Entry, in left loin; exit, at lower margin of buttock. The
wound was followed immediately by complete peroneal
paralysis, both motor and sensory. Fourteen days later
hyperæsthesia developed in the area of distribution of the
internal popliteal nerve, the superficial pain being greatest in the
sole; the muscles of the calf were also very tender on
manipulation. The pain increased, and at the end of twenty-four
days the patient's sufferings were so great that Mr. Thornton cut
down upon and exposed the nerve. It was found embedded in
firm cicatricial tissue close to the sciatic notch; this compressed
the nerve to such a degree that a waist was apparent upon it.
The nerve was freed and resumed its normal outline. For a few
days the patient was much relieved, but the neuralgia then
returned in greater intensity than ever. Morphia was injected
hypodermically, and other hypnotics employed, but with little
effect, the patient developing the hysterical condition so
common in the subjects of severe sciatica. Some five weeks
later a sudden improvement took place, the morphia was
decreased, and the patient became sufficiently well to return to
England, but there was still deep tenderness in the calf, and
well-marked hyperæsthesia of the sole.
A year later the patient had been discharged from the Service,
but was earning his living in a shop. He walked fairly well, but
still with foot-drop, and complained of tenderness in the sole. I
am indebted to Dr. Turney for the following report on the
condition of the muscles.
Calf muscles practically normal. In the anterior tibial and
peroneal groups the faradic irritability is much diminished, that
in the peroneus longus being the lowest of all. Contraction can
be induced in the extensor longus hallucis, extensor longus
muscles.
(131) Sacral plexus. Great sciatic nerve.—Wounded at Modder
River. Entry, in left loin; exit, at lower margin of buttock. The
wound was followed immediately by complete peroneal
paralysis, both motor and sensory. Fourteen days later
hyperæsthesia developed in the area of distribution of the
internal popliteal nerve, the superficial pain being greatest in the
sole; the muscles of the calf were also very tender on
manipulation. The pain increased, and at the end of twenty-four
days the patient's sufferings were so great that Mr. Thornton cut
down upon and exposed the nerve. It was found embedded in
firm cicatricial tissue close to the sciatic notch; this compressed
the nerve to such a degree that a waist was apparent upon it.
The nerve was freed and resumed its normal outline. For a few
days the patient was much relieved, but the neuralgia then
returned in greater intensity than ever. Morphia was injected
hypodermically, and other hypnotics employed, but with little
effect, the patient developing the hysterical condition so
common in the subjects of severe sciatica. Some five weeks
later a sudden improvement took place, the morphia was
decreased, and the patient became sufficiently well to return to
England, but there was still deep tenderness in the calf, and
well-marked hyperæsthesia of the sole.
A year later the patient had been discharged from the Service,
but was earning his living in a shop. He walked fairly well, but
still with foot-drop, and complained of tenderness in the sole. I
am indebted to Dr. Turney for the following report on the
condition of the muscles.
Calf muscles practically normal. In the anterior tibial and
peroneal groups the faradic irritability is much diminished, that
in the peroneus longus being the lowest of all. Contraction can
be induced in the extensor longus hallucis, extensor longus
Page 420
digitorum, and peroneus brevis; but reaction is doubtful in the
case of the tibialis anticus and peroneus longus.
With the galvanic current contraction is sluggish, and the
irritability diminished. No serious changes are present except in
the peroneus longus. ACC > KCC at 10 m. a.
(132) Great sciatic.—Entry, at outer aspect of the thigh, just
above the centre; exit, at the junction of the inner and posterior
aspects of thigh, about 2 inches lower. The wound was produced
by a ricochet bullet, and beyond the perforation of the sciatic
nerve the femur was fractured obliquely (see plate XVI.).
Hyperæsthesia of the sole was noted early, and when I saw the
patient three months later, there was wasting of the muscles of
the leg, and foot-drop, although he walked with a stick.
These symptoms persisted, and on his return to England an
exploration was made by Sir Thomas Smith, and the two
fragments of mantle seen in the skiagram were removed from
the substance of the sciatic nerve. Eight months after the injury,
the patient still walked with foot-drop; there was modified
sensation in the musculo-cutaneous area, and a feeling as if the
bones of the foot were uncovered when he walked. The
circumference of the affected leg was more than 1 inch less than
that of the sound one. Steady but slow improvement was taking
place.
(133) Great sciatic.—In a third patient with a buttock track, the
symptoms were identical with those observed in case 131. In
this an exploration showed that the nerve had been perforated.
Although the symptoms were never so severe as in No. 131, yet
recovery was very much slower and less complete, the muscular
weakness remained more marked, and the skin exhibited more
evidence of trophic lesion. Some contracture of the knee and
rigid foot-drop took place, and at the end of twelve months the
patient walked poorly with a stick. Improvement is, however,
continuing.
case of the tibialis anticus and peroneus longus.
With the galvanic current contraction is sluggish, and the
irritability diminished. No serious changes are present except in
the peroneus longus. ACC > KCC at 10 m. a.
(132) Great sciatic.—Entry, at outer aspect of the thigh, just
above the centre; exit, at the junction of the inner and posterior
aspects of thigh, about 2 inches lower. The wound was produced
by a ricochet bullet, and beyond the perforation of the sciatic
nerve the femur was fractured obliquely (see plate XVI.).
Hyperæsthesia of the sole was noted early, and when I saw the
patient three months later, there was wasting of the muscles of
the leg, and foot-drop, although he walked with a stick.
These symptoms persisted, and on his return to England an
exploration was made by Sir Thomas Smith, and the two
fragments of mantle seen in the skiagram were removed from
the substance of the sciatic nerve. Eight months after the injury,
the patient still walked with foot-drop; there was modified
sensation in the musculo-cutaneous area, and a feeling as if the
bones of the foot were uncovered when he walked. The
circumference of the affected leg was more than 1 inch less than
that of the sound one. Steady but slow improvement was taking
place.
(133) Great sciatic.—In a third patient with a buttock track, the
symptoms were identical with those observed in case 131. In
this an exploration showed that the nerve had been perforated.
Although the symptoms were never so severe as in No. 131, yet
recovery was very much slower and less complete, the muscular
weakness remained more marked, and the skin exhibited more
evidence of trophic lesion. Some contracture of the knee and
rigid foot-drop took place, and at the end of twelve months the
patient walked poorly with a stick. Improvement is, however,
continuing.
Page 421
(134) Great sciatic.—Wounded at Ladysmith. Entry,
immediately below left buttock fold; exit, at anterior aspect of
thigh, 3½ inches below Poupart's ligament. The left leg was
paralysed, and patient was sent down to the Base, where he
remained two months. The wound closed by primary union, the
paralysis improved, and the man rejoined his regiment. After he
had been in camp four days, his leg gave way, and he returned to
hospital, where he contracted enteric fever. Later, he was sent
home, and eight months after the reception of the injury his
condition was as follows:
Left lower limb somewhat wasted, a diminution of 1 inch in the
circumference of the leg and 1/2 an inch in the thigh being
found. The patient walks with foot-drop, and the flexor muscles
of the knee are weak. On examination the peroneal muscles
reacted but sluggishly to faradic irritation. There is complete
anæsthesia of the foot to above the ankle, and up to the knee
tactile sensation and appreciation of pain were dulled. The left
plantar reflex was absent, the right slight, the left patellar reflex
was abnormally brisk. There was neither ankle nor patellar
clonus, and the other reflexes were present and normal. The gait
was spastic, and the patient was more troubled by a contraction
of the calf muscles, which prevented his putting the heel to the
ground, than by the foot-drop.
Beyond these local phenomena there was marked tremor of the
upper extremities on any exertion, and slight lateral nystagmus.
The patient was not sure that this had not been present ever
since he recovered from the enteric fever, but it was sufficiently
marked to give rise to the suspicion of the development of
disseminated sclerosis.
The patient was a hard-headed, sensible man. He remained in
the hospital under the care of Dr. Turney, to whom I am indebted
for notes of the case, forty-six days. During this period he was
treated by faradic electricity, and, with some checks, notably the
development of passive effusion into the left knee-joint, and a
fugitive attack of redness over the dorsum of the foot, both
immediately below left buttock fold; exit, at anterior aspect of
thigh, 3½ inches below Poupart's ligament. The left leg was
paralysed, and patient was sent down to the Base, where he
remained two months. The wound closed by primary union, the
paralysis improved, and the man rejoined his regiment. After he
had been in camp four days, his leg gave way, and he returned to
hospital, where he contracted enteric fever. Later, he was sent
home, and eight months after the reception of the injury his
condition was as follows:
Left lower limb somewhat wasted, a diminution of 1 inch in the
circumference of the leg and 1/2 an inch in the thigh being
found. The patient walks with foot-drop, and the flexor muscles
of the knee are weak. On examination the peroneal muscles
reacted but sluggishly to faradic irritation. There is complete
anæsthesia of the foot to above the ankle, and up to the knee
tactile sensation and appreciation of pain were dulled. The left
plantar reflex was absent, the right slight, the left patellar reflex
was abnormally brisk. There was neither ankle nor patellar
clonus, and the other reflexes were present and normal. The gait
was spastic, and the patient was more troubled by a contraction
of the calf muscles, which prevented his putting the heel to the
ground, than by the foot-drop.
Beyond these local phenomena there was marked tremor of the
upper extremities on any exertion, and slight lateral nystagmus.
The patient was not sure that this had not been present ever
since he recovered from the enteric fever, but it was sufficiently
marked to give rise to the suspicion of the development of
disseminated sclerosis.
The patient was a hard-headed, sensible man. He remained in
the hospital under the care of Dr. Turney, to whom I am indebted
for notes of the case, forty-six days. During this period he was
treated by faradic electricity, and, with some checks, notably the
development of passive effusion into the left knee-joint, and a
fugitive attack of redness over the dorsum of the foot, both
Page 422
suggesting trophic changes, steadily improved. The anæsthesia
became limited to the outer half of the leg, at the end of one
month was limited to the dorsum of the foot only, and at the end
of six weeks entirely disappeared. Meanwhile the tendency to
drawing up of the heel by the calf muscles became less, and the
gait improved. The man left the hospital at the end of two
months, very satisfied with his condition, although the tremor of
the hands was still present in a lessened degree.
(135) External popliteal.—Wounded at Magersfontein, 250-300
yards. Entry, at the outer side of the thigh, 5 inches above the
lower extremity of the external condyle; exit, at the inner margin
of the adductors, at a level 4 inches higher in the thigh. The
track crossed behind the femur. Complete peroneal motor
paralysis and anæsthesia, except in the hinder part of the region
supplied by the mixed external saphenous. Slight hyperæsthesia
of the sole. Improving at the end of three weeks, but paralysis
still nearly complete.
(136) External popliteal.—Wounded at Magersfontein. Entry, 5
inches below the highest part of the right iliac crest, on outer
aspect of hip; exit, at the posterior margin of the gracilis, 2
inches from the perineum. Complete peroneal paralysis
followed, which rapidly improved, and on the twenty-second
day was nearly well.
(137) Internal popliteal. Secondary anæsthesia.—Shell wounds
of the right popliteal space. Wounded at Belmont. Anæsthesia of
the outer side of the calf, the leg and sole of foot. No motor
paralysis. As cicatrisation progressed, the anæsthesia became
more marked and was complete over the whole of the external
saphenous area.
(138) Internal popliteal.—Wounded at Paardeberg. 400-500
yards. Entry, about the centre of the outer half of the patella;
exit, at the centre of the calf, about 2 inches from the popliteal
crease. Five days after the injury severe burning pain developed
in the sole. A fortnight later the pain was much less severe, but
became limited to the outer half of the leg, at the end of one
month was limited to the dorsum of the foot only, and at the end
of six weeks entirely disappeared. Meanwhile the tendency to
drawing up of the heel by the calf muscles became less, and the
gait improved. The man left the hospital at the end of two
months, very satisfied with his condition, although the tremor of
the hands was still present in a lessened degree.
(135) External popliteal.—Wounded at Magersfontein, 250-300
yards. Entry, at the outer side of the thigh, 5 inches above the
lower extremity of the external condyle; exit, at the inner margin
of the adductors, at a level 4 inches higher in the thigh. The
track crossed behind the femur. Complete peroneal motor
paralysis and anæsthesia, except in the hinder part of the region
supplied by the mixed external saphenous. Slight hyperæsthesia
of the sole. Improving at the end of three weeks, but paralysis
still nearly complete.
(136) External popliteal.—Wounded at Magersfontein. Entry, 5
inches below the highest part of the right iliac crest, on outer
aspect of hip; exit, at the posterior margin of the gracilis, 2
inches from the perineum. Complete peroneal paralysis
followed, which rapidly improved, and on the twenty-second
day was nearly well.
(137) Internal popliteal. Secondary anæsthesia.—Shell wounds
of the right popliteal space. Wounded at Belmont. Anæsthesia of
the outer side of the calf, the leg and sole of foot. No motor
paralysis. As cicatrisation progressed, the anæsthesia became
more marked and was complete over the whole of the external
saphenous area.
(138) Internal popliteal.—Wounded at Paardeberg. 400-500
yards. Entry, about the centre of the outer half of the patella;
exit, at the centre of the calf, about 2 inches from the popliteal
crease. Five days after the injury severe burning pain developed
in the sole. A fortnight later the pain was much less severe, but
Page 423
varied in degree with the heat of the weather, being worse when
cool. At this date, however, rubbing became comforting.
(139) External popliteal.—-Wounded at Magersfontein. Entry, 1
inch above the upper end of the internal margin of the patella;
exit, at the margin of leg, just below the outer tuberosity of the
tibia. Complete peroneal paralysis followed the injury. A month
later the nerve was bared and found slightly thickened. An
improvement in cutaneous sensation followed quickly, and a
much slower improvement in the motor power commenced.
(140) External popliteal nerve.—Wounded at Beacon Hill. A
bayonet entered over upper quarter of fibula, and passed
between the bones of leg into the calf. An aneurismal varix of
the calf vessels developed, also incomplete peroneal paralysis.
The scar was raised from the nerve (Major Simpson, R.A.M.C.)
six weeks later, and at the end of a fortnight the power and
sensation were both much improved and the patient returned to
England.
(141) External popliteal.—Wounded at Modder River. Entry,
1/2 an inch above the internal border of the patella; exit, 1½ inch
from the head of the fibula and over that bone. The wound was
followed by peroneal paralysis. Six weeks later sensation was
still diminished in the anterior tibial and musculo-cutaneous
nerve areas, and marked foot-drop, little improved, persisted.
The patient came to England, and at the end of twelve months is
reported as very little improved.
(142) Anterior tibial.—Entry, 1 inch in front and below the
external malleolus; exit, at the centre of the sole, just anterior to
the bases of the metatarsal bones. Wasting and paralysis of
extensor brevis digitorum.
(143) Small sciatic and small saphenous.—Wounded at
Magersfontein. 200 yards. Two wounds: (i) Entry, below the
centre of the twelfth rib on the left side; exit, immediately to the
left of the buttock furrow at upper part, (ii) Entry, in the right
loin, midway between the last rib and iliac crest; exit, just within
cool. At this date, however, rubbing became comforting.
(139) External popliteal.—-Wounded at Magersfontein. Entry, 1
inch above the upper end of the internal margin of the patella;
exit, at the margin of leg, just below the outer tuberosity of the
tibia. Complete peroneal paralysis followed the injury. A month
later the nerve was bared and found slightly thickened. An
improvement in cutaneous sensation followed quickly, and a
much slower improvement in the motor power commenced.
(140) External popliteal nerve.—Wounded at Beacon Hill. A
bayonet entered over upper quarter of fibula, and passed
between the bones of leg into the calf. An aneurismal varix of
the calf vessels developed, also incomplete peroneal paralysis.
The scar was raised from the nerve (Major Simpson, R.A.M.C.)
six weeks later, and at the end of a fortnight the power and
sensation were both much improved and the patient returned to
England.
(141) External popliteal.—Wounded at Modder River. Entry,
1/2 an inch above the internal border of the patella; exit, 1½ inch
from the head of the fibula and over that bone. The wound was
followed by peroneal paralysis. Six weeks later sensation was
still diminished in the anterior tibial and musculo-cutaneous
nerve areas, and marked foot-drop, little improved, persisted.
The patient came to England, and at the end of twelve months is
reported as very little improved.
(142) Anterior tibial.—Entry, 1 inch in front and below the
external malleolus; exit, at the centre of the sole, just anterior to
the bases of the metatarsal bones. Wasting and paralysis of
extensor brevis digitorum.
(143) Small sciatic and small saphenous.—Wounded at
Magersfontein. 200 yards. Two wounds: (i) Entry, below the
centre of the twelfth rib on the left side; exit, immediately to the
left of the buttock furrow at upper part, (ii) Entry, in the right
loin, midway between the last rib and iliac crest; exit, just within
Page 424
the centre of the left buttock; the two wounds crossed
diagonally. Hyperæsthesia in area of distribution of small
saphenous and small sciatic nerves, which rapidly improved.
(144) Lumbar plexus.—Boer, wounded at Magersfontein. Entry,
eleventh interspace, posterior axillary line; exit, tenth interspace,
right mid-axillary line. Impaired sensation in area of distribution
of external cutaneous and crural branch of genito-crural nerves.
At the end of a fortnight anæsthesia was less apparent, but a
feeling of numbness persisted, which soon disappeared.
Prognosis and treatment.—In considering the prognosis in cases of nerve
injury, several of the points already raised as to the nature of the lesion are
of importance. Short of actual section, it may be broadly stated that no
lesion is too serious to render ultimate recovery impossible.
In cases in which the injury has been produced by a bullet fired at a short
range, or in which contact with the nerve has been close, the return of
functional activity is very slow. In such instances the condition probably
resembles that in which a divided nerve has been sutured, with the
additional disadvantage that a considerable portion of the nerve, both above
and below the point actually struck, has been destroyed as far as the
conduction of nervous impulses is concerned. This may reasonably be
concluded in the light of the evidence offered by the injuries of the spinal
cord, in which several segments usually suffered if the velocity of the bullet
was great, and also if the fact is remembered that, when thickening takes
place, a considerable length of the nerve is usually implicated.
Recovery is notably slow in the case of certain nerves, e.g. musculo-spiral
and peroneal, even when the injury has not been of extreme severity. Again,
these same nerves are apparently more seriously affected by moderate
degrees of damage than are others.
As favourable prognostic elements we may bear in mind: low velocity on
the part of the travelling bullet, and with this a lesser degree of contiguity of
the track to the nerve. The early return of sensation is a favourable sign, and
in this relation the development of hyperæsthesia, whether preceded by
anæsthesia or no, points to the maintenance of continuity of, and a moderate
degree of damage to, the nerve. The early return of sensation, even if
diagonally. Hyperæsthesia in area of distribution of small
saphenous and small sciatic nerves, which rapidly improved.
(144) Lumbar plexus.—Boer, wounded at Magersfontein. Entry,
eleventh interspace, posterior axillary line; exit, tenth interspace,
right mid-axillary line. Impaired sensation in area of distribution
of external cutaneous and crural branch of genito-crural nerves.
At the end of a fortnight anæsthesia was less apparent, but a
feeling of numbness persisted, which soon disappeared.
Prognosis and treatment.—In considering the prognosis in cases of nerve
injury, several of the points already raised as to the nature of the lesion are
of importance. Short of actual section, it may be broadly stated that no
lesion is too serious to render ultimate recovery impossible.
In cases in which the injury has been produced by a bullet fired at a short
range, or in which contact with the nerve has been close, the return of
functional activity is very slow. In such instances the condition probably
resembles that in which a divided nerve has been sutured, with the
additional disadvantage that a considerable portion of the nerve, both above
and below the point actually struck, has been destroyed as far as the
conduction of nervous impulses is concerned. This may reasonably be
concluded in the light of the evidence offered by the injuries of the spinal
cord, in which several segments usually suffered if the velocity of the bullet
was great, and also if the fact is remembered that, when thickening takes
place, a considerable length of the nerve is usually implicated.
Recovery is notably slow in the case of certain nerves, e.g. musculo-spiral
and peroneal, even when the injury has not been of extreme severity. Again,
these same nerves are apparently more seriously affected by moderate
degrees of damage than are others.
As favourable prognostic elements we may bear in mind: low velocity on
the part of the travelling bullet, and with this a lesser degree of contiguity of
the track to the nerve. The early return of sensation is a favourable sign, and
in this relation the development of hyperæsthesia, whether preceded by
anæsthesia or no, points to the maintenance of continuity of, and a moderate
degree of damage to, the nerve. The early return of sensation, even if
Page 425
modified in acuteness, was always a very hopeful sign; also the production
of formication in the area of distribution of the nerve on manipulation of the
injured spot. As in the case of nerve injuries of every nature, the disposition
and temperament of the patient exerted considerable influence on the course
of the cases.
Complete section of the nerves in these bullet wounds only obtained special
importance in two ways: first, in that a considerable portion of the trunk
might be shot away in oblique tracks, and, secondly, in that very severe
contusion might affect the nerve for a considerable distance beyond the
point actually implicated. In point of fact, complete section when treated by
suture was often more rapidly recovered from than an injury in which only
a portion of the width of a trunk was divided. This was no doubt to be
explained on the theory that the contiguous portion of the nerve suffered
less when tension and resistance were lessened by complete severance of
the cord.
The treatment of slight nerve contusion was simple; rest alone was
necessary, and in the course of hours or days paralysis was recovered from.
The symptoms were most troublesome in patients of a neurotic
temperament, or those who had suffered from severe systemic shock.
In severe concussions and contusions the first care had to be devoted to the
discrimination of the lesion from that of division. A period of rest then
needed to be followed by one of massage and movement, to maintain the
nutrition of the muscles. In a considerable portion of the cases a stage of
neuritis had to be expected. In all cases, either of severe concussion,
contusion, or complete section, accompanied by the fracture of a bone,
especial care was necessary that the bandaging and fixation of the limb
were not sufficiently tight to add the dangers of muscular ischæmia to those
of the nerve injury already present.
Neuritis, whether dependent on local injury, implication in the scar, pressure
from callus, or of the ascending variety, needed the same treatment: rest,
preservation of the limb from cold or damp, and the local application of
anodynes, as belladonna, or hot laudanum fomentations. In some cases a
general anodyne, as morphia, was preferable; then always to be used with
caution, as the patients soon craved inordinately for it, and were unwilling
of formication in the area of distribution of the nerve on manipulation of the
injured spot. As in the case of nerve injuries of every nature, the disposition
and temperament of the patient exerted considerable influence on the course
of the cases.
Complete section of the nerves in these bullet wounds only obtained special
importance in two ways: first, in that a considerable portion of the trunk
might be shot away in oblique tracks, and, secondly, in that very severe
contusion might affect the nerve for a considerable distance beyond the
point actually implicated. In point of fact, complete section when treated by
suture was often more rapidly recovered from than an injury in which only
a portion of the width of a trunk was divided. This was no doubt to be
explained on the theory that the contiguous portion of the nerve suffered
less when tension and resistance were lessened by complete severance of
the cord.
The treatment of slight nerve contusion was simple; rest alone was
necessary, and in the course of hours or days paralysis was recovered from.
The symptoms were most troublesome in patients of a neurotic
temperament, or those who had suffered from severe systemic shock.
In severe concussions and contusions the first care had to be devoted to the
discrimination of the lesion from that of division. A period of rest then
needed to be followed by one of massage and movement, to maintain the
nutrition of the muscles. In a considerable portion of the cases a stage of
neuritis had to be expected. In all cases, either of severe concussion,
contusion, or complete section, accompanied by the fracture of a bone,
especial care was necessary that the bandaging and fixation of the limb
were not sufficiently tight to add the dangers of muscular ischæmia to those
of the nerve injury already present.
Neuritis, whether dependent on local injury, implication in the scar, pressure
from callus, or of the ascending variety, needed the same treatment: rest,
preservation of the limb from cold or damp, and the local application of
anodynes, as belladonna, or hot laudanum fomentations. In some cases a
general anodyne, as morphia, was preferable; then always to be used with
caution, as the patients soon craved inordinately for it, and were unwilling
Page 426
to give it up. Later, local blisters in the line of the nerve trunk, careful
massage and exercise when muscular and cutaneous tenderness had
subsided, the application of the continuous current to the nerves, and
perhaps faradisation of the muscles, were all useful.
Splints were often temporarily required to resist contracture, or the
assumption of false positions; in either case they needed to be frequently
removed, and movement &c. made, in order to avoid any chance of
troublesome stiffness.
Operative treatment.—Early interference was only warranted by positive
knowledge that some source of irritation or pressure could be removed; thus
a bone spicule, or a bullet, or part of one, particularly portions of mantles.
In case of contusion the expiration of three months is the earliest date at
which any operation should be taken into consideration, and interference is
only then advisable if there is good prospect of freeing the nerve from
compressing adhesions. The two strongest indications for operation are (1)
signs pointing to the secondary implication of the nerve in a cicatrix,
especially when these are of such a nature as to indicate local tension,
fixation, or pressure; (2) the possibility of the irritation being the result of
the presence of some foreign body, such as a bone spicule, or portions of a
bullet mantle; in such cases the X rays will often give useful help.
With regard to the early exploration of cases of traumatic neuralgia, it may
be pointed out that when this was undertaken the results were as a rule very
temporary. In many cases in which the measure was resorted to, either no
macroscopic evidence of injury to the nerve was discovered, or a bulbous
thickening was met with of such extent as to make excision inadvisable,
even if it were considered otherwise the most suitable treatment.
Even when complete section of the nerve was assured by the absence of any
power of reaction to stimulation by electricity from above on the part of the
muscles, operation was better not undertaken until cicatrisation had reached
a certain stage. If done earlier than at the end of three weeks, the sutured
spot became implicated in a hard cicatrix, and any advantage to be obtained
by early interference was lost. When partial division of a trunk was
determined, the same date was the most favourable one for exploration, the
gap in the nerve being freshened and closed by suture. There is little doubt,
massage and exercise when muscular and cutaneous tenderness had
subsided, the application of the continuous current to the nerves, and
perhaps faradisation of the muscles, were all useful.
Splints were often temporarily required to resist contracture, or the
assumption of false positions; in either case they needed to be frequently
removed, and movement &c. made, in order to avoid any chance of
troublesome stiffness.
Operative treatment.—Early interference was only warranted by positive
knowledge that some source of irritation or pressure could be removed; thus
a bone spicule, or a bullet, or part of one, particularly portions of mantles.
In case of contusion the expiration of three months is the earliest date at
which any operation should be taken into consideration, and interference is
only then advisable if there is good prospect of freeing the nerve from
compressing adhesions. The two strongest indications for operation are (1)
signs pointing to the secondary implication of the nerve in a cicatrix,
especially when these are of such a nature as to indicate local tension,
fixation, or pressure; (2) the possibility of the irritation being the result of
the presence of some foreign body, such as a bone spicule, or portions of a
bullet mantle; in such cases the X rays will often give useful help.
With regard to the early exploration of cases of traumatic neuralgia, it may
be pointed out that when this was undertaken the results were as a rule very
temporary. In many cases in which the measure was resorted to, either no
macroscopic evidence of injury to the nerve was discovered, or a bulbous
thickening was met with of such extent as to make excision inadvisable,
even if it were considered otherwise the most suitable treatment.
Even when complete section of the nerve was assured by the absence of any
power of reaction to stimulation by electricity from above on the part of the
muscles, operation was better not undertaken until cicatrisation had reached
a certain stage. If done earlier than at the end of three weeks, the sutured
spot became implicated in a hard cicatrix, and any advantage to be obtained
by early interference was lost. When partial division of a trunk was
determined, the same date was the most favourable one for exploration, the
gap in the nerve being freshened and closed by suture. There is little doubt,
Page 427
however, that in some cases such injuries were recovered from
spontaneously.
In view of the uniformly bad results observed in the case of the seventh
nerve, I am inclined to think that the above rules might be tentatively
relaxed, and the nerve primarily explored by an operation resembling that
for mastoid suppuration. It is of course doubtful whether the trouble does
not generally result from the vibratory concussion alone; but as this is not
certain, and the operation would only have to be performed on patients
already permanently deaf, it might be worth while at any rate opening the
Fallopian canal with the object of relieving tension. It is not probable that in
any of the cases quoted much splintering of the bone had occurred, as the
wounds appeared to be of the nature of pure perforations.
spontaneously.
In view of the uniformly bad results observed in the case of the seventh
nerve, I am inclined to think that the above rules might be tentatively
relaxed, and the nerve primarily explored by an operation resembling that
for mastoid suppuration. It is of course doubtful whether the trouble does
not generally result from the vibratory concussion alone; but as this is not
certain, and the operation would only have to be performed on patients
already permanently deaf, it might be worth while at any rate opening the
Fallopian canal with the object of relieving tension. It is not probable that in
any of the cases quoted much splintering of the bone had occurred, as the
wounds appeared to be of the nature of pure perforations.
Page 428
CHAPTER X
INJURIES TO THE CHEST
In regard to Prognosis wounds of the chest furnished the most hopeful class
of the whole series of trunk or visceral injuries. Cases of wound of the heart
and great vessels afforded the only exceptions to an almost universally
favourable course, both as regards life and the non-occurrence of serious
after-effects.
This was mainly explicable on two grounds: first, the sharply localised
character of the lesion produced by the bullet of small calibre; and,
secondly, the fact that the lung, the most frequently injured organ, is not
materially affected by the grade of velocity with which the bullet strikes. In
point of fact, wounds of this organ probably afford an instance in which
high grades of velocity are distinctly favourable to the nature of the injury,
and this is possibly true in the case of wounds of the chest-wall also.
The significance of the calibre of the bullet in wounds of the chest is
evident. The late Mr. Archibald Forbes, in one of his letters from the seat of
the Franco-German war, remarked that in crossing a battlefield it was easy
to recognise the patients who had suffered a wound of the lung from the fact
that the whistle of the air entering and leaving the chest was plainly audible.
This was, indeed, not uncommonly the case in wounds produced by the
older bullets of large calibre, but with the employment of the smaller
projectile it has become an experience of the past. Some evidence as to the
comparative severity of wounds produced by the larger forms of bullet was,
moreover, afforded by the present campaign, since Martini-Henry wounds
were occasionally met with. Of some instances observed by myself, in one,
external hæmorrhage was a prominent symptom; in another, a piece of lung
was prolapsed from a wound in the back, and twice I observed
pneumothorax, an uncommon sequela to wounds from bullets of small
calibre.
INJURIES TO THE CHEST
In regard to Prognosis wounds of the chest furnished the most hopeful class
of the whole series of trunk or visceral injuries. Cases of wound of the heart
and great vessels afforded the only exceptions to an almost universally
favourable course, both as regards life and the non-occurrence of serious
after-effects.
This was mainly explicable on two grounds: first, the sharply localised
character of the lesion produced by the bullet of small calibre; and,
secondly, the fact that the lung, the most frequently injured organ, is not
materially affected by the grade of velocity with which the bullet strikes. In
point of fact, wounds of this organ probably afford an instance in which
high grades of velocity are distinctly favourable to the nature of the injury,
and this is possibly true in the case of wounds of the chest-wall also.
The significance of the calibre of the bullet in wounds of the chest is
evident. The late Mr. Archibald Forbes, in one of his letters from the seat of
the Franco-German war, remarked that in crossing a battlefield it was easy
to recognise the patients who had suffered a wound of the lung from the fact
that the whistle of the air entering and leaving the chest was plainly audible.
This was, indeed, not uncommonly the case in wounds produced by the
older bullets of large calibre, but with the employment of the smaller
projectile it has become an experience of the past. Some evidence as to the
comparative severity of wounds produced by the larger forms of bullet was,
moreover, afforded by the present campaign, since Martini-Henry wounds
were occasionally met with. Of some instances observed by myself, in one,
external hæmorrhage was a prominent symptom; in another, a piece of lung
was prolapsed from a wound in the back, and twice I observed
pneumothorax, an uncommon sequela to wounds from bullets of small
calibre.
Page 429
It may be remarked, however, that all these more serious injuries were
recovered from, also that when we consider that the patients were
comparatively young and healthy subjects, the favourable prognosis was
what might have reasonably been expected. When, as occasionally
happened, a patient of more mature years, with enlarged facial capillaries,
received a wound of the lung, the course was in no way so favourable as
that witnessed in the case of the younger men.
In support of this opinion I may add that wounds from shrapnel and
fragments of shell also did remarkably well, although they sometimes gave
rise to more troublesome symptoms than did wounds produced by bullets of
the Mauser type. Again, these injuries as a whole were of nothing like so
serious a nature as the lacerations of the lung produced by fractured ribs,
which we commonly have to treat in civil practice, and are not accustomed
to regard as especially dangerous.
It is also a striking fact that the most common and troublesome
complication of wounds of the chest, hæmothorax, was usually the result of
the wound of the chest-wall and not of the lung. I preface these remarks to
the detailed account of the thoracic injuries, because I think the favourable
course usually taken by patients with wounds of the lung has been accorded
somewhat greater prominence than the circumstances warranted.
Non-penetrating wounds of the chest-wall.—Surface wounds were not very
common, and were chiefly of interest in so far as they illustrated the very
superficial course that may be occasionally taken by a bullet without breach
of the integument, and as sometimes affording opportunity for the exercise
of diagnostic skill when the track traversed the axilla.
The most common situation for tracks taking a long course on the surface of
the thoracic skeleton was the back. Such wounds were usually received
while the patients were prone on the ground; thus I might instance a case in
which the bullet entered the posterior aspect of the shoulder 3 inches above
the spine of the scapula, passed downwards, pierced that process, and
emerged 2 inches below the inferior angle of the bone. Wounds of a similar
nature coursing in transverse and oblique directions, and not implicating
bone, were also seen. Those implicating the vertebræ have been already
dealt with. The scapular region was also a favourite one for the lodgment of
recovered from, also that when we consider that the patients were
comparatively young and healthy subjects, the favourable prognosis was
what might have reasonably been expected. When, as occasionally
happened, a patient of more mature years, with enlarged facial capillaries,
received a wound of the lung, the course was in no way so favourable as
that witnessed in the case of the younger men.
In support of this opinion I may add that wounds from shrapnel and
fragments of shell also did remarkably well, although they sometimes gave
rise to more troublesome symptoms than did wounds produced by bullets of
the Mauser type. Again, these injuries as a whole were of nothing like so
serious a nature as the lacerations of the lung produced by fractured ribs,
which we commonly have to treat in civil practice, and are not accustomed
to regard as especially dangerous.
It is also a striking fact that the most common and troublesome
complication of wounds of the chest, hæmothorax, was usually the result of
the wound of the chest-wall and not of the lung. I preface these remarks to
the detailed account of the thoracic injuries, because I think the favourable
course usually taken by patients with wounds of the lung has been accorded
somewhat greater prominence than the circumstances warranted.
Non-penetrating wounds of the chest-wall.—Surface wounds were not very
common, and were chiefly of interest in so far as they illustrated the very
superficial course that may be occasionally taken by a bullet without breach
of the integument, and as sometimes affording opportunity for the exercise
of diagnostic skill when the track traversed the axilla.
The most common situation for tracks taking a long course on the surface of
the thoracic skeleton was the back. Such wounds were usually received
while the patients were prone on the ground; thus I might instance a case in
which the bullet entered the posterior aspect of the shoulder 3 inches above
the spine of the scapula, passed downwards, pierced that process, and
emerged 2 inches below the inferior angle of the bone. Wounds of a similar
nature coursing in transverse and oblique directions, and not implicating
bone, were also seen. Those implicating the vertebræ have been already
dealt with. The scapular region was also a favourite one for the lodgment of
Page 430
retained bullets, some resting in the supra- and infra-spinatus muscles,
others lying beneath the bone itself.
On the anterior aspect of the chest, bullets coming from the front sometimes
traversed and fractured the clavicle, and then took a short course
downwards, emerging over the ribs or sternum. Figure 81 represents a
particularly long track in this region. In other cases the precordial region
was crossed, but I never witnessed any serious effect on the heart's action in
any such injury at the time the patients came under my notice.
Wounds received with the arm outstretched and traversing the axilla
sometimes gave considerable trouble in excluding with certainty a
perforation of the thoracic cavity. Thus a bullet entered below the centre of
the right clavicle and emerged 2½ inches below, above the angle of the
scapula, at its axillary margin. The arm was outstretched at the moment of
the reception of the injury; but when the wound was viewed with the limb
placed alongside the trunk, it seemed almost impossible that the chest
cavity could have escaped. In some cases of this kind the difficulty was at
once cleared up by noting evidence of injury to the axillary nerves.
A word will suffice as to the treatment of these wounds. The only special
indication was to keep the scapula at rest for a sufficient period. I have dealt
with the anatomy of them at such length only because in their extreme form
they are so highly characteristic of the nature of the injuries which may be
produced by bullets of small calibre.
Penetrating wounds of the chest.—Tracks crossing the thoracic cavity in
every direction were common. When the erect attitude was maintained,
frontal and sagittal wounds, pure or oblique, were received; when the prone
position was assumed, longitudinal tracks, either purely or obliquely
vertical, were the rule. Experience of wounds of the latter class was
extensive in the present campaign, from the fact that so many of the
advances were made in prone or crawling attitudes. The vertical and
transverse tracks each possessed the special characteristic of frequently
implicating both the thoracic and abdominal cavities, but the vertical were
often prolonged into the neck, or even downwards through the pelvis. The
vertical wounds in addition sometimes exhibited one very important
others lying beneath the bone itself.
On the anterior aspect of the chest, bullets coming from the front sometimes
traversed and fractured the clavicle, and then took a short course
downwards, emerging over the ribs or sternum. Figure 81 represents a
particularly long track in this region. In other cases the precordial region
was crossed, but I never witnessed any serious effect on the heart's action in
any such injury at the time the patients came under my notice.
Wounds received with the arm outstretched and traversing the axilla
sometimes gave considerable trouble in excluding with certainty a
perforation of the thoracic cavity. Thus a bullet entered below the centre of
the right clavicle and emerged 2½ inches below, above the angle of the
scapula, at its axillary margin. The arm was outstretched at the moment of
the reception of the injury; but when the wound was viewed with the limb
placed alongside the trunk, it seemed almost impossible that the chest
cavity could have escaped. In some cases of this kind the difficulty was at
once cleared up by noting evidence of injury to the axillary nerves.
A word will suffice as to the treatment of these wounds. The only special
indication was to keep the scapula at rest for a sufficient period. I have dealt
with the anatomy of them at such length only because in their extreme form
they are so highly characteristic of the nature of the injuries which may be
produced by bullets of small calibre.
Penetrating wounds of the chest.—Tracks crossing the thoracic cavity in
every direction were common. When the erect attitude was maintained,
frontal and sagittal wounds, pure or oblique, were received; when the prone
position was assumed, longitudinal tracks, either purely or obliquely
vertical, were the rule. Experience of wounds of the latter class was
extensive in the present campaign, from the fact that so many of the
advances were made in prone or crawling attitudes. The vertical and
transverse tracks each possessed the special characteristic of frequently
implicating both the thoracic and abdominal cavities, but the vertical were
often prolonged into the neck, or even downwards through the pelvis. The
vertical wounds in addition sometimes exhibited one very important
Page 431
feature, the fracture of several ribs from within, often at a very considerable
distance from the aperture of either entry or exit.
Fig. 81.—Superficial Track in anterior
Wall of Trunk
Characters of the apertures of entry and exit.—As has already been
mentioned, the chest-wall was one of the situations in which the aperture of
entry was often large, and the oval form due to obliquity of impact on the
part of the bullet was particularly well marked. The exit wounds were often
smaller than those of entry, especially if the bullet emerged by an intercostal
space; even when the ribs were comminuted, the fragments were, as a rule,
too small to occasion more than a slightly enlarged and irregular aperture.
Taken as a class, however, and putting aside explosive exit wounds, wounds
of the chest afforded more numerous examples of irregular outline and
variation in size than were met with in any other region of the body.
distance from the aperture of either entry or exit.
Fig. 81.—Superficial Track in anterior
Wall of Trunk
Characters of the apertures of entry and exit.—As has already been
mentioned, the chest-wall was one of the situations in which the aperture of
entry was often large, and the oval form due to obliquity of impact on the
part of the bullet was particularly well marked. The exit wounds were often
smaller than those of entry, especially if the bullet emerged by an intercostal
space; even when the ribs were comminuted, the fragments were, as a rule,
too small to occasion more than a slightly enlarged and irregular aperture.
Taken as a class, however, and putting aside explosive exit wounds, wounds
of the chest afforded more numerous examples of irregular outline and
variation in size than were met with in any other region of the body.
Page 432
When the tracks penetrated the broad upper intercostal spaces, an
interesting feature, due to the tense and rigid nature of the muscles closing
the intervals, and their large admixture of fibrous tissue, was sometimes
noticed. The bullet, especially if passing obliquely, was apt to cut a slit in
the muscles far exceeding in size the opening in the overlying integument,
with the result of leaving a palpable subcutaneous defect. Under these
circumstances the yielding spot was often noticed to rise and fall with the
movements of respiration, external palpation met with an absence of normal
resistance, and there was impulse on coughing.
Fractures of the ribs.—These injuries were produced in either transverse or
longitudinal coursing tracks, their special feature being a sharp localisation
of the lesion of the bone.
In tracks crossing the chest transversely the injury to the ribs might consist
in notching, perforation, or complete solution of continuity, sometimes with
fine comminution. In the incomplete injuries some importance attached to
the localisation of the lesion to the upper or lower border of the rib, in so far
as the intercostal artery was concerned. Comminution at the wound of entry
was, as a rule, not so extensive as at the aperture of exit, and in any case
was less apparent, since the fragments were driven inward. The wider
comminution at the exit aperture depends on the lesser degree of support
afforded by the thoracic coverings to the convex outer surface of the rib,
and on the fact that the velocity of the bullet has been lowered by its
passage through the opposite rib and the chest cavity.
The splinters of comminuted ribs are small, and wide-reaching fissures rare.
These characters depend on the elastic nature of the resistance offered by
the curved rib to the passage of the bullet, which is calculated to preserve
the bone from the full force of impact, except at the point actually impinged
upon.
Fractures of the ribs, produced from within by bullets taking a longitudinal
course through the thorax, were still more special in character. They were
also more important, as giving rise to troublesome symptoms.
In these, again, the degree of injury to the bones varied considerably. In
some cases the bones were merely grooved internally, without any external
deformity; in other cases a sort of green-stick fracture was produced,
interesting feature, due to the tense and rigid nature of the muscles closing
the intervals, and their large admixture of fibrous tissue, was sometimes
noticed. The bullet, especially if passing obliquely, was apt to cut a slit in
the muscles far exceeding in size the opening in the overlying integument,
with the result of leaving a palpable subcutaneous defect. Under these
circumstances the yielding spot was often noticed to rise and fall with the
movements of respiration, external palpation met with an absence of normal
resistance, and there was impulse on coughing.
Fractures of the ribs.—These injuries were produced in either transverse or
longitudinal coursing tracks, their special feature being a sharp localisation
of the lesion of the bone.
In tracks crossing the chest transversely the injury to the ribs might consist
in notching, perforation, or complete solution of continuity, sometimes with
fine comminution. In the incomplete injuries some importance attached to
the localisation of the lesion to the upper or lower border of the rib, in so far
as the intercostal artery was concerned. Comminution at the wound of entry
was, as a rule, not so extensive as at the aperture of exit, and in any case
was less apparent, since the fragments were driven inward. The wider
comminution at the exit aperture depends on the lesser degree of support
afforded by the thoracic coverings to the convex outer surface of the rib,
and on the fact that the velocity of the bullet has been lowered by its
passage through the opposite rib and the chest cavity.
The splinters of comminuted ribs are small, and wide-reaching fissures rare.
These characters depend on the elastic nature of the resistance offered by
the curved rib to the passage of the bullet, which is calculated to preserve
the bone from the full force of impact, except at the point actually impinged
upon.
Fractures of the ribs, produced from within by bullets taking a longitudinal
course through the thorax, were still more special in character. They were
also more important, as giving rise to troublesome symptoms.
In these, again, the degree of injury to the bones varied considerably. In
some cases the bones were merely grooved internally, without any external
deformity; in other cases a sort of green-stick fracture was produced,
Page 433
accompanied by the projection of a tender salient angle externally; in others
complete solution of continuity was effected.
Another feature of importance was the occasional implication of several
ribs. In this case the symptoms accompanying the injury were very much
more like those observed in the corresponding injuries resulting from
indirect violence seen in civil practice.
Injuries to the costal cartilages closely resembled those to the ribs.
Perforation, bending from injury to the inner aspect, and comminution were
observed. The latter condition differed from the similar one seen in the case
of the ribs only in so far as the tougher consistence of the cartilage did not
lend itself to such free comminution, and the splinters remained in great
part attached. The nature of the fractures, in fact, somewhat resembled that
seen on breaking a piece of cane.
I saw no fracture of the sternum except of the nature of a pure perforation;
these were not uncommon in the hospitals, either in the upper or the
extreme lower portions of the bone. Fractures in other portions were no
doubt usually associated with fatal injuries to the heart. The openings were
usually so small as to be difficult of palpation, and I never had the
opportunity of examining one post mortem.
Perforations of the body of the scapula were common, but they were of
little importance in symptoms or prognosis.
Symptoms of fracture of the ribs.—Fractures accompanying transverse
wounds of the chest were characterised by the insignificance of the
symptoms produced. Every common sign of fracture of the rib was in fact
absent. Neither pain, stitch on inspiration, nor crepitus, either audible or
palpable, was, as a rule, present. This absence of signs was accounted for by
the nature of the lesion: thus in perforations or notchings there was no loss
of continuity, while in the freely comminuted fractures the loss of
continuity was so absolute as to allow no possibility of the main fragments
rubbing together. Again, part of the symptoms attending these injuries, as
seen in civil practice, depends upon contusion and laceration of the
surrounding structures—a condition precluded by the localised nature of the
application of the violence by a bullet of small calibre. In order to establish
complete solution of continuity was effected.
Another feature of importance was the occasional implication of several
ribs. In this case the symptoms accompanying the injury were very much
more like those observed in the corresponding injuries resulting from
indirect violence seen in civil practice.
Injuries to the costal cartilages closely resembled those to the ribs.
Perforation, bending from injury to the inner aspect, and comminution were
observed. The latter condition differed from the similar one seen in the case
of the ribs only in so far as the tougher consistence of the cartilage did not
lend itself to such free comminution, and the splinters remained in great
part attached. The nature of the fractures, in fact, somewhat resembled that
seen on breaking a piece of cane.
I saw no fracture of the sternum except of the nature of a pure perforation;
these were not uncommon in the hospitals, either in the upper or the
extreme lower portions of the bone. Fractures in other portions were no
doubt usually associated with fatal injuries to the heart. The openings were
usually so small as to be difficult of palpation, and I never had the
opportunity of examining one post mortem.
Perforations of the body of the scapula were common, but they were of
little importance in symptoms or prognosis.
Symptoms of fracture of the ribs.—Fractures accompanying transverse
wounds of the chest were characterised by the insignificance of the
symptoms produced. Every common sign of fracture of the rib was in fact
absent. Neither pain, stitch on inspiration, nor crepitus, either audible or
palpable, was, as a rule, present. This absence of signs was accounted for by
the nature of the lesion: thus in perforations or notchings there was no loss
of continuity, while in the freely comminuted fractures the loss of
continuity was so absolute as to allow no possibility of the main fragments
rubbing together. Again, part of the symptoms attending these injuries, as
seen in civil practice, depends upon contusion and laceration of the
surrounding structures—a condition precluded by the localised nature of the
application of the violence by a bullet of small calibre. In order to establish
Page 434
a diagnosis, therefore, we were in many cases reduced to palpation, and
occasionally to direct examination of the wound.
Fractures accompanying longitudinal tracks formed a class rather apart in
the matter of symptoms. In these mere groovings might also be
accompanied by no signs, or at the most by slight local pain and tenderness.
When, however, the grooving was sufficiently deep to be accompanied by
deformity, or a complete solution of continuity was effected, the signs were
often severe. The tender salient angle, or, in the absence of this, a highly
tender localised spot, often pointed to the less severe injuries, and when the
fractures were complete or multiple, pain was a very prominent symptom,
both constant and in the form of inspiratory stitch. The severity of the pain
was probably to be in part ascribed to implication of the intercostal nerves,
which in these injuries was direct and often multiple. Again, severe
contusion or actual laceration of the nerves, with resulting anæsthesia, was
less common than when the bullet directly implicated the nerves in
transverse wounds. Free comminution and absolute solution of continuity
were also less common than in the fractures accompanying transverse
wounds; hence pain from rubbing of the fragments on inspiratory
movement or palpation was more common, and crepitus, either on
auscultation or palpation, was more often met with. Patients with this class
of fracture often suffered greatly from painful dyspnœa, and were unable to
assume the supine position.
External hæmorrhage of severity was rare from these thoracic wounds; in
many cases it did not amount to more than local staining of the shirt;
altogether I saw only one or two cases where any serious bleeding occurred.
Internal hæmorrhage into the pleura, in consequence of the position of the
intercostal arteries, was common, and often abundant; this will be treated of
under the heading of hæmothorax.
Treatment of fractured ribs.—Transverse wounds of the thorax, with no
symptoms of fractured ribs, needed to be dealt with as wounds of the soft
parts alone.
In multiple fractures accompanying longitudinal tracks, bandaging or
strapping for the purpose of fixation was necessary to relieve pain. A few
fragments of bone sometimes needed primary removal, and occasionally
occasionally to direct examination of the wound.
Fractures accompanying longitudinal tracks formed a class rather apart in
the matter of symptoms. In these mere groovings might also be
accompanied by no signs, or at the most by slight local pain and tenderness.
When, however, the grooving was sufficiently deep to be accompanied by
deformity, or a complete solution of continuity was effected, the signs were
often severe. The tender salient angle, or, in the absence of this, a highly
tender localised spot, often pointed to the less severe injuries, and when the
fractures were complete or multiple, pain was a very prominent symptom,
both constant and in the form of inspiratory stitch. The severity of the pain
was probably to be in part ascribed to implication of the intercostal nerves,
which in these injuries was direct and often multiple. Again, severe
contusion or actual laceration of the nerves, with resulting anæsthesia, was
less common than when the bullet directly implicated the nerves in
transverse wounds. Free comminution and absolute solution of continuity
were also less common than in the fractures accompanying transverse
wounds; hence pain from rubbing of the fragments on inspiratory
movement or palpation was more common, and crepitus, either on
auscultation or palpation, was more often met with. Patients with this class
of fracture often suffered greatly from painful dyspnœa, and were unable to
assume the supine position.
External hæmorrhage of severity was rare from these thoracic wounds; in
many cases it did not amount to more than local staining of the shirt;
altogether I saw only one or two cases where any serious bleeding occurred.
Internal hæmorrhage into the pleura, in consequence of the position of the
intercostal arteries, was common, and often abundant; this will be treated of
under the heading of hæmothorax.
Treatment of fractured ribs.—Transverse wounds of the thorax, with no
symptoms of fractured ribs, needed to be dealt with as wounds of the soft
parts alone.
In multiple fractures accompanying longitudinal tracks, bandaging or
strapping for the purpose of fixation was necessary to relieve pain. A few
fragments of bone sometimes needed primary removal, and occasionally
Page 435
small sequestra were removed at a later date; but necrosis was rare, unless
some complication led to the development of a fistula.
Retained bullets were occasionally met with in the chest wall. In such cases
the last remaining energy of the bullet often seemed to have been spent in
diving under the margin of a rib and turning longitudinally up or down.
Removal was sometimes necessary, either from the prominence produced,
the presence of pain, or the continuance of suppuration. Some of the
specimens removed offered interesting evidence of the capacity of the ribs
to withstand considerable violence from a bullet. These were slightly bent,
and marked by a half-spiral groove. I saw such bullets removed from the
thoracic and the abdominal wall, and the evidence seemed rather against the
groove having been produced prior to their entrance into the body.
Fig. 82.—Spirally
grooved Mauser Bullet
Wounds of the diaphragm.—Perforations of the diaphragm were very
frequent, and as a rule of small significance. When, however, the course
taken by the bullet was parallel with that of the slope of the diaphragm, a
more or less extensive slit was the result. I saw such a wound still gaping,
and 2 inches in length, in the body of a patient who died three weeks after
the infliction of a fatal abdominal injury.
some complication led to the development of a fistula.
Retained bullets were occasionally met with in the chest wall. In such cases
the last remaining energy of the bullet often seemed to have been spent in
diving under the margin of a rib and turning longitudinally up or down.
Removal was sometimes necessary, either from the prominence produced,
the presence of pain, or the continuance of suppuration. Some of the
specimens removed offered interesting evidence of the capacity of the ribs
to withstand considerable violence from a bullet. These were slightly bent,
and marked by a half-spiral groove. I saw such bullets removed from the
thoracic and the abdominal wall, and the evidence seemed rather against the
groove having been produced prior to their entrance into the body.
Fig. 82.—Spirally
grooved Mauser Bullet
Wounds of the diaphragm.—Perforations of the diaphragm were very
frequent, and as a rule of small significance. When, however, the course
taken by the bullet was parallel with that of the slope of the diaphragm, a
more or less extensive slit was the result. I saw such a wound still gaping,
and 2 inches in length, in the body of a patient who died three weeks after
the infliction of a fatal abdominal injury.
Page 436
In several other obliquely transverse thoracic wounds there was reason to
assume the existence of similar slits. Certain signs were more or less
constant under these circumstances. These consisted in shallow respiration,
often accompanied by a groan or the slightest degree of hiccough on
inspiration, and considerable increase in respiratory frequency. In one
patient the respirations were at first 48, only dropping to 36 some seventy
hours after the reception of the injury. In some of the cases in which the
abdominal cavity was implicated, wound to the diaphragm seemed a more
likely explanation of early, frequent, and painful vomiting than did visceral
injury. The possibility of the later development of diaphragmatic herniæ in
some of these patients will have to be borne in mind in the future.
Visceral injuries.—The frequent escape of the thoracic viscera from injury,
putting aside the lungs which fill so great a part of the cavity, was very
remarkable. I never saw a case in which I could assume injury to any of the
posterior mediastinal viscera, although such may have occurred on the field
of battle. An injury to the œsophagus, for instance, would almost of
necessity be accompanied by wound of either one of the large vessels, even
the thoracic aorta, or the spinal column. I was somewhat surprised,
however, to learn on enquiry from surgeons who had seen a large number of
the dead and dying on the field, that thoracic wounds, putting aside those
that directly implicated the heart, were responsible for but a small
proportion of the fatalities.
The escape of the posterior mediastinal viscera, the great vessels, and the
heart, is, I believe, to be explained by the fact that all are supported and
held in position by the loose meshed mediastinal tissue, which allows for
their displacement after the manner observed in the case of the vessels and
nerves lying in the loose tissue of the great vascular clefts.
Wounds of the heart.—Perforating wounds of the heart were probably fatal
in all instances, in spite of the fact that, in some patients who survived, the
position of wound apertures on the surface of the body made it difficult to
believe that the heart had not been penetrated. (See cases below.)
In the case of this organ, we must bear in mind its constant variations in
bulk, its elastic compressibility, and its variations in position in systole and
diastole. The variations in bulk and position would be capable of explaining
assume the existence of similar slits. Certain signs were more or less
constant under these circumstances. These consisted in shallow respiration,
often accompanied by a groan or the slightest degree of hiccough on
inspiration, and considerable increase in respiratory frequency. In one
patient the respirations were at first 48, only dropping to 36 some seventy
hours after the reception of the injury. In some of the cases in which the
abdominal cavity was implicated, wound to the diaphragm seemed a more
likely explanation of early, frequent, and painful vomiting than did visceral
injury. The possibility of the later development of diaphragmatic herniæ in
some of these patients will have to be borne in mind in the future.
Visceral injuries.—The frequent escape of the thoracic viscera from injury,
putting aside the lungs which fill so great a part of the cavity, was very
remarkable. I never saw a case in which I could assume injury to any of the
posterior mediastinal viscera, although such may have occurred on the field
of battle. An injury to the œsophagus, for instance, would almost of
necessity be accompanied by wound of either one of the large vessels, even
the thoracic aorta, or the spinal column. I was somewhat surprised,
however, to learn on enquiry from surgeons who had seen a large number of
the dead and dying on the field, that thoracic wounds, putting aside those
that directly implicated the heart, were responsible for but a small
proportion of the fatalities.
The escape of the posterior mediastinal viscera, the great vessels, and the
heart, is, I believe, to be explained by the fact that all are supported and
held in position by the loose meshed mediastinal tissue, which allows for
their displacement after the manner observed in the case of the vessels and
nerves lying in the loose tissue of the great vascular clefts.
Wounds of the heart.—Perforating wounds of the heart were probably fatal
in all instances, in spite of the fact that, in some patients who survived, the
position of wound apertures on the surface of the body made it difficult to
believe that the heart had not been penetrated. (See cases below.)
In the case of this organ, we must bear in mind its constant variations in
bulk, its elastic compressibility, and its variations in position in systole and
diastole. The variations in bulk and position would be capable of explaining
Page 437
the escape of the organ from injury at some particular moment, when a
second shot apparently through the same wound track might implicate it.
Beyond this, reasoning from the case of analogous hollow viscera, as the
arteries or the intestine, a bullet might readily score the surface of the heart
without perforating its cavity.
Such accidents were observed. Thus, in a case examined by Mr. Cheatle, the
patient died of suppurative pericarditis, secondary to a wound of which the
external apertures had closed. In this patient both auricle and ventricle were
scored externally by the passage of the bullet.
I am, however, disinclined to allow that many patients survived direct
blows on the heart, since I believe that in the majority if not in all cardiac
wounds the actual cause of death was not hæmorrhage, but sudden stoppage
of the heart's action. This is to be inferred from the fact that severe external
hæmorrhage did not occur; in some cases the shirt was hardly stained, and
in all death occurred in the course of a very few minutes. Again, in none of
the patients whom I saw who had received possible wounds of the heart-
wall were there evident signs of hæmo-pericardium. In view of the
difficulty of detecting this condition from physical signs, this argument is
naturally not of great weight, but must be allowed.
One or two death scenes from cardiac wound were described to me. In one
the patient muttered 'They have got me this time,' and died quietly; in a
second the patient's face became ghastly pale, he lay on his back with the
knees flexed, clutching the ground, gasping for breath, and died only after
some minutes of evident great agony. The absence of any post-mortem
details as to the condition of the heart in these injuries is much to be
regretted.
(145) Entry, in the seventh left intercostal space, in the posterior
axillary line; exit, immediately below the ninth costal cartilage,
close to the position of the gall bladder.
This track in all probability involved the diaphragm twice, both
lungs and pleuræ, and passed immediately beneath the heart.
The liver was also perforated, but the spleen and stomach
probably escaped as far as could be judged from the symptoms.
The patient afterwards developed a pneumo-hæmo-thorax on the
second shot apparently through the same wound track might implicate it.
Beyond this, reasoning from the case of analogous hollow viscera, as the
arteries or the intestine, a bullet might readily score the surface of the heart
without perforating its cavity.
Such accidents were observed. Thus, in a case examined by Mr. Cheatle, the
patient died of suppurative pericarditis, secondary to a wound of which the
external apertures had closed. In this patient both auricle and ventricle were
scored externally by the passage of the bullet.
I am, however, disinclined to allow that many patients survived direct
blows on the heart, since I believe that in the majority if not in all cardiac
wounds the actual cause of death was not hæmorrhage, but sudden stoppage
of the heart's action. This is to be inferred from the fact that severe external
hæmorrhage did not occur; in some cases the shirt was hardly stained, and
in all death occurred in the course of a very few minutes. Again, in none of
the patients whom I saw who had received possible wounds of the heart-
wall were there evident signs of hæmo-pericardium. In view of the
difficulty of detecting this condition from physical signs, this argument is
naturally not of great weight, but must be allowed.
One or two death scenes from cardiac wound were described to me. In one
the patient muttered 'They have got me this time,' and died quietly; in a
second the patient's face became ghastly pale, he lay on his back with the
knees flexed, clutching the ground, gasping for breath, and died only after
some minutes of evident great agony. The absence of any post-mortem
details as to the condition of the heart in these injuries is much to be
regretted.
(145) Entry, in the seventh left intercostal space, in the posterior
axillary line; exit, immediately below the ninth costal cartilage,
close to the position of the gall bladder.
This track in all probability involved the diaphragm twice, both
lungs and pleuræ, and passed immediately beneath the heart.
The liver was also perforated, but the spleen and stomach
probably escaped as far as could be judged from the symptoms.
The patient afterwards developed a pneumo-hæmo-thorax on the
Page 438
right side. The immediate symptoms were great distress in
breathing and rapid irregular pulse. The difficulty in respiration
was probably in part accounted for by the injuries to the lung
and diaphragm. The pulse remained from 112 to 120 for three
days, at first soft and hardly perceptible, later very irregular, and
dropping one every fifth or sixth beat; and it seemed fair to
attribute this to the shock to the nervous mechanism of the heart.
The patient recovered from the chest injury.
In some other patients in whom the track passed close below the
heart a disturbance of the pulse rate was noted, but this was in
some cases a slowing, not below 48, in others quickening to
100, with irregularity both in force and beat.
(146) Entry, in the fourth right interspace, 3 inches from the
middle line; exit, in the seventh left interspace, in the mid-
axillary line. This wound was received at a distance of 500-600
yards, but the bullet penetrated both sides of a stout silver
cigarette case and some cigarettes before entering the body.
There were minor signs of pulmonary injury, 'coughing day and
night,' and slight discoloration of the sputum on three or four
occasions. The respirations were quickened to 32, and as much
as ten days after the injury the pulse only beat 48 to the minute;
it then rose to 56, but beat in a very deliberate manner.
In other cases the signs were almost nil.
(147) Entry, in the fourth right intercostal space 3/4 of an inch
from the sternum; exit, in the sixth left interspace in the
posterior axillary line. This patient had no symptoms, beyond
quickening of the pulse to 100, and a 'feeling of tightness at the
heart.' He shortly returned to active duty.
(148) Entry, situated in the third right interspace 3 inches from
the sternal margin; exit, in the fourth left space 2¾ inches from
the sternal margin. In this case the bullet without doubt passed
through the anterior mediastinum, and slight injury to the lung
was evidenced by transient hæmoptysis.
breathing and rapid irregular pulse. The difficulty in respiration
was probably in part accounted for by the injuries to the lung
and diaphragm. The pulse remained from 112 to 120 for three
days, at first soft and hardly perceptible, later very irregular, and
dropping one every fifth or sixth beat; and it seemed fair to
attribute this to the shock to the nervous mechanism of the heart.
The patient recovered from the chest injury.
In some other patients in whom the track passed close below the
heart a disturbance of the pulse rate was noted, but this was in
some cases a slowing, not below 48, in others quickening to
100, with irregularity both in force and beat.
(146) Entry, in the fourth right interspace, 3 inches from the
middle line; exit, in the seventh left interspace, in the mid-
axillary line. This wound was received at a distance of 500-600
yards, but the bullet penetrated both sides of a stout silver
cigarette case and some cigarettes before entering the body.
There were minor signs of pulmonary injury, 'coughing day and
night,' and slight discoloration of the sputum on three or four
occasions. The respirations were quickened to 32, and as much
as ten days after the injury the pulse only beat 48 to the minute;
it then rose to 56, but beat in a very deliberate manner.
In other cases the signs were almost nil.
(147) Entry, in the fourth right intercostal space 3/4 of an inch
from the sternum; exit, in the sixth left interspace in the
posterior axillary line. This patient had no symptoms, beyond
quickening of the pulse to 100, and a 'feeling of tightness at the
heart.' He shortly returned to active duty.
(148) Entry, situated in the third right interspace 3 inches from
the sternal margin; exit, in the fourth left space 2¾ inches from
the sternal margin. In this case the bullet without doubt passed
through the anterior mediastinum, and slight injury to the lung
was evidenced by transient hæmoptysis.
Page 439
Some remarks regarding wounds of the thoracic vessels have already been
made in Chapter IV., where instances of injury to the innominate and left
subclavian arteries are recounted. The escape of the large trunks was
generally quite as astonishing as in other parts of the body, especially in the
superior mediastinum.
made in Chapter IV., where instances of injury to the innominate and left
subclavian arteries are recounted. The escape of the large trunks was
generally quite as astonishing as in other parts of the body, especially in the
superior mediastinum.
Page 440
(149) Entry, over the first right intercostal space beneath the
centre of the clavicle; exit, at left anterior axillary fold. The great
vessels must have been crossed here in immediate contact, and
considerable hæmorrhage from the wound of entry caused great
anxiety; this ceased spontaneously, however, and, beyond
transient hæmoptysis and a right pneumo-thorax, no further
trouble occurred.
(150) Entry, in the ninth interspace, just anterior to the anterior
axillary line; exit, through the right half of the sternum, 1/2 an
inch below the upper border. No primary hæmorrhage of
importance followed, but I believe this patient subsequently
died. The wound was received at a range of within fifty yards.
Wounds of the lungs.—Numerically, pulmonary wounds formed the most
important series of visceral injuries met with in the thorax, the frequency of
incidence corresponding with the proportionate sectional area occupied by
the organs. Although these injuries did well, and needed little interference
on the part of the surgeon, many points of interest were raised by them.
Thus the comparative importance of the wound in the chest-wall to that in
the lung itself, was scarcely what, without actual experience, would have
been expected, the former proving so very much the more important
element of the two.
The question of velocity on the part of the bullet took a very secondary
position in these injuries. I saw a number of cases in which the patients
estimated the range at which they received their wounds as from 30 to 50
yards, and although some of the wounds were of a severe type, the
increased gravity depended rather on the injury to the chest-wall than to that
of the lung. If the bullet passed by the intercostal space, avoiding the rib, I
very much doubt if the relative velocity was of any importance, further than
from the fact that a sufficiently low degree to allow of lodgment of the
bullet was distinctly unfavourable.
In view of the general lack of significance in these injuries it was interesting
to note how very definite was the ill effect of early transport on the after
centre of the clavicle; exit, at left anterior axillary fold. The great
vessels must have been crossed here in immediate contact, and
considerable hæmorrhage from the wound of entry caused great
anxiety; this ceased spontaneously, however, and, beyond
transient hæmoptysis and a right pneumo-thorax, no further
trouble occurred.
(150) Entry, in the ninth interspace, just anterior to the anterior
axillary line; exit, through the right half of the sternum, 1/2 an
inch below the upper border. No primary hæmorrhage of
importance followed, but I believe this patient subsequently
died. The wound was received at a range of within fifty yards.
Wounds of the lungs.—Numerically, pulmonary wounds formed the most
important series of visceral injuries met with in the thorax, the frequency of
incidence corresponding with the proportionate sectional area occupied by
the organs. Although these injuries did well, and needed little interference
on the part of the surgeon, many points of interest were raised by them.
Thus the comparative importance of the wound in the chest-wall to that in
the lung itself, was scarcely what, without actual experience, would have
been expected, the former proving so very much the more important
element of the two.
The question of velocity on the part of the bullet took a very secondary
position in these injuries. I saw a number of cases in which the patients
estimated the range at which they received their wounds as from 30 to 50
yards, and although some of the wounds were of a severe type, the
increased gravity depended rather on the injury to the chest-wall than to that
of the lung. If the bullet passed by the intercostal space, avoiding the rib, I
very much doubt if the relative velocity was of any importance, further than
from the fact that a sufficiently low degree to allow of lodgment of the
bullet was distinctly unfavourable.
In view of the general lack of significance in these injuries it was interesting
to note how very definite was the ill effect of early transport on the after
Page 441
course. This depended on the frequent development of parietal hæmothorax
in patients who were not kept absolutely at rest.
The tracks produced in the lungs by the bullets were very minute, and in the
few cases in which opportunity arose for their examination post mortem
some little time after the infliction of the wound, there was great difficulty
in localising them. The slight damage incurred by the pulmonary tissue is
due to its elasticity and non-resistent character.
Pulmonary hæmothorax was distinctly rare. Reasoning from the analogous
wounds of the liver, tracks scoring the surface of these organs might be
much more to be feared than clean perforations. The elasticity of the lung
tissue, however, must make such lesions rare. In point of fact, there is no
reason why a perforation by a bullet of small calibre should be much more
feared than a puncture from an exploring trocar, and the danger of the two
wounds is probably very nearly the same.
The only points of importance as to the particular region of the lung
traversed were the distance from the periphery as affecting the probable size
of the vessels injured, and perhaps the implication of the base or apex of the
organ respectively. I am under the impression that wounds in the apical
region were somewhat more liable to be followed by the development of
pneumothorax, and possibly hæmothorax, while wounds at the base gained
their chief importance from the frequency of concurrent injury to the
abdominal viscera. I had no experience of the immediate results of wound
of the great vessels at the root of the lung, but assume that they led to
speedy death.
Symptoms of wound of the lung.—I shall describe the whole complex
usually observed, although it is obvious that the wound of the chest-wall is
responsible for a large proportion of the signs.
The majority of these injuries were accompanied by a certain degree of
systemic shock, and this was more marked in wounds received at a short
range. The shock was, however, rather to be attributed to the injury to the
chest-wall and thoracic concussion than to that to the lung itself. I think it
may also be stated that few patients were inclined to walk or remain in the
erect position after receiving these wounds; this feature was also noted in
horses in whom a bullet passed through the lungs.
in patients who were not kept absolutely at rest.
The tracks produced in the lungs by the bullets were very minute, and in the
few cases in which opportunity arose for their examination post mortem
some little time after the infliction of the wound, there was great difficulty
in localising them. The slight damage incurred by the pulmonary tissue is
due to its elasticity and non-resistent character.
Pulmonary hæmothorax was distinctly rare. Reasoning from the analogous
wounds of the liver, tracks scoring the surface of these organs might be
much more to be feared than clean perforations. The elasticity of the lung
tissue, however, must make such lesions rare. In point of fact, there is no
reason why a perforation by a bullet of small calibre should be much more
feared than a puncture from an exploring trocar, and the danger of the two
wounds is probably very nearly the same.
The only points of importance as to the particular region of the lung
traversed were the distance from the periphery as affecting the probable size
of the vessels injured, and perhaps the implication of the base or apex of the
organ respectively. I am under the impression that wounds in the apical
region were somewhat more liable to be followed by the development of
pneumothorax, and possibly hæmothorax, while wounds at the base gained
their chief importance from the frequency of concurrent injury to the
abdominal viscera. I had no experience of the immediate results of wound
of the great vessels at the root of the lung, but assume that they led to
speedy death.
Symptoms of wound of the lung.—I shall describe the whole complex
usually observed, although it is obvious that the wound of the chest-wall is
responsible for a large proportion of the signs.
The majority of these injuries were accompanied by a certain degree of
systemic shock, and this was more marked in wounds received at a short
range. The shock was, however, rather to be attributed to the injury to the
chest-wall and thoracic concussion than to that to the lung itself. I think it
may also be stated that few patients were inclined to walk or remain in the
erect position after receiving these wounds; this feature was also noted in
horses in whom a bullet passed through the lungs.
Page 442
The remarks made as to the pain accompanying fractures of the ribs apply
equally here. Pain was not a prominent symptom, except in so far as the
actual impact caused temporary suffering. It was striking how often patients
who received wounds through the arm prior to the same bullet traversing
the chest appreciated the chest wound only, yet the chest might pass
unnoticed when a still more sensitive part was struck later, as has been
already mentioned in the section on wounds in general.
Dyspnœa was not a prominent primary symptom. The patients sometimes
had 'all the wind knocked out of them' at the moment of impact, but when
seen at the Field hospitals a short time later, the respirations were shallow,
but easy and regular, and only moderately quickened; thus 24 was a not
uncommon rate. Naturally if accumulation of blood in the pleura began
early and continued, these remarks do not hold good; and again in some
older men of full-blooded type and the subjects of recurrent attacks of
bronchitis, a considerable degree of pain, dyspnœa, and even cyanosis was
sometimes present soon after the injury. The complication of wound of the
diaphragm has already been referred to in this relation.
Local respiratory immobility of the thoracic parietes and consequent
asymmetry of movement were constant. This was especially a marked
feature when the upper part of the chest was implicated on one side only. It
rather corresponded, however, to the local shock observed in wounds of the
limbs than to the instinctive immobility accompanying fractures of the ribs;
since, as already explained, small-calibre bullet wounds of the ribs are not
necessarily painful on movement, and the sign existed even when the bullet
had passed by an intercostal space. This sign was naturally a transitory one.
Hæmoptysis was a fairly constant sign, but sometimes quite absent when no
doubt could exist as to the perforation of the lung. As a rule, a considerable
quantity of blood might be coughed up shortly after the injury; but I never
knew this to be sufficient in amount to give rise to any misgivings as to
danger from the hæmorrhage. After the first evacuation of blood from the
wounded lung, the sign varied much; in the majority of instances the
patients continued to expectorate small quantities of blood mixed with
mucus, for some three or four days, the blood gradually assuming a
coagulated condition. Sometimes only the primary hæmoptysis was noted,
and still more rarely the expectoration of clots was continued for a week, or
equally here. Pain was not a prominent symptom, except in so far as the
actual impact caused temporary suffering. It was striking how often patients
who received wounds through the arm prior to the same bullet traversing
the chest appreciated the chest wound only, yet the chest might pass
unnoticed when a still more sensitive part was struck later, as has been
already mentioned in the section on wounds in general.
Dyspnœa was not a prominent primary symptom. The patients sometimes
had 'all the wind knocked out of them' at the moment of impact, but when
seen at the Field hospitals a short time later, the respirations were shallow,
but easy and regular, and only moderately quickened; thus 24 was a not
uncommon rate. Naturally if accumulation of blood in the pleura began
early and continued, these remarks do not hold good; and again in some
older men of full-blooded type and the subjects of recurrent attacks of
bronchitis, a considerable degree of pain, dyspnœa, and even cyanosis was
sometimes present soon after the injury. The complication of wound of the
diaphragm has already been referred to in this relation.
Local respiratory immobility of the thoracic parietes and consequent
asymmetry of movement were constant. This was especially a marked
feature when the upper part of the chest was implicated on one side only. It
rather corresponded, however, to the local shock observed in wounds of the
limbs than to the instinctive immobility accompanying fractures of the ribs;
since, as already explained, small-calibre bullet wounds of the ribs are not
necessarily painful on movement, and the sign existed even when the bullet
had passed by an intercostal space. This sign was naturally a transitory one.
Hæmoptysis was a fairly constant sign, but sometimes quite absent when no
doubt could exist as to the perforation of the lung. As a rule, a considerable
quantity of blood might be coughed up shortly after the injury; but I never
knew this to be sufficient in amount to give rise to any misgivings as to
danger from the hæmorrhage. After the first evacuation of blood from the
wounded lung, the sign varied much; in the majority of instances the
patients continued to expectorate small quantities of blood mixed with
mucus, for some three or four days, the blood gradually assuming a
coagulated condition. Sometimes only the primary hæmoptysis was noted,
and still more rarely the expectoration of clots was continued for a week, or
Page 443
even longer. This probably depended partly on personal idiosyncrasy, partly
on the size of the vessels which had been implicated in the track.
Cough was not commonly the troublesome symptom noted in the contused
wounds of the lung seen in civil practice accompanying fracture of the ribs.
Moist sounds were usually audible on auscultation, but in many cases over
a very limited area and only on the first few days.
Cellular emphysema was distinctly rare, and usually limited in extent: thus I
saw it in the posterior triangle of the neck alone in an apical wound; over
about a third of the upper part of the thorax in another wound through the
second intercostal space, and in this case oddly enough the emphysema was
the only sign of injury to the lung; and very occasionally widely distributed
—in the latter case there were also usually multiple fractures of the ribs.
Neither issue of air from the external wound nor frothy blood was ever seen
with small-calibre wounds, but I saw one instance in a case of Martini-
Henry wound.
Pneumothorax was also rare. I saw pneumothorax three times out of about
half a dozen Martini-Henry wounds, but I do not think it occurred as often
in 100 small-calibre wounds. The Martini-Henry wounds all recovered; but
convalescence was very prolonged, and the same remark to a less degree
holds good in the small-calibre cases.
That the slow recovery in cases of pneumothorax in the Martini-Henry
wounds was due mainly to the size of the opening in the thoracic parietes
was, I think, proved by the fact that in the small-calibre bullet wounds,
followed by the development of pneumothorax, the external wounds were
usually large and irregular in type; also, that in the only pneumothorax
which I saw produced during an extraction operation, the air was very
rapidly absorbed. In the latter case, however, there was little reason to
conclude that wound of the lung had occurred primarily, and certainly no
opening existed at the time the thorax was incised.
Hæmothorax.—This was the most frequent and also the most interesting of
the complications of wound of the chest. In 90 per cent. or more of the
cases, the hæmorrhage was of parietal source, and due either to direct injury
to the intercostal vessels by the bullet or to laceration by spicules of
comminuted ribs. For this reason, the passage of the bullet whether by an
on the size of the vessels which had been implicated in the track.
Cough was not commonly the troublesome symptom noted in the contused
wounds of the lung seen in civil practice accompanying fracture of the ribs.
Moist sounds were usually audible on auscultation, but in many cases over
a very limited area and only on the first few days.
Cellular emphysema was distinctly rare, and usually limited in extent: thus I
saw it in the posterior triangle of the neck alone in an apical wound; over
about a third of the upper part of the thorax in another wound through the
second intercostal space, and in this case oddly enough the emphysema was
the only sign of injury to the lung; and very occasionally widely distributed
—in the latter case there were also usually multiple fractures of the ribs.
Neither issue of air from the external wound nor frothy blood was ever seen
with small-calibre wounds, but I saw one instance in a case of Martini-
Henry wound.
Pneumothorax was also rare. I saw pneumothorax three times out of about
half a dozen Martini-Henry wounds, but I do not think it occurred as often
in 100 small-calibre wounds. The Martini-Henry wounds all recovered; but
convalescence was very prolonged, and the same remark to a less degree
holds good in the small-calibre cases.
That the slow recovery in cases of pneumothorax in the Martini-Henry
wounds was due mainly to the size of the opening in the thoracic parietes
was, I think, proved by the fact that in the small-calibre bullet wounds,
followed by the development of pneumothorax, the external wounds were
usually large and irregular in type; also, that in the only pneumothorax
which I saw produced during an extraction operation, the air was very
rapidly absorbed. In the latter case, however, there was little reason to
conclude that wound of the lung had occurred primarily, and certainly no
opening existed at the time the thorax was incised.
Hæmothorax.—This was the most frequent and also the most interesting of
the complications of wound of the chest. In 90 per cent. or more of the
cases, the hæmorrhage was of parietal source, and due either to direct injury
to the intercostal vessels by the bullet or to laceration by spicules of
comminuted ribs. For this reason, the passage of the bullet whether by an
Page 444
intercostal space, or through a rib, provided the wound was not at the
posterior part of the space where the artery crosses, was a point of
considerable prognostic importance. Exclusion of the lung as the source of
hæmorrhage was, I think, amply justified by the absence of continuous
recurrent or progressive hæmoptysis in the majority of the cases, and by the
very small trace of injury found in the lungs of patients who died some
weeks after the injury. In such it was difficult to discriminate the tracks at
all. I only happened to see one case where free hæmoptysis, during the
course of development of a hæmothorax, pointed to the lung as the source
of the blood.
Hæmorrhage into the pleural cavity occurred in some degree in a very large
proportion of the chest wounds, but it was especially interesting to note how
greatly its extent was influenced by the amount of transport to which the
patients were subjected in the early stages after the injury. During the early
part of the campaign, on the western side, I saw a large number of chest
wounds, and had I been asked my opinion as to the relative frequency of
occurrence of hæmothorax I should have placed it at about 30 per cent. The
patients in these early battles needed little wagon transport, and when sent
down to the Base travelled in comfortable ambulance trains. After the
commencement of the march from Modder River to Bloemfontein,
however, these conditions were changed, and all the chest as other cases
were exposed to the necessity of three days and nights' journey to the
Stationary hospitals and afterwards to the long journey to Cape Town. Of
these patients, at least 90 per cent. suffered with hæmothorax of varying
degrees of severity.
In some cases, the least common, signs of considerable intra-pleural
hæmorrhage immediately followed the wound; in others, the accumulation
of blood was gradual, and only manifest in any degree at the end of three or
four days, when it became stationary if the patient was kept at rest. In a
second series the hæmorrhage was of the recurrent variety; these cases
differing little in character from those of slight continuous hæmorrhage. In a
third, the bleeding was definitely of a secondary character, corresponding
with one of the classes of secondary hæmorrhage described in Chapter IV.,
and occurring on the eighth or tenth day from giving way of an imperfectly
closed wounded vessel. In either of the two latter classes the development
posterior part of the space where the artery crosses, was a point of
considerable prognostic importance. Exclusion of the lung as the source of
hæmorrhage was, I think, amply justified by the absence of continuous
recurrent or progressive hæmoptysis in the majority of the cases, and by the
very small trace of injury found in the lungs of patients who died some
weeks after the injury. In such it was difficult to discriminate the tracks at
all. I only happened to see one case where free hæmoptysis, during the
course of development of a hæmothorax, pointed to the lung as the source
of the blood.
Hæmorrhage into the pleural cavity occurred in some degree in a very large
proportion of the chest wounds, but it was especially interesting to note how
greatly its extent was influenced by the amount of transport to which the
patients were subjected in the early stages after the injury. During the early
part of the campaign, on the western side, I saw a large number of chest
wounds, and had I been asked my opinion as to the relative frequency of
occurrence of hæmothorax I should have placed it at about 30 per cent. The
patients in these early battles needed little wagon transport, and when sent
down to the Base travelled in comfortable ambulance trains. After the
commencement of the march from Modder River to Bloemfontein,
however, these conditions were changed, and all the chest as other cases
were exposed to the necessity of three days and nights' journey to the
Stationary hospitals and afterwards to the long journey to Cape Town. Of
these patients, at least 90 per cent. suffered with hæmothorax of varying
degrees of severity.
In some cases, the least common, signs of considerable intra-pleural
hæmorrhage immediately followed the wound; in others, the accumulation
of blood was gradual, and only manifest in any degree at the end of three or
four days, when it became stationary if the patient was kept at rest. In a
second series the hæmorrhage was of the recurrent variety; these cases
differing little in character from those of slight continuous hæmorrhage. In a
third, the bleeding was definitely of a secondary character, corresponding
with one of the classes of secondary hæmorrhage described in Chapter IV.,
and occurring on the eighth or tenth day from giving way of an imperfectly
closed wounded vessel. In either of the two latter classes the development
Page 445
of the hæmothorax often corresponded with a journey, or with allowing the
patient to get up.
The general course of these effusions was towards spontaneous absorption
and recovery. Coagulation of the blood took place early, the fluid serum
separated, and tended to undergo absorption with some rapidity, leaving a
small amount of coagulum at the base, which evidenced its presence for
many weeks by a persistence of a certain degree of dulness on percussion.
Early coagulation, I think, accounted for the usual absence of gravitation
ecchymosis as a sign.
The course to recovery was sometimes broken by signs of slight pleuritic
inflammation, which, as affecting the amount of effusion, will be spoken of
under the heading of symptoms. In some cases the amount of blood was so
great as to necessitate means being taken for its removal; in these a
reaccumulation often took place. Occasionally an empyema followed in
cases thus treated.
The nature of the blood evacuated on tapping varied much. In very early
aspirations unchanged blood was often met with, but clot sometimes made
evacuation difficult and necessitated a second puncture. In the tappings
done at the end of a week or more a dark porter-like fluid was common,
while when suppuration was imminent a brick-red-coloured grumous fluid
replaced normal blood. In the cases where early incision was resorted to,
blood both fluid and in clots was often mixed with a certain proportion of
lymph flakes, perhaps indicating the part taken by inflammatory reaction to
the irritation of the clot in producing the rise of temperature.
Symptoms of hæmothorax.—In the more severe cases of primary bleeding
the symptoms did not, as a rule, reach their full height until the third or
fourth day after the injury. The patients then often suffered severely. The
pulse and temperature rose, and to general symptoms of loss of blood were
added: occasional lividity of countenance; severe dyspnœa, accompanied by
inability to lie on the sound side or to assume the supine position; absence
of respiratory movement on the injured side; pain, restlessness, cough, and
sometimes continuance of hæmoptysis, small clots usually being
expectorated.
patient to get up.
The general course of these effusions was towards spontaneous absorption
and recovery. Coagulation of the blood took place early, the fluid serum
separated, and tended to undergo absorption with some rapidity, leaving a
small amount of coagulum at the base, which evidenced its presence for
many weeks by a persistence of a certain degree of dulness on percussion.
Early coagulation, I think, accounted for the usual absence of gravitation
ecchymosis as a sign.
The course to recovery was sometimes broken by signs of slight pleuritic
inflammation, which, as affecting the amount of effusion, will be spoken of
under the heading of symptoms. In some cases the amount of blood was so
great as to necessitate means being taken for its removal; in these a
reaccumulation often took place. Occasionally an empyema followed in
cases thus treated.
The nature of the blood evacuated on tapping varied much. In very early
aspirations unchanged blood was often met with, but clot sometimes made
evacuation difficult and necessitated a second puncture. In the tappings
done at the end of a week or more a dark porter-like fluid was common,
while when suppuration was imminent a brick-red-coloured grumous fluid
replaced normal blood. In the cases where early incision was resorted to,
blood both fluid and in clots was often mixed with a certain proportion of
lymph flakes, perhaps indicating the part taken by inflammatory reaction to
the irritation of the clot in producing the rise of temperature.
Symptoms of hæmothorax.—In the more severe cases of primary bleeding
the symptoms did not, as a rule, reach their full height until the third or
fourth day after the injury. The patients then often suffered severely. The
pulse and temperature rose, and to general symptoms of loss of blood were
added: occasional lividity of countenance; severe dyspnœa, accompanied by
inability to lie on the sound side or to assume the supine position; absence
of respiratory movement on the injured side; pain, restlessness, cough, and
sometimes continuance of hæmoptysis, small clots usually being
expectorated.
Page 446
Accompanying these symptoms were the usual physical signs of fluid in the
pleura in differing degrees and combination. Dulness of varying extent up
to complete absence of resonance on one side, often accompanied in the
incomplete cases by well-marked skodaic resonance anteriorly. Loss of
vocal resonance, and fremitus; œgophony, tubular respiration over the root
of the lung or at the upper limit of the dulness, and more or less extensive
displacement of the heart. Obvious increase in girth, fulness of the
intercostal spaces, or gravitation ecchymosis was rare. The latter was most
common in instances in which multiple fracture of the ribs existed (see fig.
83). I think the rarity of the last sign must have been due to the early
coagulation of the blood, and its retention by the pleura, as I saw well-
marked gravitation ecchymosis in one or two cases of mediastinal
hæmorrhage.
The above complex of symptoms was common to all the cases, but in the
slighter ones they gave rise to little trouble, and cleared up with great
rapidity.
pleura in differing degrees and combination. Dulness of varying extent up
to complete absence of resonance on one side, often accompanied in the
incomplete cases by well-marked skodaic resonance anteriorly. Loss of
vocal resonance, and fremitus; œgophony, tubular respiration over the root
of the lung or at the upper limit of the dulness, and more or less extensive
displacement of the heart. Obvious increase in girth, fulness of the
intercostal spaces, or gravitation ecchymosis was rare. The latter was most
common in instances in which multiple fracture of the ribs existed (see fig.
83). I think the rarity of the last sign must have been due to the early
coagulation of the blood, and its retention by the pleura, as I saw well-
marked gravitation ecchymosis in one or two cases of mediastinal
hæmorrhage.
The above complex of symptoms was common to all the cases, but in the
slighter ones they gave rise to little trouble, and cleared up with great
rapidity.
Page 447
Fig. 83.
Gravitation Ecchymosis in a case of Hæmothorax, accompanying
fracture of three ribs from within. The influence of the fractures on the
development of the ecchymosis is shown by the linear arrangement of
the discoloration
The most interesting feature was offered by the temperature, as this was
very liable to lead one astray. A primary rise always occurred with the
collection of blood in the pleura, this reaching its height on the third or
fourth day, usually about 102° F. in well-marked cases; it then fell, and in
favourable instances remained normal. In a large number of cases, however,
where the amount of blood was considerable, this was not the case, the
primary fall not reaching the normal, and a second rise occurred which
reached the same height as before or higher. The second rise was
accompanied by sweating, quickened pulse, and the probability of the
development of an empyema had always to be considered. I believe in most
cases this secondary rise was an indication of a further increase in the
hæmorrhage, for the dulness usually increased in extent, and such rises
were often seen when the patient had been moved or taken a journey. Again,
the temperature often fell to normal after paracentesis and removal of the
blood, to rise again with a fresh accumulation, which was not uncommon. I
have already mentioned the large proportional incidence of hæmothorax
observed in the patients who had to travel down from Paardeberg, and I
might instance another case related to me by Dr. Flockemann of the German
ambulance, which was very striking. A Boer, wounded at Colesberg,
developed a hæmothorax which quieted down, and he was removed to
Bloemfontein; on arrival at the latter place the temperature rose, and other
signs of fever suggested the development of an empyema; an exploring
needle, however, only brought blood to light. After a short stay at
Bloemfontein the symptoms entirely subsided, and the man was sent to
Kroonstadt, when an exactly similar attack resulted, again quieting down
with rest.
Similar recurrent attacks of hæmorrhage and fever occurred, however, in
patients confined to their beds without moving after the first journey. Some
temperature charts, in illustration of this point, are added to the cases
quoted later. The explanation of the recurrent hæmorrhages is, I think, to be
Gravitation Ecchymosis in a case of Hæmothorax, accompanying
fracture of three ribs from within. The influence of the fractures on the
development of the ecchymosis is shown by the linear arrangement of
the discoloration
The most interesting feature was offered by the temperature, as this was
very liable to lead one astray. A primary rise always occurred with the
collection of blood in the pleura, this reaching its height on the third or
fourth day, usually about 102° F. in well-marked cases; it then fell, and in
favourable instances remained normal. In a large number of cases, however,
where the amount of blood was considerable, this was not the case, the
primary fall not reaching the normal, and a second rise occurred which
reached the same height as before or higher. The second rise was
accompanied by sweating, quickened pulse, and the probability of the
development of an empyema had always to be considered. I believe in most
cases this secondary rise was an indication of a further increase in the
hæmorrhage, for the dulness usually increased in extent, and such rises
were often seen when the patient had been moved or taken a journey. Again,
the temperature often fell to normal after paracentesis and removal of the
blood, to rise again with a fresh accumulation, which was not uncommon. I
have already mentioned the large proportional incidence of hæmothorax
observed in the patients who had to travel down from Paardeberg, and I
might instance another case related to me by Dr. Flockemann of the German
ambulance, which was very striking. A Boer, wounded at Colesberg,
developed a hæmothorax which quieted down, and he was removed to
Bloemfontein; on arrival at the latter place the temperature rose, and other
signs of fever suggested the development of an empyema; an exploring
needle, however, only brought blood to light. After a short stay at
Bloemfontein the symptoms entirely subsided, and the man was sent to
Kroonstadt, when an exactly similar attack resulted, again quieting down
with rest.
Similar recurrent attacks of hæmorrhage and fever occurred, however, in
patients confined to their beds without moving after the first journey. Some
temperature charts, in illustration of this point, are added to the cases
quoted later. The explanation of the recurrent hæmorrhages is, I think, to be
Page 448
found in the reduction of the intra-thoracic pressure with coagulation and
shrinkage of the clot in the pleura in the patients kept quiet in bed, while in
the patients who had to travel it was probably the result of direct
mechanical disturbance.
In many of these cases a pleural rub was audible at the upper margin of the
dulness with the development of the fresh symptoms. Whether this was due
to actual pleurisy or to the rubbing of surfaces rough from the breaking
down of slight recent adhesions which had formed a barrier to the effusion,
I am unable to say, but the signs were fairly constant. In some instances the
increase in the amount of fluid was, no doubt, due to pleural effusion
resulting from irritation from the presence of blood-clot, or perhaps the
shifting of the latter; in these the secondary rise of temperature may well be
ascribed to the development of pleurisy.
I am inclined to believe, however, that the primary rise of temperature was
similar to that seen when blood accumulates in the peritoneal cavity as the
result of trauma, and the secondary rises in most cases to those which we
saw so frequently accompanying the interstitial secondary hæmorrhages
spoken of in Chapter IV., and are to be explained on the theory of
absorption of a blood ferment. The secondary rises always occurred with a
fresh effusion, often of blood, occasioning an extension, which broke down
probable light adhesions and exposed a fresh area of normal pleural
membrane to act as a surface for absorption.
It is, of course, manifest that the fever might also be ascribed to the
infection of the clot or serum from without, and in the first cases I saw I
was inclined to take this view, since we had in every case the primary
wounds of chest-wall, and possibly of lung, and in some the addition of a
puncture by an exploring needle between the first and second rise. After a
wider experience, however, I abandoned the infection theory, as it seemed
opposed by the very infrequent sequence of suppuration. The effect of
simple removal of the blood or serum was also often so striking as to
strongly suggest that it alone was responsible for the fever. Exactly the
same result, moreover, followed evacuation of the interstitial blood
effusions already mentioned elsewhere.
shrinkage of the clot in the pleura in the patients kept quiet in bed, while in
the patients who had to travel it was probably the result of direct
mechanical disturbance.
In many of these cases a pleural rub was audible at the upper margin of the
dulness with the development of the fresh symptoms. Whether this was due
to actual pleurisy or to the rubbing of surfaces rough from the breaking
down of slight recent adhesions which had formed a barrier to the effusion,
I am unable to say, but the signs were fairly constant. In some instances the
increase in the amount of fluid was, no doubt, due to pleural effusion
resulting from irritation from the presence of blood-clot, or perhaps the
shifting of the latter; in these the secondary rise of temperature may well be
ascribed to the development of pleurisy.
I am inclined to believe, however, that the primary rise of temperature was
similar to that seen when blood accumulates in the peritoneal cavity as the
result of trauma, and the secondary rises in most cases to those which we
saw so frequently accompanying the interstitial secondary hæmorrhages
spoken of in Chapter IV., and are to be explained on the theory of
absorption of a blood ferment. The secondary rises always occurred with a
fresh effusion, often of blood, occasioning an extension, which broke down
probable light adhesions and exposed a fresh area of normal pleural
membrane to act as a surface for absorption.
It is, of course, manifest that the fever might also be ascribed to the
infection of the clot or serum from without, and in the first cases I saw I
was inclined to take this view, since we had in every case the primary
wounds of chest-wall, and possibly of lung, and in some the addition of a
puncture by an exploring needle between the first and second rise. After a
wider experience, however, I abandoned the infection theory, as it seemed
opposed by the very infrequent sequence of suppuration. The effect of
simple removal of the blood or serum was also often so striking as to
strongly suggest that it alone was responsible for the fever. Exactly the
same result, moreover, followed evacuation of the interstitial blood
effusions already mentioned elsewhere.
Page 449
The common course of all the cases of hæmothorax was to spontaneous
recovery, the rapidity of the subsidence of the signs depending mainly on
the quantity of the primary hæmorrhage, and the occurrence of further
increases. The blood serum tended to collect at the upper limit of the
original blood effusion (as was often proved on tapping), and this was first
absorbed; the clot deposited on the pleural surface and at the basal part of
the cavity was, however, not absorbed with the same rapidity. In the
majority of the patients when they left the hospitals, at the end of six weeks
on an average, some dulness and deficiency of vesicular murmur always
remained, and the clot and the surrounding surface, irritated by its presence,
will, no doubt, be responsible for permanent adhesions in many cases. That
such adhesions do form in the majority of cases I feel certain, as, although
these patients when they left the hospital were to all intents and purposes
apparently well, few of them could undertake sustained exertion without
getting short of breath, and sometimes suffering from transitory pain, and
for this reason it became customary to invalid them home.
In a small proportion of the cases empyema followed; but I never saw this
in any case that had neither been tapped nor opened, and I saw only one
patient die from a chest wound uncomplicated by other injuries. This case
was an interesting one of recurrent hæmorrhage followed by inflammatory
troubles:—
Temperature Chart 2.—Secondary Hæmorrhages in
a case of Hæmothorax. Case No. 151
recovery, the rapidity of the subsidence of the signs depending mainly on
the quantity of the primary hæmorrhage, and the occurrence of further
increases. The blood serum tended to collect at the upper limit of the
original blood effusion (as was often proved on tapping), and this was first
absorbed; the clot deposited on the pleural surface and at the basal part of
the cavity was, however, not absorbed with the same rapidity. In the
majority of the patients when they left the hospitals, at the end of six weeks
on an average, some dulness and deficiency of vesicular murmur always
remained, and the clot and the surrounding surface, irritated by its presence,
will, no doubt, be responsible for permanent adhesions in many cases. That
such adhesions do form in the majority of cases I feel certain, as, although
these patients when they left the hospital were to all intents and purposes
apparently well, few of them could undertake sustained exertion without
getting short of breath, and sometimes suffering from transitory pain, and
for this reason it became customary to invalid them home.
In a small proportion of the cases empyema followed; but I never saw this
in any case that had neither been tapped nor opened, and I saw only one
patient die from a chest wound uncomplicated by other injuries. This case
was an interesting one of recurrent hæmorrhage followed by inflammatory
troubles:—
Temperature Chart 2.—Secondary Hæmorrhages in
a case of Hæmothorax. Case No. 151
Page 450
(151) The wound was received at short range, probably at from
100 to 200 yards. Entry, 1 inch from the left axillary margin in
the first intercostal space; exit, at the back of the right arm 1½
inch below the acromial angle; both pleuræ were therefore
crossed. The patient expectorated at first fluid, then clotted,
blood in considerable quantity. When brought into the advanced
Base hospital on the third day, there were signs of blood in the
left pleura, cellular emphysema over the right side of the chest,
and signs of collapse of the right lung. The temperature chart
gives shortly the course of the case: the right pneumo-thorax
cleared up spontaneously, also the emphysema; but the left
pleura needed tapping to relieve symptoms of pressure on four
occasions, the 13th, 15th, 19th, and 25th days respectively. On
the first two occasions blood was removed, on the third blood
serum only, and on the last pus. The patient was relieved after
each aspiration; after the third, the temperature fell to normal,
the general condition also improved, and he promised to do
well. None the less, reaccumulation took place, the evacuated
fluid assumed an inflammatory character, and an incision to
evacuate pus was eventually followed by death on the twenty-
seventh day. The amount of hæmoptysis throughout was
considerable, and the case was possibly one of pulmonary
hæmothorax, as after death no source of hæmorrhage could be
localised in the intercostal space. The track in the lung was
almost healed, and although a part of it allowed the introduction
of a probe for about an inch, it could be traced no further even
on section of the organ, and no special vessel could be located as
the original bleeding spot.
Empyema.—I may here add the little that I have to say on this subject.
During the whole campaign the single case of primary empyema that I saw
was the one recorded below, which deserves special mention as illustrating
the disadvantage of extracting bullets on the field. Under the conditions
which necessarily accompanied this operation the ensurance of asepsis was
impossible, and the additional wound no doubt proved the source of
infection.
100 to 200 yards. Entry, 1 inch from the left axillary margin in
the first intercostal space; exit, at the back of the right arm 1½
inch below the acromial angle; both pleuræ were therefore
crossed. The patient expectorated at first fluid, then clotted,
blood in considerable quantity. When brought into the advanced
Base hospital on the third day, there were signs of blood in the
left pleura, cellular emphysema over the right side of the chest,
and signs of collapse of the right lung. The temperature chart
gives shortly the course of the case: the right pneumo-thorax
cleared up spontaneously, also the emphysema; but the left
pleura needed tapping to relieve symptoms of pressure on four
occasions, the 13th, 15th, 19th, and 25th days respectively. On
the first two occasions blood was removed, on the third blood
serum only, and on the last pus. The patient was relieved after
each aspiration; after the third, the temperature fell to normal,
the general condition also improved, and he promised to do
well. None the less, reaccumulation took place, the evacuated
fluid assumed an inflammatory character, and an incision to
evacuate pus was eventually followed by death on the twenty-
seventh day. The amount of hæmoptysis throughout was
considerable, and the case was possibly one of pulmonary
hæmothorax, as after death no source of hæmorrhage could be
localised in the intercostal space. The track in the lung was
almost healed, and although a part of it allowed the introduction
of a probe for about an inch, it could be traced no further even
on section of the organ, and no special vessel could be located as
the original bleeding spot.
Empyema.—I may here add the little that I have to say on this subject.
During the whole campaign the single case of primary empyema that I saw
was the one recorded below, which deserves special mention as illustrating
the disadvantage of extracting bullets on the field. Under the conditions
which necessarily accompanied this operation the ensurance of asepsis was
impossible, and the additional wound no doubt proved the source of
infection.
Page 451
(152) Entry, at the posterior margin of the sterno-mastoid
muscle, 2 inches above the clavicle; the bullet came to the
surface beneath the skin over the fifth rib, in the nipple line of
the right side. There was never any hæmoptysis, but the patient
suffered with some dyspnœa throughout. After a three days' stay
in the Field hospital, where the subcutaneous bullet was
removed, the patient was transported by wagon and train to the
Base, a journey of about 600 miles.
On the fifth day pus escaped from the extraction wound, and
when the case was examined at the Base, the temperature was
101°, the pulse over 100, the respirations 30, and the whole side
of the chest was dull, with the exception of a patch of boxy
resonance over the apex anteriorly. On the following day the
chest was drained, and a considerable amount of pus evacuated,
which was mixed with breaking-down blood-clot. A fortnight
later a second operation had to be performed to improve the
drainage, and the patient made a tedious recovery.
The following case well illustrates the symptoms in a severe case of
hæmothorax, and empyema following aspiration:—
(153) The patient was wounded at Paardeberg at a range of from
500 to 700 yards. Entry, just to the left of the episternal notch;
exit, in the fifth left interspace posteriorly, midway between the
spine and vertebral margin of the scapula. A quantity of bright
blood was brought up at once, and later blood was coughed up
in clots.
There was no great pain at the moment of the injury; the man
again got up to the firing line, and later walked two miles to the
Field hospital without aid. He remained here a week, when he
was sent down to the Base, and during the first three days'
journey in the wagon he began to get worse. On the fourth day
cough began to be very troublesome.
When he arrived at the Base, fifteen days after the original
injury, there was much dyspnœa; the temperature was 102°, and
the pulse 110. The left side of the chest was dull throughout; an
muscle, 2 inches above the clavicle; the bullet came to the
surface beneath the skin over the fifth rib, in the nipple line of
the right side. There was never any hæmoptysis, but the patient
suffered with some dyspnœa throughout. After a three days' stay
in the Field hospital, where the subcutaneous bullet was
removed, the patient was transported by wagon and train to the
Base, a journey of about 600 miles.
On the fifth day pus escaped from the extraction wound, and
when the case was examined at the Base, the temperature was
101°, the pulse over 100, the respirations 30, and the whole side
of the chest was dull, with the exception of a patch of boxy
resonance over the apex anteriorly. On the following day the
chest was drained, and a considerable amount of pus evacuated,
which was mixed with breaking-down blood-clot. A fortnight
later a second operation had to be performed to improve the
drainage, and the patient made a tedious recovery.
The following case well illustrates the symptoms in a severe case of
hæmothorax, and empyema following aspiration:—
(153) The patient was wounded at Paardeberg at a range of from
500 to 700 yards. Entry, just to the left of the episternal notch;
exit, in the fifth left interspace posteriorly, midway between the
spine and vertebral margin of the scapula. A quantity of bright
blood was brought up at once, and later blood was coughed up
in clots.
There was no great pain at the moment of the injury; the man
again got up to the firing line, and later walked two miles to the
Field hospital without aid. He remained here a week, when he
was sent down to the Base, and during the first three days'
journey in the wagon he began to get worse. On the fourth day
cough began to be very troublesome.
When he arrived at the Base, fifteen days after the original
injury, there was much dyspnœa; the temperature was 102°, and
the pulse 110. The left side of the chest was dull throughout; an
Page 452
aspirating needle was introduced, and a pint of very dark liquid
blood drawn off. The whole of the blood was not removed on
account of the very severe cough and pain which the evacuation
occasioned. The man appeared to steadily improve until three
weeks later, when the temperature, which throughout had been
uneven, became consistently high, and signs of fluid at the base
increased. An aspirating needle was introduced, and 16 ounces
of pus were drawn off. Two days later a piece of rib was
resected (Mr. Pegg) and another pint of pus evacuated. After
this, rapid improvement took place, and in ten days the man was
able to be up and dressed, although a small amount of discharge
still persisted. He eventually made an excellent recovery.
Secondary empyemata not uncommonly followed incision of the chest, or
excision of a rib for draining a hæmothorax. These operations in the early
part of the campaign were more freely undertaken on the supposition that
rise of temperature and other symptoms of fever pointed to incipient
breaking down of the clot. Subsequent experience showed this not to be the
case, and early operations for drainage ceased to be undertaken. In these
operations a primary difficulty was met with in effectively clearing out the
clot, a drain had to be left, and suppuration occurred later in a considerable
proportion. The suppurations were most troublesome; local adhesions
formed, and the pus collected in small pockets, which were difficult to find
and to drain, and even when the collections seemed to have been
successfully dealt with at the time, residual abscesses often followed at a
very late date. Thus, I saw a case with a contracted chest and a fresh abscess
the day before I left Cape Town, in whom I had advised and witnessed an
operation for the evacuation of clot in the presence of signs of fever a week
after my arrival in the country, nine months previously. I saw another case
where general infection followed incision of a hæmothorax, but the patient
fortunately recovered.
The question of pleurisy has already been mentioned in connection with
hæmothorax; it no doubt accounted for secondary effusion in some cases,
and beyond this I have nothing to add to what has been there said.
Pneumonia was rare; there were occasionally signs of consolidation, but, I
think, quite as often in the opposite lung as in the one injured. I never saw a
blood drawn off. The whole of the blood was not removed on
account of the very severe cough and pain which the evacuation
occasioned. The man appeared to steadily improve until three
weeks later, when the temperature, which throughout had been
uneven, became consistently high, and signs of fluid at the base
increased. An aspirating needle was introduced, and 16 ounces
of pus were drawn off. Two days later a piece of rib was
resected (Mr. Pegg) and another pint of pus evacuated. After
this, rapid improvement took place, and in ten days the man was
able to be up and dressed, although a small amount of discharge
still persisted. He eventually made an excellent recovery.
Secondary empyemata not uncommonly followed incision of the chest, or
excision of a rib for draining a hæmothorax. These operations in the early
part of the campaign were more freely undertaken on the supposition that
rise of temperature and other symptoms of fever pointed to incipient
breaking down of the clot. Subsequent experience showed this not to be the
case, and early operations for drainage ceased to be undertaken. In these
operations a primary difficulty was met with in effectively clearing out the
clot, a drain had to be left, and suppuration occurred later in a considerable
proportion. The suppurations were most troublesome; local adhesions
formed, and the pus collected in small pockets, which were difficult to find
and to drain, and even when the collections seemed to have been
successfully dealt with at the time, residual abscesses often followed at a
very late date. Thus, I saw a case with a contracted chest and a fresh abscess
the day before I left Cape Town, in whom I had advised and witnessed an
operation for the evacuation of clot in the presence of signs of fever a week
after my arrival in the country, nine months previously. I saw another case
where general infection followed incision of a hæmothorax, but the patient
fortunately recovered.
The question of pleurisy has already been mentioned in connection with
hæmothorax; it no doubt accounted for secondary effusion in some cases,
and beyond this I have nothing to add to what has been there said.
Pneumonia was rare; there were occasionally signs of consolidation, but, I
think, quite as often in the opposite lung as in the one injured. I never saw a
Page 453
fatal case, and I am inclined to think that when it occurred it was as often
the result of cold and exposure as of the injury to the lung. Abscess of the
lung I only saw once, and that in a case in which the injury to the chest was
complicated by paraplegia from spinal injury and septicæmia, and it was
possibly pyæmic.
Diagnosis.—No difficulties special to small-calibre wounds were
experienced, except such as have been already dealt with. The only class of
case which frequently gave rise to difficulty was hæmothorax. Here two
points especially needed consideration. (1) The source of the hæmorrhage
as parietal or visceral. As has been already foreshadowed, this was mainly
to be decided by the amount and persistence of the hæmoptysis, but
naturally free hæmoptysis did not negative concurrent parietal bleeding.
Then the actual source of the bleeding other than from the lung had to be
considered; in the great majority of cases the intercostal vessels were
responsible, and attention to the course of the tracks often allowed this to be
definitely decided upon.
A case included in the chapter on Injuries to the Blood Vessels (No. 5, p.
127) is of great interest in this particular; in that instance feebleness of the
radial pulse, together with the position of the wound, was a valuable
indication of injury to the subclavian artery, but weakened somewhat by the
fact of retention of the bullet, and hence uncertainty as to the exact course
that it had taken, and as to whether the bullet itself was not responsible for
pressure on the vessel. Such indications, however, should make one very
chary of interference with a hæmothorax, even with extremely urgent
symptoms, in the light of our present knowledge of the nature of the lesions
to the great vessels produced by small-calibre bullets, and their tendency to
be incomplete.
(2) The imminence of suppuration or its actual occurrence.—In most cases
it sufficed to preserve an expectant attitude, and in the persistence or
increase of symptoms, to have recourse to an exploratory puncture as the
best means of solution of the difficulty.
Prognosis.—The prognosis both as to life and as to subsequent ill-effects
was remarkably good; in many cases of uncomplicated injury to the lung
the patients rejoined their regiments at the end of a month or six weeks. In
the result of cold and exposure as of the injury to the lung. Abscess of the
lung I only saw once, and that in a case in which the injury to the chest was
complicated by paraplegia from spinal injury and septicæmia, and it was
possibly pyæmic.
Diagnosis.—No difficulties special to small-calibre wounds were
experienced, except such as have been already dealt with. The only class of
case which frequently gave rise to difficulty was hæmothorax. Here two
points especially needed consideration. (1) The source of the hæmorrhage
as parietal or visceral. As has been already foreshadowed, this was mainly
to be decided by the amount and persistence of the hæmoptysis, but
naturally free hæmoptysis did not negative concurrent parietal bleeding.
Then the actual source of the bleeding other than from the lung had to be
considered; in the great majority of cases the intercostal vessels were
responsible, and attention to the course of the tracks often allowed this to be
definitely decided upon.
A case included in the chapter on Injuries to the Blood Vessels (No. 5, p.
127) is of great interest in this particular; in that instance feebleness of the
radial pulse, together with the position of the wound, was a valuable
indication of injury to the subclavian artery, but weakened somewhat by the
fact of retention of the bullet, and hence uncertainty as to the exact course
that it had taken, and as to whether the bullet itself was not responsible for
pressure on the vessel. Such indications, however, should make one very
chary of interference with a hæmothorax, even with extremely urgent
symptoms, in the light of our present knowledge of the nature of the lesions
to the great vessels produced by small-calibre bullets, and their tendency to
be incomplete.
(2) The imminence of suppuration or its actual occurrence.—In most cases
it sufficed to preserve an expectant attitude, and in the persistence or
increase of symptoms, to have recourse to an exploratory puncture as the
best means of solution of the difficulty.
Prognosis.—The prognosis both as to life and as to subsequent ill-effects
was remarkably good; in many cases of uncomplicated injury to the lung
the patients rejoined their regiments at the end of a month or six weeks. In
Page 454
the more serious cases complicated by the collection of blood in the pleura,
convalescence was more prolonged, and an average time of six to eight
weeks often elapsed before the patients could be safely discharged from
hospital. In the more serious a certain amount of dulness always persisted at
this time over the base of the lung, and the chest was usually somewhat
contracted on the injured side, with evidence in the way of decreased
vesicular murmur that the lung was still not free from compression. With
regard to the persistence of dulness on percussion, it is well to bear in mind
that a thin layer of blood apparently produces as serious impairment of
resonance as a much larger quantity of serum. The signs appeared to favour
the view that the space necessary for the location of the hæmorrhage had
been obtained at the expense of the lung rather than by distension of the
thoracic parietes, and also, I think, denoted the presence of adhesions.
Possibly they will entirely disappear with the return of full excursion
movements of respiration, the latter being often still somewhat restricted
when the patients left hospital. All the patients with such signs were liable
to attacks of pain and shortness of breath on actual bodily exertion. I
happened to meet with an officer, the subject of a Lee-Metford wound of
the thorax, sustained five years previously, and he told me that he was nine
months before he could take active exercise without feeling short of breath.
As to the cases of hæmothorax and empyema which needed drainage, all
did well; but expansion of the lung was much less satisfactory than would
have been expected, probably on account of especially firm adhesions. The
importance of concurrent injury I need hardly dwell on; but I might add that
perforation of one or both arms, the most common one, did not materially
affect the general statements above made.
Treatment.—In the early stages of the pulmonary wounds rest was the all-
important indication, and when this was assured few serious cases of
hæmothorax occurred. Beyond simple rest, the administration of opium
with a view to checking internal hæmorrhage was used with good effect.
The wounds needed simple dressing only.
The treatment of hæmothorax at a later date, however, was of much interest
and difficulty. I think the following lines may be laid down for guidance in
such cases:—
convalescence was more prolonged, and an average time of six to eight
weeks often elapsed before the patients could be safely discharged from
hospital. In the more serious a certain amount of dulness always persisted at
this time over the base of the lung, and the chest was usually somewhat
contracted on the injured side, with evidence in the way of decreased
vesicular murmur that the lung was still not free from compression. With
regard to the persistence of dulness on percussion, it is well to bear in mind
that a thin layer of blood apparently produces as serious impairment of
resonance as a much larger quantity of serum. The signs appeared to favour
the view that the space necessary for the location of the hæmorrhage had
been obtained at the expense of the lung rather than by distension of the
thoracic parietes, and also, I think, denoted the presence of adhesions.
Possibly they will entirely disappear with the return of full excursion
movements of respiration, the latter being often still somewhat restricted
when the patients left hospital. All the patients with such signs were liable
to attacks of pain and shortness of breath on actual bodily exertion. I
happened to meet with an officer, the subject of a Lee-Metford wound of
the thorax, sustained five years previously, and he told me that he was nine
months before he could take active exercise without feeling short of breath.
As to the cases of hæmothorax and empyema which needed drainage, all
did well; but expansion of the lung was much less satisfactory than would
have been expected, probably on account of especially firm adhesions. The
importance of concurrent injury I need hardly dwell on; but I might add that
perforation of one or both arms, the most common one, did not materially
affect the general statements above made.
Treatment.—In the early stages of the pulmonary wounds rest was the all-
important indication, and when this was assured few serious cases of
hæmothorax occurred. Beyond simple rest, the administration of opium
with a view to checking internal hæmorrhage was used with good effect.
The wounds needed simple dressing only.
The treatment of hæmothorax at a later date, however, was of much interest
and difficulty. I think the following lines may be laid down for guidance in
such cases:—
Page 455
(i) Hæmothorax, even of considerable severity, will undergo spontaneous
cure. An early rise of temperature may be disregarded.
(ii) Tapping the chest is indicated when pressure signs on the lung are
sufficiently severe to cause serious symptoms, and the removal of the blood
undoubtedly shortens the period of recovery, as well as relieves symptoms.
In such cases the collection of blood has usually been rapid and continuous;
hence a fresh hæmorrhage is always probable when the local pressure has
been removed. Tapping therefore should not necessarily mean complete
evacuation, and should be followed by careful firm binding up of the chest,
the administration of opium, and the most stringent precautions for rest.
(iii) Tapping may be needed as a diagnostic aid, and in such circumstances
as much fluid as can be removed should be evacuated with the same
precautions as mentioned in the last paragraph.
(iv) Tapping may be indicated for the evacuation of serum expressed from
the blood-clot, or due to pleural effusion, on the same lines as in any other
collection of fluid in the pleural cavity.
(v) Early free incision is, as a rule, to be steadfastly avoided. Some cases
already quoted fully illustrate its disadvantages.
(vi) Cases in which an incision and the ligature of a parietal artery are
indicated are very rare. I never saw such a one myself.
(vii) If a hæmothorax suppurates, it must be treated on the ordinary lines of
an empyema. In view of the constant formation of adhesions and difficulty
in drainage, a portion of a rib should always be resected in order to ensure
sufficient space for after-treatment. The cavities, as a rule, are better
irrigated, the usual precautions being taken where there is any reason to fear
that the lung is still in communication with the cavity.
Care in carrying out asepsis in tapping, which should be performed with an
aspirator, need hardly be more than mentioned. It will be noted that in some
of the cases quoted suppuration followed tapping, but it must be
remembered that in these the two primary wounds already existed as
possible channels of infection.
cure. An early rise of temperature may be disregarded.
(ii) Tapping the chest is indicated when pressure signs on the lung are
sufficiently severe to cause serious symptoms, and the removal of the blood
undoubtedly shortens the period of recovery, as well as relieves symptoms.
In such cases the collection of blood has usually been rapid and continuous;
hence a fresh hæmorrhage is always probable when the local pressure has
been removed. Tapping therefore should not necessarily mean complete
evacuation, and should be followed by careful firm binding up of the chest,
the administration of opium, and the most stringent precautions for rest.
(iii) Tapping may be needed as a diagnostic aid, and in such circumstances
as much fluid as can be removed should be evacuated with the same
precautions as mentioned in the last paragraph.
(iv) Tapping may be indicated for the evacuation of serum expressed from
the blood-clot, or due to pleural effusion, on the same lines as in any other
collection of fluid in the pleural cavity.
(v) Early free incision is, as a rule, to be steadfastly avoided. Some cases
already quoted fully illustrate its disadvantages.
(vi) Cases in which an incision and the ligature of a parietal artery are
indicated are very rare. I never saw such a one myself.
(vii) If a hæmothorax suppurates, it must be treated on the ordinary lines of
an empyema. In view of the constant formation of adhesions and difficulty
in drainage, a portion of a rib should always be resected in order to ensure
sufficient space for after-treatment. The cavities, as a rule, are better
irrigated, the usual precautions being taken where there is any reason to fear
that the lung is still in communication with the cavity.
Care in carrying out asepsis in tapping, which should be performed with an
aspirator, need hardly be more than mentioned. It will be noted that in some
of the cases quoted suppuration followed tapping, but it must be
remembered that in these the two primary wounds already existed as
possible channels of infection.
Page 456
Retained bullets of small calibre in the thoracic cavity were not common,
unless the lodgment had occurred in the bodies of the vertebræ. I saw very
few. Shrapnel bullets and fragments of shells, however, were, in proportion
to the frequency of wounds from such projectiles, more commonly retained.
The rules to be followed in such cases do not materially deviate from those
to be observed in the body generally.
When the bullet is causing no trouble, and is lodged in either the bone of
the spine or the lung substance, no interference is advisable. When, on the
other hand, the bullet as viewed by the X-rays is seen to be in the pleural
cavity, and any symptoms of its presence exist, it may be justifiable to
remove it. I saw this done in one case for the removal of a shrapnel bullet
from the lower reflexion of the pleura on account of fixed pain and
tenderness complained of by the patient. The bullet, a shrapnel, had
perforated the arm, which the patient was sure was by his side at the
moment of injury, and the X-rays showed it to lie at the bottom of the
pleural cavity, where we assumed it had fallen. When, however, the bullet
was removed by Mr. Watson, he found that the fixed pain and tenderness
had been the result of a fracture of a rib from the inner side, not involving
loss of continuity; hence the actual indication for the operation had been a
delusive one, since the bullet had not fallen, but expended its last force in
injuring the rib. The patient made an excellent recovery, and rejoined his
regiment at the end of six weeks. I saw several cases in which the bullet
was lodged in either the lung or bones of the spine do well with no
interference. The great disadvantage of primary removal in inducing an
artificial pneumo-thorax and in laying open a hæmothorax is obvious.
In case of lodgment of the bullet in the lung, bearing in mind the
infrequency of untoward symptoms, the latter should be watched for prior
to interference.
The following cases illustrate some typical instances of wound of chest
accompanied by the development of hæmothorax:—
unless the lodgment had occurred in the bodies of the vertebræ. I saw very
few. Shrapnel bullets and fragments of shells, however, were, in proportion
to the frequency of wounds from such projectiles, more commonly retained.
The rules to be followed in such cases do not materially deviate from those
to be observed in the body generally.
When the bullet is causing no trouble, and is lodged in either the bone of
the spine or the lung substance, no interference is advisable. When, on the
other hand, the bullet as viewed by the X-rays is seen to be in the pleural
cavity, and any symptoms of its presence exist, it may be justifiable to
remove it. I saw this done in one case for the removal of a shrapnel bullet
from the lower reflexion of the pleura on account of fixed pain and
tenderness complained of by the patient. The bullet, a shrapnel, had
perforated the arm, which the patient was sure was by his side at the
moment of injury, and the X-rays showed it to lie at the bottom of the
pleural cavity, where we assumed it had fallen. When, however, the bullet
was removed by Mr. Watson, he found that the fixed pain and tenderness
had been the result of a fracture of a rib from the inner side, not involving
loss of continuity; hence the actual indication for the operation had been a
delusive one, since the bullet had not fallen, but expended its last force in
injuring the rib. The patient made an excellent recovery, and rejoined his
regiment at the end of six weeks. I saw several cases in which the bullet
was lodged in either the lung or bones of the spine do well with no
interference. The great disadvantage of primary removal in inducing an
artificial pneumo-thorax and in laying open a hæmothorax is obvious.
In case of lodgment of the bullet in the lung, bearing in mind the
infrequency of untoward symptoms, the latter should be watched for prior
to interference.
The following cases illustrate some typical instances of wound of chest
accompanied by the development of hæmothorax:—
Page 457
Temperature Chart 3.—Primary Hæmothorax, with
rise of temperature. Secondary rise, with fresh
effusion and pneumonia. Spontaneous recovery.
Case No. 154
(154) Severe hæmothorax. Spontaneous recovery.—Wounded at
Modder River at a distance of 30 yards. Entry, at the junction of
the left anterior axillary fold with the chest-wall; exit,
immediately to the left of the seventh dorsal spinous process.
The patient arrived at the Base with signs of an extensive
hæmothorax, accompanied by a temperature which reached 102°
on the fourth day, and on the evening of the tenth 103°. The man
was very ill, and an exploring needle was inserted, by which
about an ounce of blood was evacuated. The signs of fluid in the
left pleura were accompanied by those of consolidation over the
lower fourth of the right lung, and the sputa were rusty.
Evidence of perforation of the left axillary artery existed in
feebleness of the radial pulse; and there was musculo-spiral
paralysis.
After the preliminary puncture, the man refused any further
operative treatment, although a second rise of temperature
commenced on the fifteenth day, culminating in a temperature of
103.2° on the eighteenth. The further treatment of the patient
consisted in the ensurance of rest and the alleviation of pain. A
steady fall in the temperature extended over another three
weeks, together with diminution in the signs of fluid in the
pleura. At the end of seventy-four days the man was sent home,
rise of temperature. Secondary rise, with fresh
effusion and pneumonia. Spontaneous recovery.
Case No. 154
(154) Severe hæmothorax. Spontaneous recovery.—Wounded at
Modder River at a distance of 30 yards. Entry, at the junction of
the left anterior axillary fold with the chest-wall; exit,
immediately to the left of the seventh dorsal spinous process.
The patient arrived at the Base with signs of an extensive
hæmothorax, accompanied by a temperature which reached 102°
on the fourth day, and on the evening of the tenth 103°. The man
was very ill, and an exploring needle was inserted, by which
about an ounce of blood was evacuated. The signs of fluid in the
left pleura were accompanied by those of consolidation over the
lower fourth of the right lung, and the sputa were rusty.
Evidence of perforation of the left axillary artery existed in
feebleness of the radial pulse; and there was musculo-spiral
paralysis.
After the preliminary puncture, the man refused any further
operative treatment, although a second rise of temperature
commenced on the fifteenth day, culminating in a temperature of
103.2° on the eighteenth. The further treatment of the patient
consisted in the ensurance of rest and the alleviation of pain. A
steady fall in the temperature extended over another three
weeks, together with diminution in the signs of fluid in the
pleura. At the end of seventy-four days the man was sent home,
Page 458
some slight dulness at the left base, and contraction of the chest
sufficient to influence the spine in the way of lateral curvature,
being the only remaining signs.
Temperature Chart 4.—Primary Hæmothorax.
Secondary rise of temperature, with increase in the
effusion. Spontaneous recovery. Case No. 155
(155) Severe hæmothorax. Secondary effusion. Spontaneous
recovery.—Wounded at Koodoosberg Drift, at a distance of 200
yards. Entry, at angle of the right scapula; exit, at the junction of
the left anterior axillary fold with the chest-wall. No signs of
spinal cord injury. The patient was brought in from the field
twelve miles by an ambulance wagon on the second day, and in
crossing the Modder River he was accidentally upset into the
stream. For the first four days there was no hæmoptysis, but for
the succeeding nine days small brightish red clots were
expectorated. There was some tenderness over the ribs from the
fifth to the ninth in the axillary line, and on the ninth day some
gravitation ecchymosis appeared over the same region. Cough
was an early troublesome symptom in this case, and when
admitted to the Base hospital, about the seventh day, there was
evidence of fluid extending about a third of the way up the back.
On the tenth day after admission a pleural rub was detected at
the upper margin of the dulness, and the latter shortly extended
upwards over a little more than half the back. Meanwhile, there
was no further hæmoptysis, respiration was fairly easy, 24 per
sufficient to influence the spine in the way of lateral curvature,
being the only remaining signs.
Temperature Chart 4.—Primary Hæmothorax.
Secondary rise of temperature, with increase in the
effusion. Spontaneous recovery. Case No. 155
(155) Severe hæmothorax. Secondary effusion. Spontaneous
recovery.—Wounded at Koodoosberg Drift, at a distance of 200
yards. Entry, at angle of the right scapula; exit, at the junction of
the left anterior axillary fold with the chest-wall. No signs of
spinal cord injury. The patient was brought in from the field
twelve miles by an ambulance wagon on the second day, and in
crossing the Modder River he was accidentally upset into the
stream. For the first four days there was no hæmoptysis, but for
the succeeding nine days small brightish red clots were
expectorated. There was some tenderness over the ribs from the
fifth to the ninth in the axillary line, and on the ninth day some
gravitation ecchymosis appeared over the same region. Cough
was an early troublesome symptom in this case, and when
admitted to the Base hospital, about the seventh day, there was
evidence of fluid extending about a third of the way up the back.
On the tenth day after admission a pleural rub was detected at
the upper margin of the dulness, and the latter shortly extended
upwards over a little more than half the back. Meanwhile, there
was no further hæmoptysis, respiration was fairly easy, 24 per
Page 459
minute, but accompanied by slight dilatation of the alæ nasi, and
the temperature, which had been ranging from 99° to 100°,
began to rise steadily, on the fifteenth day reaching 102.5°. The
patient refused even an exploratory puncture, and was treated on
the expectant plan. The temperature slowly subsided, with a
steady improvement in the physical signs, and at the end of
about ten weeks he left for home with only slight dulness and
incapacity for active exertion remaining. (Now again on active
service.)
Temperature Chart 5.—Hæmothorax, primary and
secondary rises of temperature, on each occasion
falling on the evacuation of the blood. Case No. 156
(156) Severe hæmothorax. Recurrent secondary effusion.
Tapping on two occasions. Cure.—The patient was wounded at
Paardeberg, and arrived at the Base on the eighteenth day. Entry,
below the first rib, just external to its junction with the costal
cartilage; exit, through the ninth rib, just within the posterior
axillary line. The whole right side of the chest was dull, with
signs of the presence of fluid, the heart being displaced to the
left. There was considerable distress; the respirations averaged
the temperature, which had been ranging from 99° to 100°,
began to rise steadily, on the fifteenth day reaching 102.5°. The
patient refused even an exploratory puncture, and was treated on
the expectant plan. The temperature slowly subsided, with a
steady improvement in the physical signs, and at the end of
about ten weeks he left for home with only slight dulness and
incapacity for active exertion remaining. (Now again on active
service.)
Temperature Chart 5.—Hæmothorax, primary and
secondary rises of temperature, on each occasion
falling on the evacuation of the blood. Case No. 156
(156) Severe hæmothorax. Recurrent secondary effusion.
Tapping on two occasions. Cure.—The patient was wounded at
Paardeberg, and arrived at the Base on the eighteenth day. Entry,
below the first rib, just external to its junction with the costal
cartilage; exit, through the ninth rib, just within the posterior
axillary line. The whole right side of the chest was dull, with
signs of the presence of fluid, the heart being displaced to the
left. There was considerable distress; the respirations averaged
Page 460
40, the pulse 100, and the temperature reached 101.5° the first
evening after arrival.
On the nineteenth day the thorax was aspirated (Mr. Hanwell)
and 50 ounces of dirty red-coloured fluid, half clot, half serum,
were evacuated. Considerable relief was afforded; the
respirations became slightly less frequent; the heart returned to a
normal position, and distant tubular respiration was audible. The
temperature dropped to normal the third day after evacuation of
the fluid, but on the sixth day it again commenced to rise, and
meanwhile fluid again began to collect.
On the twenty-sixth day a second aspiration resulted in the
evacuation of 35 ounces of bloody fluid in which flakes of
lymph were found. Three days later the temperature became
normal. The respirations fell to 22, and the patient made an
uninterrupted recovery.
evening after arrival.
On the nineteenth day the thorax was aspirated (Mr. Hanwell)
and 50 ounces of dirty red-coloured fluid, half clot, half serum,
were evacuated. Considerable relief was afforded; the
respirations became slightly less frequent; the heart returned to a
normal position, and distant tubular respiration was audible. The
temperature dropped to normal the third day after evacuation of
the fluid, but on the sixth day it again commenced to rise, and
meanwhile fluid again began to collect.
On the twenty-sixth day a second aspiration resulted in the
evacuation of 35 ounces of bloody fluid in which flakes of
lymph were found. Three days later the temperature became
normal. The respirations fell to 22, and the patient made an
uninterrupted recovery.
Page 461
Temperature Chart 6.—Wound of Lung. Secondary
development of Hæmothorax, with rise of
temperature. Spontaneous recovery. Case No 157
(157) Moderate hæmothorax. Secondary effusion at the end of
twenty days. Spontaneous recovery.—Wounded at Paardeberg;
range from 700 to 1,000 yards. Entry, in the centre of the second
right intercostal space, anteriorly; exit, at the level of the sixth
rib posteriorly, through the scapula, close to its vertebral margin.
The patient arrived at the Base on the sixth day; he said he
expectorated some blood at the end of about ten minutes after
being shot, and experienced a 'half-choking sensation.' A small
quantity of phlegm and occasional clots had been expectorated
since. He had walked about a good deal; movement occasioned
cough, and he became 'blown' very rapidly.
On admission there were signs of fluid in the lower third of the
pleural cavity, but no general symptoms beyond an evening rise
of temperature to an average of 99°. About the twentieth day the
temperature commenced to rise, and on the twenty-third and
four following evenings reached 102°. The fever was
accompanied by some distress, and a well-marked increase in
the physical signs of the presence of fluid in the chest. The pulse
rose to 96, and the respirations considerably above the average
of 24, which was at first noted. A strictly expectant attitude was
maintained, and the temperature steadily fell in a curve
corresponding to the rise, gradually reaching the normal at the
end of a week. The physical signs at the base steadily cleared
up, and at the end of six weeks the patient returned to England
convalescent.
development of Hæmothorax, with rise of
temperature. Spontaneous recovery. Case No 157
(157) Moderate hæmothorax. Secondary effusion at the end of
twenty days. Spontaneous recovery.—Wounded at Paardeberg;
range from 700 to 1,000 yards. Entry, in the centre of the second
right intercostal space, anteriorly; exit, at the level of the sixth
rib posteriorly, through the scapula, close to its vertebral margin.
The patient arrived at the Base on the sixth day; he said he
expectorated some blood at the end of about ten minutes after
being shot, and experienced a 'half-choking sensation.' A small
quantity of phlegm and occasional clots had been expectorated
since. He had walked about a good deal; movement occasioned
cough, and he became 'blown' very rapidly.
On admission there were signs of fluid in the lower third of the
pleural cavity, but no general symptoms beyond an evening rise
of temperature to an average of 99°. About the twentieth day the
temperature commenced to rise, and on the twenty-third and
four following evenings reached 102°. The fever was
accompanied by some distress, and a well-marked increase in
the physical signs of the presence of fluid in the chest. The pulse
rose to 96, and the respirations considerably above the average
of 24, which was at first noted. A strictly expectant attitude was
maintained, and the temperature steadily fell in a curve
corresponding to the rise, gradually reaching the normal at the
end of a week. The physical signs at the base steadily cleared
up, and at the end of six weeks the patient returned to England
convalescent.
Page 462
CHAPTER XI
INJURIES TO THE ABDOMEN
Perhaps no chapter of military surgery was looked forward to with more
eager interest than that dealing with wounds of the abdomen. In none was
greater expectation indulged in with regard to probable advance in active
surgical treatment, and in none did greater disappointment lie in store for
us.
Wounds of the solid viscera, it is true, proved to be of minor importance
when produced by bullets of small calibre; but wounds of the intestinal
tract, although they showed themselves capable of spontaneous recovery in
a certain proportion of the cases observed, afforded but slight opportunity
for surgical skill, and results generally deviated but slightly from those of
past experience. Such success as was met with depended rather on the
mechanical genesis and nature of the wounds than upon the efforts of the
surgeon, and operative surgery scored but few successes.
It is true that to the Civil Surgeon accustomed to surroundings replete with
every modern appliance and convenience, and the possibility of exercising
the most stringent precautions against the introduction of sepsis from
without, abdominal operations presented difficulties only faintly
appreciated in advance; but this alone scarcely accounted for the want of
success attending the active treatment of wounds of the intestine when
occasion demanded. Failure was rather to be referred to the severity of the
local injury to be dealt with, or to the operations being necessarily
undertaken at too late a date. Many fatalities, again, were due to the
association of other injuries, a large proportion of the wound tracks
involving other organs or parts beyond the boundaries of the abdominal
cavity.
The frequent association of wounds of the thoracic cavity with those of the
abdomen afforded many of the most striking examples of immunity from
serious consequences as a result of wound of the pleura. It must be
INJURIES TO THE ABDOMEN
Perhaps no chapter of military surgery was looked forward to with more
eager interest than that dealing with wounds of the abdomen. In none was
greater expectation indulged in with regard to probable advance in active
surgical treatment, and in none did greater disappointment lie in store for
us.
Wounds of the solid viscera, it is true, proved to be of minor importance
when produced by bullets of small calibre; but wounds of the intestinal
tract, although they showed themselves capable of spontaneous recovery in
a certain proportion of the cases observed, afforded but slight opportunity
for surgical skill, and results generally deviated but slightly from those of
past experience. Such success as was met with depended rather on the
mechanical genesis and nature of the wounds than upon the efforts of the
surgeon, and operative surgery scored but few successes.
It is true that to the Civil Surgeon accustomed to surroundings replete with
every modern appliance and convenience, and the possibility of exercising
the most stringent precautions against the introduction of sepsis from
without, abdominal operations presented difficulties only faintly
appreciated in advance; but this alone scarcely accounted for the want of
success attending the active treatment of wounds of the intestine when
occasion demanded. Failure was rather to be referred to the severity of the
local injury to be dealt with, or to the operations being necessarily
undertaken at too late a date. Many fatalities, again, were due to the
association of other injuries, a large proportion of the wound tracks
involving other organs or parts beyond the boundaries of the abdominal
cavity.
The frequent association of wounds of the thoracic cavity with those of the
abdomen afforded many of the most striking examples of immunity from
serious consequences as a result of wound of the pleura. It must be
Page 463
conceded that in a large number of such injuries only the extreme limits of
the pleural sac were encroached upon, yet in some the tracks passed through
the lungs, although without serious consequences. Under the heading of
injury to the large intestine a somewhat special form of pleural septicæmia
will be referred to.
It may at once be stated that such favourable results as occurred in
abdominal injuries were practically limited to wounds caused by bullets of
small calibre, and that, although in the short chapter dealing with shell
injuries a few recoveries from visceral wounds will be mentioned, I never
met with a penetrating visceral injury from a Martini-Henry or large
sporting bullet which did not prove fatal.
Wounds of the abdominal wall.—It is somewhat paradoxical to say that
these injuries possessed special interest from their comparative rarity of
occurrence, since they were not of intrinsic importance. Their infrequency
depended on the difficulty of striking the body in such a plane as to
implicate the belly wall alone, and their interest in the diagnostic difficulty
which they gave rise to.
In many cases the position of the openings and the strongly oval or gutter
character possessed by them were sufficient proof of the superficial passage
of the bullet; in others we had to bear in mind that the position of the patient
when struck was rarely that of rest in the supine position, in which the
surgical examination was made, and considerable difficulty arose. Some
superficial tracks crossing the belly wall have already been referred to in
the chapter on wounds in general and in that dealing with injuries to the
chest, in which the above characters sufficed to indicate that penetration of
the abdominal cavity had not occurred. In other instances a definite
subcutaneous gutter could be traced, and often in these a well-marked cord
in the abdominal wall corresponding to the track could be felt at a later date.
Again, limitation to the abdominal wall was sometimes proved by the
position of the retained bullet, or sometimes by the presence in the track of
foreign bodies carried in with the projectile. See case 160.
Fig. 84 illustrates an example where the limitation to the abdominal wall
was evident on inspection. Here the division of the thick muscles of the
abdominal wall had led to the formation of a swelling exactly similar to that
the pleural sac were encroached upon, yet in some the tracks passed through
the lungs, although without serious consequences. Under the heading of
injury to the large intestine a somewhat special form of pleural septicæmia
will be referred to.
It may at once be stated that such favourable results as occurred in
abdominal injuries were practically limited to wounds caused by bullets of
small calibre, and that, although in the short chapter dealing with shell
injuries a few recoveries from visceral wounds will be mentioned, I never
met with a penetrating visceral injury from a Martini-Henry or large
sporting bullet which did not prove fatal.
Wounds of the abdominal wall.—It is somewhat paradoxical to say that
these injuries possessed special interest from their comparative rarity of
occurrence, since they were not of intrinsic importance. Their infrequency
depended on the difficulty of striking the body in such a plane as to
implicate the belly wall alone, and their interest in the diagnostic difficulty
which they gave rise to.
In many cases the position of the openings and the strongly oval or gutter
character possessed by them were sufficient proof of the superficial passage
of the bullet; in others we had to bear in mind that the position of the patient
when struck was rarely that of rest in the supine position, in which the
surgical examination was made, and considerable difficulty arose. Some
superficial tracks crossing the belly wall have already been referred to in
the chapter on wounds in general and in that dealing with injuries to the
chest, in which the above characters sufficed to indicate that penetration of
the abdominal cavity had not occurred. In other instances a definite
subcutaneous gutter could be traced, and often in these a well-marked cord
in the abdominal wall corresponding to the track could be felt at a later date.
Again, limitation to the abdominal wall was sometimes proved by the
position of the retained bullet, or sometimes by the presence in the track of
foreign bodies carried in with the projectile. See case 160.
Fig. 84 illustrates an example where the limitation to the abdominal wall
was evident on inspection. Here the division of the thick muscles of the
abdominal wall had led to the formation of a swelling exactly similar to that
Page 464
seen after the subcutaneous rupture of a muscle, and two soft fluctuating
tumours bounded by contracted muscle existed in the substance of the
oblique and rectus muscles.
Fig. 84.
Wound of Abdominal Wall (Lee-Metford). Division of fibres of external
oblique and rectus abdominis muscles. Case 159
The cases which presented the most serious diagnostic difficulty in this
relation were those in which the wound was situated in the thicker muscular
portions of the lower part of the abdominal and pelvic walls. Such a case is
illustrated in the chapter on fractures (see fig. 55, p. 191). I saw one or two
such instances, in which only the exploration necessary for treatment of the
fracture decided the point. In many of the wounds affecting the lateral
portion of the abdominal wall the question of penetration could never be
definitely cleared up, as wounds of the colon sometimes gave rise to
absolutely no symptoms.
In a certain proportion of the injuries the peritoneal cavity was no doubt
perforated without the infliction of any further visceral injury, and in these
also the doubt as to the occurrence of penetration was never solved.
tumours bounded by contracted muscle existed in the substance of the
oblique and rectus muscles.
Fig. 84.
Wound of Abdominal Wall (Lee-Metford). Division of fibres of external
oblique and rectus abdominis muscles. Case 159
The cases which presented the most serious diagnostic difficulty in this
relation were those in which the wound was situated in the thicker muscular
portions of the lower part of the abdominal and pelvic walls. Such a case is
illustrated in the chapter on fractures (see fig. 55, p. 191). I saw one or two
such instances, in which only the exploration necessary for treatment of the
fracture decided the point. In many of the wounds affecting the lateral
portion of the abdominal wall the question of penetration could never be
definitely cleared up, as wounds of the colon sometimes gave rise to
absolutely no symptoms.
In a certain proportion of the injuries the peritoneal cavity was no doubt
perforated without the infliction of any further visceral injury, and in these
also the doubt as to the occurrence of penetration was never solved.
Page 465
(158) Wound of belly wall.—Wounded at Modder River. Entry
(Mauser), 2 inches below the centre of the left iliac crest; exit,
1½ inch above and internal to the left anterior superior iliac
spine. The patient was on horseback at the time of the injury and
did not fall; he got down, however, and lay on the field an hour,
whence he was removed to hospital. Probably the track pierced
the ilium, and remained confined to the abdominal wall. There
were no signs of visceral injury.
(159) Cape Boy. Wounded at Modder River. Entry (Lee-
Metford), immediately above and outside right anterior superior
spine; exit, 1½ inch below and to right of umbilicus. A well-
marked swelling corresponded with division of the fibres of the
oblique muscles and of the rectus, and on palpation a hollow
corresponding with the track was felt. The abdominal muscles
were exceptionally well developed (fig. 84).
(160) Wounded at Magersfontein while lying prone. Entry,
irregular, oblique, and somewhat contused, over the eighth left
rib, in the anterior axillary line; exit, a slit wound immediately
above and to the left of the umbilicus. The bullet struck a small
circular metal looking-glass before entering, hence the
irregularity of the wound. The patient developed a hæmothorax,
but no abdominal signs; the former was probably parietal in
origin, secondary to the fractured rib, and the whole wound non-
penetrating as far as the abdominal cavity was concerned.
(161) Wounded at Magersfontein. Entry (Mauser), 1½ inch
external to and 1/2 inch below the left posterior superior iliac
spine; exit, 1 inch internal horizontally to the left anterior
superior spine.
No signs of intra-peritoneal injury were noted, but free
suppuration occurred in left loin; the ilium was tunnelled.
The same patient was wounded by a Jeffrey bullet in the hand;
the third metacarpal was pulverised, although the bullet, which
was longitudinally flanged, was retained.
(Mauser), 2 inches below the centre of the left iliac crest; exit,
1½ inch above and internal to the left anterior superior iliac
spine. The patient was on horseback at the time of the injury and
did not fall; he got down, however, and lay on the field an hour,
whence he was removed to hospital. Probably the track pierced
the ilium, and remained confined to the abdominal wall. There
were no signs of visceral injury.
(159) Cape Boy. Wounded at Modder River. Entry (Lee-
Metford), immediately above and outside right anterior superior
spine; exit, 1½ inch below and to right of umbilicus. A well-
marked swelling corresponded with division of the fibres of the
oblique muscles and of the rectus, and on palpation a hollow
corresponding with the track was felt. The abdominal muscles
were exceptionally well developed (fig. 84).
(160) Wounded at Magersfontein while lying prone. Entry,
irregular, oblique, and somewhat contused, over the eighth left
rib, in the anterior axillary line; exit, a slit wound immediately
above and to the left of the umbilicus. The bullet struck a small
circular metal looking-glass before entering, hence the
irregularity of the wound. The patient developed a hæmothorax,
but no abdominal signs; the former was probably parietal in
origin, secondary to the fractured rib, and the whole wound non-
penetrating as far as the abdominal cavity was concerned.
(161) Wounded at Magersfontein. Entry (Mauser), 1½ inch
external to and 1/2 inch below the left posterior superior iliac
spine; exit, 1 inch internal horizontally to the left anterior
superior spine.
No signs of intra-peritoneal injury were noted, but free
suppuration occurred in left loin; the ilium was tunnelled.
The same patient was wounded by a Jeffrey bullet in the hand;
the third metacarpal was pulverised, although the bullet, which
was longitudinally flanged, was retained.
Page 466
(162) Wounded outside Heilbron. Entry, below the eighth right
costal cartilage; exit, below the eighth cartilage of the left side.
The wound of entry was slightly oval; that of exit continued out
as a 'flame'-like groove for 2 inches. A week later the wound
track could be palpated as an evident hard continuous cord.
Penetration of the intestinal area without definite evidence of visceral
injury.—This accident occurred with a sufficient degree of frequency to
obtain the greatest importance, both from the point of view of diagnosis and
prognosis, and as affecting the question of operative interference. Amongst
the cases reported below a number occurred in which it was impossible to
settle the question whether injury to the bowel had occurred or not, and I
will here shortly give what explanation I can for the apparent escape of the
intestine from serious injury.
We may first recall the general question of the escape of structures lying to
one or other side of the track of the bullet. I believe that there can be no
doubt as to the accuracy of the remarks already made as to the escape of
such structures as the nerves by means of displacement, and that the
occurrence of such escapes is manifestly dependent on the degree of fixity
of the nerve or the special segment of it implicated. The general tendency of
the tissues around the tracks to escape extensive destruction from actual
contusion has also been referred to, and is, I think, indisputable.
If these observations be accepted, I think there can be no difficulty in
allowing that the small intestine is exceptionally well arranged to escape
injury. First of all, it is very moveable; secondly, it is so arranged that in
certain directions a bullet may pass almost parallel to the long axis of the
coils; thirdly, it is elastic, capable of compression, and light, and hence
offers but a small degree of resistance to the passage of the bullet across the
abdominal cavity.
Certain evidence both clinical and pathological supports the contention that
the small intestine may escape injury from the passing bullet.
First of all, the fact may be broadly stated that injuries to the small intestine
were fatal in the great majority of certainly diagnosed cases, while, on the
other hand, many tracks crossed the area occupied by the small intestine
without serious symptoms of any kind resulting. Secondly, experience
costal cartilage; exit, below the eighth cartilage of the left side.
The wound of entry was slightly oval; that of exit continued out
as a 'flame'-like groove for 2 inches. A week later the wound
track could be palpated as an evident hard continuous cord.
Penetration of the intestinal area without definite evidence of visceral
injury.—This accident occurred with a sufficient degree of frequency to
obtain the greatest importance, both from the point of view of diagnosis and
prognosis, and as affecting the question of operative interference. Amongst
the cases reported below a number occurred in which it was impossible to
settle the question whether injury to the bowel had occurred or not, and I
will here shortly give what explanation I can for the apparent escape of the
intestine from serious injury.
We may first recall the general question of the escape of structures lying to
one or other side of the track of the bullet. I believe that there can be no
doubt as to the accuracy of the remarks already made as to the escape of
such structures as the nerves by means of displacement, and that the
occurrence of such escapes is manifestly dependent on the degree of fixity
of the nerve or the special segment of it implicated. The general tendency of
the tissues around the tracks to escape extensive destruction from actual
contusion has also been referred to, and is, I think, indisputable.
If these observations be accepted, I think there can be no difficulty in
allowing that the small intestine is exceptionally well arranged to escape
injury. First of all, it is very moveable; secondly, it is so arranged that in
certain directions a bullet may pass almost parallel to the long axis of the
coils; thirdly, it is elastic, capable of compression, and light, and hence
offers but a small degree of resistance to the passage of the bullet across the
abdominal cavity.
Certain evidence both clinical and pathological supports the contention that
the small intestine may escape injury from the passing bullet.
First of all, the fact may be broadly stated that injuries to the small intestine
were fatal in the great majority of certainly diagnosed cases, while, on the
other hand, many tracks crossed the area occupied by the small intestine
without serious symptoms of any kind resulting. Secondly, experience
Page 467
showed that when the bullet crossed the line of the fixed portions of the
large intestine the gut rarely escaped, and that, although a considerable
proportion of these cases recovered spontaneously, in a large number of
them immediate symptoms, or secondary complications, clearly
substantiated the nature of the original injury. As far as my experience went,
however, I never saw any instance in which an undoubted injury of the
small intestine was followed by the development of a local peritoneal
suppuration and recovery, a sequence by no means uncommon in the case
of wounds of the large intestine. Although, therefore, I am not prepared to
deny the possibility of spontaneous recovery from an injury to the small
intestine, under certain conditions which will be stated later, I believe that
in the immense majority of cases in which a bullet crossed the small
intestine area without the supervention of serious symptoms, the small
intestine escaped perforating injury.
Beyond the clinical evidence offered above, certain pathological
observations support the view that the intestine escapes perforation by
displacement. Most of my knowledge on this subject was derived from the
limited number of abdominal sections I performed on cases of injury to the
small intestine, and may be summed up as follows.
The small intestine may present evidence of lateral contusion in the shape
of elongated ecchymoses, either parallel, oblique, or transverse to its long
axis. These ecchymoses resemble in extent and outline those which
ordinarily surround a wound of the intestinal wall produced by a bullet (see
fig. 87, p. 418).
The wall of the small intestine may be wounded to an extent short of
perforation, either the peritoneal coat alone being split, or the wound
implicating the muscular coat and producing an appearance similar to that
seen when the intestine is dragged upon during an operation, but without so
much gaping of the edges (see fig. 85, p. 416).
I met with these conditions in association with co-existing complete
perforations of the small intestine, and in one case of intra-peritoneal
hæmorrhage in which no complete perforation was discoverable (No. 169,
p. 432).
large intestine the gut rarely escaped, and that, although a considerable
proportion of these cases recovered spontaneously, in a large number of
them immediate symptoms, or secondary complications, clearly
substantiated the nature of the original injury. As far as my experience went,
however, I never saw any instance in which an undoubted injury of the
small intestine was followed by the development of a local peritoneal
suppuration and recovery, a sequence by no means uncommon in the case
of wounds of the large intestine. Although, therefore, I am not prepared to
deny the possibility of spontaneous recovery from an injury to the small
intestine, under certain conditions which will be stated later, I believe that
in the immense majority of cases in which a bullet crossed the small
intestine area without the supervention of serious symptoms, the small
intestine escaped perforating injury.
Beyond the clinical evidence offered above, certain pathological
observations support the view that the intestine escapes perforation by
displacement. Most of my knowledge on this subject was derived from the
limited number of abdominal sections I performed on cases of injury to the
small intestine, and may be summed up as follows.
The small intestine may present evidence of lateral contusion in the shape
of elongated ecchymoses, either parallel, oblique, or transverse to its long
axis. These ecchymoses resemble in extent and outline those which
ordinarily surround a wound of the intestinal wall produced by a bullet (see
fig. 87, p. 418).
The wall of the small intestine may be wounded to an extent short of
perforation, either the peritoneal coat alone being split, or the wound
implicating the muscular coat and producing an appearance similar to that
seen when the intestine is dragged upon during an operation, but without so
much gaping of the edges (see fig. 85, p. 416).
I met with these conditions in association with co-existing complete
perforations of the small intestine, and in one case of intra-peritoneal
hæmorrhage in which no complete perforation was discoverable (No. 169,
p. 432).
Page 468
The implication and perforation of the small intestine are to some extent
influenced by the direction of the wound. A striking case is included below,
No. 201, in which a bullet passed from the loin to the iliac fossa on each
side of the body, approximately parallel to the course of the inner margin of
the colon, and I also saw some other wounds in this direction in which no
evidence of injury to the small intestine was detected, and which got well.
Again wounds from flank to flank were, as a rule, very fatal; but I saw more
than one instance where these wounds were situated immediately below the
crest of the ilium, in which the intestine escaped injury (see case 171). A
very striking observation was made by Mr. Cheatle in such a wound. The
patient died as a result of a double perforation of both cæcum and sigmoid
flexure; none the less the bullet had crossed the small intestine area without
inflicting any injury.
The sum of my experience, in fact, was to encourage the belief that, unless
the intestine was struck in such a direction as to render lateral displacement
an impossibility, the gut often escaped perforation.
As a rule, the wounds of the abdomen which from their position proved the
most dangerous to the intestine were—
1. Wounds passing from one flank to the other were very dangerous, as
crossing complicated coils of the small intestine, and two fixed portions of
the colon. This danger was most marked when the wounds were situated
between the eighth rib in the mid axillary line and the crest of the ilium;
above this level the liver, or possibly liver and stomach, were sometimes
alone implicated, and the cases did well. Again, when the wounds crossed
the false pelvis the patients sometimes escaped all injury to viscera.
2. Antero-posterior wounds in the small intestine area were very fatal if the
course was direct; in such the small intestine seldom escaped injury.
3. Wounds with a certain degree of obliquity from anterior wall to flank, or
from flank to loin, were on the other hand comparatively favourable, as the
small intestine often escaped, and if any gut was wounded, it was often the
colon.
4. Vertical wounds implicating the chest and abdomen, or the abdomen and
pelvis, were on the whole not very unfavourable. For instance, when the
influenced by the direction of the wound. A striking case is included below,
No. 201, in which a bullet passed from the loin to the iliac fossa on each
side of the body, approximately parallel to the course of the inner margin of
the colon, and I also saw some other wounds in this direction in which no
evidence of injury to the small intestine was detected, and which got well.
Again wounds from flank to flank were, as a rule, very fatal; but I saw more
than one instance where these wounds were situated immediately below the
crest of the ilium, in which the intestine escaped injury (see case 171). A
very striking observation was made by Mr. Cheatle in such a wound. The
patient died as a result of a double perforation of both cæcum and sigmoid
flexure; none the less the bullet had crossed the small intestine area without
inflicting any injury.
The sum of my experience, in fact, was to encourage the belief that, unless
the intestine was struck in such a direction as to render lateral displacement
an impossibility, the gut often escaped perforation.
As a rule, the wounds of the abdomen which from their position proved the
most dangerous to the intestine were—
1. Wounds passing from one flank to the other were very dangerous, as
crossing complicated coils of the small intestine, and two fixed portions of
the colon. This danger was most marked when the wounds were situated
between the eighth rib in the mid axillary line and the crest of the ilium;
above this level the liver, or possibly liver and stomach, were sometimes
alone implicated, and the cases did well. Again, when the wounds crossed
the false pelvis the patients sometimes escaped all injury to viscera.
2. Antero-posterior wounds in the small intestine area were very fatal if the
course was direct; in such the small intestine seldom escaped injury.
3. Wounds with a certain degree of obliquity from anterior wall to flank, or
from flank to loin, were on the other hand comparatively favourable, as the
small intestine often escaped, and if any gut was wounded, it was often the
colon.
4. Vertical wounds implicating the chest and abdomen, or the abdomen and
pelvis, were on the whole not very unfavourable. For instance, when the
Page 469
bullet entered by the buttock and emerged below the umbilicus, a number of
patients escaped fatal injury; this depended on the comparatively good
prognosis in wounds of the rectum and bladder. A good many patients in
whom the bullet entered by the upper part of the loin, and escaped 1½ inch
within the anterior superior spine of the ilium, also did well. The same
holds good when the wounds either entered or emerged under the anterior
costal margin of the thorax, either prior to or after traversing the thorax.
Wounds passing directly backward from the iliac regions were in my
experience very unfavourable; but I believe mainly as a result of
hæmorrhage from the iliac arteries.
The occurrence of wounds of the abdomen of an 'explosive' character.—The
vast majority of the abdominal wounds observed in the Stationary or Base
hospitals were of the type dimensions. A certain number of the abdominal
injuries which proved fatal on the field or shortly afterwards were described
as explosive in character, and were referred by the observers to the
employment of expanding bullets.
A few words on this subject seem necessary, because it seems doubtful
whether such injuries could be produced by any of the forms of expanding
bullet of small calibre in use, unless the track crossed one of the bones in
the abdominal or pelvic wall. That this was sometimes the case there is no
doubt: thus I saw two cases in which the splenic flexure of the colon was
wounded, in which the external opening was large, and a comminuted
fracture of the ribs of the left side existed. One can well believe that bullets
passing through the pelvic bones might 'set up' to a considerable extent, and
although I never happened to see such a case, an explanation of some of the
wounds described by others might be found in this occurrence.
In instances in which the soft parts alone were perforated, I am disinclined
to believe that bullets of small calibre, either regulation or soft-nosed, were
responsible for the injuries. I had the opportunity of examining two Mauser
bullets of the Jeffreys variety which crossed the abdomen and caused death.
In the first (figured on page 94, fig. 40) very little alteration beyond slight
shortening had occurred. In the second the deformity was almost the same,
except that the side of the bullet was indented, probably from impact with
some object prior to its entry into the body. In each case the bullet was of
patients escaped fatal injury; this depended on the comparatively good
prognosis in wounds of the rectum and bladder. A good many patients in
whom the bullet entered by the upper part of the loin, and escaped 1½ inch
within the anterior superior spine of the ilium, also did well. The same
holds good when the wounds either entered or emerged under the anterior
costal margin of the thorax, either prior to or after traversing the thorax.
Wounds passing directly backward from the iliac regions were in my
experience very unfavourable; but I believe mainly as a result of
hæmorrhage from the iliac arteries.
The occurrence of wounds of the abdomen of an 'explosive' character.—The
vast majority of the abdominal wounds observed in the Stationary or Base
hospitals were of the type dimensions. A certain number of the abdominal
injuries which proved fatal on the field or shortly afterwards were described
as explosive in character, and were referred by the observers to the
employment of expanding bullets.
A few words on this subject seem necessary, because it seems doubtful
whether such injuries could be produced by any of the forms of expanding
bullet of small calibre in use, unless the track crossed one of the bones in
the abdominal or pelvic wall. That this was sometimes the case there is no
doubt: thus I saw two cases in which the splenic flexure of the colon was
wounded, in which the external opening was large, and a comminuted
fracture of the ribs of the left side existed. One can well believe that bullets
passing through the pelvic bones might 'set up' to a considerable extent, and
although I never happened to see such a case, an explanation of some of the
wounds described by others might be found in this occurrence.
In instances in which the soft parts alone were perforated, I am disinclined
to believe that bullets of small calibre, either regulation or soft-nosed, were
responsible for the injuries. I had the opportunity of examining two Mauser
bullets of the Jeffreys variety which crossed the abdomen and caused death.
In the first (figured on page 94, fig. 40) very little alteration beyond slight
shortening had occurred. In the second the deformity was almost the same,
except that the side of the bullet was indented, probably from impact with
some object prior to its entry into the body. In each case the bullet was of
Page 470
course travelling at a low rate of velocity; hence no very strong inference
can be drawn from either. In the case of the second specimen, which was
removed by Mr. Cheatle, a remarkable observation was made, which tends
to throw some light on one possible mode of production of large exit
apertures. This bullet crossed the cæcum, making two small type openings;
but later, when it crossed the sigmoid flexure, it tore two large irregular
openings in the gut. This might be explained on the ground that the velocity
was so small as only just to allow of perforation, which therefore took the
nature of a tear. I am inclined to suggest, as a more likely explanation, that
the spent bullet turned head over heels in its course across the abdomen,
and made lateral or irregular impact with the last piece of bowel it touched.
A slightly greater degree of force would have allowed a similar large and
irregular opening to be made in the abdominal wall also.
In this relation the question will naturally be raised as to how far the
explosive appearances may have been due to high velocity alone on the part
of the bullet. I am disinclined from my general experience to believe that
explosive injuries of the soft parts were to be thus explained. On the other
hand, I believe that the possession of a low degree of velocity very greatly
increased the danger in abdominal wounds. I believe that the bowel was,
under these circumstances, less likely to escape by displacement, and was
more widely torn when wounded; again, that inexact impact led to increase
of size in the external apertures, and the bullet was of course more often
retained.
Mr. Watson Cheyne[19] published a very remarkable instance of one of the
dangers of an injury from a spent bullet, in which, in spite of non-
penetration of the abdominal cavity, the small intestine was ruptured in two
places.
I believe the majority of the wounds designated as explosive were the result
of the passage of large leaden bullets, either of the Martini-Henry or
Express type. The small opportunity of observing such injuries in the
hospitals of course depended on the fact that the majority were rapidly fatal.
Nature of the anatomical lesion in wounds of the intestine.—The openings
in the parietal peritoneum tended to assume the slit or star forms, probably
on account of the elasticity of the membrane. A diagram of one of these
can be drawn from either. In the case of the second specimen, which was
removed by Mr. Cheatle, a remarkable observation was made, which tends
to throw some light on one possible mode of production of large exit
apertures. This bullet crossed the cæcum, making two small type openings;
but later, when it crossed the sigmoid flexure, it tore two large irregular
openings in the gut. This might be explained on the ground that the velocity
was so small as only just to allow of perforation, which therefore took the
nature of a tear. I am inclined to suggest, as a more likely explanation, that
the spent bullet turned head over heels in its course across the abdomen,
and made lateral or irregular impact with the last piece of bowel it touched.
A slightly greater degree of force would have allowed a similar large and
irregular opening to be made in the abdominal wall also.
In this relation the question will naturally be raised as to how far the
explosive appearances may have been due to high velocity alone on the part
of the bullet. I am disinclined from my general experience to believe that
explosive injuries of the soft parts were to be thus explained. On the other
hand, I believe that the possession of a low degree of velocity very greatly
increased the danger in abdominal wounds. I believe that the bowel was,
under these circumstances, less likely to escape by displacement, and was
more widely torn when wounded; again, that inexact impact led to increase
of size in the external apertures, and the bullet was of course more often
retained.
Mr. Watson Cheyne[19] published a very remarkable instance of one of the
dangers of an injury from a spent bullet, in which, in spite of non-
penetration of the abdominal cavity, the small intestine was ruptured in two
places.
I believe the majority of the wounds designated as explosive were the result
of the passage of large leaden bullets, either of the Martini-Henry or
Express type. The small opportunity of observing such injuries in the
hospitals of course depended on the fact that the majority were rapidly fatal.
Nature of the anatomical lesion in wounds of the intestine.—The openings
in the parietal peritoneum tended to assume the slit or star forms, probably
on account of the elasticity of the membrane. A diagram of one of these
Page 471
forms is appended to fig. 89. In this instance the opening in the peritoneum
was made from the abdominal aspect, prior to the escape of the bullet from
the cavity, and on the impact of the tip, the long axis of the bullet was
oblique to the surface of the abdominal wall.
In the intestinal wall the openings varied in character according to the mode
of impact.
In some cases the gut was merely contused by lateral contact of the passing
bullet. The result of this was evidenced later by the presence of localised
oval patches of ecchymosis. These were identical in appearance with the
patches shown surrounding the wounds in fig. 87.
Fig. 85.
Lateral Slit in Small Intestine produced by passage of bullet. Slit
somewhat obscured by deposition of inflammatory lymph. (St.
Thomas's Hospital Museum)
More forcible lateral impact produced a split of the peritoneum, or of this
together with the muscular coat. Such a lateral slit is shown in fig. 85,
although the clearness of outline is somewhat impaired by the presence of a
considerable amount of inflammatory lymph.
was made from the abdominal aspect, prior to the escape of the bullet from
the cavity, and on the impact of the tip, the long axis of the bullet was
oblique to the surface of the abdominal wall.
In the intestinal wall the openings varied in character according to the mode
of impact.
In some cases the gut was merely contused by lateral contact of the passing
bullet. The result of this was evidenced later by the presence of localised
oval patches of ecchymosis. These were identical in appearance with the
patches shown surrounding the wounds in fig. 87.
Fig. 85.
Lateral Slit in Small Intestine produced by passage of bullet. Slit
somewhat obscured by deposition of inflammatory lymph. (St.
Thomas's Hospital Museum)
More forcible lateral impact produced a split of the peritoneum, or of this
together with the muscular coat. Such a lateral slit is shown in fig. 85,
although the clearness of outline is somewhat impaired by the presence of a
considerable amount of inflammatory lymph.
Page 472
Fig. 86 exhibits a lateral injury of a more pronounced form. The bullet here
struck the most prominent portion of the under surface of the bowel, and
produced a circular perforation not very unlike one produced by rectangular
impact, except in the lesser degree of eversion of the mucous membrane.
Here again the appearance is somewhat altered by the presence of a
considerable amount of lymph, but this is of less importance in this figure
because the lymph is localised to the portion of the bowel in the immediate
neighbourhood of the opening which had suffered contusion and erasion.
Fig. 86.
Gutter Wound of Small Intestine caused by lateral impact. Position of
shallow portion of gutter indicated by deposition of inflammatory
lymph. Circular perforation. (St. Thomas's Hospital Museum)
Fig. 87, a b, illustrates a symmetrical perforation of the small intestine; the
aperture of entry (a) is roughly circular, and a ring of mucous membrane
protrudes and partially closes the opening. The aperture of exit is a curved
slit, again partially occluded by the mucous membrane. The same amount
struck the most prominent portion of the under surface of the bowel, and
produced a circular perforation not very unlike one produced by rectangular
impact, except in the lesser degree of eversion of the mucous membrane.
Here again the appearance is somewhat altered by the presence of a
considerable amount of lymph, but this is of less importance in this figure
because the lymph is localised to the portion of the bowel in the immediate
neighbourhood of the opening which had suffered contusion and erasion.
Fig. 86.
Gutter Wound of Small Intestine caused by lateral impact. Position of
shallow portion of gutter indicated by deposition of inflammatory
lymph. Circular perforation. (St. Thomas's Hospital Museum)
Fig. 87, a b, illustrates a symmetrical perforation of the small intestine; the
aperture of entry (a) is roughly circular, and a ring of mucous membrane
protrudes and partially closes the opening. The aperture of exit is a curved
slit, again partially occluded by the mucous membrane. The same amount
Page 473
of difference between the two apertures did not always exist; in many cases
both were circular, and apparently symmetrical. Beyond this I have seen
three apertures in close proximity, two lying on the same aspect of the
bowel, and the first of these was no doubt an opening due to lateral impact
similar to that seen in fig. 86. In the recent condition little difference existed
between the three apertures.
The localised ecchymosis surrounding the apertures is quite characteristic
of this form of injury, and is a valuable aid to finding the openings during
an operation.
Fig. 88 shows the interior of the same segment of bowel, as fig. 87. It shows
the localised ecchymosis as seen from the inner surface, here rather more
extensive from the fact that the blood spreads more readily in the
submucous tissue.
Fig. 87.—Perforating Wounds
of Small Intestine.
both were circular, and apparently symmetrical. Beyond this I have seen
three apertures in close proximity, two lying on the same aspect of the
bowel, and the first of these was no doubt an opening due to lateral impact
similar to that seen in fig. 86. In the recent condition little difference existed
between the three apertures.
The localised ecchymosis surrounding the apertures is quite characteristic
of this form of injury, and is a valuable aid to finding the openings during
an operation.
Fig. 88 shows the interior of the same segment of bowel, as fig. 87. It shows
the localised ecchymosis as seen from the inner surface, here rather more
extensive from the fact that the blood spreads more readily in the
submucous tissue.
Fig. 87.—Perforating Wounds
of Small Intestine.
Page 474
A. Entry; note circular outline and eversion of mucous membrane. B.
Wound of exit; curved slit-like character, eversion of mucous
membrane. Note the localised ecchymosis, more abundant round exit
aperture. (St. Thomas's Hospital Museum)
It will be noted that the main feature of the form of injury is the regular
outline and the small size of the wounds. Another feature not illustrated by
the figures should also be mentioned. In the ruptures of intestine with which
we are acquainted in civil practice the wound in the gut is almost without
exception situated at the free border of the bowel, but in these injuries it
was just as frequently at the mesenteric margin. The importance of this
factor is considerable, since wounds near the mesenteric edge are much
more likely to be accompanied by hæmorrhage, and thus the opportunity for
diffusion of infection is considerably multiplied, to say nothing of the
danger from loss of blood.
Beyond these more or less pure perforations, long slits or gutters were
occasionally cut. I saw instances of these in the case of the ascending colon,
and in the small curvature of the stomach. The comparative fixity of the
portion of bowel struck is a matter of great importance in the production of
this form of injury.
Wound of exit; curved slit-like character, eversion of mucous
membrane. Note the localised ecchymosis, more abundant round exit
aperture. (St. Thomas's Hospital Museum)
It will be noted that the main feature of the form of injury is the regular
outline and the small size of the wounds. Another feature not illustrated by
the figures should also be mentioned. In the ruptures of intestine with which
we are acquainted in civil practice the wound in the gut is almost without
exception situated at the free border of the bowel, but in these injuries it
was just as frequently at the mesenteric margin. The importance of this
factor is considerable, since wounds near the mesenteric edge are much
more likely to be accompanied by hæmorrhage, and thus the opportunity for
diffusion of infection is considerably multiplied, to say nothing of the
danger from loss of blood.
Beyond these more or less pure perforations, long slits or gutters were
occasionally cut. I saw instances of these in the case of the ascending colon,
and in the small curvature of the stomach. The comparative fixity of the
portion of bowel struck is a matter of great importance in the production of
this form of injury.
Page 475
Fig. 88.
The same piece of Intestine as that shown in fig. 87, laid open to show
the ecchymosis on the inner aspect of the Bowel. The two indicating
lines lead to the openings, which appear slit-like, and are sunk at the
bottom of folds. (St. Thomas's Hospital Museum)
It may be well to add that, although the figures inserted are all taken from
small-intestine wounds, the nature of the wounds of the peritoneum-clad
part of the large intestine in no way differed from them, except in so far as
fixity of the bowel exposed it to a more extensive wound when the bullet
took a parallel course to its long axis.
A more important point in the injuries to the large intestine was the
possibility of an extra-peritoneal wound. I saw several such lesions of the
colon, every one of which ended fatally. I became still more fully convinced
of the greater seriousness of extra- to intra-peritoneal rupture of this portion
of the gut than I was when I expressed a similar opinion in a former paper.
The same piece of Intestine as that shown in fig. 87, laid open to show
the ecchymosis on the inner aspect of the Bowel. The two indicating
lines lead to the openings, which appear slit-like, and are sunk at the
bottom of folds. (St. Thomas's Hospital Museum)
It may be well to add that, although the figures inserted are all taken from
small-intestine wounds, the nature of the wounds of the peritoneum-clad
part of the large intestine in no way differed from them, except in so far as
fixity of the bowel exposed it to a more extensive wound when the bullet
took a parallel course to its long axis.
A more important point in the injuries to the large intestine was the
possibility of an extra-peritoneal wound. I saw several such lesions of the
colon, every one of which ended fatally. I became still more fully convinced
of the greater seriousness of extra- to intra-peritoneal rupture of this portion
of the gut than I was when I expressed a similar opinion in a former paper.
Page 476
[20]
It will be seen later that the results of intra- and extra-peritoneal wounds
of the bladder fully confirm this view, as all extra-peritoneal injuries died,
while many intra-peritoneal perforations recovered spontaneously.
Wounds of the mesentery.—I had little experience of this injury; in fact, case
169, on which I operated, was my sole observation. It stands to reason,
however, that injuries to the mesentery would be much more frequent
proportionately to wounds of the gut than is the case in the ruptures seen in
civil practice, since the whole area of the mesentery is equally open to
injury. Viewing the extreme danger of hæmorrhage into the peritoneal
cavity in these injuries, I should be inclined to expect that a considerable
proportion of those deaths from abdominal wounds which took place on the
field of battle were due to this source.
Wounds of the omentum.—Here, again, I am unable to express any opinion,
although the supposition that hæmorrhage from this source took place is
natural.
Prolapse of omentum was comparatively rare, except in cases with large
wounds; it was apparently seen with some frequency among patients who
died rapidly on the field of battle. I only saw it twice, and on each occasion
in shell wounds. The wounds from small-calibre bullets were as a rule too
small to allow of external prolapse.
Fig. 89, however, illustrates a very interesting observation. A patient in the
German Ambulance in Heilbron, under Dr. Flockemann, died as a result of
suppuration and hæmorrhage secondary to an injury to the colon. At the
autopsy a portion of the omentum was found adherent in the wound of exit,
but it had not reached the external surface. The chief interest of the
observation lies in the light it throws on the mechanism of these injuries. It
is impossible to conceive that a small-calibre bullet coming into direct
contact with the omentum could do anything but perforate it. It, therefore,
appears clear that in a displacement like that figured, only lateral impact
occurred with the omentum, which was carried along by the spin and rush
of the bullet into the canal of exit, where it lodged.
It will be seen later that the results of intra- and extra-peritoneal wounds
of the bladder fully confirm this view, as all extra-peritoneal injuries died,
while many intra-peritoneal perforations recovered spontaneously.
Wounds of the mesentery.—I had little experience of this injury; in fact, case
169, on which I operated, was my sole observation. It stands to reason,
however, that injuries to the mesentery would be much more frequent
proportionately to wounds of the gut than is the case in the ruptures seen in
civil practice, since the whole area of the mesentery is equally open to
injury. Viewing the extreme danger of hæmorrhage into the peritoneal
cavity in these injuries, I should be inclined to expect that a considerable
proportion of those deaths from abdominal wounds which took place on the
field of battle were due to this source.
Wounds of the omentum.—Here, again, I am unable to express any opinion,
although the supposition that hæmorrhage from this source took place is
natural.
Prolapse of omentum was comparatively rare, except in cases with large
wounds; it was apparently seen with some frequency among patients who
died rapidly on the field of battle. I only saw it twice, and on each occasion
in shell wounds. The wounds from small-calibre bullets were as a rule too
small to allow of external prolapse.
Fig. 89, however, illustrates a very interesting observation. A patient in the
German Ambulance in Heilbron, under Dr. Flockemann, died as a result of
suppuration and hæmorrhage secondary to an injury to the colon. At the
autopsy a portion of the omentum was found adherent in the wound of exit,
but it had not reached the external surface. The chief interest of the
observation lies in the light it throws on the mechanism of these injuries. It
is impossible to conceive that a small-calibre bullet coming into direct
contact with the omentum could do anything but perforate it. It, therefore,
appears clear that in a displacement like that figured, only lateral impact
occurred with the omentum, which was carried along by the spin and rush
of the bullet into the canal of exit, where it lodged.
Page 477
Fig. 89.
Great Omentum carried by the bullet into an exit track leading from
the abdominal cavity. A. Outline of opening in the peritoneum
Results of injury to the intestine. 1. Escape of contents and infection of the
peritoneal cavity.—I think there is little special to be said on this subject.
The escape of contents into the peritoneal cavity was by no means free,
unless the injury was multiple. Thus in one case of injury to the small
intestine, No. 166, on which I operated, there was absolutely no gross
escape until the bowel was removed from the abdominal cavity, when the
contents spurted out freely. In one case of very oblique injury to the colon
there was a considerable quantity of fæcal matter in a localised space, but as
a rule the ordinary condition best described as 'peritoneal infection' from the
wound was found. The bad effect of anything like free escape was well
shown in multiple perforations; in these suppurative peritonitis rapidly
developed and the patients died at the end of thirty-six hours or less. A
typical case is quoted in No. 168.
Great Omentum carried by the bullet into an exit track leading from
the abdominal cavity. A. Outline of opening in the peritoneum
Results of injury to the intestine. 1. Escape of contents and infection of the
peritoneal cavity.—I think there is little special to be said on this subject.
The escape of contents into the peritoneal cavity was by no means free,
unless the injury was multiple. Thus in one case of injury to the small
intestine, No. 166, on which I operated, there was absolutely no gross
escape until the bowel was removed from the abdominal cavity, when the
contents spurted out freely. In one case of very oblique injury to the colon
there was a considerable quantity of fæcal matter in a localised space, but as
a rule the ordinary condition best described as 'peritoneal infection' from the
wound was found. The bad effect of anything like free escape was well
shown in multiple perforations; in these suppurative peritonitis rapidly
developed and the patients died at the end of thirty-six hours or less. A
typical case is quoted in No. 168.
Page 478
2. Peritoneal infection, and general septicæmia.—As is evident from the
results quoted among the cases, the degree which this reached varied
greatly. It may of course be assumed that in some measure it occurred in
every case in which the bowel was perforated, but it was sometimes so
slight as to be scarcely noticeable. This may be said to have been most
common in injuries to the large intestine. Wounds of the cæcum, ascending
and descending colon, the sigmoid flexure, or the rectum, were sometimes
followed by no serious symptoms, either local or general. Again in these
portions of the bowel the development of local signs, and the later
formation of an abscess, were by no means uncommon.
In the case of the small intestine I never observed this sequence, and the
same may be said of the transverse colon, which in its anatomical
arrangement and position so nearly approximates to the small bowel. In
suspected wounds of these portions of the bowel either the symptoms were
so slight as to render it doubtful whether a perforation had occurred, or
marked signs of general peritoneal septicæmia developed, and death
resulted.
The condition of the peritoneum in fatal cases varied much. In some a dry
peritonitis, or one in which a considerable quantity of slightly turbid fluid
was effused, was found. In others a rapid suppurative process, accompanied
by the effusion of large quantities of plastic lymph, was met with. My
experience suggested that the latter condition was the result of free infection
from multiple wounds of the gut, the former the accompaniment of single
wounds. Hence I should ascribe the difference mainly to the extent of the
primary infection.
This is perhaps a suitable place to further discuss the explanation of the
escape of a considerable number of the patients who received wounds of the
abdomen, possibly implicating the bowel. Although this was not, I think, so
common an occurrence as has been sometimes assumed, yet many
examples were met with. Several reasons have been advanced.
(1) Great importance has been given to the fact that many of the men were
wounded while in a state of hunger, no food having been taken for twelve or
more hours before the reception of the injury. In view of the well-proved
fact in these, as in other intestinal injuries, that free intestinal escape does
results quoted among the cases, the degree which this reached varied
greatly. It may of course be assumed that in some measure it occurred in
every case in which the bowel was perforated, but it was sometimes so
slight as to be scarcely noticeable. This may be said to have been most
common in injuries to the large intestine. Wounds of the cæcum, ascending
and descending colon, the sigmoid flexure, or the rectum, were sometimes
followed by no serious symptoms, either local or general. Again in these
portions of the bowel the development of local signs, and the later
formation of an abscess, were by no means uncommon.
In the case of the small intestine I never observed this sequence, and the
same may be said of the transverse colon, which in its anatomical
arrangement and position so nearly approximates to the small bowel. In
suspected wounds of these portions of the bowel either the symptoms were
so slight as to render it doubtful whether a perforation had occurred, or
marked signs of general peritoneal septicæmia developed, and death
resulted.
The condition of the peritoneum in fatal cases varied much. In some a dry
peritonitis, or one in which a considerable quantity of slightly turbid fluid
was effused, was found. In others a rapid suppurative process, accompanied
by the effusion of large quantities of plastic lymph, was met with. My
experience suggested that the latter condition was the result of free infection
from multiple wounds of the gut, the former the accompaniment of single
wounds. Hence I should ascribe the difference mainly to the extent of the
primary infection.
This is perhaps a suitable place to further discuss the explanation of the
escape of a considerable number of the patients who received wounds of the
abdomen, possibly implicating the bowel. Although this was not, I think, so
common an occurrence as has been sometimes assumed, yet many
examples were met with. Several reasons have been advanced.
(1) Great importance has been given to the fact that many of the men were
wounded while in a state of hunger, no food having been taken for twelve or
more hours before the reception of the injury. In view of the well-proved
fact in these, as in other intestinal injuries, that free intestinal escape does
Page 479
not occur, and that it is usually a mere question of infection, this
explanation, in my opinion, is of small importance. It might with far more
justice be pointed out that many of these wounded men were for them in the
happy position of not having friends freely dosing them with brandy and
water after the reception of the injury, and this was possibly an element of
some importance.
Some of the men did, however, drink freely, and in one case which
terminated fatally a comrade gave a man wounded through the belly an
immediate dose of Beecham's pills.
(2) Mr. Treves has suggested that the effect of the severe trauma on the
muscular coat of the bowel is to cause a cessation of peristaltic movement.
This, as in the case of 'local shock' elsewhere, may no doubt be of
importance, and to it should be added the simultaneous cessation of
abdominal respiratory movements in the segment of the belly wall covering
the injured part. The occurrence of general cessation of peristaltic
movement is, however, to some extent opposed by the fact that in a certain
number of the cases early passage of motions was seen just as happens in
the intestinal ruptures seen in civil practice.
I should be inclined to ascribe the escape from serious infection in these
injuries to the same cause which accounts for their comparative
insignificance in other regions—namely, the small calibre of the bullet and
consequent small size of the lesion: in point of fact to the minimal nature of
the primary infection. I very much doubt if any patient who had more than
one complete perforation of the small intestine got well during the whole
campaign. This opinion is, moreover, supported by the fact that the
prognosis was so far better in cases of injury to the large than to the small
intestine, in which former segment of the bowel we have the advantages of
a position beyond the region in which intestinal movement is most free, the
unlikelihood of multiple injury, and a drier and more solid type of fæcal
contents.
In the instances in which recovery followed perforating injuries without any
bad signs we can only assume a minimal infection, and sufficient irritation
and reaction on the part of the bowel to produce rapid adhesion between
contiguous coils, and thus provisional closure.
explanation, in my opinion, is of small importance. It might with far more
justice be pointed out that many of these wounded men were for them in the
happy position of not having friends freely dosing them with brandy and
water after the reception of the injury, and this was possibly an element of
some importance.
Some of the men did, however, drink freely, and in one case which
terminated fatally a comrade gave a man wounded through the belly an
immediate dose of Beecham's pills.
(2) Mr. Treves has suggested that the effect of the severe trauma on the
muscular coat of the bowel is to cause a cessation of peristaltic movement.
This, as in the case of 'local shock' elsewhere, may no doubt be of
importance, and to it should be added the simultaneous cessation of
abdominal respiratory movements in the segment of the belly wall covering
the injured part. The occurrence of general cessation of peristaltic
movement is, however, to some extent opposed by the fact that in a certain
number of the cases early passage of motions was seen just as happens in
the intestinal ruptures seen in civil practice.
I should be inclined to ascribe the escape from serious infection in these
injuries to the same cause which accounts for their comparative
insignificance in other regions—namely, the small calibre of the bullet and
consequent small size of the lesion: in point of fact to the minimal nature of
the primary infection. I very much doubt if any patient who had more than
one complete perforation of the small intestine got well during the whole
campaign. This opinion is, moreover, supported by the fact that the
prognosis was so far better in cases of injury to the large than to the small
intestine, in which former segment of the bowel we have the advantages of
a position beyond the region in which intestinal movement is most free, the
unlikelihood of multiple injury, and a drier and more solid type of fæcal
contents.
In the instances in which recovery followed perforating injuries without any
bad signs we can only assume a minimal infection, and sufficient irritation
and reaction on the part of the bowel to produce rapid adhesion between
contiguous coils, and thus provisional closure.
Page 480
The other mode of spontaneous recovery which I saw several times take
place in the injuries to the large bowel consisted in the limitation of the
spread of infection by early adhesions and the development of a local
abscess. The non-observance of this process in any case of injury to the
small intestine raises very great doubts in my mind as to the frequent
recovery of patients in whom the small intestine was perforated.
Injuries To the Intestinal Tract
1. Wounds of the stomach.—A considerable number of wounds in such a
situation as to have possibly implicated the stomach were observed, and of
these a certain number recovered spontaneously. The only two instances
that came under my own observation are recorded below. It will be noted
that in each the special symptoms were the classic ones of vomiting and
hæmatemesis. In the first case blood was also passed per anum, and in the
second the diagnosis was reinforced by the escape of stomach contents from
the external wound.
The second case was a surgical disappointment. No doubt the fatal issue
was mainly dependent on the fact that the external wound had to be kept
open to allow of the escape of the abundant discharge from the wounded
liver. In the absence of the hepatic wound, however, I believe it would have
been possible for this patient to have got well spontaneously, in view of the
firm adhesions which had formed around the opening in the stomach, and
the consequent localisation which had been effected. Another unfortunate
element in this case was the comminuted fracture of the seventh costal
cartilage, which maintained the patency of the aperture of exit. The latter
point, however, was of doubtful importance from this aspect, as the vent
provided for the gastric and biliary secretions may have been the safety-
valve that had allowed localisation to develop.
I believe that the secondary hæmorrhage was the main element in robbing
us of a success in this case, and that this depended on the digestion of the
wound by the gastric secretion. The early troubles which arose in the
treatment of this patient well illustrate the difficulties by which the military
surgeon is at times met; but the patient was admirably attended to and
nursed by my friend Mr. Pershouse, and an orderly who was specially put
on duty for the purpose.
place in the injuries to the large bowel consisted in the limitation of the
spread of infection by early adhesions and the development of a local
abscess. The non-observance of this process in any case of injury to the
small intestine raises very great doubts in my mind as to the frequent
recovery of patients in whom the small intestine was perforated.
Injuries To the Intestinal Tract
1. Wounds of the stomach.—A considerable number of wounds in such a
situation as to have possibly implicated the stomach were observed, and of
these a certain number recovered spontaneously. The only two instances
that came under my own observation are recorded below. It will be noted
that in each the special symptoms were the classic ones of vomiting and
hæmatemesis. In the first case blood was also passed per anum, and in the
second the diagnosis was reinforced by the escape of stomach contents from
the external wound.
The second case was a surgical disappointment. No doubt the fatal issue
was mainly dependent on the fact that the external wound had to be kept
open to allow of the escape of the abundant discharge from the wounded
liver. In the absence of the hepatic wound, however, I believe it would have
been possible for this patient to have got well spontaneously, in view of the
firm adhesions which had formed around the opening in the stomach, and
the consequent localisation which had been effected. Another unfortunate
element in this case was the comminuted fracture of the seventh costal
cartilage, which maintained the patency of the aperture of exit. The latter
point, however, was of doubtful importance from this aspect, as the vent
provided for the gastric and biliary secretions may have been the safety-
valve that had allowed localisation to develop.
I believe that the secondary hæmorrhage was the main element in robbing
us of a success in this case, and that this depended on the digestion of the
wound by the gastric secretion. The early troubles which arose in the
treatment of this patient well illustrate the difficulties by which the military
surgeon is at times met; but the patient was admirably attended to and
nursed by my friend Mr. Pershouse, and an orderly who was specially put
on duty for the purpose.
Page 481
(163) Wounded at Rensburg. Entry (Mauser), in ninth left
intercostal space in posterior axillary line; exit, a transverse slit
1/2 an inch in length to left of xiphoid appendage. Patient was
retiring when struck; he did not fall, but ran for about 1,000
yards, whence he was conveyed to hospital. He vomited half an
hour after the injury (last meal bread and 'bully beef,' taken two
hours previously), and during the evening three times again, the
vomit consisting mainly 'of dark thick blood.' He was put on
milk diet, and not completely starved; on the third day a large
quantity of dark clotted blood was passed per rectum with the
stool, and this continued for two days.
Ten days after the injury the temperature was still rising to 100°,
and did not become normal till the fourteenth day. The pulse
averaged 80. The abdomen, meanwhile, moved fairly well,
respirations 18 to 20. Some tenderness was present in the
epigastrium and towards the spleen. Resonance throughout.
Ordinary diet was now resumed, and beyond slight epigastric
pain on deep inspiration, no further symptoms were observed,
and the patient left for England at the end of the month. The
spleen may have been traversed in this patient, as well as the
lower margin of the right lung.
(164*) Wounded at Enslin. Entry (Mauser), 3/4 of an inch from
the spine, opposite the eighth intercostal space; exit, through the
seventh left costal cartilage, 1 inch from the median line. The
patient was lying in the prone position when shot: he vomited
blood freely, and the bowels acted three times before he was
seen forty hours after the accident, each motion containing dark
blood.
On the commencement of the third day the patient's expression
was extremely anxious, and he was suffering great pain. Pulse
96, temperature 100°. Tongue moist, occasional vomiting,
bowels open yesterday. Has taken fluid nourishment since
injury. The abdomen moved with respiration, but was
moderately distended, especially in the line of the transverse
colon; it was tympanitic on percussion, there was no dulness in
intercostal space in posterior axillary line; exit, a transverse slit
1/2 an inch in length to left of xiphoid appendage. Patient was
retiring when struck; he did not fall, but ran for about 1,000
yards, whence he was conveyed to hospital. He vomited half an
hour after the injury (last meal bread and 'bully beef,' taken two
hours previously), and during the evening three times again, the
vomit consisting mainly 'of dark thick blood.' He was put on
milk diet, and not completely starved; on the third day a large
quantity of dark clotted blood was passed per rectum with the
stool, and this continued for two days.
Ten days after the injury the temperature was still rising to 100°,
and did not become normal till the fourteenth day. The pulse
averaged 80. The abdomen, meanwhile, moved fairly well,
respirations 18 to 20. Some tenderness was present in the
epigastrium and towards the spleen. Resonance throughout.
Ordinary diet was now resumed, and beyond slight epigastric
pain on deep inspiration, no further symptoms were observed,
and the patient left for England at the end of the month. The
spleen may have been traversed in this patient, as well as the
lower margin of the right lung.
(164*) Wounded at Enslin. Entry (Mauser), 3/4 of an inch from
the spine, opposite the eighth intercostal space; exit, through the
seventh left costal cartilage, 1 inch from the median line. The
patient was lying in the prone position when shot: he vomited
blood freely, and the bowels acted three times before he was
seen forty hours after the accident, each motion containing dark
blood.
On the commencement of the third day the patient's expression
was extremely anxious, and he was suffering great pain. Pulse
96, temperature 100°. Tongue moist, occasional vomiting,
bowels open yesterday. Has taken fluid nourishment since
injury. The abdomen moved with respiration, but was
moderately distended, especially in the line of the transverse
colon; it was tympanitic on percussion, there was no dulness in
Page 482
the flanks, and only moderate rigidity of the wall on palpation.
Frothy fluid stained with bile and fæcal in odour was escaping
from the wound of exit, and the everted margins of the latter
were bile-stained.
A vertical incision was carried downwards from the wound for 4
inches. A rugged furrow was found on the under surface of the
left lobe of the liver; the stomach was contracted and firmly
adherent by recent lymph to the under surface of the liver and
the diaphragm. The transverse colon was much distended. On
separating the stomach a slit wound was found at the lesser
curvature, immediately to the right of the œsophagus. This
wound was closed with some difficulty with two tiers of sutures;
the cavity was mopped out, and then irrigated with boiled water;
a plug was introduced along the line of the furrow in the liver,
and the lower part of the abdominal incision closed.
The patient stood the operation well, and was removed to his
tent; during the day, however, two thunder showers occurred
during each of which water, several inches if not a foot deep,
rushed through the camp. After the second flood he was
removed to the operating room, the only house we had, and slept
there. The pulse rose to 120, and respiration to 26, and there was
pain, which was subdued by 1/3 grain of morphia, administered
subcutaneously. A fair amount of urine was passed, and the
bowels acted once, the motion containing blood.
On the second day after operation there was some improvement;
the pulse still numbered 116, and the temperature was raised to
100°, but the belly moved fairly, and pain was moderate.
Abundant foul-smelling, bile-stained discharge came from the
wound when the plug was removed. Rectal feeding was
supplemented by small quantities of milk and soda by the
mouth.
The condition did not materially change, but on the fourth day it
was evident that the suturing of the stomach wound had given
way, and liquid food escaped readily when taken. The discharge
Frothy fluid stained with bile and fæcal in odour was escaping
from the wound of exit, and the everted margins of the latter
were bile-stained.
A vertical incision was carried downwards from the wound for 4
inches. A rugged furrow was found on the under surface of the
left lobe of the liver; the stomach was contracted and firmly
adherent by recent lymph to the under surface of the liver and
the diaphragm. The transverse colon was much distended. On
separating the stomach a slit wound was found at the lesser
curvature, immediately to the right of the œsophagus. This
wound was closed with some difficulty with two tiers of sutures;
the cavity was mopped out, and then irrigated with boiled water;
a plug was introduced along the line of the furrow in the liver,
and the lower part of the abdominal incision closed.
The patient stood the operation well, and was removed to his
tent; during the day, however, two thunder showers occurred
during each of which water, several inches if not a foot deep,
rushed through the camp. After the second flood he was
removed to the operating room, the only house we had, and slept
there. The pulse rose to 120, and respiration to 26, and there was
pain, which was subdued by 1/3 grain of morphia, administered
subcutaneously. A fair amount of urine was passed, and the
bowels acted once, the motion containing blood.
On the second day after operation there was some improvement;
the pulse still numbered 116, and the temperature was raised to
100°, but the belly moved fairly, and pain was moderate.
Abundant foul-smelling, bile-stained discharge came from the
wound when the plug was removed. Rectal feeding was
supplemented by small quantities of milk and soda by the
mouth.
The condition did not materially change, but on the fourth day it
was evident that the suturing of the stomach wound had given
way, and liquid food escaped readily when taken. The discharge
Page 483
remained bile-stained and very foul. No extension of
inflammation to the general peritoneal cavity occurred, but it
was evident that the patient was suffering from constitutional
infection from the foul wound, the lower part of which opened
up somewhat after the removal of the stitches on the seventh
day. The wound was irrigated three times daily with 1-300
creolin lotion, but remained very foul. The man slowly lost
strength, although escape from the stomach considerably
decreased. On the tenth day a sudden severe hæmorrhage
occurred, presumably from a large branch of the cœliac axis.
The bleeding was readily controlled by a plug, and did not recur;
but the patient rapidly sank, and died on the twelfth day after the
operation, and fourteen days after reception of the injury. No
post-mortem examination was made.
2. Wounds of the small intestine.—These were comparatively common, but
offered little that was special either in their symptoms or the results
attending them. Wounds were met with in every part of the small gut; but I
saw no case in which an injury to the duodenum could be specially
diagnosed.
As to the symptoms which attended these injuries, it is somewhat difficult
to speak with precision, and it must be left to my readers to form an opinion
as to how many of the cases recounted below were really instances of
perforating wounds. My own view is that in the majority of the cases that
got well spontaneously, the injury was not of a perforating nature, and that
for reasons which have been already set forth. It will, however, be at once
noted that in all the five cases in which the injury was certainly diagnosed
in hospital death occurred.
The cases of injury to the small intestine are perhaps best arranged in three
classes.
1. Those who died upon the field, or shortly after removal from it. In these
the external wounds were often large, the omentum was not rarely
prolapsed, and escape of fæces sometimes occurred early. Shock from the
severity of the lesion, and hæmorrhage, were no doubt important factors in
the early lethal issue in this class. Many of the injuries were no doubt
inflammation to the general peritoneal cavity occurred, but it
was evident that the patient was suffering from constitutional
infection from the foul wound, the lower part of which opened
up somewhat after the removal of the stitches on the seventh
day. The wound was irrigated three times daily with 1-300
creolin lotion, but remained very foul. The man slowly lost
strength, although escape from the stomach considerably
decreased. On the tenth day a sudden severe hæmorrhage
occurred, presumably from a large branch of the cœliac axis.
The bleeding was readily controlled by a plug, and did not recur;
but the patient rapidly sank, and died on the twelfth day after the
operation, and fourteen days after reception of the injury. No
post-mortem examination was made.
2. Wounds of the small intestine.—These were comparatively common, but
offered little that was special either in their symptoms or the results
attending them. Wounds were met with in every part of the small gut; but I
saw no case in which an injury to the duodenum could be specially
diagnosed.
As to the symptoms which attended these injuries, it is somewhat difficult
to speak with precision, and it must be left to my readers to form an opinion
as to how many of the cases recounted below were really instances of
perforating wounds. My own view is that in the majority of the cases that
got well spontaneously, the injury was not of a perforating nature, and that
for reasons which have been already set forth. It will, however, be at once
noted that in all the five cases in which the injury was certainly diagnosed
in hospital death occurred.
The cases of injury to the small intestine are perhaps best arranged in three
classes.
1. Those who died upon the field, or shortly after removal from it. In these
the external wounds were often large, the omentum was not rarely
prolapsed, and escape of fæces sometimes occurred early. Shock from the
severity of the lesion, and hæmorrhage, were no doubt important factors in
the early lethal issue in this class. Many of the injuries were no doubt
Page 484
produced by bullets striking irregularly, by ricochets, by bullets of the
expanding forms, or by bullets of large calibre. As being beyond the bounds
of surgical aid, this class possessed the least interest.
2. Cases brought into the Field, or even the Stationary hospitals, with
symptoms of moderate severity, or even of an insignificant character, in
which evidence of septic peritonitis suddenly developed and death ensued.
3. Cases in which the position of the wounds raised the possibility of injury
to the intestine, but in which the symptoms were slight or of moderate
severity, and which recovered spontaneously.
The whole crux in diagnosis lay in the attempt to separate the two latter
classes, and, personally, I must own to having been no nearer a position of
being able to form an opinion on this point, in the late than in the early
stage of my stay in South Africa. The advent of peritoneal septicæmia was
in many instances the only determining moment. On this matter I can only
add that, in civil practice, an exploratory abdominal section is often the only
means of determination of a rupture of the bowel wall.
With regard to the cases of suspected injury to the bowel which recovered
spontaneously, the symptoms were somewhat special in their comparative
slightness, and in the limited nature of the local signs. Thus the pulse
seldom rose to as much as 100 in rate, 80 was a common average.
Respiration was never greatly quickened, 24 was a common rate. The
temperature rarely exceeded 100°. Vomiting was occasionally severe, but
usually not persistent, ceasing on the second day. A good quantity of urine
was passed. As to the local signs, these again were of a limited nature;
distension did not occur, or was slight; movement of the abdominal wall
was only restricted in the neighbourhood of the wound, the affected area
amounted to a quarter, or at most half, the abdominal wall, and rigidity was
localised to a similar segment. Local tenderness usually existed; but, as a
rule, there was little or no dulness to point to the occurrence either of fluid
effusion or a considerable deposition of lymph.
Again many of the patients suffered with very slight symptoms of
constitutional shock, although there was considerable variation in this
particular.
expanding forms, or by bullets of large calibre. As being beyond the bounds
of surgical aid, this class possessed the least interest.
2. Cases brought into the Field, or even the Stationary hospitals, with
symptoms of moderate severity, or even of an insignificant character, in
which evidence of septic peritonitis suddenly developed and death ensued.
3. Cases in which the position of the wounds raised the possibility of injury
to the intestine, but in which the symptoms were slight or of moderate
severity, and which recovered spontaneously.
The whole crux in diagnosis lay in the attempt to separate the two latter
classes, and, personally, I must own to having been no nearer a position of
being able to form an opinion on this point, in the late than in the early
stage of my stay in South Africa. The advent of peritoneal septicæmia was
in many instances the only determining moment. On this matter I can only
add that, in civil practice, an exploratory abdominal section is often the only
means of determination of a rupture of the bowel wall.
With regard to the cases of suspected injury to the bowel which recovered
spontaneously, the symptoms were somewhat special in their comparative
slightness, and in the limited nature of the local signs. Thus the pulse
seldom rose to as much as 100 in rate, 80 was a common average.
Respiration was never greatly quickened, 24 was a common rate. The
temperature rarely exceeded 100°. Vomiting was occasionally severe, but
usually not persistent, ceasing on the second day. A good quantity of urine
was passed. As to the local signs, these again were of a limited nature;
distension did not occur, or was slight; movement of the abdominal wall
was only restricted in the neighbourhood of the wound, the affected area
amounted to a quarter, or at most half, the abdominal wall, and rigidity was
localised to a similar segment. Local tenderness usually existed; but, as a
rule, there was little or no dulness to point to the occurrence either of fluid
effusion or a considerable deposition of lymph.
Again many of the patients suffered with very slight symptoms of
constitutional shock, although there was considerable variation in this
particular.
Page 485
(165*) Wounded at Graspan, sustaining a compound fracture of
the fibula. While being carried off the field, a second bullet
(Lee-Metford) entered immediately outside the left posterior
superior iliac spine, perforated the pelvis, and emerged 1½ inch
within the left anterior superior spine. The patient was then put
down and left on the field ten hours; later he was carried to
shelter for the night, and arrived at Orange River on the second
day. He suffered with some pain in the abdomen, especially
during the journey in the train, but was not sick; the bowels
were confined.
When seen on the third day at 6 p.m., some pain was complained
of in the abdomen, which moved freely in the upper part, but
was motionless below the umbilicus. No distension. Tenderness
around wound of exit and some rigidity. The bowels had acted
four times during the day; motions loose, dark brown, and
containing no blood. Face not anxious, eyes bright, temperature
102°. Pulse 96, regular, and of good strength. Tongue moist and
little furred.
The abdomen was opened at 5 a.m. on the fourth day, as the
local signs had become more pronounced, and the patient had
passed a restless night in great abdominal pain. A local incision
was chosen, as the wound was presumably in the sigmoid
flexure. The sigmoid flexure was adherent to the abdominal wall
opposite the wound of exit, and a dark ecchymosed patch was
found, but no perforation could be detected. Foul pus and gas
escaped freely from the pelvis, but no wound of the large bowel
could be discovered here. On enlarging the incision upwards
three openings were found in a coil of jejunum, probably that
about five feet from the duodenal junction usually provided with
the longest mesentery. No fourth opening could be found. The
openings were circular, about 1/3 inch in diameter, clean cut,
with a ring of everted mucous membrane, and the wall of the
bowel in the neighbourhood was thickened. All three openings
were included within a length of 2½ inches. There was no
surrounding ecchymosis of the bowel wall. Very little escaped
intestinal contents were found in the situation of the bowel. The
the fibula. While being carried off the field, a second bullet
(Lee-Metford) entered immediately outside the left posterior
superior iliac spine, perforated the pelvis, and emerged 1½ inch
within the left anterior superior spine. The patient was then put
down and left on the field ten hours; later he was carried to
shelter for the night, and arrived at Orange River on the second
day. He suffered with some pain in the abdomen, especially
during the journey in the train, but was not sick; the bowels
were confined.
When seen on the third day at 6 p.m., some pain was complained
of in the abdomen, which moved freely in the upper part, but
was motionless below the umbilicus. No distension. Tenderness
around wound of exit and some rigidity. The bowels had acted
four times during the day; motions loose, dark brown, and
containing no blood. Face not anxious, eyes bright, temperature
102°. Pulse 96, regular, and of good strength. Tongue moist and
little furred.
The abdomen was opened at 5 a.m. on the fourth day, as the
local signs had become more pronounced, and the patient had
passed a restless night in great abdominal pain. A local incision
was chosen, as the wound was presumably in the sigmoid
flexure. The sigmoid flexure was adherent to the abdominal wall
opposite the wound of exit, and a dark ecchymosed patch was
found, but no perforation could be detected. Foul pus and gas
escaped freely from the pelvis, but no wound of the large bowel
could be discovered here. On enlarging the incision upwards
three openings were found in a coil of jejunum, probably that
about five feet from the duodenal junction usually provided with
the longest mesentery. No fourth opening could be found. The
openings were circular, about 1/3 inch in diameter, clean cut,
with a ring of everted mucous membrane, and the wall of the
bowel in the neighbourhood was thickened. All three openings
were included within a length of 2½ inches. There was no
surrounding ecchymosis of the bowel wall. Very little escaped
intestinal contents were found in the situation of the bowel. The
Page 486
latter had apparently been retracted upwards, and lay to the left
of the lumbar spine. The wounds were readily closed by five
Lembert's sutures, three crossing the openings, and one at each
end. The belly was then washed out with boiled water and
closed. The delay in finding the wounds due to the mistaken
impression that they would be found in the pelvis materially
prolonged the operation, which lasted an hour and a half. The
patient never rallied, and died seventeen hours later. It is
possible that a wound in the sigmoid flexure was present which
had already closed at the time of operation.
(166*) Wounded at Magersfontein. Entry (Mauser), opposite
central point of left ilium; exit, 1½ inch above the centre of the
right Poupart's ligament. Vomiting commenced soon after the
injury, and this was continuous until the patient's arrival in the
Stationary hospital on the fourth day, when the condition was as
follows:—
Face extremely anxious in expression. Temperature 101°,
sweating freely. Pulse 110, fair strength. Tongue moist.
Abdomen much distended, rigid, motionless, tympanitic
throughout. Bowels confined. No urine had been passed for
twenty-four hours, ℥ij in bladder on catheterisation, clear, and
containing no blood.
Abdominal section. Median incision. A considerable quantity of
bloody effusion was evacuated. Intestine generally congested
and distended. No lymph. Two wounds were found in the ileum
on the opposite sides of one coil; the openings were circular,
with the mucous membrane everted. No escape of fæcal matter
was visible until the intestine was delivered, when intestinal
contents spurted freely across the room. The openings were
sutured with five Lembert's stitches. The bowel was punctured
in two places to relieve distension, and then returned into the
belly, after washing with boiled water.
Four pints of saline solution were infused into the median basilic
vein, and 1/30 grain strychnine sulph. was injected
of the lumbar spine. The wounds were readily closed by five
Lembert's sutures, three crossing the openings, and one at each
end. The belly was then washed out with boiled water and
closed. The delay in finding the wounds due to the mistaken
impression that they would be found in the pelvis materially
prolonged the operation, which lasted an hour and a half. The
patient never rallied, and died seventeen hours later. It is
possible that a wound in the sigmoid flexure was present which
had already closed at the time of operation.
(166*) Wounded at Magersfontein. Entry (Mauser), opposite
central point of left ilium; exit, 1½ inch above the centre of the
right Poupart's ligament. Vomiting commenced soon after the
injury, and this was continuous until the patient's arrival in the
Stationary hospital on the fourth day, when the condition was as
follows:—
Face extremely anxious in expression. Temperature 101°,
sweating freely. Pulse 110, fair strength. Tongue moist.
Abdomen much distended, rigid, motionless, tympanitic
throughout. Bowels confined. No urine had been passed for
twenty-four hours, ℥ij in bladder on catheterisation, clear, and
containing no blood.
Abdominal section. Median incision. A considerable quantity of
bloody effusion was evacuated. Intestine generally congested
and distended. No lymph. Two wounds were found in the ileum
on the opposite sides of one coil; the openings were circular,
with the mucous membrane everted. No escape of fæcal matter
was visible until the intestine was delivered, when intestinal
contents spurted freely across the room. The openings were
sutured with five Lembert's stitches. The bowel was punctured
in two places to relieve distension, and then returned into the
belly, after washing with boiled water.
Four pints of saline solution were infused into the median basilic
vein, and 1/30 grain strychnine sulph. was injected
Page 487
hypodermically.
The patient did not rally, and died twelve hours after the
operation.
(167*) Wounded at Graspan. Entry (Lee-Metford), midway
between the umbilicus and pubes; exit, 1 inch to the left of the
fifth lumbar spine. The patient was seen on the third day in the
following condition: in great pain, expression extremely
anxious, vomiting constantly. Pulse 150 running, respirations
48. Temperature 100°, sweating freely. Great distension, rigidity,
and general tenderness of immobile abdomen. No improvement
followed the administration of brandy and hypodermic injection
of strychnine 1/30 grain, and operation was deemed hopeless.
In the evening the patient was apparently dying. Face blue and
sunken and covered with sweat, eyes dull, speechless, pulse
imperceptible, restlessness extreme, bowels acting involuntarily,
no urine in bladder.
The man was placed in a tent by himself, and to my surprise was
alive and better the next morning; the expression was still
anxious, but the face brighter and not sweating; the pulse only
numbered 100, but was very weak, and the hands and feet were
cold. The condition of the abdomen was unaltered, but the
thoracic respiration had decreased in rapidity from 48 to 28.
His condition still seemed to preclude any chance of successful
intervention, but none the less life was retained until the
morning of the seventh day, the state alternating between a
moribund one and one of slight improvement. He was lucid at
times, although for the most part wandering, and was so restless
that no covering could be kept upon him. Vomiting was
continuous, so that no nourishment could be retained; the
bowels acted frequently involuntarily, and little or no urine was
passed. Meanwhile, the abdomen became flat, then sunken, an
area of induration and tenderness about 6 inches in diameter
developing around the wound of entry. Slight variations in the
pulse, and from normal to subnormal in the temperature, were
The patient did not rally, and died twelve hours after the
operation.
(167*) Wounded at Graspan. Entry (Lee-Metford), midway
between the umbilicus and pubes; exit, 1 inch to the left of the
fifth lumbar spine. The patient was seen on the third day in the
following condition: in great pain, expression extremely
anxious, vomiting constantly. Pulse 150 running, respirations
48. Temperature 100°, sweating freely. Great distension, rigidity,
and general tenderness of immobile abdomen. No improvement
followed the administration of brandy and hypodermic injection
of strychnine 1/30 grain, and operation was deemed hopeless.
In the evening the patient was apparently dying. Face blue and
sunken and covered with sweat, eyes dull, speechless, pulse
imperceptible, restlessness extreme, bowels acting involuntarily,
no urine in bladder.
The man was placed in a tent by himself, and to my surprise was
alive and better the next morning; the expression was still
anxious, but the face brighter and not sweating; the pulse only
numbered 100, but was very weak, and the hands and feet were
cold. The condition of the abdomen was unaltered, but the
thoracic respiration had decreased in rapidity from 48 to 28.
His condition still seemed to preclude any chance of successful
intervention, but none the less life was retained until the
morning of the seventh day, the state alternating between a
moribund one and one of slight improvement. He was lucid at
times, although for the most part wandering, and was so restless
that no covering could be kept upon him. Vomiting was
continuous, so that no nourishment could be retained; the
bowels acted frequently involuntarily, and little or no urine was
passed. Meanwhile, the abdomen became flat, then sunken, an
area of induration and tenderness about 6 inches in diameter
developing around the wound of entry. Slight variations in the
pulse, and from normal to subnormal in the temperature, were
Page 488
noted, and death eventually occurred from septicæmia and
inanition.
(168*) Wounded at Driefontein. Entry (Mauser), above the
posterior third of the left iliac crest, at the margin of the last
lumbar transverse process (probably through ilio-lumbar
ligament); exit, 1 inch below and to the left of the umbilicus.
The patient was wounded at 3 p.m., but not brought into the
Field hospital until 9 p.m., when the temperature of the tents was
below 28°F. He was considerably collapsed, suffering much
pain, and vomited freely. The abdomen was flat, but very tender.
Bowels confined. The column had to move at 5 a.m. the next
morning, when the temperature was still near freezing, and
during the day continuous fighting prevented any chance of
operation. The man steadily sank during the day, and died thirty-
six hours after the reception of the injury.
Post-mortem condition.—Belly not distended, dull anteriorly in
patches, and right flank dull throughout. When the belly was
opened, extensive adhesion of omentum and intestine enclosing
numerous collections of pus were disclosed, and on disturbing
the adhesions a large collection of turbid blood-stained fluid was
set free from the right loin. The great omentum was much
thickened and matted, with deposition of thick patches of
lymph; very firm recent adhesions also united numerous coils of
small intestine. The pus was fœtid, but no appreciable quantity
of intestinal contents was detected in it. The lower half or more
of the small intestine was injected, reddened, and thickened. The
wounds which were situated in the lower part of the jejunum
and ileum were multiple, and seven perforations were detected;
besides these the intestine was marked by bruises, and some
gutter slits affecting the serous and muscular coats only.
Considerable ecchymosis surrounded these latter. The clean
perforations were circular, less than 1/4 inch in diameter, and for
the most part closed by eversion of the mucous membrane.
Intestinal contents were not apparent, but escaped freely on
manipulation of the bowel.
inanition.
(168*) Wounded at Driefontein. Entry (Mauser), above the
posterior third of the left iliac crest, at the margin of the last
lumbar transverse process (probably through ilio-lumbar
ligament); exit, 1 inch below and to the left of the umbilicus.
The patient was wounded at 3 p.m., but not brought into the
Field hospital until 9 p.m., when the temperature of the tents was
below 28°F. He was considerably collapsed, suffering much
pain, and vomited freely. The abdomen was flat, but very tender.
Bowels confined. The column had to move at 5 a.m. the next
morning, when the temperature was still near freezing, and
during the day continuous fighting prevented any chance of
operation. The man steadily sank during the day, and died thirty-
six hours after the reception of the injury.
Post-mortem condition.—Belly not distended, dull anteriorly in
patches, and right flank dull throughout. When the belly was
opened, extensive adhesion of omentum and intestine enclosing
numerous collections of pus were disclosed, and on disturbing
the adhesions a large collection of turbid blood-stained fluid was
set free from the right loin. The great omentum was much
thickened and matted, with deposition of thick patches of
lymph; very firm recent adhesions also united numerous coils of
small intestine. The pus was fœtid, but no appreciable quantity
of intestinal contents was detected in it. The lower half or more
of the small intestine was injected, reddened, and thickened. The
wounds which were situated in the lower part of the jejunum
and ileum were multiple, and seven perforations were detected;
besides these the intestine was marked by bruises, and some
gutter slits affecting the serous and muscular coats only.
Considerable ecchymosis surrounded these latter. The clean
perforations were circular, less than 1/4 inch in diameter, and for
the most part closed by eversion of the mucous membrane.
Intestinal contents were not apparent, but escaped freely on
manipulation of the bowel.
Page 489
(169*) Wounded at Magersfontein. Entry (Mauser), over the
eighth rib in the anterior axillary line; exit, 1 inch to the left of
second lumbar spinous process, just below the last rib. Vomiting
commenced almost immediately after reception of the injury,
and the bowels acted frequently. This condition persisted until
the fourth day, when the patient was brought down to Orange
River, and the signs were as follows. Considerable pain in left
half of abdomen, pulse 110, fair strength, temperature 101°.
Some general distension of abdomen with complete
disappearance of hepatic dulness. Some movement of right half
of abdomen, left half immobile, dulness extending from the
flank as far forwards as linea semilunaris. An incision was made
in left linea semilunaris, and Oj blood evacuated from the left
loin. There was no lymph on the intestines nor sign of
inflammation. No perforation was discovered in either stomach
or intestine, but on two coils of jejunum there were deep slits
3/4 inch long, extending through both peritoneal and muscular
coats. Beyond these wounds, on other coils oval patches of
ecchymosis, due to direct bruising, were present. The peritoneal
cavity was sponged free of all blood and irrigated with boiled
water; no bleeding point was discovered, and the abdomen was
closed.
The next morning the patient was comfortable; temperature
100.2°, pulse 100. Tongue clean and moist; he vomited once
during the night.
Some bloody discharge had collected in the dressing, and at the
lower angle of wound there was a local swelling, apparently in
the abdominal wall. The flank was resonant.
During the afternoon the patient became faint, and when seen at
6 p.m. was in a state of collapse, in which he shortly died.
Death was apparently due to renewal of the previous
hæmorrhage. No post-mortem examination was made.
(170*) Wounded at Magersfontein. Entry (Mauser), 1/2 inch to
the left of the second sacral spine; exit, immediately below the
eighth rib in the anterior axillary line; exit, 1 inch to the left of
second lumbar spinous process, just below the last rib. Vomiting
commenced almost immediately after reception of the injury,
and the bowels acted frequently. This condition persisted until
the fourth day, when the patient was brought down to Orange
River, and the signs were as follows. Considerable pain in left
half of abdomen, pulse 110, fair strength, temperature 101°.
Some general distension of abdomen with complete
disappearance of hepatic dulness. Some movement of right half
of abdomen, left half immobile, dulness extending from the
flank as far forwards as linea semilunaris. An incision was made
in left linea semilunaris, and Oj blood evacuated from the left
loin. There was no lymph on the intestines nor sign of
inflammation. No perforation was discovered in either stomach
or intestine, but on two coils of jejunum there were deep slits
3/4 inch long, extending through both peritoneal and muscular
coats. Beyond these wounds, on other coils oval patches of
ecchymosis, due to direct bruising, were present. The peritoneal
cavity was sponged free of all blood and irrigated with boiled
water; no bleeding point was discovered, and the abdomen was
closed.
The next morning the patient was comfortable; temperature
100.2°, pulse 100. Tongue clean and moist; he vomited once
during the night.
Some bloody discharge had collected in the dressing, and at the
lower angle of wound there was a local swelling, apparently in
the abdominal wall. The flank was resonant.
During the afternoon the patient became faint, and when seen at
6 p.m. was in a state of collapse, in which he shortly died.
Death was apparently due to renewal of the previous
hæmorrhage. No post-mortem examination was made.
(170*) Wounded at Magersfontein. Entry (Mauser), 1/2 inch to
the left of the second sacral spine; exit, immediately below the
Page 490
left anterior superior iliac spine; the patient was kneeling at the
time, and the same bullet traversed his left thigh in the lower
third. When seen on the third day, the lower part of the abdomen
was motionless, tumid, and tender. The bowels had been
confined for three days; there had been no sickness, and the
tongue was moist and clean. Temperature 100°, pulse 90, fair
strength, respirations 38. The patient had once had an attack of
acute appendicitis, and he himself said he was sure he now had
'peritonitis,' as he had pain exactly similar in the belly to that he
had suffered in his previous illness.
No further signs, however, developed under an expectant
treatment, and he remained some two months in hospital, while
the wound in the thigh and a third injury to the elbow-joint were
healing.
(171) Entry (Mauser), at the highest point of the left crista ilii;
exit, through the right ilium, 2 inches horizontally anterior to the
posterior superior spine. Absolutely no abdominal symptoms
followed. The bowels were confined five days, and then opened
by enema. The patient complained of some stiffness in the
lumbo-sacral region, but the right synchondrosis was no doubt
implicated in the track.
(172) Wounded at Paardeberg (range 800 yards). Entry
(Mauser), 2 inches diagonally below and to the right of the
umbilicus; exit, not discoverable. For the first two days the
patient had to lie out with the regiment; on the fourth he was
removed to the Field hospital. During the first three days the
patient vomited (green matter) frequently, and the belly was
hard and painful; as biscuit was the only available food, no
nourishment was taken. The bowels acted on the second night.
At the end of a week the patient was sent by bullock wagon
(three days and nights) to Modder River, and then down to
Capetown, where he walked into the hospital on the thirteenth
day, apparently well.
time, and the same bullet traversed his left thigh in the lower
third. When seen on the third day, the lower part of the abdomen
was motionless, tumid, and tender. The bowels had been
confined for three days; there had been no sickness, and the
tongue was moist and clean. Temperature 100°, pulse 90, fair
strength, respirations 38. The patient had once had an attack of
acute appendicitis, and he himself said he was sure he now had
'peritonitis,' as he had pain exactly similar in the belly to that he
had suffered in his previous illness.
No further signs, however, developed under an expectant
treatment, and he remained some two months in hospital, while
the wound in the thigh and a third injury to the elbow-joint were
healing.
(171) Entry (Mauser), at the highest point of the left crista ilii;
exit, through the right ilium, 2 inches horizontally anterior to the
posterior superior spine. Absolutely no abdominal symptoms
followed. The bowels were confined five days, and then opened
by enema. The patient complained of some stiffness in the
lumbo-sacral region, but the right synchondrosis was no doubt
implicated in the track.
(172) Wounded at Paardeberg (range 800 yards). Entry
(Mauser), 2 inches diagonally below and to the right of the
umbilicus; exit, not discoverable. For the first two days the
patient had to lie out with the regiment; on the fourth he was
removed to the Field hospital. During the first three days the
patient vomited (green matter) frequently, and the belly was
hard and painful; as biscuit was the only available food, no
nourishment was taken. The bowels acted on the second night.
At the end of a week the patient was sent by bullock wagon
(three days and nights) to Modder River, and then down to
Capetown, where he walked into the hospital on the thirteenth
day, apparently well.
Page 491
Two days later the temperature rose to 104°, and enteric fever
was diagnosed, no local signs pointing to the injury existing.
The patient made a good recovery.
(173) Wounded at Colenso. Entry (Mauser), at junction of outer
2/5 with inner 3/5 of line from right anterior superior iliac spine
to umbilicus; exit, at upper part of right great sacro-sciatic
foramen, in line of posterior superior iliac spine. Advancing on
foot when struck; he then fell and crept fifty yards to behind a
rock, where he remained seven and a half hours. For two days
subsequently he vomited freely; the bowels acted nine hours
after the injury, and then became constipated. No further
symptoms were noted, and at the end of three weeks the
abdomen was absolutely normal. The man is now again on
active service.
(174*) Wounded at Modder River while retiring on foot. Entry
(Mauser), at highest point of right iliac crest; exit, 2½ inches to
right of and 1/2 inch above level of umbilicus. The injury was
not followed by sickness, and the bowels remained confined.
During the first two days 'pain struck across the abdomen' when
micturition was performed.
When the patient came under observation on the third day the
condition was as follows:—Complains of little pain, temperature
normal, pulse 72, respirations 24, tongue moist, bowels
confined. Rigidity of abdominal wall and deficient mobility of
nearly whole right half of belly, the whole lower half of which
moves little with respiration. No track palpable in abdominal
parietes. No dulness, no distension. The temperature rose to
99.5° at night. On the fourth day the bowels acted freely, the
pulse fell to 60, the respirations were 24, and the temperature
normal.
Tenderness and rigidity persisted in the right flank to the end of
a week, after which time no further signs persisted.
(175*) Wounded at Modder River while lying on right side.
Range 500 yards. Walked 400 yards after injury. Entry (Mauser),
was diagnosed, no local signs pointing to the injury existing.
The patient made a good recovery.
(173) Wounded at Colenso. Entry (Mauser), at junction of outer
2/5 with inner 3/5 of line from right anterior superior iliac spine
to umbilicus; exit, at upper part of right great sacro-sciatic
foramen, in line of posterior superior iliac spine. Advancing on
foot when struck; he then fell and crept fifty yards to behind a
rock, where he remained seven and a half hours. For two days
subsequently he vomited freely; the bowels acted nine hours
after the injury, and then became constipated. No further
symptoms were noted, and at the end of three weeks the
abdomen was absolutely normal. The man is now again on
active service.
(174*) Wounded at Modder River while retiring on foot. Entry
(Mauser), at highest point of right iliac crest; exit, 2½ inches to
right of and 1/2 inch above level of umbilicus. The injury was
not followed by sickness, and the bowels remained confined.
During the first two days 'pain struck across the abdomen' when
micturition was performed.
When the patient came under observation on the third day the
condition was as follows:—Complains of little pain, temperature
normal, pulse 72, respirations 24, tongue moist, bowels
confined. Rigidity of abdominal wall and deficient mobility of
nearly whole right half of belly, the whole lower half of which
moves little with respiration. No track palpable in abdominal
parietes. No dulness, no distension. The temperature rose to
99.5° at night. On the fourth day the bowels acted freely, the
pulse fell to 60, the respirations were 24, and the temperature
normal.
Tenderness and rigidity persisted in the right flank to the end of
a week, after which time no further signs persisted.
(175*) Wounded at Modder River while lying on right side.
Range 500 yards. Walked 400 yards after injury. Entry (Mauser),
Page 492
at the junction of the posterior and middle thirds of the right
iliac crest; exit, 3 inches to right of and 1/2 inch below the level
of the umbilicus. The injury was followed by no signs of intra-
abdominal lesion; on the third day the temperature was normal,
pulse 80, and the tongue clean and moist. Some soreness at
times and tenderness on pressure were complained of, but the
man was discharged well at the end of one month.
(176*) Wounded while doubling in retirement at Modder River.
Entry (Mauser), immediately above the junction of the posterior
and middle thirds of the left iliac crest; exit, 1 inch below costal
margin (eighth rib), 3 inches to the right of the median line. The
bullet was lying in the anterior wound, whence it was removed
by the orderly who applied the first dressing on the field. The
patient remained on the field seven and a half hours, and when
brought into hospital at once commenced to vomit. The ejected
matter, at first green in colour, during the next forty-eight hours
changed to a dirty brown. Meanwhile, the abdomen was
somewhat painful. When seen on the third day he had ceased to
vomit for three hours. The face was slightly anxious, and the
patient lay on the ground with the lower extremities extended.
Temperature 99°, pulse 72, fair strength. Respirations 32,
shallow. Tongue moist, lightly furred, bowels not open for four
days. He slept fairly last night. Abdomen soft, moving well with
respiration, no distension, slight tenderness below and to the
right of the umbilicus, and local dulness in right flank.
The next day the pulse fell to 60 and the bowels acted, but there
was no change in the local condition. The man looked somewhat
ill until the end of a week, but was then sent to the Base, and at
the expiration of a month was sent home well.
(177*) Wounded at Modder River. Two apertures of entry
(Mauser); (a) below cartilage of eighth rib in left nipple line; (b)
2 inches below and 4½ inches to the left of the median line. No
exit wound discovered, and no track could be palpated between
the two openings, which were both circular and depressed.
When seen on fourth day there was tenderness in the lower half
iliac crest; exit, 3 inches to right of and 1/2 inch below the level
of the umbilicus. The injury was followed by no signs of intra-
abdominal lesion; on the third day the temperature was normal,
pulse 80, and the tongue clean and moist. Some soreness at
times and tenderness on pressure were complained of, but the
man was discharged well at the end of one month.
(176*) Wounded while doubling in retirement at Modder River.
Entry (Mauser), immediately above the junction of the posterior
and middle thirds of the left iliac crest; exit, 1 inch below costal
margin (eighth rib), 3 inches to the right of the median line. The
bullet was lying in the anterior wound, whence it was removed
by the orderly who applied the first dressing on the field. The
patient remained on the field seven and a half hours, and when
brought into hospital at once commenced to vomit. The ejected
matter, at first green in colour, during the next forty-eight hours
changed to a dirty brown. Meanwhile, the abdomen was
somewhat painful. When seen on the third day he had ceased to
vomit for three hours. The face was slightly anxious, and the
patient lay on the ground with the lower extremities extended.
Temperature 99°, pulse 72, fair strength. Respirations 32,
shallow. Tongue moist, lightly furred, bowels not open for four
days. He slept fairly last night. Abdomen soft, moving well with
respiration, no distension, slight tenderness below and to the
right of the umbilicus, and local dulness in right flank.
The next day the pulse fell to 60 and the bowels acted, but there
was no change in the local condition. The man looked somewhat
ill until the end of a week, but was then sent to the Base, and at
the expiration of a month was sent home well.
(177*) Wounded at Modder River. Two apertures of entry
(Mauser); (a) below cartilage of eighth rib in left nipple line; (b)
2 inches below and 4½ inches to the left of the median line. No
exit wound discovered, and no track could be palpated between
the two openings, which were both circular and depressed.
When seen on fourth day there was tenderness in the lower half
Page 493
of the abdomen, and the left thigh was held in a flexed position.
Respirations 20, respiratory movement confined to upper half of
abdominal wall. Pulse 70, temperature 99°. Tongue moist,
covered with white fur; bowels confined since the accident; no
sickness. The patient remained under observation thirteen days,
during which time pain and difficulty in movement of the left
thigh persisted, also slight tenderness in the lower part of the
abdomen; but at the end of a month he was sent to England well,
but unfit to take further part in the campaign. I thought the bullet
might be in the left psoas, but it was not localised.
(178*) Wounded at Modder River. Entry (Mauser), 3½ inches
above and 1½ inch within the left anterior superior iliac spine;
exit, 1½ inch to the right of the tenth dorsal spinous process. The
same bullet had perforated the forearm just above the wrist prior
to entering the abdomen. No local or constitutional signs
indicated either bowel injury or perforation of liver. The man,
however, was suffering from a slight attack of dysentery, passing
blood and mucus per rectum with great tenesmus. He was sent
to the Base at the end of a week, and returned to England well
three weeks later. He attributed his dysentery to the wound, as
the symptoms did not exist prior to its reception; but as the
disease coincided exactly with what was very prevalent amongst
the troops at the time, I do not think there was any connection
between it and the injury.
(179) Wounded near Thaba-nchu. Entry, over the centre of the
sacrum at the upper border of fourth segment; exit, 1½ inch
above left Poupart's ligament, 2 inches from the median line.
Aperture of entry oval, with long vertical axis. Exit wound a
transverse slit, with slight tendency to starring (see fig. 19, p.
58). One hour after being shot the patient vomited once. There
was some evidence of shock and considerable pain. The bowels
acted involuntarily simultaneously with the vomiting, and
incontinence of fæces and retention of urine persisted for four
days. The vomit was bilious in appearance; no blood was seen
either in it or the motions.
Respirations 20, respiratory movement confined to upper half of
abdominal wall. Pulse 70, temperature 99°. Tongue moist,
covered with white fur; bowels confined since the accident; no
sickness. The patient remained under observation thirteen days,
during which time pain and difficulty in movement of the left
thigh persisted, also slight tenderness in the lower part of the
abdomen; but at the end of a month he was sent to England well,
but unfit to take further part in the campaign. I thought the bullet
might be in the left psoas, but it was not localised.
(178*) Wounded at Modder River. Entry (Mauser), 3½ inches
above and 1½ inch within the left anterior superior iliac spine;
exit, 1½ inch to the right of the tenth dorsal spinous process. The
same bullet had perforated the forearm just above the wrist prior
to entering the abdomen. No local or constitutional signs
indicated either bowel injury or perforation of liver. The man,
however, was suffering from a slight attack of dysentery, passing
blood and mucus per rectum with great tenesmus. He was sent
to the Base at the end of a week, and returned to England well
three weeks later. He attributed his dysentery to the wound, as
the symptoms did not exist prior to its reception; but as the
disease coincided exactly with what was very prevalent amongst
the troops at the time, I do not think there was any connection
between it and the injury.
(179) Wounded near Thaba-nchu. Entry, over the centre of the
sacrum at the upper border of fourth segment; exit, 1½ inch
above left Poupart's ligament, 2 inches from the median line.
Aperture of entry oval, with long vertical axis. Exit wound a
transverse slit, with slight tendency to starring (see fig. 19, p.
58). One hour after being shot the patient vomited once. There
was some evidence of shock and considerable pain. The bowels
acted involuntarily simultaneously with the vomiting, and
incontinence of fæces and retention of urine persisted for four
days. The vomit was bilious in appearance; no blood was seen
either in it or the motions.
Page 494
Forty-six hours after the injury the condition was as follows:
Face slightly anxious and pale; skin moist, temperature 100.4°;
pulse 116, regular and of fair strength; respirations 24; abdomen
slightly tumid; tenderness over lower half, especially on left
side; the lower half moves little with respiration.
Twenty-four hours later the patient had improved. He was
comfortable and hopeful; slept well with morphia 1/3 grain
hypodermically. Tongue moist, covered with white fur; has been
taking milk only, ℥ij every half-hour. No sickness. Temperature
99°. Pulse 104. Respirations 24. Abdomen flatter; general
respiratory movement; tenderness now mainly localised to an
area 2½ inches in diameter, to the left of the umbilicus, above
exit wound.
The patient continued to improve, and on the fifth day travelled
six hours in a bullock wagon to Bloemfontein. Soon after arrival
his temperature was normal: pulse 80, respirations 16, with good
abdominal movement. Local tenderness persisted in the same
area, but was less in degree. Tongue rather dry, bowels confined.
Micturition normal. Two drachms of castor oil and an enema
were given.
On the ninth day patient was practically well, except for slight
deep tenderness. He remained in bed on ordinary light diet, but
at the end of the third week he was seized by a sudden attack of
pain, the temperature rising to 103° and the pulse to 140, the
abdomen becoming swollen and tender. He was then under the
charge of Mr. Bowlby, who ordered some opium, and the
symptoms rapidly subsided. Although this wound crossed the
small intestine area, it is probable that the symptoms may have
been due to an injury of the rectum or sigmoid flexure.
3. Wounds of the large intestine.—Injuries to every part of the large bowel
were observed, and spontaneous recoveries were seen in all parts except the
transverse colon, which, as already remarked, is near akin to the small
intestine with regard to its position and anatomical arrangement.
Face slightly anxious and pale; skin moist, temperature 100.4°;
pulse 116, regular and of fair strength; respirations 24; abdomen
slightly tumid; tenderness over lower half, especially on left
side; the lower half moves little with respiration.
Twenty-four hours later the patient had improved. He was
comfortable and hopeful; slept well with morphia 1/3 grain
hypodermically. Tongue moist, covered with white fur; has been
taking milk only, ℥ij every half-hour. No sickness. Temperature
99°. Pulse 104. Respirations 24. Abdomen flatter; general
respiratory movement; tenderness now mainly localised to an
area 2½ inches in diameter, to the left of the umbilicus, above
exit wound.
The patient continued to improve, and on the fifth day travelled
six hours in a bullock wagon to Bloemfontein. Soon after arrival
his temperature was normal: pulse 80, respirations 16, with good
abdominal movement. Local tenderness persisted in the same
area, but was less in degree. Tongue rather dry, bowels confined.
Micturition normal. Two drachms of castor oil and an enema
were given.
On the ninth day patient was practically well, except for slight
deep tenderness. He remained in bed on ordinary light diet, but
at the end of the third week he was seized by a sudden attack of
pain, the temperature rising to 103° and the pulse to 140, the
abdomen becoming swollen and tender. He was then under the
charge of Mr. Bowlby, who ordered some opium, and the
symptoms rapidly subsided. Although this wound crossed the
small intestine area, it is probable that the symptoms may have
been due to an injury of the rectum or sigmoid flexure.
3. Wounds of the large intestine.—Injuries to every part of the large bowel
were observed, and spontaneous recoveries were seen in all parts except the
transverse colon, which, as already remarked, is near akin to the small
intestine with regard to its position and anatomical arrangement.
Page 495
The only case of perforation of the vermiform appendix that I heard of, one
under the care of Mr. Stonham, died of peritoneal septicæmia. Several cases
of recovery from wounds of the cæcum and ascending colon are recounted
below. The only points of importance in the nature of the signs of these
injuries were their primary insignificance, and the comparative frequency
with which local peritoneal suppuration followed them. The absence of a
similar sequence in some of the cases in which wounds of the small
intestine were assumed, was, in my opinion, one of the strongest reasons for
doubting the correctness of the diagnosis. It is also a significant fact that
injuries of the ascending colon—that is to say, of the portion of the large
bowel which perhaps lies most free from the area occupied by the small
intestine—were those which most frequently recovered.
The following cases afford examples of the course followed in a number of
injuries to the large intestine, and illustrate both the uncomplicated and the
complicated modes of spontaneous recovery.
No. 180 affords a good example of an extra-peritoneal injury, and of the
especially fatal character of such lesions. This case was also one of my
surgical disappointments.
Nos. 182, 183 are of great interest in several particulars. First, the aperture
of exit was large and allowed the escape of fæces, not a very common
feature in wounds not proving immediately fatal. Secondly, in neither were
any peritoneal signs observed. Thirdly, in each the exit wound
communicated with the pleura, and the patients died from septicæmia
mainly due to absorption from the surface of that membrane (Pleural
septicæmia).
No. 190 is a most striking instance of spontaneous cure, since no doubt can
exist that both rectum and bladder were perforated.
(180*) Injury to the cæcum and ascending colon.—Boer,
wounded at Graspan while sheltering behind a rock, lying on his
back.
Entry (Lee-Metford), in right thigh, 3 inches below and 1 inch
within anterior superior spine of ilium; exit, in back, on a level
under the care of Mr. Stonham, died of peritoneal septicæmia. Several cases
of recovery from wounds of the cæcum and ascending colon are recounted
below. The only points of importance in the nature of the signs of these
injuries were their primary insignificance, and the comparative frequency
with which local peritoneal suppuration followed them. The absence of a
similar sequence in some of the cases in which wounds of the small
intestine were assumed, was, in my opinion, one of the strongest reasons for
doubting the correctness of the diagnosis. It is also a significant fact that
injuries of the ascending colon—that is to say, of the portion of the large
bowel which perhaps lies most free from the area occupied by the small
intestine—were those which most frequently recovered.
The following cases afford examples of the course followed in a number of
injuries to the large intestine, and illustrate both the uncomplicated and the
complicated modes of spontaneous recovery.
No. 180 affords a good example of an extra-peritoneal injury, and of the
especially fatal character of such lesions. This case was also one of my
surgical disappointments.
Nos. 182, 183 are of great interest in several particulars. First, the aperture
of exit was large and allowed the escape of fæces, not a very common
feature in wounds not proving immediately fatal. Secondly, in neither were
any peritoneal signs observed. Thirdly, in each the exit wound
communicated with the pleura, and the patients died from septicæmia
mainly due to absorption from the surface of that membrane (Pleural
septicæmia).
No. 190 is a most striking instance of spontaneous cure, since no doubt can
exist that both rectum and bladder were perforated.
(180*) Injury to the cæcum and ascending colon.—Boer,
wounded at Graspan while sheltering behind a rock, lying on his
back.
Entry (Lee-Metford), in right thigh, 3 inches below and 1 inch
within anterior superior spine of ilium; exit, in back, on a level
Page 496
with the fourth lumbar spinous process and 3 inches from that
point.
Half an hour after the wound the patient commenced to suffer
severe stabbing pain; he lay on the field one hour; later he was
taken to a Field hospital, and on the second day was sent by
train a distance of twenty-five miles.
When seen at the end of fifty hours the condition was as
follows. Face anxious, complexion dusky. Great abdominal
pain, especially about the umbilicus. Vomiting frequent and
distressing; bowels confined since the accident; tongue dry and
furred. Urine scanty. Pulse full and strong, 125; respirations,
entirely thoracic, 30.
Abdomen generally distended and tympanitic, wall rigid and
motionless. Dulness in right flank, together with superficial
œdema and emphysema.
Abdominal section fifty-three and a half hours after accident.
Incision in right linea semilunaris. Great omentum adherent to
ascending colon, which was covered with plastic lymph. Gas
and intestinal contents escaped from an opening at the line of
reflexion of the peritoneum from the ascending colon; retro-
peritoneal extravasation and emphysema extended the whole
length of the ascending colon and around duodenum, the wall of
the colon itself exhibiting subperitoneal emphysema. The colon
was freed and the rent sewn up with interrupted sutures. About
℥iv of foul fæcal fluid were evacuated from loin, and a free
counter-opening made. The opening in the ilium by which the
bullet had entered the abdomen was found at the brim of the
pelvis; the loin and peritoneal cavity were sponged dry and
flushed with boiled water; no lymph was seen on the small
intestine. A large gauze plug was inserted into the posterior
wound, one end of the plug being brought out of the operation
incision.
During the succeeding six days progress was not unsatisfactory:
the abdomen became soft, moved with respiration, there was no
point.
Half an hour after the wound the patient commenced to suffer
severe stabbing pain; he lay on the field one hour; later he was
taken to a Field hospital, and on the second day was sent by
train a distance of twenty-five miles.
When seen at the end of fifty hours the condition was as
follows. Face anxious, complexion dusky. Great abdominal
pain, especially about the umbilicus. Vomiting frequent and
distressing; bowels confined since the accident; tongue dry and
furred. Urine scanty. Pulse full and strong, 125; respirations,
entirely thoracic, 30.
Abdomen generally distended and tympanitic, wall rigid and
motionless. Dulness in right flank, together with superficial
œdema and emphysema.
Abdominal section fifty-three and a half hours after accident.
Incision in right linea semilunaris. Great omentum adherent to
ascending colon, which was covered with plastic lymph. Gas
and intestinal contents escaped from an opening at the line of
reflexion of the peritoneum from the ascending colon; retro-
peritoneal extravasation and emphysema extended the whole
length of the ascending colon and around duodenum, the wall of
the colon itself exhibiting subperitoneal emphysema. The colon
was freed and the rent sewn up with interrupted sutures. About
℥iv of foul fæcal fluid were evacuated from loin, and a free
counter-opening made. The opening in the ilium by which the
bullet had entered the abdomen was found at the brim of the
pelvis; the loin and peritoneal cavity were sponged dry and
flushed with boiled water; no lymph was seen on the small
intestine. A large gauze plug was inserted into the posterior
wound, one end of the plug being brought out of the operation
incision.
During the succeeding six days progress was not unsatisfactory:
the abdomen became soft, moved with respiration, there was no
Page 497
sickness, and the bowels acted. The pulse fell to 90, respirations
to 20, and the temperature did not exceed 102° F. The wound
suppurated freely, however, and although there were no further
signs of peritoneal septicæmia, it was evident that general
infection had taken place, and on the sixth day a parotid bubo
developed on the right side, which was opened.
On the seventh day the patient suddenly commenced to fail
rapidly; vomiting was almost continuous—at first curdled milk,
later frothy watery fluid—and on the eighth day he died. The
abdomen remained soft, sunken, and flaccid, and death no doubt
resulted from general septicæmia rather than from peritoneal
infection, absorption taking place from the large foul cavity
behind the colon. As the cavity in part surrounded the
descending duodenum, this possibly accounted for the attack of
vomiting which preceded death.
(181*) Ascending colon.—Wounded at Graspan while lying in
prone position. Entry (Mauser), over ninth rib in line of right
linea semilunaris; exit, in right buttock, just below and behind
the top of the great trochanter.
The injury was followed by little abdominal pain, but a strange
sensation of local gurgling was noted. The bowels acted as soon
as the patient reached camp, some hours after being wounded.
There was no sickness and nothing abnormal was noted in the
motions, except that they were loose and light-coloured.
On the evening of the third day the patient came under
observation in the ambulance train for Capetown. He looked
somewhat anxious and ill, but he complained of little pain; the
temperature was 102°, pulse 88, fair strength, soft and regular.
There was local dulness, tenderness, and deficiency of
movement in the right iliac region. As it was night, he was
removed from the train and an operation was performed the next
morning.
Prior to operation the condition was as follows: Pulse 84,
temperature 100°; respiration easy, 20. Tongue moist, but thickly
to 20, and the temperature did not exceed 102° F. The wound
suppurated freely, however, and although there were no further
signs of peritoneal septicæmia, it was evident that general
infection had taken place, and on the sixth day a parotid bubo
developed on the right side, which was opened.
On the seventh day the patient suddenly commenced to fail
rapidly; vomiting was almost continuous—at first curdled milk,
later frothy watery fluid—and on the eighth day he died. The
abdomen remained soft, sunken, and flaccid, and death no doubt
resulted from general septicæmia rather than from peritoneal
infection, absorption taking place from the large foul cavity
behind the colon. As the cavity in part surrounded the
descending duodenum, this possibly accounted for the attack of
vomiting which preceded death.
(181*) Ascending colon.—Wounded at Graspan while lying in
prone position. Entry (Mauser), over ninth rib in line of right
linea semilunaris; exit, in right buttock, just below and behind
the top of the great trochanter.
The injury was followed by little abdominal pain, but a strange
sensation of local gurgling was noted. The bowels acted as soon
as the patient reached camp, some hours after being wounded.
There was no sickness and nothing abnormal was noted in the
motions, except that they were loose and light-coloured.
On the evening of the third day the patient came under
observation in the ambulance train for Capetown. He looked
somewhat anxious and ill, but he complained of little pain; the
temperature was 102°, pulse 88, fair strength, soft and regular.
There was local dulness, tenderness, and deficiency of
movement in the right iliac region. As it was night, he was
removed from the train and an operation was performed the next
morning.
Prior to operation the condition was as follows: Pulse 84,
temperature 100°; respiration easy, 20. Tongue moist, but thickly
Page 498
coated in centre. Abdomen moves fairly, and is resonant, except
in right lower quadrant. No distension. Dulness, tenderness, and
rigidity in right iliac region, marked to outer side of cæcum.
Entry wound nearly and exit quite healed. Cannot flex right
thigh. The following operation was performed. Appendix
incision, about ℥j of fæcal fluid and fæces in a localised cavity
on outer and anterior aspect of cæcum evacuated; adhesions
very firm. Cavity sloughy throughout and cæcum covered with
dull grey lymph. The opening in the bowel was not localised,
and it was considered wiser to treat the case like one of
perforation from appendicitis than to run the risk of breaking
down adhesions. A small awl-like opening was found in the
ilium with powdered bone at its entrance leading to the wound
of exit.
The after-treatment of the case gave rise to no anxiety, but
healing of the resulting sinus was slow; fæcal-smelling pus
escaped for some days, and a number of small sloughs came
away. On the twelfth day the patient was sent down to Wynberg,
where he remained twelve weeks. A counter-incision was
needed in the loin to drain the suppurating cavity three weeks
after the primary operation, and five weeks after the operation
an escape of gas and fæces took place from the anterior wound,
while the bowels were acting, as a result of a dose of castor oil.
No further escape of fæces occurred, and he left for England
with a small sinus only. No extension of inflammation into the
original wound track ever occurred, both openings and the canal
healing by primary union.
The sinus remained open, and occasionally discharged for a
further period of six months, and then healed firmly; since when
the patient has been in perfect health.
(182*) Splenic flexure, descending colon.—Wounded at
Magersfontein. Entry (Mauser), in sixth left intercostal space in
mid-axillary line; exit, in left loin, below last rib, at outer margin
of erector spinæ. The patient remained in the Field hospital three
days, during which time he exhibited no serious abdominal
in right lower quadrant. No distension. Dulness, tenderness, and
rigidity in right iliac region, marked to outer side of cæcum.
Entry wound nearly and exit quite healed. Cannot flex right
thigh. The following operation was performed. Appendix
incision, about ℥j of fæcal fluid and fæces in a localised cavity
on outer and anterior aspect of cæcum evacuated; adhesions
very firm. Cavity sloughy throughout and cæcum covered with
dull grey lymph. The opening in the bowel was not localised,
and it was considered wiser to treat the case like one of
perforation from appendicitis than to run the risk of breaking
down adhesions. A small awl-like opening was found in the
ilium with powdered bone at its entrance leading to the wound
of exit.
The after-treatment of the case gave rise to no anxiety, but
healing of the resulting sinus was slow; fæcal-smelling pus
escaped for some days, and a number of small sloughs came
away. On the twelfth day the patient was sent down to Wynberg,
where he remained twelve weeks. A counter-incision was
needed in the loin to drain the suppurating cavity three weeks
after the primary operation, and five weeks after the operation
an escape of gas and fæces took place from the anterior wound,
while the bowels were acting, as a result of a dose of castor oil.
No further escape of fæces occurred, and he left for England
with a small sinus only. No extension of inflammation into the
original wound track ever occurred, both openings and the canal
healing by primary union.
The sinus remained open, and occasionally discharged for a
further period of six months, and then healed firmly; since when
the patient has been in perfect health.
(182*) Splenic flexure, descending colon.—Wounded at
Magersfontein. Entry (Mauser), in sixth left intercostal space in
mid-axillary line; exit, in left loin, below last rib, at outer margin
of erector spinæ. The patient remained in the Field hospital three
days, during which time he exhibited no serious abdominal
Page 499
symptoms, but during the journey to Orange River (53½ miles)
he was sick. He remained at Orange River two days, and while
there an enema was administered, producing a normal motion.
The abdomen was slightly distended; it moved fairly, there was
slight rigidity, but little tenderness. Temperature 100.8°, pulse
120. No appearance of fæces in wound.
When seen on the sixth day the condition was as follows:—
Patient cheerful and not in great pain. Temperature 99.2°; pulse
120; respirations 48, very shallow. Abdomen soft, moving
freely, no distension or general tenderness. Fluid fæces escaping
in abundance from the wound in loin. Redness of skin and
swelling below level of wound, and cellular emphysema above.
Fæcal-smelling fluid was also escaping from the thoracic
wound.
The wound was enlarged, but the patient rapidly sank, and died
of septicæmia on the seventh day.
(183*) An exactly similar case came under observation from the
battle of Modder River, except that the opening in the loin was
somewhat larger, and earlier and freer escape of fæces took
place from it. In this also fæcal matter passed freely into the left
pleural cavity, and fæcal matter was expectorated, while there
was an almost complete absence of abdominal symptoms. Death
occurred on the fourth day.
No post-mortem examination was made in either case, but I
believe in both the extra-peritoneal aspect of the colon was
implicated and that the septicæmia was in great part due to
absorption from the pleural rather than the peritoneal cavity,
since in neither case were the abdominal symptoms a prominent
feature.
(184) Possible wound of cæcum.—Wounded at Spion Kop.
Bullet (Mauser) perforated the right forearm, then entered belly.
Entry, 3 inches from the right anterior superior iliac spine, in the
line of the supra-pubic fold of the belly wall (a transverse slit);
exit, in right buttock, on a level with the tip of the great
he was sick. He remained at Orange River two days, and while
there an enema was administered, producing a normal motion.
The abdomen was slightly distended; it moved fairly, there was
slight rigidity, but little tenderness. Temperature 100.8°, pulse
120. No appearance of fæces in wound.
When seen on the sixth day the condition was as follows:—
Patient cheerful and not in great pain. Temperature 99.2°; pulse
120; respirations 48, very shallow. Abdomen soft, moving
freely, no distension or general tenderness. Fluid fæces escaping
in abundance from the wound in loin. Redness of skin and
swelling below level of wound, and cellular emphysema above.
Fæcal-smelling fluid was also escaping from the thoracic
wound.
The wound was enlarged, but the patient rapidly sank, and died
of septicæmia on the seventh day.
(183*) An exactly similar case came under observation from the
battle of Modder River, except that the opening in the loin was
somewhat larger, and earlier and freer escape of fæces took
place from it. In this also fæcal matter passed freely into the left
pleural cavity, and fæcal matter was expectorated, while there
was an almost complete absence of abdominal symptoms. Death
occurred on the fourth day.
No post-mortem examination was made in either case, but I
believe in both the extra-peritoneal aspect of the colon was
implicated and that the septicæmia was in great part due to
absorption from the pleural rather than the peritoneal cavity,
since in neither case were the abdominal symptoms a prominent
feature.
(184) Possible wound of cæcum.—Wounded at Spion Kop.
Bullet (Mauser) perforated the right forearm, then entered belly.
Entry, 3 inches from the right anterior superior iliac spine, in the
line of the supra-pubic fold of the belly wall (a transverse slit);
exit, in right buttock, on a level with the tip of the great
Page 500
trochanter and 2 inches within it. The wound was received
immediately after breakfast had been eaten. There was retention
of urine and constipation for three days, but no sickness. Local
pain and tenderness were severe, and at the end of three weeks
there was still local tenderness, slight induration, and dragging
pain on defæcation. The patient returned to England at the end
of a month well, except for slight local tenderness.
(185) Possible wound of colon.—Wounded at Paardeberg; range
200 yards. Walking at time. The bullet (Mauser) perforated the
left forearm, just below the elbow-joint. Entry, into belly 1 inch
anterior to the tip of the left eleventh costal cartilage; no exit.
The injury was followed by pain in the left half of the abdomen
and vomiting, which continued for two days. The bowels acted
on the third day; no nourishment was taken for two days, but a
small quantity of water was allowed. No further symptoms were
noted, and at the end of a fortnight the patient was well, except
for slight local tenderness. The bullet could not be detected with
the X-rays.
(186) Wound of cæcum.—Wounded at Paardeberg. Entry
(Mauser), 2 inches diagonally above and within right anterior
superior iliac spine; exit, immediately to the right of the fifth
lumbar spinous process; the patient was lying on his left side
when struck. A burning pain down the right thigh immediately
followed the accident, and lasted some days. There was no
sickness, the bowels were confined three days, and there was
pain across the back and down the thigh.
On the tenth day he arrived at the Base, when he was lying on
his back suffering considerable pain. The temperature ranged to
101°. There was diarrhœa and cystitis, with a considerable
amount of pus in the urine, which was very offensive. A small
fluctuating spot existed on the back, just to the right of the
original exit wound which was firmly healed. The abdomen
moved fairly with respiration in its upper part, but was
immediately after breakfast had been eaten. There was retention
of urine and constipation for three days, but no sickness. Local
pain and tenderness were severe, and at the end of three weeks
there was still local tenderness, slight induration, and dragging
pain on defæcation. The patient returned to England at the end
of a month well, except for slight local tenderness.
(185) Possible wound of colon.—Wounded at Paardeberg; range
200 yards. Walking at time. The bullet (Mauser) perforated the
left forearm, just below the elbow-joint. Entry, into belly 1 inch
anterior to the tip of the left eleventh costal cartilage; no exit.
The injury was followed by pain in the left half of the abdomen
and vomiting, which continued for two days. The bowels acted
on the third day; no nourishment was taken for two days, but a
small quantity of water was allowed. No further symptoms were
noted, and at the end of a fortnight the patient was well, except
for slight local tenderness. The bullet could not be detected with
the X-rays.
(186) Wound of cæcum.—Wounded at Paardeberg. Entry
(Mauser), 2 inches diagonally above and within right anterior
superior iliac spine; exit, immediately to the right of the fifth
lumbar spinous process; the patient was lying on his left side
when struck. A burning pain down the right thigh immediately
followed the accident, and lasted some days. There was no
sickness, the bowels were confined three days, and there was
pain across the back and down the thigh.
On the tenth day he arrived at the Base, when he was lying on
his back suffering considerable pain. The temperature ranged to
101°. There was diarrhœa and cystitis, with a considerable
amount of pus in the urine, which was very offensive. A small
fluctuating spot existed on the back, just to the right of the
original exit wound which was firmly healed. The abdomen
moved fairly with respiration in its upper part, but was
Page 501
motionless below, especially in the right iliac fossa; some
induration was to be felt here. The right thigh was kept flexed.
During the next few days the pus disappeared from the urine,
and with this change the induration in the right iliac fossa
increased. An incision (Mr. Gairdner) was made into the
fluctuating spot behind, and pus evacuated. The patient
recovered.
(187) Possible wound of cæcum.—Wounded outside Heilbron.
Entry (Mauser), in the right loin, 2½ inches above the iliac crest,
at the margin of the erector spinæ; exit, 1½ inch above and
within the right anterior superior spine of the ilium. There was
little shock. The patient was brought six miles in a wagon into
camp, and slept comfortably with a small morphia injection.
Prior to the accident the patient was suffering from diarrhœa, but
afterwards the bowels were confined. The next morning there
had been no sickness and little pain. The tongue was moist and
clean, the pulse 80, the respirations 24, the belly moved
generally, although inspiration was shallow; the temperature was
99°. Slight tenderness in the belly to the inner side of the exit
wound, but no dulness.
The patient was starved for the first thirty-six hours, a little
warm water then being allowed. No symptoms developed, and a
perfect recovery followed.
(188) Colon, liver.—Wounded outside Heilbron. Entry
(Mauser), midway between the last right rib and the crista ilii;
exit, below the eighth costal cartilage in nipple line. There were
no serious primary symptoms, but ten days after the accident the
temperature rose, swelling and pain developed in the right loin,
and on the fourteenth day a large tympanitic abscess was opened
(Dr. Flockemann, German Ambulance.) Fæcal-smelling gas and
pus were evacuated. There was no extension of the abscess
forwards. A week later the patient had much improved, although
there were evident signs of general absorption, and the discharge
from the abscess cavity was abundant and very foul. On the
induration was to be felt here. The right thigh was kept flexed.
During the next few days the pus disappeared from the urine,
and with this change the induration in the right iliac fossa
increased. An incision (Mr. Gairdner) was made into the
fluctuating spot behind, and pus evacuated. The patient
recovered.
(187) Possible wound of cæcum.—Wounded outside Heilbron.
Entry (Mauser), in the right loin, 2½ inches above the iliac crest,
at the margin of the erector spinæ; exit, 1½ inch above and
within the right anterior superior spine of the ilium. There was
little shock. The patient was brought six miles in a wagon into
camp, and slept comfortably with a small morphia injection.
Prior to the accident the patient was suffering from diarrhœa, but
afterwards the bowels were confined. The next morning there
had been no sickness and little pain. The tongue was moist and
clean, the pulse 80, the respirations 24, the belly moved
generally, although inspiration was shallow; the temperature was
99°. Slight tenderness in the belly to the inner side of the exit
wound, but no dulness.
The patient was starved for the first thirty-six hours, a little
warm water then being allowed. No symptoms developed, and a
perfect recovery followed.
(188) Colon, liver.—Wounded outside Heilbron. Entry
(Mauser), midway between the last right rib and the crista ilii;
exit, below the eighth costal cartilage in nipple line. There were
no serious primary symptoms, but ten days after the accident the
temperature rose, swelling and pain developed in the right loin,
and on the fourteenth day a large tympanitic abscess was opened
(Dr. Flockemann, German Ambulance.) Fæcal-smelling gas and
pus were evacuated. There was no extension of the abscess
forwards. A week later the patient had much improved, although
there were evident signs of general absorption, and the discharge
from the abscess cavity was abundant and very foul. On the
Page 502
thirteenth day a serious hæmorrhage occurred from the loin
wound, which was opened up, but no evident source was
discovered; hæmorrhage was repeated the next day, and the man
died.
At the post-mortem examination a large quantity of chocolate-
coloured fluid was found free in the abdomen and pelvis. A
chain of small local abscesses was found surrounding the
ascending colon, and a larger one over the front of the cæcum.
The wall of the ascending colon was generally thickened, and
from this, in three places, openings with rounded margins
connected the abscess cavities with the lumen of the bowel. One
of the openings, larger than the others, was possibly the aperture
of entry of the bullet; the others were apparently spontaneous.
At the anterior border of the right lobe of the liver an abscess
cavity existed in connection with the wound of the liver, and this
was continuous with the aperture of exit, although not
discharging. The aperture of exit was plugged by a tag of
omentum (see fig. 89). No obvious source of the hæmorrhage
was forthcoming, but it probably originated in one of the large
branches of the vena cava. The bullet had struck the transverse
process of the lumbar vertebra, but had not given rise to any
signs of spinal concussion.
(189*) Ascending colon.—Wounded at Modder River. Entry
(Mauser), midway between the tip of the tenth right rib and the
iliac crest. Bullet retained. A second wound existed over the
centre of the left sterno-mastoid, and the bullet here was also
retained and never localised. The patient stated that he brought
up blood at short intervals for half an hour immediately after he
was wounded. This might have been explained by the wound in
the neck, but no difficulty in swallowing was noted. The bowels
acted the day after he was shot, and, except for some local
tenderness and immobility, no abdominal signs were noted.
Three weeks later a swelling was obvious to the right side of the
umbilicus, and a tympanitic abscess developed; this was opened,
and a deformed Mauser bullet extracted. Foul pus, but no fæcal
wound, which was opened up, but no evident source was
discovered; hæmorrhage was repeated the next day, and the man
died.
At the post-mortem examination a large quantity of chocolate-
coloured fluid was found free in the abdomen and pelvis. A
chain of small local abscesses was found surrounding the
ascending colon, and a larger one over the front of the cæcum.
The wall of the ascending colon was generally thickened, and
from this, in three places, openings with rounded margins
connected the abscess cavities with the lumen of the bowel. One
of the openings, larger than the others, was possibly the aperture
of entry of the bullet; the others were apparently spontaneous.
At the anterior border of the right lobe of the liver an abscess
cavity existed in connection with the wound of the liver, and this
was continuous with the aperture of exit, although not
discharging. The aperture of exit was plugged by a tag of
omentum (see fig. 89). No obvious source of the hæmorrhage
was forthcoming, but it probably originated in one of the large
branches of the vena cava. The bullet had struck the transverse
process of the lumbar vertebra, but had not given rise to any
signs of spinal concussion.
(189*) Ascending colon.—Wounded at Modder River. Entry
(Mauser), midway between the tip of the tenth right rib and the
iliac crest. Bullet retained. A second wound existed over the
centre of the left sterno-mastoid, and the bullet here was also
retained and never localised. The patient stated that he brought
up blood at short intervals for half an hour immediately after he
was wounded. This might have been explained by the wound in
the neck, but no difficulty in swallowing was noted. The bowels
acted the day after he was shot, and, except for some local
tenderness and immobility, no abdominal signs were noted.
Three weeks later a swelling was obvious to the right side of the
umbilicus, and a tympanitic abscess developed; this was opened,
and a deformed Mauser bullet extracted. Foul pus, but no fæcal
Page 503
matter, was evacuated, and after discharging for a fortnight the
wound closed, and the man was sent home as 'well.' In this case
I assumed a wound of the ascending colon had occurred.
(190*) Rectum and bladder.—Wounded at Graspan, while
retiring at the double. Entry (Mauser), 1 inch to the right of the
coccyx; exit, 1 inch above the junction of the middle and outer
thirds of left Poupart's ligament. The man suffered with some
pain in the abdomen, and for first two days with retention of
urine. The urine was drawn off with the catheter, and contained
blood. During the next five days micturition was hourly or more
frequent; gas was passed per urethram, and the urine was very
foul, containing evident fæcal matter. Micturition continued
frequent, with purulent cystitis for one month. Local tenderness,
pain, and immobility developed over the lower quarter of the
abdomen, extending to the right iliac fossa. A local abscess
pointed a little to the right of the mid line, and 2 inches above
the symphysis, and from this foul-smelling pus, but no fæces,
was discharged for three months, during which period the
surrounding dulness and induration gradually decreased and the
sinus healed. When the patient left for England there was still
occasional slight discharge from the original wound of entry,
and there was slight discomfort on micturition, but he was
otherwise well.
A year later the man had resumed active duty, and, except for
occasional pain on stooping, considered himself well.
The following cases are appended as of some general interest. The first two
(191, 192) illustrate extra-peritoneal injuries to the rectum. In neither did
positive evidence exist of wound of the bowel, but the symptoms in each
rendered this accident probable. Case 193 is an illustration of apparent
escape of the anal canal in a wound in which from the position of the
external apertures this escape would have appeared impossible.
Wounds of the extra-peritoneal portion of the rectum, as a rule, appeared to
have a somewhat better prognosis than would have been expected; in any
case, the prognosis was far better than that obtaining in wounds of the base
wound closed, and the man was sent home as 'well.' In this case
I assumed a wound of the ascending colon had occurred.
(190*) Rectum and bladder.—Wounded at Graspan, while
retiring at the double. Entry (Mauser), 1 inch to the right of the
coccyx; exit, 1 inch above the junction of the middle and outer
thirds of left Poupart's ligament. The man suffered with some
pain in the abdomen, and for first two days with retention of
urine. The urine was drawn off with the catheter, and contained
blood. During the next five days micturition was hourly or more
frequent; gas was passed per urethram, and the urine was very
foul, containing evident fæcal matter. Micturition continued
frequent, with purulent cystitis for one month. Local tenderness,
pain, and immobility developed over the lower quarter of the
abdomen, extending to the right iliac fossa. A local abscess
pointed a little to the right of the mid line, and 2 inches above
the symphysis, and from this foul-smelling pus, but no fæces,
was discharged for three months, during which period the
surrounding dulness and induration gradually decreased and the
sinus healed. When the patient left for England there was still
occasional slight discharge from the original wound of entry,
and there was slight discomfort on micturition, but he was
otherwise well.
A year later the man had resumed active duty, and, except for
occasional pain on stooping, considered himself well.
The following cases are appended as of some general interest. The first two
(191, 192) illustrate extra-peritoneal injuries to the rectum. In neither did
positive evidence exist of wound of the bowel, but the symptoms in each
rendered this accident probable. Case 193 is an illustration of apparent
escape of the anal canal in a wound in which from the position of the
external apertures this escape would have appeared impossible.
Wounds of the extra-peritoneal portion of the rectum, as a rule, appeared to
have a somewhat better prognosis than would have been expected; in any
case, the prognosis was far better than that obtaining in wounds of the base
Page 504
of the urinary bladder. My experience on the subject of these wounds was,
however, limited to the two cases quoted.
Case 194 is inserted as an example of the complicated nature of the
abdominal injuries not so very unfrequently met with. It illustrates well the
difficulty which may arise at any stage in the course of treatment of an
injury, in the certain determination or exclusion of wound of a part of the
alimentary canal.
(191) Wounded at Magersfontein. Entry (Mauser), in the right
loin, immediately below the ribs in the mid-axillary line; exit,
about the centre of the left buttock, on a level with the tip of the
great trochanter. A second lacerated shell wound of back was
present. All the wounds suppurated. For the first sixteen days
following the injury all control was lost over the anal sphincter,
and bloody fæces, and later slime, constantly escaped, but no
fæcal matter ever escaped from the wound in the buttock. There
was no history of previous dysentery, and rectal examination
afforded no information. The buttock wound had to be opened
up, disclosing a tunnel in the ilium.
The wounds granulated slowly with continuous suppuration, but
were healed, and the patient returned home at the end of
fourteen weeks, the bowels acting normally.
(192) Wounded at Paardeberg. Entry (Mauser), at the junction of
the middle and posterior thirds of the left iliac crest; the bullet
was retained, and removed (Mr. Pegg) from the back of the right
thigh, 3 inches below the back of the great trochanter. After the
injury retention of urine followed, with incapacity to control
loose motions, though solid ones could be retained. The
retention was treated by catheterisation, which was followed by
cystitis. The power of micturition was slowly recovered, and
three weeks later he could pass water, at times in a dribbling
stream only; the cystitis had improved. The man returned to
England very much improved, but not quite well, at the end of
five weeks.
however, limited to the two cases quoted.
Case 194 is inserted as an example of the complicated nature of the
abdominal injuries not so very unfrequently met with. It illustrates well the
difficulty which may arise at any stage in the course of treatment of an
injury, in the certain determination or exclusion of wound of a part of the
alimentary canal.
(191) Wounded at Magersfontein. Entry (Mauser), in the right
loin, immediately below the ribs in the mid-axillary line; exit,
about the centre of the left buttock, on a level with the tip of the
great trochanter. A second lacerated shell wound of back was
present. All the wounds suppurated. For the first sixteen days
following the injury all control was lost over the anal sphincter,
and bloody fæces, and later slime, constantly escaped, but no
fæcal matter ever escaped from the wound in the buttock. There
was no history of previous dysentery, and rectal examination
afforded no information. The buttock wound had to be opened
up, disclosing a tunnel in the ilium.
The wounds granulated slowly with continuous suppuration, but
were healed, and the patient returned home at the end of
fourteen weeks, the bowels acting normally.
(192) Wounded at Paardeberg. Entry (Mauser), at the junction of
the middle and posterior thirds of the left iliac crest; the bullet
was retained, and removed (Mr. Pegg) from the back of the right
thigh, 3 inches below the back of the great trochanter. After the
injury retention of urine followed, with incapacity to control
loose motions, though solid ones could be retained. The
retention was treated by catheterisation, which was followed by
cystitis. The power of micturition was slowly recovered, and
three weeks later he could pass water, at times in a dribbling
stream only; the cystitis had improved. The man returned to
England very much improved, but not quite well, at the end of
five weeks.
Page 505
(193) Wounded at Modder River. Entry, in the right buttock,
near the outer border at the upper part; exit, at the lower part of
outer border of left buttock. The line of the wound exactly
crossed the position of the anus, but no sign of injury to the
rectum could be discovered.
(194) Wounded at Magersfontein. Entry (Mauser), 1/2 inch
below the margin of the iliac crest, at the junction of its middle
and posterior thirds, and on a level with the fifth lumbar spinous
process; exit, below the cartilage of the eighth rib, just within
the left nipple line. Struck while retiring; fell at once, and
remained thirty hours on the field. Patient stated that he vomited
'blood like coffee grounds' six times while lying on the field, and
twice after being brought in. His bowels were confined for three
days. His right lower extremity was paralysed.
On the fifth day there was considerable induration around the
wound of exit, and the upper half of the abdomen was immobile
and tender. The temperature rose to 100°, and the pulse was 96.
Shortly afterwards a similar condition was noted in the lower
half of the abdomen; the temperature continued to be raised and
the pulse quickened, when on the thirteenth day a considerable
quantity of pus was passed per rectum, and diarrhœa set in; this
continued for three days, with marked improvement in the
general symptoms. Micturition, which had been painful, became
normal; the pulse and temperature fell, and the expression
became less anxious. The patient continued to sleep badly,
however, and complained of pain.
At the end of the third week he still looked ill, but was easier.
Temperature normal in the morning, 100° in evening, pulse 80.
Tongue thickly furred, but moist. Still on milk diet; appetite bad;
bowels irregular.
The abdomen moved little in the lower half, induration persisted
in the left iliac fossa, the left thigh continued flexed, and
resonance was impaired to the left of the umbilicus.
near the outer border at the upper part; exit, at the lower part of
outer border of left buttock. The line of the wound exactly
crossed the position of the anus, but no sign of injury to the
rectum could be discovered.
(194) Wounded at Magersfontein. Entry (Mauser), 1/2 inch
below the margin of the iliac crest, at the junction of its middle
and posterior thirds, and on a level with the fifth lumbar spinous
process; exit, below the cartilage of the eighth rib, just within
the left nipple line. Struck while retiring; fell at once, and
remained thirty hours on the field. Patient stated that he vomited
'blood like coffee grounds' six times while lying on the field, and
twice after being brought in. His bowels were confined for three
days. His right lower extremity was paralysed.
On the fifth day there was considerable induration around the
wound of exit, and the upper half of the abdomen was immobile
and tender. The temperature rose to 100°, and the pulse was 96.
Shortly afterwards a similar condition was noted in the lower
half of the abdomen; the temperature continued to be raised and
the pulse quickened, when on the thirteenth day a considerable
quantity of pus was passed per rectum, and diarrhœa set in; this
continued for three days, with marked improvement in the
general symptoms. Micturition, which had been painful, became
normal; the pulse and temperature fell, and the expression
became less anxious. The patient continued to sleep badly,
however, and complained of pain.
At the end of the third week he still looked ill, but was easier.
Temperature normal in the morning, 100° in evening, pulse 80.
Tongue thickly furred, but moist. Still on milk diet; appetite bad;
bowels irregular.
The abdomen moved little in the lower half, induration persisted
in the left iliac fossa, the left thigh continued flexed, and
resonance was impaired to the left of the umbilicus.
Page 506
At the end of six weeks a distinct hard swelling in two parts,
separated by a resonant area, was noted to the left of the
umbilicus and in the left iliac fossa. The abdomen moved fairly,
and there was little tenderness over the swelling. During the
next week the swelling appeared to increase and to fluctuate; at
the same time the temperature again began to rise to 100° and
101° at eve. The swelling was taken to be a localised peritoneal
suppuration, and an incision was made over it; but this led down
to a free peritoneal cavity, with a tumour pressing up from the
posterior abdominal wall. The wound was therefore closed, and
a fresh extra-peritoneal incision made, immediately above
Poupart's ligament, when the swelling proved to be a large retro-
peritoneal hæmatoma. As the cavity extended into the pelvis and
up to the level of the costal margin, it was deemed wise only to
evacuate a part of the blood-clot. The origin of the bleeding was
not determined, and the wound was closed and healed by first
intention. The man continued to improve, and left for home five
weeks later.
This patient has continued to improve since his return, but the
left thigh is still somewhat flexed.
Prognosis in intestinal injuries.—This was of a most discouraging character
compared with the prognosis in abdominal injuries as a whole. The cases
were of two classes, however: those that died within twenty-four hours, and
those that died at the end of from three days to a week.
Cases falling into the first category are obviously of little importance from
the point of view of surgical treatment. Many of them died from the
widespread nature of the injury, and the shock produced by it; others from
hæmorrhage from the large abdominal vessels. It is unlikely that any could
have been saved, even under the most satisfactory conditions.
In the following small table, therefore, I have included only the cases which
have been already quoted, which survived long enough to be amenable to
surgical treatment, and which were for some days under my own
observation. Some of them, in fact almost all, I watched until they were
either convalescent, or died, and in six I performed operations.
separated by a resonant area, was noted to the left of the
umbilicus and in the left iliac fossa. The abdomen moved fairly,
and there was little tenderness over the swelling. During the
next week the swelling appeared to increase and to fluctuate; at
the same time the temperature again began to rise to 100° and
101° at eve. The swelling was taken to be a localised peritoneal
suppuration, and an incision was made over it; but this led down
to a free peritoneal cavity, with a tumour pressing up from the
posterior abdominal wall. The wound was therefore closed, and
a fresh extra-peritoneal incision made, immediately above
Poupart's ligament, when the swelling proved to be a large retro-
peritoneal hæmatoma. As the cavity extended into the pelvis and
up to the level of the costal margin, it was deemed wise only to
evacuate a part of the blood-clot. The origin of the bleeding was
not determined, and the wound was closed and healed by first
intention. The man continued to improve, and left for home five
weeks later.
This patient has continued to improve since his return, but the
left thigh is still somewhat flexed.
Prognosis in intestinal injuries.—This was of a most discouraging character
compared with the prognosis in abdominal injuries as a whole. The cases
were of two classes, however: those that died within twenty-four hours, and
those that died at the end of from three days to a week.
Cases falling into the first category are obviously of little importance from
the point of view of surgical treatment. Many of them died from the
widespread nature of the injury, and the shock produced by it; others from
hæmorrhage from the large abdominal vessels. It is unlikely that any could
have been saved, even under the most satisfactory conditions.
In the following small table, therefore, I have included only the cases which
have been already quoted, which survived long enough to be amenable to
surgical treatment, and which were for some days under my own
observation. Some of them, in fact almost all, I watched until they were
either convalescent, or died, and in six I performed operations.
Page 507
I am aware, and have short details of the histories of eight patients wounded
in the same battles who died prior to the termination of the first thirty-six
hours; but these are not included, for the reason stated above, and also
because I am uncertain whether all the injuries were produced by bullets of
small calibre.
Viscous Number of Localised Secondary
Recovered Died
wounded cases suppuration occurred
Stomach certain 2 — 1 1
Stomach
1 — 1 —
possible
Small intestine
5 0 — 5
certain
Small intestine
10 0 10 —
possible
Large intestine
8 4[21] 4 4
certain
Large intestine
4 — 4 —
possible
Bladder certain 3 3 1 2
Bladder possible 1 — 1 —
Liver 6 — 6 —
Kidneys 6 — 4 2
Spleen 3 — 2 1
Total 49[22] — 34 15
Included in the above table are thirty instances of intestinal injury, and these
are divided up according to the segment of the intestinal canal implicated,
and also as to whether the perforation was certain, or only assumed from
the position of the external apertures and the presence of abdominal
symptoms of a noticeable grade.
From this analysis it appears clear—
1. That wounds of the stomach have a comparatively good prognosis, and
that they may recover spontaneously. It is true that only two examples are
included in my table; but I was at various times shown patients with similar
in the same battles who died prior to the termination of the first thirty-six
hours; but these are not included, for the reason stated above, and also
because I am uncertain whether all the injuries were produced by bullets of
small calibre.
Viscous Number of Localised Secondary
Recovered Died
wounded cases suppuration occurred
Stomach certain 2 — 1 1
Stomach
1 — 1 —
possible
Small intestine
5 0 — 5
certain
Small intestine
10 0 10 —
possible
Large intestine
8 4[21] 4 4
certain
Large intestine
4 — 4 —
possible
Bladder certain 3 3 1 2
Bladder possible 1 — 1 —
Liver 6 — 6 —
Kidneys 6 — 4 2
Spleen 3 — 2 1
Total 49[22] — 34 15
Included in the above table are thirty instances of intestinal injury, and these
are divided up according to the segment of the intestinal canal implicated,
and also as to whether the perforation was certain, or only assumed from
the position of the external apertures and the presence of abdominal
symptoms of a noticeable grade.
From this analysis it appears clear—
1. That wounds of the stomach have a comparatively good prognosis, and
that they may recover spontaneously. It is true that only two examples are
included in my table; but I was at various times shown patients with similar
Page 508
injuries and histories, and a number of cases which have been published
appear to substantiate the opinion. From our experience of the occasional
spontaneous recovery of gastric perforations from disease, I think we might
be prepared to expect that the stomach would offer a comparatively
favourable seat for these wounds. It may be pointed out, however, that
hæmatemesis, the main feature in the symptoms pointing to wound, is by no
means direct proof of more than contusion.
2. That perforating wounds of the small intestine are very fatal injuries;
every patient in whom the condition was certainly diagnosed died.
3. That in the cases in which a perforation was inferred from the position of
the external apertures and the symptoms, not one patient suffered from the
secondary complications—e.g. local peritonitis and suppuration, which
were common in the case of the large intestine, and which we are
accustomed to see after perforation from disease. This renders the
occurrence of actual perforation in the majority of the cases a matter of very
grave doubt.
If spontaneous recovery does take place after this injury, it is only in cases
in which the wounds are single, and slight in character.
4. That in eight cases in which perforation of the large intestine was certain,
four recoveries took place; but in each instance suppuration occurred. I am,
however, quite prepared to believe that perforation may have occurred in
some or all of the other four cases included as 'possible,' provided the
wounds were intra-peritoneal.
Wounds of the cæcum and ascending colon are those which have the best
prognosis, and after these of the rectum. The comparatively good prognosis
in these parts is what would be expected, on account of their greater fixity,
and lesser tendency to be covered by the small intestine.
An extra-peritoneal wound of any of these portions of the bowel is more
dangerous than an intra-peritoneal, and more likely to give rise to
septicæmia.
Of the cases included in my table eighteen of the possible intestinal injuries
were observed among the wounded of the four battles of the Kimberley
relief force. These cases I saw early and followed to their termination, and I
appear to substantiate the opinion. From our experience of the occasional
spontaneous recovery of gastric perforations from disease, I think we might
be prepared to expect that the stomach would offer a comparatively
favourable seat for these wounds. It may be pointed out, however, that
hæmatemesis, the main feature in the symptoms pointing to wound, is by no
means direct proof of more than contusion.
2. That perforating wounds of the small intestine are very fatal injuries;
every patient in whom the condition was certainly diagnosed died.
3. That in the cases in which a perforation was inferred from the position of
the external apertures and the symptoms, not one patient suffered from the
secondary complications—e.g. local peritonitis and suppuration, which
were common in the case of the large intestine, and which we are
accustomed to see after perforation from disease. This renders the
occurrence of actual perforation in the majority of the cases a matter of very
grave doubt.
If spontaneous recovery does take place after this injury, it is only in cases
in which the wounds are single, and slight in character.
4. That in eight cases in which perforation of the large intestine was certain,
four recoveries took place; but in each instance suppuration occurred. I am,
however, quite prepared to believe that perforation may have occurred in
some or all of the other four cases included as 'possible,' provided the
wounds were intra-peritoneal.
Wounds of the cæcum and ascending colon are those which have the best
prognosis, and after these of the rectum. The comparatively good prognosis
in these parts is what would be expected, on account of their greater fixity,
and lesser tendency to be covered by the small intestine.
An extra-peritoneal wound of any of these portions of the bowel is more
dangerous than an intra-peritoneal, and more likely to give rise to
septicæmia.
Of the cases included in my table eighteen of the possible intestinal injuries
were observed among the wounded of the four battles of the Kimberley
relief force. These cases I saw early and followed to their termination, and I
Page 509
believe the list contains the great majority of all the patients who received
intestinal wounds in those battles. On inquiry I could not learn of others
from the officers of the Field hospitals; but no doubt some patients died
before their reception into hospital, and some may have been overlooked;
again, I know of two cases in which death took place within the first week,
but which went direct to the Base and did not come under my observation.
These exceptions being made, we have a fairly complete series, from which
some deductions may be drawn. The cases included are marked with an
asterisk.
Of the eighteen cases, eight or 44.4 per cent. died. These were made up as
follows:—Stomach, one case; this patient died at the end of fourteen days,
as a result of secondary hæmorrhage and septicæmia. It was complicated by
a severe wound of the liver and also one of the lung.
Small intestine, four certain cases; all died, two after operation in the stage
of septicæmia, and one after operation from recurrent hæmorrhage, possibly
from the mesentery. Of the other six cases one can only say that the position
of the wounds was such as to render wound of the intestine possible, and
that all suffered with abdominal symptoms of some severity.
Large intestine. Of six cases in which wound was certain, three died, one
after operation. One recovered after operation, two recovered with local
peritoneal suppuration. In one case the injury could only be returned as
possible.
In connection with this subject I have received permission from Mr. Watson
Cheyne to quote the statistics published by him[23] concerning the
abdominal wounds observed after the fighting at Karree Siding, on March
29, which are as follows:—
intestinal wounds in those battles. On inquiry I could not learn of others
from the officers of the Field hospitals; but no doubt some patients died
before their reception into hospital, and some may have been overlooked;
again, I know of two cases in which death took place within the first week,
but which went direct to the Base and did not come under my observation.
These exceptions being made, we have a fairly complete series, from which
some deductions may be drawn. The cases included are marked with an
asterisk.
Of the eighteen cases, eight or 44.4 per cent. died. These were made up as
follows:—Stomach, one case; this patient died at the end of fourteen days,
as a result of secondary hæmorrhage and septicæmia. It was complicated by
a severe wound of the liver and also one of the lung.
Small intestine, four certain cases; all died, two after operation in the stage
of septicæmia, and one after operation from recurrent hæmorrhage, possibly
from the mesentery. Of the other six cases one can only say that the position
of the wounds was such as to render wound of the intestine possible, and
that all suffered with abdominal symptoms of some severity.
Large intestine. Of six cases in which wound was certain, three died, one
after operation. One recovered after operation, two recovered with local
peritoneal suppuration. In one case the injury could only be returned as
possible.
In connection with this subject I have received permission from Mr. Watson
Cheyne to quote the statistics published by him[23] concerning the
abdominal wounds observed after the fighting at Karree Siding, on March
29, which are as follows:—
Page 510
'The number of the wounded was 154, and in fifteen it was
considered that the abdominal cavity had been penetrated. Of
these patients, five had already died within twenty-four to
twenty-eight hours after the injury, and I saw ten who were still
alive. Of these nine were left alone, and four died within the
next twenty-four or thirty-six hours; five were still alive when I
left Karee on Sunday afternoon, April 1. On one I operated, but
he died on April 2.
The Karee statistics are really the only complete ones which I
have as yet been able to obtain. The following are the notes of
the cases above alluded to.
Besides the five cases of abdominal wounds which had already
died, and of which I could get no complete details, the following
ten are cases which I saw from twenty-four to thirty hours after
they were shot:—
Cases From the Action at Karee
Case I.—The point of entrance was 2 inches to the right of the
umbilicus, and the bullet was found lying under the skin far
back in the left loin. The patient was pulseless, and there was
much rigidity of the abdomen, tenderness, and vomiting. He
died a few hours later.
Case II.—The bullet, coming from the side, had entered the
abdomen 4 inches below and behind the right nipple. There was
no exit wound. The patient had been vomiting a good deal, but
not any blood; the abdomen was very rigid and tender. He was
obviously very ill, and died the next morning. The bullet had
probably perforated the liver and stomach.
Case III.—There was a large wound above the right anterior
iliac spine (probably the point of exit), and a small opening
behind and near the spine on the same side. There was great
tenderness and rigidity of the abdomen. He died a few hours
later.
considered that the abdominal cavity had been penetrated. Of
these patients, five had already died within twenty-four to
twenty-eight hours after the injury, and I saw ten who were still
alive. Of these nine were left alone, and four died within the
next twenty-four or thirty-six hours; five were still alive when I
left Karee on Sunday afternoon, April 1. On one I operated, but
he died on April 2.
The Karee statistics are really the only complete ones which I
have as yet been able to obtain. The following are the notes of
the cases above alluded to.
Besides the five cases of abdominal wounds which had already
died, and of which I could get no complete details, the following
ten are cases which I saw from twenty-four to thirty hours after
they were shot:—
Cases From the Action at Karee
Case I.—The point of entrance was 2 inches to the right of the
umbilicus, and the bullet was found lying under the skin far
back in the left loin. The patient was pulseless, and there was
much rigidity of the abdomen, tenderness, and vomiting. He
died a few hours later.
Case II.—The bullet, coming from the side, had entered the
abdomen 4 inches below and behind the right nipple. There was
no exit wound. The patient had been vomiting a good deal, but
not any blood; the abdomen was very rigid and tender. He was
obviously very ill, and died the next morning. The bullet had
probably perforated the liver and stomach.
Case III.—There was a large wound above the right anterior
iliac spine (probably the point of exit), and a small opening
behind and near the spine on the same side. There was great
tenderness and rigidity of the abdomen. He died a few hours
later.
Page 511
Case IV.—In this case there was a transverse wound of the
abdomen, the bullet having entered on the right side in the
middle of the lumbar region and passed out on the left side,
rather higher up and further back. All the symptoms of acute
peritonitis were present. The patient died the next morning.
Case V.—The bullet had entered the anterior end of the sixth
intercostal space on the left side, and was found lying under the
skin over the seventh intercostal space on the right side and
about 2 inches further back. He had vomited blood on the
previous day. The bullet may have perforated the stomach. The
epigastrium was somewhat tender, but there were no marked
symptoms. On April 1 he was going on well.
Case VI.—The place of entrance of the bullet was 1 inch in
front of the right anterior superior spine, and of exit behind the
left sacro-iliac synchondrosis. There was much hæmorrhage at
the time. His condition when I saw him was fair, and there was
no marked abdominal tenderness. On April 1 his morning
temperature was 101°. There were no signs of general
peritonitis, and his condition was good.
Case VII.—The bullet had entered from behind, about the tip of
the twelfth rib on the left side, and had left about the middle of
the epigastrium, and rather to the left of the middle line.
Vomiting was still going on, but not of blood. There was much
tenderness and rigidity of the abdomen, and he was almost
pulseless. On April 1 his general condition was better, but the
abdomen was very rigid and tender. (Subsequently died.)
Case VIII.—The point of entrance of the bullet was about 2
inches from the anterior end of the seventh left intercostal space,
and of exit rather lower down and further back on the right side.
The patient said that he had vomited brown fluid after the injury.
There was much abdominal pain, but his general condition was
fair. On April 1 there was still much pain, but his general
condition was good.
abdomen, the bullet having entered on the right side in the
middle of the lumbar region and passed out on the left side,
rather higher up and further back. All the symptoms of acute
peritonitis were present. The patient died the next morning.
Case V.—The bullet had entered the anterior end of the sixth
intercostal space on the left side, and was found lying under the
skin over the seventh intercostal space on the right side and
about 2 inches further back. He had vomited blood on the
previous day. The bullet may have perforated the stomach. The
epigastrium was somewhat tender, but there were no marked
symptoms. On April 1 he was going on well.
Case VI.—The place of entrance of the bullet was 1 inch in
front of the right anterior superior spine, and of exit behind the
left sacro-iliac synchondrosis. There was much hæmorrhage at
the time. His condition when I saw him was fair, and there was
no marked abdominal tenderness. On April 1 his morning
temperature was 101°. There were no signs of general
peritonitis, and his condition was good.
Case VII.—The bullet had entered from behind, about the tip of
the twelfth rib on the left side, and had left about the middle of
the epigastrium, and rather to the left of the middle line.
Vomiting was still going on, but not of blood. There was much
tenderness and rigidity of the abdomen, and he was almost
pulseless. On April 1 his general condition was better, but the
abdomen was very rigid and tender. (Subsequently died.)
Case VIII.—The point of entrance of the bullet was about 2
inches from the anterior end of the seventh left intercostal space,
and of exit rather lower down and further back on the right side.
The patient said that he had vomited brown fluid after the injury.
There was much abdominal pain, but his general condition was
fair. On April 1 there was still much pain, but his general
condition was good.
Page 512
Case IX.—The bullet had entered about 1½ inch in front of the
anterior inferior spine on the right side, had gone directly
backwards, and had come out in the buttock. The patient,
however, suffered very little. On March 31 there was slight
tympanites and tenderness in the right iliac fossa. The bowels
acted well, and no blood was passed. On April 1 he was very
well, and it was considered very doubtful if any viscus was
wounded.
Case X.—The point of entrance was in the middle of the right
buttock, a little above the level of the trochanter; the exit was
through the anterior abdominal wall in the right semilunar line at
the level of the umbilicus. The patient was decidedly ill; the
abdomen was a good deal distended, and pressure on it caused
an escape of gas through the anterior opening. There was a good
deal of abdominal tenderness and rigidity. I opened the abdomen
outside the right linea semilunaris, and found a perforation in
the anterior wall of the ascending colon, without any adhesions
around, which was easily stitched up. The posterior opening was
found about 2 inches lower down, with a piece of omentum
firmly adherent to it and completely closing it. As the patient
was in a bad state, I thought it better, instead of excising the
piece of intestine beyond the holes or tearing off the omentum,
to leave the wounds alone, merely cleaning out the peritoneal
cavity as well as I could and arranging for free drainage. He
rallied from the operation very well, and for twenty-four hours it
looked as if he might get better; but he gradually got worse and
died on April 2.'
The above statistics are particularly valuable, as they give the incidence of
abdominal injuries compared with those in general in one definite battle.
This amounted to the high number of 15 in 154 or 9.74 per cent. wounded. I
am inclined to think that this is a higher proportion than the average of the
campaign, and that more of the men must have been exposed in the erect
position than was ordinarily the case during the fighting.
The statistics also show that 33.33 per cent. of the patients with abdominal
injuries died within from twenty-four to twenty-eight hours, and that the
anterior inferior spine on the right side, had gone directly
backwards, and had come out in the buttock. The patient,
however, suffered very little. On March 31 there was slight
tympanites and tenderness in the right iliac fossa. The bowels
acted well, and no blood was passed. On April 1 he was very
well, and it was considered very doubtful if any viscus was
wounded.
Case X.—The point of entrance was in the middle of the right
buttock, a little above the level of the trochanter; the exit was
through the anterior abdominal wall in the right semilunar line at
the level of the umbilicus. The patient was decidedly ill; the
abdomen was a good deal distended, and pressure on it caused
an escape of gas through the anterior opening. There was a good
deal of abdominal tenderness and rigidity. I opened the abdomen
outside the right linea semilunaris, and found a perforation in
the anterior wall of the ascending colon, without any adhesions
around, which was easily stitched up. The posterior opening was
found about 2 inches lower down, with a piece of omentum
firmly adherent to it and completely closing it. As the patient
was in a bad state, I thought it better, instead of excising the
piece of intestine beyond the holes or tearing off the omentum,
to leave the wounds alone, merely cleaning out the peritoneal
cavity as well as I could and arranging for free drainage. He
rallied from the operation very well, and for twenty-four hours it
looked as if he might get better; but he gradually got worse and
died on April 2.'
The above statistics are particularly valuable, as they give the incidence of
abdominal injuries compared with those in general in one definite battle.
This amounted to the high number of 15 in 154 or 9.74 per cent. wounded. I
am inclined to think that this is a higher proportion than the average of the
campaign, and that more of the men must have been exposed in the erect
position than was ordinarily the case during the fighting.
The statistics also show that 33.33 per cent. of the patients with abdominal
injuries died within from twenty-four to twenty-eight hours, and that the
Page 513
percentage of deaths had risen to 73.33 per cent. at the end of the third day.
These numbers again seem high, but in this relation it may be noted that, as
a small force only was present, and as all the patients were together, Mr.
Cheyne had unusually good opportunities for seeing all the cases.
One other point is doubtful from the report, and that is what percentage of
the wounds were caused by bullets of small calibre. In one case it is
definitely stated that the wound was large, and in the second that gas
escaped from the wound; both of these may have been instances in which a
large bullet, or some expanding form, had been employed, and there is no
doubt that the use of such projectiles was more common at this stage of the
campaign than it was earlier.
Treatment of injuries to the intestine.—Some general rules for the
immediate treatment of all cases may be laid down. First, the patients must
be removed with as little disturbance as possible, and absolute starvation
must be insisted upon. If the patients be suffering from severe shock,
hypodermic injections of strychnine should be administered, or possibly
some stimulant by the rectum.
After a battle, when these cases may be brought in in considerable number,
they should be collected and placed in the same tent. The objection to
congregating a number of severely wounded patients together must be
disregarded in the face of the manifest advantage of being able to treat all
alike in the matter of feeding. After the battles of the Kimberley relief force,
Surgeon-General Wilson, at my request, had all the abdominal cases placed
in a large marquee, where we were able to carefully watch the whole of the
patients from hour to hour, and little chance existed for any indiscretion on
the part of the patients in the way of eating or drinking.
If possible, the patients should be kept absolutely quiet until they are
evidently out of danger. A week's stay at Orange River sufficed for this
object in the cases referred to. The avoidance of transport is manifestly of
extreme prognostic importance.
When feeding is commenced at the end of twenty-four or thirty-six hours, it
must be in the form at first of warm water, then milk administered in tea-
spoonfuls only.
These numbers again seem high, but in this relation it may be noted that, as
a small force only was present, and as all the patients were together, Mr.
Cheyne had unusually good opportunities for seeing all the cases.
One other point is doubtful from the report, and that is what percentage of
the wounds were caused by bullets of small calibre. In one case it is
definitely stated that the wound was large, and in the second that gas
escaped from the wound; both of these may have been instances in which a
large bullet, or some expanding form, had been employed, and there is no
doubt that the use of such projectiles was more common at this stage of the
campaign than it was earlier.
Treatment of injuries to the intestine.—Some general rules for the
immediate treatment of all cases may be laid down. First, the patients must
be removed with as little disturbance as possible, and absolute starvation
must be insisted upon. If the patients be suffering from severe shock,
hypodermic injections of strychnine should be administered, or possibly
some stimulant by the rectum.
After a battle, when these cases may be brought in in considerable number,
they should be collected and placed in the same tent. The objection to
congregating a number of severely wounded patients together must be
disregarded in the face of the manifest advantage of being able to treat all
alike in the matter of feeding. After the battles of the Kimberley relief force,
Surgeon-General Wilson, at my request, had all the abdominal cases placed
in a large marquee, where we were able to carefully watch the whole of the
patients from hour to hour, and little chance existed for any indiscretion on
the part of the patients in the way of eating or drinking.
If possible, the patients should be kept absolutely quiet until they are
evidently out of danger. A week's stay at Orange River sufficed for this
object in the cases referred to. The avoidance of transport is manifestly of
extreme prognostic importance.
When feeding is commenced at the end of twenty-four or thirty-six hours, it
must be in the form at first of warm water, then milk administered in tea-
spoonfuls only.
Page 514
In doubtful cases the use of morphia must be avoided.
Operative treatment is required in a certain number of the cases, but in the
majority of instances we are met with the extreme difficulty that in a very
large proportion of the occasions upon which these wounds are received an
exploratory abdominal section is not warranted in consequence of the
conditions under which it has to be performed.
A word must be added as to these difficulties; they are in part purely of an
administrative nature, partly surgical. After a great battle the wounded are
numerous, and amongst them a very considerable proportion of the wounds
and injuries are of such a nature as to do extremely well if promptly dealt
with, and each of these makes small demands on the time of the staff.
Abdominal operations, on the other hand, are unsatisfactory from a
prognostic point of view, and their performance requires much time and the
assistance of a considerable number of the men, who are obliged to neglect
the treatment of the more promising cases for those of doubtful issue. This
difficulty, although not surgical in its nature, is nevertheless a practical one
of great importance and appeals strongly to the Principal Medical Officers
in charge of the arrangements. It is only to be avoided by an increase of the
staff, which is not likely to be made except on very special occasions.
Other difficulties are purely surgical. First, the difficulty of diagnosing with
certainty a perforating lesion. In the presence of the fact that many
incomplete lesions follow wounds crossing the intestinal area, and that
these give rise to modified symptoms, I believe this determination to be
impossible without the aid of an exploratory incision. Here we are met with
the remaining surgical difficulties—disadvantages such as the absence of
sufficient aid to the operating surgeon, difficulties connected with the
temperature, wind, and dust, and as to the subsequent treatment of the
patient. Again difficulty in obtaining the most important adjunct, suitable
water, or indeed any water in a sufficient quantity.
It is of course obvious that conditions may exist in which all these troubles
may be avoided. Again, the practical difficulty adverted to above does not
come in the way when a single man happens to sustain an abdominal wound
on the march. Under such circumstances an exploration may be not only
Operative treatment is required in a certain number of the cases, but in the
majority of instances we are met with the extreme difficulty that in a very
large proportion of the occasions upon which these wounds are received an
exploratory abdominal section is not warranted in consequence of the
conditions under which it has to be performed.
A word must be added as to these difficulties; they are in part purely of an
administrative nature, partly surgical. After a great battle the wounded are
numerous, and amongst them a very considerable proportion of the wounds
and injuries are of such a nature as to do extremely well if promptly dealt
with, and each of these makes small demands on the time of the staff.
Abdominal operations, on the other hand, are unsatisfactory from a
prognostic point of view, and their performance requires much time and the
assistance of a considerable number of the men, who are obliged to neglect
the treatment of the more promising cases for those of doubtful issue. This
difficulty, although not surgical in its nature, is nevertheless a practical one
of great importance and appeals strongly to the Principal Medical Officers
in charge of the arrangements. It is only to be avoided by an increase of the
staff, which is not likely to be made except on very special occasions.
Other difficulties are purely surgical. First, the difficulty of diagnosing with
certainty a perforating lesion. In the presence of the fact that many
incomplete lesions follow wounds crossing the intestinal area, and that
these give rise to modified symptoms, I believe this determination to be
impossible without the aid of an exploratory incision. Here we are met with
the remaining surgical difficulties—disadvantages such as the absence of
sufficient aid to the operating surgeon, difficulties connected with the
temperature, wind, and dust, and as to the subsequent treatment of the
patient. Again difficulty in obtaining the most important adjunct, suitable
water, or indeed any water in a sufficient quantity.
It is of course obvious that conditions may exist in which all these troubles
may be avoided. Again, the practical difficulty adverted to above does not
come in the way when a single man happens to sustain an abdominal wound
on the march. Under such circumstances an exploration may be not only
Page 515
justifiable, but obligatory, and the general rules of surgery must be followed
rather than such incomplete indications as are suggested below.
My own experience led me to the following conclusions:
1. A wound in the intestinal area should be watched with care. In the face of
the numerous recoveries in such cases, habitual abdominal exploration is
not justified, under the conditions usually prevailing in the field.
2. The very large class of patients excluded by this rule from operation
leads us to a smaller and less satisfactory number to be divided into two
categories:
Patients who die during the first twelve hours. The whole of these are
naturally unfit for operation, and their general condition when seen often
precludes any thought of it.
Patients with very severe injuries, as evidenced by the escape of fæces, or
with wounds from flank to flank or taking an antero-posterior course in the
small intestinal area. These patients die, and the majority of them will
always die whether operated upon or not. The undertaking of operations
upon them is unpleasant to the surgeon, as being unlikely to be attended
with any great degree of success, whence the impression may gain ground
that patients are killed by the operations. None the less, I think these
operations ought to be undertaken when the attendant conditions allow, and
it is from this class of case that the real successes will be drawn in the
future. The history of such injuries, after all, corresponds exactly with what
we were long familiar with in traumatic ruptures in civil practice, and now
know may be avoided by a sufficiently early interference. The whole
question here is one of time, and this will always be the trouble in military
work.
3. The expectant attitude which is obligatory under the above rules in
doubtful cases, brings us face to face with a large proportion of patients in
the early or late stage of peritoneal septicæmia. These cases run on exactly
the same lines as those in which the same condition is secondary to
spontaneous perforation of the bowel, in which we consider it our duty to
operate, and in which a definite percentage of recoveries is obtained. Hence
another unpleasant duty is here imposed upon the surgeon. Two such cases
rather than such incomplete indications as are suggested below.
My own experience led me to the following conclusions:
1. A wound in the intestinal area should be watched with care. In the face of
the numerous recoveries in such cases, habitual abdominal exploration is
not justified, under the conditions usually prevailing in the field.
2. The very large class of patients excluded by this rule from operation
leads us to a smaller and less satisfactory number to be divided into two
categories:
Patients who die during the first twelve hours. The whole of these are
naturally unfit for operation, and their general condition when seen often
precludes any thought of it.
Patients with very severe injuries, as evidenced by the escape of fæces, or
with wounds from flank to flank or taking an antero-posterior course in the
small intestinal area. These patients die, and the majority of them will
always die whether operated upon or not. The undertaking of operations
upon them is unpleasant to the surgeon, as being unlikely to be attended
with any great degree of success, whence the impression may gain ground
that patients are killed by the operations. None the less, I think these
operations ought to be undertaken when the attendant conditions allow, and
it is from this class of case that the real successes will be drawn in the
future. The history of such injuries, after all, corresponds exactly with what
we were long familiar with in traumatic ruptures in civil practice, and now
know may be avoided by a sufficiently early interference. The whole
question here is one of time, and this will always be the trouble in military
work.
3. The expectant attitude which is obligatory under the above rules in
doubtful cases, brings us face to face with a large proportion of patients in
the early or late stage of peritoneal septicæmia. These cases run on exactly
the same lines as those in which the same condition is secondary to
spontaneous perforation of the bowel, in which we consider it our duty to
operate, and in which a definite percentage of recoveries is obtained. Hence
another unpleasant duty is here imposed upon the surgeon. Two such cases
Page 516
on which I operated are recounted above, and although I cannot say they
give much encouragement, I should add that in the only one I left
untouched, I regretted my want of courage for the five days during which
the patient continued to carry on a miserable existence.
4. The treatment of the cases in which an expectant attitude is followed by
the advent of localised suppuration presents no difficulty; simple incision
alone is needed, and healing follows.
As a rule this is a late condition. In one case of injury to the ascending
colon recounted above, however, considerable local escape of fæces had
occurred, and a successful result was obtained by a local incision on the
third day without suture of the bowel. In this case I believe the wound in the
bowel to have been of the nature of a long slit, but the surrounding
adhesions were so firm as to render any interference with them a great risk,
and a successful result was obtained at the cost of a somewhat prolonged
recovery. I am convinced that the best course was followed here. (No. 131.)
When the suppuration was of a less acute character, it was generally
advisable to allow the pus to make its way towards the surface before
interference.
5. Cases of injury to the colon in which the posterior aspect is involved
should be treated by free opening up of the wound, and either by suture of
the bowel or else its fixation to the surface. I operated on one such case, and
although the patient eventually died on the eighth day, from septicæmia, he
certainly had a chance. Two cases where the opening looked so free that one
almost thought the wound could be regarded as a lumbar colotomy did
badly; in both infection of the pleura took place, besides extension of
suppuration into the retro-peritoneal areolar tissue. In the future I should
always feel inclined to enlarge such wounds and bring the bowel to the
surface.
As regards actual technique the majority of the wounds are particularly well
suited to suture; three stitches across the opening and one at either end of
the resulting crease sufficed to close the opening effectively. The openings
in the small intestine were not as a rule difficult to find, on account of the
ecchymosis which surrounded them. From what I have seen stated in the
reports given by other surgeons, there seems to have been more difficulty in
give much encouragement, I should add that in the only one I left
untouched, I regretted my want of courage for the five days during which
the patient continued to carry on a miserable existence.
4. The treatment of the cases in which an expectant attitude is followed by
the advent of localised suppuration presents no difficulty; simple incision
alone is needed, and healing follows.
As a rule this is a late condition. In one case of injury to the ascending
colon recounted above, however, considerable local escape of fæces had
occurred, and a successful result was obtained by a local incision on the
third day without suture of the bowel. In this case I believe the wound in the
bowel to have been of the nature of a long slit, but the surrounding
adhesions were so firm as to render any interference with them a great risk,
and a successful result was obtained at the cost of a somewhat prolonged
recovery. I am convinced that the best course was followed here. (No. 131.)
When the suppuration was of a less acute character, it was generally
advisable to allow the pus to make its way towards the surface before
interference.
5. Cases of injury to the colon in which the posterior aspect is involved
should be treated by free opening up of the wound, and either by suture of
the bowel or else its fixation to the surface. I operated on one such case, and
although the patient eventually died on the eighth day, from septicæmia, he
certainly had a chance. Two cases where the opening looked so free that one
almost thought the wound could be regarded as a lumbar colotomy did
badly; in both infection of the pleura took place, besides extension of
suppuration into the retro-peritoneal areolar tissue. In the future I should
always feel inclined to enlarge such wounds and bring the bowel to the
surface.
As regards actual technique the majority of the wounds are particularly well
suited to suture; three stitches across the opening and one at either end of
the resulting crease sufficed to close the opening effectively. The openings
in the small intestine were not as a rule difficult to find, on account of the
ecchymosis which surrounded them. From what I have seen stated in the
reports given by other surgeons, there seems to have been more difficulty in
Page 517
discovering wounds in the large gut. Under ordinary circumstances the only
instruments specially needed are a needle and some silk. At my first two
operations, as my instruments had gone astray, the wounds were readily
closed by a needle and cotton borrowed from the wife of a railway porter.
If aseptic sponges or pads are not available, boiled squares of ordinary lint
may be employed for the belly, and towels wrung out of 1 to 20 carbolic
acid solution used to surround the field of operation. Whenever there is any
likelihood of the necessity for operations, water boiled and filtered should
be kept ready in special bottles.
When septic peritonitis was already present, the ordinary procedure of dry
mopping, followed by irrigation, was necessary, before closing the belly.
The after-treatment should be on the usual lines as to feeding, &c.
I am unaware to what degree success followed intestinal operations
generally during the campaign. I saw only one case in which the small
intestine had been treated by excision and the insertion of a Murphy's
button in which a cure followed: this case was in the Scottish Royal Red
Cross hospital under the care of Mr. Luke. I heard of two cases in which the
large intestine was successfully sutured, and of one other in which recovery
followed the removal of a considerable length of the small bowel for
multiple wounds.
In concluding these most unsatisfactory remarks, I should add that the
impressions are those that were gained as the result of the conditions by
which we were bound in South Africa, and which might recur even in a
more civilised region. Under really satisfactory conditions nothing I saw in
my South African experience would lead me to recommend any deviation
from the ordinary rules of modern surgery, except in so far as I should be
more readily inclined to believe that wounds in certain positions already
indicated might occur without perforation of the bowel when produced by
bullets of small calibre; and further in cases where I believed the fixed
portion of the large bowel was the segment of the alimentary canal that had
been exposed to risk, I should not be inclined to operate hastily.
A careful consideration of the whole of the cases that I saw leaves me with
the firm impression that perforating wounds of the small intestine differ in
instruments specially needed are a needle and some silk. At my first two
operations, as my instruments had gone astray, the wounds were readily
closed by a needle and cotton borrowed from the wife of a railway porter.
If aseptic sponges or pads are not available, boiled squares of ordinary lint
may be employed for the belly, and towels wrung out of 1 to 20 carbolic
acid solution used to surround the field of operation. Whenever there is any
likelihood of the necessity for operations, water boiled and filtered should
be kept ready in special bottles.
When septic peritonitis was already present, the ordinary procedure of dry
mopping, followed by irrigation, was necessary, before closing the belly.
The after-treatment should be on the usual lines as to feeding, &c.
I am unaware to what degree success followed intestinal operations
generally during the campaign. I saw only one case in which the small
intestine had been treated by excision and the insertion of a Murphy's
button in which a cure followed: this case was in the Scottish Royal Red
Cross hospital under the care of Mr. Luke. I heard of two cases in which the
large intestine was successfully sutured, and of one other in which recovery
followed the removal of a considerable length of the small bowel for
multiple wounds.
In concluding these most unsatisfactory remarks, I should add that the
impressions are those that were gained as the result of the conditions by
which we were bound in South Africa, and which might recur even in a
more civilised region. Under really satisfactory conditions nothing I saw in
my South African experience would lead me to recommend any deviation
from the ordinary rules of modern surgery, except in so far as I should be
more readily inclined to believe that wounds in certain positions already
indicated might occur without perforation of the bowel when produced by
bullets of small calibre; and further in cases where I believed the fixed
portion of the large bowel was the segment of the alimentary canal that had
been exposed to risk, I should not be inclined to operate hastily.
A careful consideration of the whole of the cases that I saw leaves me with
the firm impression that perforating wounds of the small intestine differ in
Page 518
no way in their results and consequences when produced by small-calibre
bullets, from those of every-day experience, although when there is reason
merely to suspect their presence an exploration is not indicated under
circumstances that may add a fresh danger to the patient.
Wounds of the urinary bladder.—Perforating wounds of the bladder are the
injuries nearest akin to those we have just considered, but a great gulf
separates them, in so far as the escape of a few drops or even a considerable
quantity of normal urine does not necessarily mean peritoneal infection.
The difference in this particular was very forcibly demonstrated in my
experience, since an uncomplicated perforation of the bladder in the intra-
peritoneal portion of the viscus proved to be an injury that not infrequently
recovered spontaneously, I believe in a considerable proportion of the cases.
I include only one such case in my list because it was the only example
which happened to be under my personal observation during its whole
course, but from time to time I was shown several others in which the
position of the external apertures and the transient presence of hæmaturia
left little doubt as to the nature of the injury. The case recounted above, No.
190, is of especial interest, since the patient recovered from an injury which
involved both the bladder and a fixed portion of the large intestine in
contact with its posterior surface.
In another, No. 194, a transient inflammatory thickening pointed to a local
inflammation of a non-infective character, since no suppuration ensued, and
this may have been a case of extra-peritoneal wound; on the other hand, the
bladder may have entirely escaped injury. In wounds of the portions of the
viscus not clad in peritoneum, as a rule, a very different prognosis obtains.
Two typical cases are related, which I believe fairly represent the general
results which follow when the bladder is either wounded behind the
symphysis or at the base. The first case, No. 195, exemplifies a very
characteristic form of wound when small-calibred bullets are concerned.
The bullet, taking a course more or less parallel to that of the wall of the
viscus, cut a long slit in its anterior wall. This bullet in its onward passage
comminuted the horizontal ramus of the pubes, and lodged in the thigh. Into
the latter region the greater part of the extravasated urine escaped. I think
the history of this case fully shows that I made a blunder in not performing
a proper exploration, instead of contenting myself with an incision in the
bullets, from those of every-day experience, although when there is reason
merely to suspect their presence an exploration is not indicated under
circumstances that may add a fresh danger to the patient.
Wounds of the urinary bladder.—Perforating wounds of the bladder are the
injuries nearest akin to those we have just considered, but a great gulf
separates them, in so far as the escape of a few drops or even a considerable
quantity of normal urine does not necessarily mean peritoneal infection.
The difference in this particular was very forcibly demonstrated in my
experience, since an uncomplicated perforation of the bladder in the intra-
peritoneal portion of the viscus proved to be an injury that not infrequently
recovered spontaneously, I believe in a considerable proportion of the cases.
I include only one such case in my list because it was the only example
which happened to be under my personal observation during its whole
course, but from time to time I was shown several others in which the
position of the external apertures and the transient presence of hæmaturia
left little doubt as to the nature of the injury. The case recounted above, No.
190, is of especial interest, since the patient recovered from an injury which
involved both the bladder and a fixed portion of the large intestine in
contact with its posterior surface.
In another, No. 194, a transient inflammatory thickening pointed to a local
inflammation of a non-infective character, since no suppuration ensued, and
this may have been a case of extra-peritoneal wound; on the other hand, the
bladder may have entirely escaped injury. In wounds of the portions of the
viscus not clad in peritoneum, as a rule, a very different prognosis obtains.
Two typical cases are related, which I believe fairly represent the general
results which follow when the bladder is either wounded behind the
symphysis or at the base. The first case, No. 195, exemplifies a very
characteristic form of wound when small-calibred bullets are concerned.
The bullet, taking a course more or less parallel to that of the wall of the
viscus, cut a long slit in its anterior wall. This bullet in its onward passage
comminuted the horizontal ramus of the pubes, and lodged in the thigh. Into
the latter region the greater part of the extravasated urine escaped. I think
the history of this case fully shows that I made a blunder in not performing
a proper exploration, instead of contenting myself with an incision in the
Page 519
thigh. My only excuse was that the patient at the time I saw him was in a
very collapsed state, and a severe grade of abdominal distension suggested
that septic peritonitis was already in an advanced stage. In point of fact, the
patient at once improved, sufficiently so to be able to undergo a second
exploration at a later date by Mr. Hanwell at the Base, only dying of
septicæmia at the end of twenty-one days. Even a free supra-pubic vent
might, I believe, have given him a chance of life.
When the perforation was at the base of the bladder, however, the prognosis
was very bad, and, as far as I know, not a single patient escaped death. The
increase of risk in an extra-peritoneal wound of this viscus is indeed very
great, while an intra-peritoneal perforation may be considered an injury of
lesser severity, provided the urine be of normal character.
(194a) Possible wound of the bladder.—Wounded at
Magersfontein. Entry (Mauser), immediately above the
symphysis pubis; exit, in the buttock, behind the tip of the left
great trochanter. The man was struck while advancing, and fell,
thinking at the time 'that he was struck in the foot.' He lay
twelve hours on the field, and passed water for the first time
when the bearer removed him. During the next two days he
passed urine only twice, and no blood was noticed. The bowels
acted on the evening of the third day. When seen on the fourth
day he complained of aching pain in the lower part of the belly,
and a concentric patch of tender induration extended for about
1½ inch around the wound. The abdominal wall was moving
well. The tongue was clean and moist. There was no blood in
the urine, and micturition was not frequent. Temperature 99.4°.
Pulse 80, good strength. The patient was then sent to the Base.
At the end of seventeen days there was still a little tenderness in
the left iliac fossa; but the man was otherwise well, and at the
end of a month he was sent home.
(195) Extra-peritoneal wound of the bladder.—Wounded at
Magersfontein. Entry (Mauser), at the fore part of the right
buttock. No exit. The patient was seen on the third day. He had
an expression of extreme anxiety, and complained of very great
pain in the abdomen and thigh. The abdomen was greatly
very collapsed state, and a severe grade of abdominal distension suggested
that septic peritonitis was already in an advanced stage. In point of fact, the
patient at once improved, sufficiently so to be able to undergo a second
exploration at a later date by Mr. Hanwell at the Base, only dying of
septicæmia at the end of twenty-one days. Even a free supra-pubic vent
might, I believe, have given him a chance of life.
When the perforation was at the base of the bladder, however, the prognosis
was very bad, and, as far as I know, not a single patient escaped death. The
increase of risk in an extra-peritoneal wound of this viscus is indeed very
great, while an intra-peritoneal perforation may be considered an injury of
lesser severity, provided the urine be of normal character.
(194a) Possible wound of the bladder.—Wounded at
Magersfontein. Entry (Mauser), immediately above the
symphysis pubis; exit, in the buttock, behind the tip of the left
great trochanter. The man was struck while advancing, and fell,
thinking at the time 'that he was struck in the foot.' He lay
twelve hours on the field, and passed water for the first time
when the bearer removed him. During the next two days he
passed urine only twice, and no blood was noticed. The bowels
acted on the evening of the third day. When seen on the fourth
day he complained of aching pain in the lower part of the belly,
and a concentric patch of tender induration extended for about
1½ inch around the wound. The abdominal wall was moving
well. The tongue was clean and moist. There was no blood in
the urine, and micturition was not frequent. Temperature 99.4°.
Pulse 80, good strength. The patient was then sent to the Base.
At the end of seventeen days there was still a little tenderness in
the left iliac fossa; but the man was otherwise well, and at the
end of a month he was sent home.
(195) Extra-peritoneal wound of the bladder.—Wounded at
Magersfontein. Entry (Mauser), at the fore part of the right
buttock. No exit. The patient was seen on the third day. He had
an expression of extreme anxiety, and complained of very great
pain in the abdomen and thigh. The abdomen was greatly
Page 520
distended and tympanitic, and the left thigh and groin were very
much swollen and œdematous, with some redness of surface.
Temperature 100°, pulse 120. No sickness, tongue moist, bowels
confined. Retention of urine. The condition of the patient was
very grave; but he was anæsthetised, clear urine was withdrawn
from the bladder by catheter, and an incision was made into the
thigh just below the inner third of Poupart's ligament, where
fluctuation was evident. Two pints of bloody urine were
evacuated, and when a finger was introduced it passed over a
fracture of the pubes into the pelvis, but not into the peritoneal
cavity. In view of the patient's condition it was not thought wise
to proceed further, and he somewhat improved later, and was
sent to the Base. Loss of power in the right lower extremity
pointed to injury to the anterior crural nerve.
On the patient's arrival at Wynberg there were signs of local
peritonitis in the lower half of the abdomen, and all his urine
was passed from the wound in the left thigh. Some days later
this wound was enlarged to allow of the freer exit of pus, and a
fragment of bone was removed. The wound granulated healthily,
but the man steadily emaciated and lost ground, with signs of
chronic septicæmia, and he died on the twenty-first day. At the
post-mortem examination a transverse wound of the anterior
wall of the bladder behind the pubes, below the peritoneal
reflexion, was found gaping somewhat widely, and 2 inches in
length. There was little sign of previous peritonitis. The retained
bullet was discovered beneath the femoral vessels in the left
thigh.
(196) Extra-peritoneal perforation of the bladder.—Wounded at
Paardeberg. Entry (Mauser), 3 inches above the left tuber ischii;
exit, above the symphysis, immediately over the right margin of
the penis. The patient was retiring to fetch ammunition when
shot. Urine was noted to escape from both apertures the day
after, and this continued until he was sent down to the Base on
the fourteenth day. The patient was then considerably emaciated,
complained of great pain, especially down the left thigh (sciatic
nerve), the temperature averaged 100°, the pulse 80, tongue
much swollen and œdematous, with some redness of surface.
Temperature 100°, pulse 120. No sickness, tongue moist, bowels
confined. Retention of urine. The condition of the patient was
very grave; but he was anæsthetised, clear urine was withdrawn
from the bladder by catheter, and an incision was made into the
thigh just below the inner third of Poupart's ligament, where
fluctuation was evident. Two pints of bloody urine were
evacuated, and when a finger was introduced it passed over a
fracture of the pubes into the pelvis, but not into the peritoneal
cavity. In view of the patient's condition it was not thought wise
to proceed further, and he somewhat improved later, and was
sent to the Base. Loss of power in the right lower extremity
pointed to injury to the anterior crural nerve.
On the patient's arrival at Wynberg there were signs of local
peritonitis in the lower half of the abdomen, and all his urine
was passed from the wound in the left thigh. Some days later
this wound was enlarged to allow of the freer exit of pus, and a
fragment of bone was removed. The wound granulated healthily,
but the man steadily emaciated and lost ground, with signs of
chronic septicæmia, and he died on the twenty-first day. At the
post-mortem examination a transverse wound of the anterior
wall of the bladder behind the pubes, below the peritoneal
reflexion, was found gaping somewhat widely, and 2 inches in
length. There was little sign of previous peritonitis. The retained
bullet was discovered beneath the femoral vessels in the left
thigh.
(196) Extra-peritoneal perforation of the bladder.—Wounded at
Paardeberg. Entry (Mauser), 3 inches above the left tuber ischii;
exit, above the symphysis, immediately over the right margin of
the penis. The patient was retiring to fetch ammunition when
shot. Urine was noted to escape from both apertures the day
after, and this continued until he was sent down to the Base on
the fourteenth day. The patient was then considerably emaciated,
complained of great pain, especially down the left thigh (sciatic
nerve), the temperature averaged 100°, the pulse 80, tongue
Page 521
clean and moist, bowels acted regularly, no sign of injury to the
rectum. He was taking food fairly, but was very sleepless. Urine
was passed per urethram, and also escaped by both wounds. The
abdomen was flaccid and sunken, respiratory movements being
confined to the upper half.
As there was evidence of considerable infiltration in the buttock,
the original entry wound was enlarged, and a catheter was tied
into the bladder. Little change occurred in the symptoms and the
local condition, urine and pus continued to escape freely from
the posterior wound, and the patient gradually sank, dying on
the thirty-eighth day. At the post-mortem examination the
peritoneum was found intact and unaltered, but there was
extensive pelvic cellulitis around the bladder, a large slough and
some pus lying in the cavum Retzii. An aperture of entry still
open existed in the centre of the anterior wall of the bladder, and
a patent exit opening at the base of the trigone. The bullet had
passed out of the pelvis by the great sciatic notch.
The above remarks and cases sufficiently set forth the prognosis in these
injuries. For the intra-peritoneal lesions an expectant plan of treatment may
be followed by uncomplicated recovery. Mention has already been made of
a case in which a Mauser bullet was retained in the bladder and was
subsequently passed per urethram. In such a case a cystotomy would be
indicated were the bullet discovered in the viscus.
As to extra-peritoneal injuries it is difficult to lay down guiding lines. I
believe the ideal treatment would be a supra-pubic cystotomy and drainage
of the bladder by a Sprengel's pump apparatus, such as we employ at home.
Under these circumstances, with the possibility of keeping the bladder
actually empty, I believe good results might be obtained. Certainly drainage
of the bladder by a catheter tied in proved worse than useless, and I very
much doubt whether a simple supra-pubic opening would give any better
results under the circumstances under which a patient has to be treated in a
Field hospital.
Cases might, however, occur in which oblique passage of the bullet cuts a
groove and makes a large opening in the peritoneum-clad portion of the
rectum. He was taking food fairly, but was very sleepless. Urine
was passed per urethram, and also escaped by both wounds. The
abdomen was flaccid and sunken, respiratory movements being
confined to the upper half.
As there was evidence of considerable infiltration in the buttock,
the original entry wound was enlarged, and a catheter was tied
into the bladder. Little change occurred in the symptoms and the
local condition, urine and pus continued to escape freely from
the posterior wound, and the patient gradually sank, dying on
the thirty-eighth day. At the post-mortem examination the
peritoneum was found intact and unaltered, but there was
extensive pelvic cellulitis around the bladder, a large slough and
some pus lying in the cavum Retzii. An aperture of entry still
open existed in the centre of the anterior wall of the bladder, and
a patent exit opening at the base of the trigone. The bullet had
passed out of the pelvis by the great sciatic notch.
The above remarks and cases sufficiently set forth the prognosis in these
injuries. For the intra-peritoneal lesions an expectant plan of treatment may
be followed by uncomplicated recovery. Mention has already been made of
a case in which a Mauser bullet was retained in the bladder and was
subsequently passed per urethram. In such a case a cystotomy would be
indicated were the bullet discovered in the viscus.
As to extra-peritoneal injuries it is difficult to lay down guiding lines. I
believe the ideal treatment would be a supra-pubic cystotomy and drainage
of the bladder by a Sprengel's pump apparatus, such as we employ at home.
Under these circumstances, with the possibility of keeping the bladder
actually empty, I believe good results might be obtained. Certainly drainage
of the bladder by a catheter tied in proved worse than useless, and I very
much doubt whether a simple supra-pubic opening would give any better
results under the circumstances under which a patient has to be treated in a
Field hospital.
Cases might, however, occur in which oblique passage of the bullet cuts a
groove and makes a large opening in the peritoneum-clad portion of the
Page 522
viscus. Under satisfactory conditions a laparotomy would be here indicated.
I take it that this condition would most probably be accompanied by
retention of bloody urine, which fact would arouse suspicion.
Injuries to the Solid Abdominal Viscera
Wounds of the kidney.—Tracks implicating the kidneys were of
comparatively common occurrence. As uncomplicated injuries they healed
rapidly, and without producing any serious symptoms beyond transient
hæmaturia.
The nature of the lesion appeared to vary with the direction of the wound.
In many cases a simple puncture no doubt alone existed, an injury no more
to be feared than the exploratory punctures often made for surgical
purposes. In other cases the wounds may have been of the nature of notches
and grooves.
Two of the cases recounted below were of a more severe variety; in one
(No. 201) both kidneys were implicated by symmetrical wounds of the loin,
and in the case of the right organ a transverse rupture was produced, which
was followed by the development of a hydro-nephrosis, and later by
suppuration. This injury was probably the result of a wound from a short
range, as the patient was one of those wounded in the early part of the day
at the battle of Magersfontein. It was complicated by a wound of the spleen
and an injury to the spinal cord producing incomplete paraplegia
accompanied by retention of urine. The last complication was responsible
for the death of the patient, since ascending infection from the bladder led
to the development of pyo-nephrosis and death from secondary peritonitis.
Case 202 is an instance of a transverse wound of the upper part of the
abdominal cavity; it is impossible to say what further complications were
present. The early development of a tympanitic abscess suggested an injury
to the colon, but this was not by any means certain. The condition of the
kidney was very likely similar to that in the last case, but the ultimate
recovery of the patient left this a matter of doubt. The case was also one
dependent on a short-range wound, since the patient, one of the
Scandinavian contingent, was wounded at Magersfontein during close
fighting.
I take it that this condition would most probably be accompanied by
retention of bloody urine, which fact would arouse suspicion.
Injuries to the Solid Abdominal Viscera
Wounds of the kidney.—Tracks implicating the kidneys were of
comparatively common occurrence. As uncomplicated injuries they healed
rapidly, and without producing any serious symptoms beyond transient
hæmaturia.
The nature of the lesion appeared to vary with the direction of the wound.
In many cases a simple puncture no doubt alone existed, an injury no more
to be feared than the exploratory punctures often made for surgical
purposes. In other cases the wounds may have been of the nature of notches
and grooves.
Two of the cases recounted below were of a more severe variety; in one
(No. 201) both kidneys were implicated by symmetrical wounds of the loin,
and in the case of the right organ a transverse rupture was produced, which
was followed by the development of a hydro-nephrosis, and later by
suppuration. This injury was probably the result of a wound from a short
range, as the patient was one of those wounded in the early part of the day
at the battle of Magersfontein. It was complicated by a wound of the spleen
and an injury to the spinal cord producing incomplete paraplegia
accompanied by retention of urine. The last complication was responsible
for the death of the patient, since ascending infection from the bladder led
to the development of pyo-nephrosis and death from secondary peritonitis.
Case 202 is an instance of a transverse wound of the upper part of the
abdominal cavity; it is impossible to say what further complications were
present. The early development of a tympanitic abscess suggested an injury
to the colon, but this was not by any means certain. The condition of the
kidney was very likely similar to that in the last case, but the ultimate
recovery of the patient left this a matter of doubt. The case was also one
dependent on a short-range wound, since the patient, one of the
Scandinavian contingent, was wounded at Magersfontein during close
fighting.
Page 523
The common history of the symptoms after a wound of the kidney was
moderate hæmorrhage from the organ, persisting for two to four days. In
one of the cases recounted below the hæmaturia was accompanied by the
passage of ureteral clots, but this was not a common occurrence.
For the sake of comparison I have included one case of wound of the
kidney from a large bullet, in which death was due to internal hæmorrhage.
In this instance the injury was a complex one, the lung certainly, and the
back of the liver probably, being concurrently injured. None the less if the
same track had been produced by a bullet of small calibre I believe the
injury would not have proved a fatal one. I never saw such free renal
hæmorrhage in any of the Mauser or Lee-Metford wounds.
(197) Wound of right kidney.—Wounded at Modder River while
lying in the prone position; retired 100 yards at the double with
his company, and walked a further 1½ 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
moderate hæmorrhage from the organ, persisting for two to four days. In
one of the cases recounted below the hæmaturia was accompanied by the
passage of ureteral clots, but this was not a common occurrence.
For the sake of comparison I have included one case of wound of the
kidney from a large bullet, in which death was due to internal hæmorrhage.
In this instance the injury was a complex one, the lung certainly, and the
back of the liver probably, being concurrently injured. None the less if the
same track had been produced by a bullet of small calibre I believe the
injury would not have proved a fatal one. I never saw such free renal
hæmorrhage in any of the Mauser or Lee-Metford wounds.
(197) Wound of right kidney.—Wounded at Modder River while
lying in the prone position; retired 100 yards at the double with
his company, and walked a further 1½ 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
Page 524
hæmaturia ceased. No thoracic signs, and no other sign of
abdominal injury. There was tenderness in the left loin below the
twelfth rib for some days, possibly over the position of the
bullet, but the latter was neither localised nor removed.
(200) Wound of the right kidney.—Wounded at Magersfontein
while retiring on his feet. Entry (Mauser), immediately to the
right of the second lumbar spinous process; bullet retained and
lay beneath margin of ninth right costal cartilage. The man
passed urine containing blood twelve times during the first day,
and hæmaturia continued until the evening of the third day. On
the third day the belly was tumid and did not move well; there
was no dulness in the right flank. Pulse 120, fair strength.
Temperature 99°. Respirations 20. Tongue moist, bowels
confined for four days. The fifth day the pulse fell to 76, and the
bowels were moved by an enema. Great tenderness over bullet.
The tenderness persisted over the bullet and also in the right
flank until the tenth day, when the bullet was removed. At the
end of a month the patient returned to England well but during
the third week there was occasionally blood in the urine.
(201) Wound of both kidneys (rupture of right) and spleen.—
Wounded at Magersfontein. Entry (Mauser), (a) 1 inch to right
of second lumbar spinous process; (b) above angle of left ninth
rib: exits, (a) 1 inch internal to right anterior superior iliac spine;
(b) in seventh intercostal space in mid-axillary line. The wound
on the right side gave rise to a lesion of the lumbar bulb (see p.
315), and the patient suffered throughout with retention. There
was complete paralysis of the right lower extremity, both motor
and sensory. For ten days there was hæmaturia, and very severe
cystitis developed, while the patient suffered with severe
abdominal pain. The cystitis persisted, also retention, which
gradually gave way to dribbling, while irregular rise of
temperature and tenderness in the loins pointed to ascending
inflammation in the ureters. The patient gradually lost ground,
and a month later suddenly developed signs of peritonitis, severe
vomiting, distension, and dulness in the right flank; and in two
days he died.
abdominal injury. There was tenderness in the left loin below the
twelfth rib for some days, possibly over the position of the
bullet, but the latter was neither localised nor removed.
(200) Wound of the right kidney.—Wounded at Magersfontein
while retiring on his feet. Entry (Mauser), immediately to the
right of the second lumbar spinous process; bullet retained and
lay beneath margin of ninth right costal cartilage. The man
passed urine containing blood twelve times during the first day,
and hæmaturia continued until the evening of the third day. On
the third day the belly was tumid and did not move well; there
was no dulness in the right flank. Pulse 120, fair strength.
Temperature 99°. Respirations 20. Tongue moist, bowels
confined for four days. The fifth day the pulse fell to 76, and the
bowels were moved by an enema. Great tenderness over bullet.
The tenderness persisted over the bullet and also in the right
flank until the tenth day, when the bullet was removed. At the
end of a month the patient returned to England well but during
the third week there was occasionally blood in the urine.
(201) Wound of both kidneys (rupture of right) and spleen.—
Wounded at Magersfontein. Entry (Mauser), (a) 1 inch to right
of second lumbar spinous process; (b) above angle of left ninth
rib: exits, (a) 1 inch internal to right anterior superior iliac spine;
(b) in seventh intercostal space in mid-axillary line. The wound
on the right side gave rise to a lesion of the lumbar bulb (see p.
315), and the patient suffered throughout with retention. There
was complete paralysis of the right lower extremity, both motor
and sensory. For ten days there was hæmaturia, and very severe
cystitis developed, while the patient suffered with severe
abdominal pain. The cystitis persisted, also retention, which
gradually gave way to dribbling, while irregular rise of
temperature and tenderness in the loins pointed to ascending
inflammation in the ureters. The patient gradually lost ground,
and a month later suddenly developed signs of peritonitis, severe
vomiting, distension, and dulness in the right flank; and in two
days he died.
Page 525
At the post-mortem examination the following condition was
found:—On the right side general pleural adhesions, recent
lymph over ascending colon and cæcum, ࡍvj of bloody fluid in a
localised cavity between colon, kidney, stomach, and liver.
Lower quarter of right kidney in half its width separated from
main part of organ, yellow in colour, and enveloped in
disintegrating clot. Blood-staining of psoas sheath; no injury to
vertebral column or to bowel detected.
On the left side recent pleural adhesions and consolidation of
base of lung, rent of diaphragm; spleen soft and disorganised
and presenting a yellow cicatrix at its upper end, and at antero-
external aspect of left kidney was a soft yellow puckered spot
about the size of a florin, dipping 3/4 of an inch into the organ,
which was otherwise healthy, beyond congestion. The capsules
of both kidneys were adherent, but there was no sign of
suppuration.
(202) Wound of right kidney. Traumatic hydronephrosis.—
Wounded at Magersfontein. Entry (Lee-Metford), in the
eleventh intercostal space in the posterior axillary line; exit, in
the tenth right interspace, in mid axillary line. The patient was in
the prone position when struck, and lay on the field from 5 a.m.
until 6 p.m. There was no sickness, and the bowels did not act.
When seen on the fourth day he was cheerful, but in some pain.
The abdominal wall moved well, but was rigid; there was some
general distension, and very marked local distension of the
gastric area extending across to the right, so that a depressed
band extended between the upper and lower parts of the belly.
There was marked local dulness in the right flank, which did not
shift on movement; the abdomen was elsewhere tympanitic.
Tongue furred, bowels confined; there has been no sickness, and
no hæmatemesis. Urine normal, and in good quantity.
Temperature 100°. Pulse 84, good strength. There was
impairment of sensation in the area of distribution of the
external cutaneous and crural branch of the genito-crural nerves.
found:—On the right side general pleural adhesions, recent
lymph over ascending colon and cæcum, ࡍvj of bloody fluid in a
localised cavity between colon, kidney, stomach, and liver.
Lower quarter of right kidney in half its width separated from
main part of organ, yellow in colour, and enveloped in
disintegrating clot. Blood-staining of psoas sheath; no injury to
vertebral column or to bowel detected.
On the left side recent pleural adhesions and consolidation of
base of lung, rent of diaphragm; spleen soft and disorganised
and presenting a yellow cicatrix at its upper end, and at antero-
external aspect of left kidney was a soft yellow puckered spot
about the size of a florin, dipping 3/4 of an inch into the organ,
which was otherwise healthy, beyond congestion. The capsules
of both kidneys were adherent, but there was no sign of
suppuration.
(202) Wound of right kidney. Traumatic hydronephrosis.—
Wounded at Magersfontein. Entry (Lee-Metford), in the
eleventh intercostal space in the posterior axillary line; exit, in
the tenth right interspace, in mid axillary line. The patient was in
the prone position when struck, and lay on the field from 5 a.m.
until 6 p.m. There was no sickness, and the bowels did not act.
When seen on the fourth day he was cheerful, but in some pain.
The abdominal wall moved well, but was rigid; there was some
general distension, and very marked local distension of the
gastric area extending across to the right, so that a depressed
band extended between the upper and lower parts of the belly.
There was marked local dulness in the right flank, which did not
shift on movement; the abdomen was elsewhere tympanitic.
Tongue furred, bowels confined; there has been no sickness, and
no hæmatemesis. Urine normal, and in good quantity.
Temperature 100°. Pulse 84, good strength. There was
impairment of sensation in the area of distribution of the
external cutaneous and crural branch of the genito-crural nerves.
Page 526
On the sixth day the bowels acted, after the administration of ℥j
of sulphate of magnesia, and the distension was much lessened,
although the belly retained its unusual appearance. The dulness
in the flank was unaltered. Temperature 100.8°, pulse 92.
A week later the man was much improved, suffering no pain.
Temperature ranged from 99 to 100°, and the pulse about 80.
The abdomen was normal in appearance, except for general
prominence of the right thorax in the hepatic area.
During the third week a large tympanitic abscess developed at
the aperture of exit, and this was opened (Mr. S. W. F.
Richardson) through the chest, and a large collection of foul-
smelling pus, but no fæcal matter, evacuated. The patient again
improved, but a fortnight later a swelling and apparent signs of
local peritonitis developed in the right inguinal and lower
umbilical and lumbar regions. An incision made over this,
however, disclosed a normal peritoneal cavity and was closed.
At the end of ten weeks the patient was sent to the Base
hospital; a large firm swelling was then evident, extending from
the liver to the inguinal region, and nearly to the median line.
This gradually increased until it filled half the belly; it was at
first thought to be a retro-peritoneal hæmatoma (similar to that
described in case 194), but it became quite soft and fluctuating,
and was then tapped, and ℥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 (℥xxiv-℥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
of sulphate of magnesia, and the distension was much lessened,
although the belly retained its unusual appearance. The dulness
in the flank was unaltered. Temperature 100.8°, pulse 92.
A week later the man was much improved, suffering no pain.
Temperature ranged from 99 to 100°, and the pulse about 80.
The abdomen was normal in appearance, except for general
prominence of the right thorax in the hepatic area.
During the third week a large tympanitic abscess developed at
the aperture of exit, and this was opened (Mr. S. W. F.
Richardson) through the chest, and a large collection of foul-
smelling pus, but no fæcal matter, evacuated. The patient again
improved, but a fortnight later a swelling and apparent signs of
local peritonitis developed in the right inguinal and lower
umbilical and lumbar regions. An incision made over this,
however, disclosed a normal peritoneal cavity and was closed.
At the end of ten weeks the patient was sent to the Base
hospital; a large firm swelling was then evident, extending from
the liver to the inguinal region, and nearly to the median line.
This gradually increased until it filled half the belly; it was at
first thought to be a retro-peritoneal hæmatoma (similar to that
described in case 194), but it became quite soft and fluctuating,
and was then tapped, and ℥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 (℥xxiv-℥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
Page 527
right nipple, opening ragged and large, bullet retained. There
was very severe shock, accompanied by vomiting, but no
hæmatemesis. Later there was some hæmoptysis. Pulse 120,
respirations 48.
Twenty-four hours later the vomiting had ceased; the patient had
passed a restless night, in spite of an injection of morphia. He
lay on his right side, pale and collapsed, but answered questions
and was quite collected. Pulse imperceptible, respirations 56; the
abdomen moved freely. The urine had been passed twice, and
was chiefly blood. The patient died shortly afterwards,
apparently mainly from internal hæmorrhage, although
restlessness was not a prominent feature. As the Column was on
the march no autopsy was possible.
The treatment of uncomplicated wounds of the kidney consisted in the
ensurance of rest, either alone, or with the administration of opium if the
hæmaturia was severe. The after-treatment in the event of the development
of hydronephrosis is on ordinary lines. Tapping, or incision followed by
extirpation of the injured viscus, if the less severe procedures failed. I never
saw a case where renal hæmorrhage suggested the removal of the kidney as
a primary step, and much doubt whether such a case is likely to be met
with, as the result of a wound from a bullet of small calibre.
Wounds of the liver.—Wounds of the liver were, I believe, responsible for
more cases of death from primary hæmorrhage than those of the kidney. I
heard of a few cases in which this occurred, although I never saw one. Case
204 is of considerable interest as illustrating the result of an injury to one of
the large bile ducts. Putting the deaths from primary hæmorrhage on one
side, the prognosis in hepatic wounds was as good as in those of the
kidneys. A few fairly uncomplicated cases are quoted below, but wounds of
the liver occurred in connection with a large number of other injuries both
of the chest and abdomen, and except in the case of wound of the stomach,
recorded on page 425, No. 164, and in case 188, I never saw any
troublesome consequences ensue.
Nature of the lesions.—I never saw any case of so-called explosive lesion
of the liver, such as have been described from experimental results; this
was very severe shock, accompanied by vomiting, but no
hæmatemesis. Later there was some hæmoptysis. Pulse 120,
respirations 48.
Twenty-four hours later the vomiting had ceased; the patient had
passed a restless night, in spite of an injection of morphia. He
lay on his right side, pale and collapsed, but answered questions
and was quite collected. Pulse imperceptible, respirations 56; the
abdomen moved freely. The urine had been passed twice, and
was chiefly blood. The patient died shortly afterwards,
apparently mainly from internal hæmorrhage, although
restlessness was not a prominent feature. As the Column was on
the march no autopsy was possible.
The treatment of uncomplicated wounds of the kidney consisted in the
ensurance of rest, either alone, or with the administration of opium if the
hæmaturia was severe. The after-treatment in the event of the development
of hydronephrosis is on ordinary lines. Tapping, or incision followed by
extirpation of the injured viscus, if the less severe procedures failed. I never
saw a case where renal hæmorrhage suggested the removal of the kidney as
a primary step, and much doubt whether such a case is likely to be met
with, as the result of a wound from a bullet of small calibre.
Wounds of the liver.—Wounds of the liver were, I believe, responsible for
more cases of death from primary hæmorrhage than those of the kidney. I
heard of a few cases in which this occurred, although I never saw one. Case
204 is of considerable interest as illustrating the result of an injury to one of
the large bile ducts. Putting the deaths from primary hæmorrhage on one
side, the prognosis in hepatic wounds was as good as in those of the
kidneys. A few fairly uncomplicated cases are quoted below, but wounds of
the liver occurred in connection with a large number of other injuries both
of the chest and abdomen, and except in the case of wound of the stomach,
recorded on page 425, No. 164, and in case 188, I never saw any
troublesome consequences ensue.
Nature of the lesions.—I never saw any case of so-called explosive lesion
of the liver, such as have been described from experimental results; this
Page 528
may have been due to the fact that such patients rapidly expired, but such
were never admitted into the hospitals.
The most favourable cases were those in which a simple perforation was
effected; such were usually attended by a practical absence of symptoms,
unless a large bile duct had been implicated, when a temporary biliary
fistula resulted.
Biliary fistulæ were, however, much more common when the bullet scored
the surface of the organ. One such case is recounted under the heading of
injuries to the stomach, No. 164. Here a deep gaping cleft with coarsely
granular margins extended the whole antero-posterior length of the under
surface of the left lobe, and the escape of bile was free. This was the nearest
approach to one of the so-called explosive injuries I met with.
Case 207 is an example of a superficial injury from a bullet possibly of
small calibre in which a superficial groove was followed by temporary
escape of bile, and it is of interest to note a very similar condition in a shell
injury (No. 210) recorded on p. 477.
Although both these cases recovered, I think notching and superficial
grooving must be considered much more serious injuries than pure
perforation. (See case 188, p. 442.)
The symptoms observed in these injuries have been already indicated in the
above description of the nature of the lesions. They consisted in the pure
perforations of practically nothing, in the grooves or the perforations
implicating a large duct in the escape of bile. In two of the cases in which a
biliary fistula was present transient jaundice was noticed.
In many cases the accompanying wound of the diaphragm gave rise to
much discomfort; again, in the transverse wounds the action of the heart
was often affected by the local cardiac shock accompanying the injury. In
one case in which the colon was at the same time wounded (No. 188), an
abscess formed at the site of the hepatic wound, as might have been
expected.
As uncomplicated injuries, these wounds were little to be feared. Except as
a source of hæmorrhage in rapidly dying patients, I never heard of a fatality.
As a complication of other injuries, however, the wound of the liver, as has
were never admitted into the hospitals.
The most favourable cases were those in which a simple perforation was
effected; such were usually attended by a practical absence of symptoms,
unless a large bile duct had been implicated, when a temporary biliary
fistula resulted.
Biliary fistulæ were, however, much more common when the bullet scored
the surface of the organ. One such case is recounted under the heading of
injuries to the stomach, No. 164. Here a deep gaping cleft with coarsely
granular margins extended the whole antero-posterior length of the under
surface of the left lobe, and the escape of bile was free. This was the nearest
approach to one of the so-called explosive injuries I met with.
Case 207 is an example of a superficial injury from a bullet possibly of
small calibre in which a superficial groove was followed by temporary
escape of bile, and it is of interest to note a very similar condition in a shell
injury (No. 210) recorded on p. 477.
Although both these cases recovered, I think notching and superficial
grooving must be considered much more serious injuries than pure
perforation. (See case 188, p. 442.)
The symptoms observed in these injuries have been already indicated in the
above description of the nature of the lesions. They consisted in the pure
perforations of practically nothing, in the grooves or the perforations
implicating a large duct in the escape of bile. In two of the cases in which a
biliary fistula was present transient jaundice was noticed.
In many cases the accompanying wound of the diaphragm gave rise to
much discomfort; again, in the transverse wounds the action of the heart
was often affected by the local cardiac shock accompanying the injury. In
one case in which the colon was at the same time wounded (No. 188), an
abscess formed at the site of the hepatic wound, as might have been
expected.
As uncomplicated injuries, these wounds were little to be feared. Except as
a source of hæmorrhage in rapidly dying patients, I never heard of a fatality.
As a complication of other injuries, however, the wound of the liver, as has
Page 529
been shown, was sometimes of importance. It was remarkable in case 204
how little trouble the biliary fistula gave rise to, although the bile was
discharged across the pleural cavity.
The treatment consisted in rest, and morphia in the cases of suspected
progressive hæmorrhage, or in the presence of great pain. In cases where
bile was escaping, it was important to ensure a free vent for the secretion.
(204) Wound of liver. Biliary fistula.—Wounded at
Magersfontein. Entry (Lee-Metford), below the seventh rib, in
the left nipple line; exit, through the eighth rib, in the mid
axillary line on the right side. The patient lay for seventeen
hours on the field, during which time the bowels acted once, but
there was no sickness. The bowels then remained confined.
When seen on the third day the abdomen was normal and the
chest resonant throughout on both sides; bile to the amount of
some ounces escaped from the wound on the right side.
Suffering no pain; temperature 99°, pulse 100. The bowels acted
freely the following day.
During the next fortnight there was little change; ℥ii-iij of bile
escaped daily, and there was occasional diarrhœa. 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.
how little trouble the biliary fistula gave rise to, although the bile was
discharged across the pleural cavity.
The treatment consisted in rest, and morphia in the cases of suspected
progressive hæmorrhage, or in the presence of great pain. In cases where
bile was escaping, it was important to ensure a free vent for the secretion.
(204) Wound of liver. Biliary fistula.—Wounded at
Magersfontein. Entry (Lee-Metford), below the seventh rib, in
the left nipple line; exit, through the eighth rib, in the mid
axillary line on the right side. The patient lay for seventeen
hours on the field, during which time the bowels acted once, but
there was no sickness. The bowels then remained confined.
When seen on the third day the abdomen was normal and the
chest resonant throughout on both sides; bile to the amount of
some ounces escaped from the wound on the right side.
Suffering no pain; temperature 99°, pulse 100. The bowels acted
freely the following day.
During the next fortnight there was little change; ℥ii-iij of bile
escaped daily, and there was occasional diarrhœa. 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.
Page 530
(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, 1½ 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
(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, 1½ 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
Page 531
on drawing a long breath. The respiration was shallow and
rapid. The bowels acted twice shortly after the injury.
The pulse was rapid and small, and a week after the injury was
still above 100. The abdomen was then normal and moving
symmetrically, and the respiration fairly easy. There were no
signs of chest trouble, but some mucous expectoration. A slight
icteric tinge existed. The patient made a good recovery.
Wounds of the spleen.—Uncomplicated wounds of the spleen were
necessarily rare, and beyond this the strict localisation of a track to the
spleen is not a matter of great ease. None the less the spleen must have been
implicated in a considerable number of the wounds crossing the chest and
abdomen. I know of only one case in which a wound which crossed the
splenic area caused death from hæmorrhage, and of this I can give no
details, as I never saw the patient. In this instance, however, a wound of the
spleen was diagnosed after death from the position of the wounds. The
patient continued to perform his duty as an officer in the fighting line for at
least an hour after being struck, and then died rapidly apparently from an
internal hæmorrhage.
In case No. 201, included amongst the renal injuries, a wound of the spleen
existed, but had given rise to no symptoms, and at the time of death, some
three weeks later, was cicatrised. The only other assertion of importance
that I can make is, that, as far as I could judge, wounds of the spleen from
bullets of small calibre were not, as a rule, accompanied by hæmorrhage,
since I never saw a case in which dulness in the left flank suggested the
presence of extravasated blood, and in no case that I saw was there any
history of general symptoms pointing to the loss of blood.
This is only to be explained by our similar experience with regard to
wounds of the liver unaccompanied by puncture of main vessels, and
perhaps hæmorrhage is still less to be expected in the case of the spleen, in
consequence of the contractile muscular tunic with which the organ is
provided.
I can quote no case of certain injury to the spleen, except that already
referred to discovered at a post-mortem examination, but many wounds
were observed in positions of which the following may be taken as a type.
rapid. The bowels acted twice shortly after the injury.
The pulse was rapid and small, and a week after the injury was
still above 100. The abdomen was then normal and moving
symmetrically, and the respiration fairly easy. There were no
signs of chest trouble, but some mucous expectoration. A slight
icteric tinge existed. The patient made a good recovery.
Wounds of the spleen.—Uncomplicated wounds of the spleen were
necessarily rare, and beyond this the strict localisation of a track to the
spleen is not a matter of great ease. None the less the spleen must have been
implicated in a considerable number of the wounds crossing the chest and
abdomen. I know of only one case in which a wound which crossed the
splenic area caused death from hæmorrhage, and of this I can give no
details, as I never saw the patient. In this instance, however, a wound of the
spleen was diagnosed after death from the position of the wounds. The
patient continued to perform his duty as an officer in the fighting line for at
least an hour after being struck, and then died rapidly apparently from an
internal hæmorrhage.
In case No. 201, included amongst the renal injuries, a wound of the spleen
existed, but had given rise to no symptoms, and at the time of death, some
three weeks later, was cicatrised. The only other assertion of importance
that I can make is, that, as far as I could judge, wounds of the spleen from
bullets of small calibre were not, as a rule, accompanied by hæmorrhage,
since I never saw a case in which dulness in the left flank suggested the
presence of extravasated blood, and in no case that I saw was there any
history of general symptoms pointing to the loss of blood.
This is only to be explained by our similar experience with regard to
wounds of the liver unaccompanied by puncture of main vessels, and
perhaps hæmorrhage is still less to be expected in the case of the spleen, in
consequence of the contractile muscular tunic with which the organ is
provided.
I can quote no case of certain injury to the spleen, except that already
referred to discovered at a post-mortem examination, but many wounds
were observed in positions of which the following may be taken as a type.
Page 532
Entry, through the seventh left costal cartilage, 3/4 of an inch from the
sternal margin; exit, 2½ 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, 1½ inch from the
lumbar spines, at the level of the last right rib.
In neither of these cases did anything except the position of the external
apertures point to the infliction of visceral injury.
General remarks as to the prognosis in abdominal injuries. The prognosis
in each form of individual visceral injury has been already considered, but a
few points affecting these injuries as a class should perhaps be further
considered.
First, as to the influence of range on the severity of the injuries inflicted; I
am not able to confirm the greater danger of short range, except in so far as
there is no doubt that more shock attends such injuries, and possibly some
of the most severely wounded were killed outright as a direct consequence
of the greater striking force of the bullet.
Among the cases in which but slight effects were noted, however, many
were said to have been hit within a range of 200 yards, as for instance the
two injuries quoted under the heading of wounds of the spleen.
I personally saw no cases in which explosive injuries of the solid viscera
were to be ascribed to this cause.
Secondly, as to the immediate prognosis in all abdominal injuries, the
ensurance of rest and limitation as far as possible of transport were of the
highest importance, either in the case of wound of the alimentary canal, or
in wounds of the solid viscera in which hæmorrhage was a possible result.
Thirdly, as to the later prognosis in these injuries; very few men are fit to
resume active service without a prolonged period of rest. In spite of the
insignificance of the primary symptoms, or of the favourable course taken
by the injuries, active exertion was almost always followed for some
sternal margin; exit, 2½ 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, 1½ inch from the
lumbar spines, at the level of the last right rib.
In neither of these cases did anything except the position of the external
apertures point to the infliction of visceral injury.
General remarks as to the prognosis in abdominal injuries. The prognosis
in each form of individual visceral injury has been already considered, but a
few points affecting these injuries as a class should perhaps be further
considered.
First, as to the influence of range on the severity of the injuries inflicted; I
am not able to confirm the greater danger of short range, except in so far as
there is no doubt that more shock attends such injuries, and possibly some
of the most severely wounded were killed outright as a direct consequence
of the greater striking force of the bullet.
Among the cases in which but slight effects were noted, however, many
were said to have been hit within a range of 200 yards, as for instance the
two injuries quoted under the heading of wounds of the spleen.
I personally saw no cases in which explosive injuries of the solid viscera
were to be ascribed to this cause.
Secondly, as to the immediate prognosis in all abdominal injuries, the
ensurance of rest and limitation as far as possible of transport were of the
highest importance, either in the case of wound of the alimentary canal, or
in wounds of the solid viscera in which hæmorrhage was a possible result.
Thirdly, as to the later prognosis in these injuries; very few men are fit to
resume active service without a prolonged period of rest. In spite of the
insignificance of the primary symptoms, or of the favourable course taken
by the injuries, active exertion was almost always followed for some
Page 533
months by the appearance of vague pains and occasionally by indications of
recurrent peritoneal symptoms, pointing to the disturbance of quiescent
hæmorrhages, or of adhesions. Wounds of the kidney are apparently those
least liable to be followed by trouble.
Lastly, the prognosis was influenced in the case of many of the viscera by
coexisting injury to other organs or parts.
For instance, at least thirty per cent. of the abdominal wounds were
complicated by wound of the thorax; and in the lower segment of the
abdomen injury to the extra-peritoneal portions of the pelvic organs was
common.
Both the immediate and ultimate prognosis were influenced greatly by this
fact.
As to the individual injuries:
1. Wounds in the intestinal area, except in certain directions, often traverse
the abdomen without inflicting a perforating injury on the bowel.
2. If the alimentary canal is perforated, injuries in certain segments, even if
perforating, may be followed by spontaneous recovery. I should say the
prognosis from this point of view is best in the ascending colon, then in the
rectum; after these most favourable segments, I should place the others in
the following order: stomach, sigmoid flexure, descending colon. As to
perforating wounds of the transverse colon and small intestine, I believe
spontaneous recovery to be very rare.
3. Wounds of the solid viscera generally, usually heal spontaneously, and
give no trouble unless one of the great vessels has been injured. I include in
this category all organs except the pancreas, of wounds of which I had no
experience.
4. Wounds of the bladder, if of the nature of pure perforations in the intra-
peritoneal segment, often heal spontaneously.
5. As a rule, injuries to the organs in their intra-peritoneal course have a far
better prognosis than those which implicate the organs in their uncovered
portions.
recurrent peritoneal symptoms, pointing to the disturbance of quiescent
hæmorrhages, or of adhesions. Wounds of the kidney are apparently those
least liable to be followed by trouble.
Lastly, the prognosis was influenced in the case of many of the viscera by
coexisting injury to other organs or parts.
For instance, at least thirty per cent. of the abdominal wounds were
complicated by wound of the thorax; and in the lower segment of the
abdomen injury to the extra-peritoneal portions of the pelvic organs was
common.
Both the immediate and ultimate prognosis were influenced greatly by this
fact.
As to the individual injuries:
1. Wounds in the intestinal area, except in certain directions, often traverse
the abdomen without inflicting a perforating injury on the bowel.
2. If the alimentary canal is perforated, injuries in certain segments, even if
perforating, may be followed by spontaneous recovery. I should say the
prognosis from this point of view is best in the ascending colon, then in the
rectum; after these most favourable segments, I should place the others in
the following order: stomach, sigmoid flexure, descending colon. As to
perforating wounds of the transverse colon and small intestine, I believe
spontaneous recovery to be very rare.
3. Wounds of the solid viscera generally, usually heal spontaneously, and
give no trouble unless one of the great vessels has been injured. I include in
this category all organs except the pancreas, of wounds of which I had no
experience.
4. Wounds of the bladder, if of the nature of pure perforations in the intra-
peritoneal segment, often heal spontaneously.
5. As a rule, injuries to the organs in their intra-peritoneal course have a far
better prognosis than those which implicate the organs in their uncovered
portions.
Page 534
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, 2½
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 œdema and ecchymosis of the scrotum
developed, but no extravasation of urine. A catheter was kept in
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, 2½
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 œdema and ecchymosis of the scrotum
developed, but no extravasation of urine. A catheter was kept in
Page 535
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.
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.
Page 536
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.
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.
Page 537
Fig. 90.
A, B, D. Fragments of 200 lb. forged Steel Howitzer Shell exploded by
lyddite. C. Fragment of Cast-iron Shell exploded by powder. B exhibits
transverse markings which might be mistaken for the lines seen in the
Boer segment shells, but which really correspond to the area of fixation
of the copper driving band
Examination of fragment C of a cast-iron shell exploded by powder shows
the characteristic granular fracture, and edges, although sharp, yet of a
comparatively rounded nature. The fragment is also heavier for its surface
measurement, as the metal is thicker than that seen in the remaining
fragments, although the cast-iron shell was of a much smaller calibre than
the steel one. The lesser degree of penetrative power, and increased capacity
to contuse, possessed by such fragments are obvious.
a b and d are fragments of a large forged steel howitzer shell exploded by
lyddite, such as were cast by our guns. The photograph well shows the more
A, B, D. Fragments of 200 lb. forged Steel Howitzer Shell exploded by
lyddite. C. Fragment of Cast-iron Shell exploded by powder. B exhibits
transverse markings which might be mistaken for the lines seen in the
Boer segment shells, but which really correspond to the area of fixation
of the copper driving band
Examination of fragment C of a cast-iron shell exploded by powder shows
the characteristic granular fracture, and edges, although sharp, yet of a
comparatively rounded nature. The fragment is also heavier for its surface
measurement, as the metal is thicker than that seen in the remaining
fragments, although the cast-iron shell was of a much smaller calibre than
the steel one. The lesser degree of penetrative power, and increased capacity
to contuse, possessed by such fragments are obvious.
a b and d are fragments of a large forged steel howitzer shell exploded by
lyddite, such as were cast by our guns. The photograph well shows the more
Page 538
tenacious structure of the metal in the incomplete longitudinal fissuring
exhibited, while the margins are of a sharp knifelike character, well
calculated to penetrate or, in the case of superficial injuries, to produce
wounds of a more sharply incised character than the cast-iron shell.
Fragments a and b also show an appearance suggestive of partial fusion,
characteristic of high explosive action, in the turning of the prominent
margins.
The larger fragments of such shells were responsible for the most serious
mutilating injuries, while small fragments sometimes caused comparatively
simple perforating wounds. I remember a fragment of the fused character
not larger than a small nut which had perforated the front of the thigh of a
Boer, and lodged near the inner surface of the femur. Removal of the
fragment was followed by a free gush of hæmorrhage. When the wound
was opened up an opening was found in the external circumflex artery,
hæmorrhage from which had been controlled by the impaction of the piece
of shell. As an example of the cutting power of sharp fragments of shell I
might instance the case of another Boer in whom light passing contact had
been made by the missile. A gaping incised wound extended from above the
angle of the scapula down to the outer surface of the buttock. The wound
involved the latissimus dorsi, and the external and internal oblique muscles
of the abdomen. The separate muscular layers were sharply defined in the
lateral parts of the floor of the wound, and remained so for some time
during the gradual contraction of the large granulating surface produced.
The degree of contusion was in fact slight, while the incised character was
strongly marked.
In some cases the fragments merely struck the soldiers on the flat without
producing any wound. In one such case a blow upon the epigastrium was,
according to the patient, followed by the vomiting of a considerable amount
of blood. A fluid diet was ordered, and no further ill effects were noted. The
following case illustrates an oblique blow of a perforating character, which
was nevertheless recovered from.
exhibited, while the margins are of a sharp knifelike character, well
calculated to penetrate or, in the case of superficial injuries, to produce
wounds of a more sharply incised character than the cast-iron shell.
Fragments a and b also show an appearance suggestive of partial fusion,
characteristic of high explosive action, in the turning of the prominent
margins.
The larger fragments of such shells were responsible for the most serious
mutilating injuries, while small fragments sometimes caused comparatively
simple perforating wounds. I remember a fragment of the fused character
not larger than a small nut which had perforated the front of the thigh of a
Boer, and lodged near the inner surface of the femur. Removal of the
fragment was followed by a free gush of hæmorrhage. When the wound
was opened up an opening was found in the external circumflex artery,
hæmorrhage from which had been controlled by the impaction of the piece
of shell. As an example of the cutting power of sharp fragments of shell I
might instance the case of another Boer in whom light passing contact had
been made by the missile. A gaping incised wound extended from above the
angle of the scapula down to the outer surface of the buttock. The wound
involved the latissimus dorsi, and the external and internal oblique muscles
of the abdomen. The separate muscular layers were sharply defined in the
lateral parts of the floor of the wound, and remained so for some time
during the gradual contraction of the large granulating surface produced.
The degree of contusion was in fact slight, while the incised character was
strongly marked.
In some cases the fragments merely struck the soldiers on the flat without
producing any wound. In one such case a blow upon the epigastrium was,
according to the patient, followed by the vomiting of a considerable amount
of blood. A fluid diet was ordered, and no further ill effects were noted. The
following case illustrates an oblique blow of a perforating character, which
was nevertheless recovered from.
Page 539
Fig. 91.—Various portions of Brass Percussion and
Time Fuses
(210) Shell-wound of abdomen. Injury to liver.—Wounded at
Paardeberg by a fragment of shell. Aperture of entry, a ragged
opening in the median line. The fragment of shell was retained
over the ninth costal cartilage in the nipple line. The wound bled
freely, but the man was taken into camp, and then four miles on
to the hospital, where he was anæsthetised and the fragment
extracted. The wound of entry was at the same time enlarged,
cleansed, and partly sutured. The patient vomited once after the
anæsthetic, and the bowels remained confined for three or four
days after the injury. The extraction wound healed readily, but a
considerable amount of slimy, bile-stained discharge was still
escaping from the ragged entrance wound on the man's arrival at
the Base on the fourteenth day. The abdomen was then normal
in appearance, and as to physical signs, except for a tympanitic
note over the hepatic area to the right of the wound. The
temperature was normal, the pulse 90, the tongue clean, and the
Time Fuses
(210) Shell-wound of abdomen. Injury to liver.—Wounded at
Paardeberg by a fragment of shell. Aperture of entry, a ragged
opening in the median line. The fragment of shell was retained
over the ninth costal cartilage in the nipple line. The wound bled
freely, but the man was taken into camp, and then four miles on
to the hospital, where he was anæsthetised and the fragment
extracted. The wound of entry was at the same time enlarged,
cleansed, and partly sutured. The patient vomited once after the
anæsthetic, and the bowels remained confined for three or four
days after the injury. The extraction wound healed readily, but a
considerable amount of slimy, bile-stained discharge was still
escaping from the ragged entrance wound on the man's arrival at
the Base on the fourteenth day. The abdomen was then normal
in appearance, and as to physical signs, except for a tympanitic
note over the hepatic area to the right of the wound. The
temperature was normal, the pulse 90, the tongue clean, and the
Page 540
bowels were acting. At the end of four weeks pleurisy, with
effusion, developed on the right side; the chest was aspirated
and ℥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
effusion, developed on the right side; the chest was aspirated
and ℥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
Page 541
necessary explosion on the part of the shell; hence the possibility of a
similar perforation of the soft parts of the body.
Fig. 92.—Unexploded
1-lb. Vickers-Maxim
Shell. (Actual size)
Fig. 93 is of a number of fragments of Vickers-Maxim shells, and it was by
such that the great majority of the wounds were produced.
Wounds from fragments of these shells were, indeed, not at all rare. They
were met with on any position; but, as far as my experience went, they were
more common on the lower extremities than in other parts of the body, if
the sufferers were in the erect position when wounded. I saw a good many
wounds in the neighbourhood of the knee, some of which implicated the
joint. When the injuries were received by patients in the lying or crouching
positions, any part of the body was equally likely to be affected, or, again,
the presence of large stones or rocks in the vicinity might determine the
similar perforation of the soft parts of the body.
Fig. 92.—Unexploded
1-lb. Vickers-Maxim
Shell. (Actual size)
Fig. 93 is of a number of fragments of Vickers-Maxim shells, and it was by
such that the great majority of the wounds were produced.
Wounds from fragments of these shells were, indeed, not at all rare. They
were met with on any position; but, as far as my experience went, they were
more common on the lower extremities than in other parts of the body, if
the sufferers were in the erect position when wounded. I saw a good many
wounds in the neighbourhood of the knee, some of which implicated the
joint. When the injuries were received by patients in the lying or crouching
positions, any part of the body was equally likely to be affected, or, again,
the presence of large stones or rocks in the vicinity might determine the
Page 542
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.
Fig. 93.
Fragments of Vickers-Maxim 1-lb. Shells. The centre fragment of the
lower row is the point of a steel armour-piercing shell; although
unsuitable for the purpose, they were occasionally employed in the field
by the Boers
(211) Perforating shell-wound of abdomen.—Wounded at
Magersfontein by the fuse screw of a small shell (Vickers-
Maxim). Aperture of entry ragged, roughly circular, and 2 inches
in diameter, with much-contused margins situated in the median
line, nearly midway between the ensiform cartilage and
umbilicus. The screw was lodged in the abdominal wall at the
margin of the thorax, just outside the left nipple line. The
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.
Fig. 93.
Fragments of Vickers-Maxim 1-lb. Shells. The centre fragment of the
lower row is the point of a steel armour-piercing shell; although
unsuitable for the purpose, they were occasionally employed in the field
by the Boers
(211) Perforating shell-wound of abdomen.—Wounded at
Magersfontein by the fuse screw of a small shell (Vickers-
Maxim). Aperture of entry ragged, roughly circular, and 2 inches
in diameter, with much-contused margins situated in the median
line, nearly midway between the ensiform cartilage and
umbilicus. The screw was lodged in the abdominal wall at the
margin of the thorax, just outside the left nipple line. The
Page 543
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.
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.
Page 544
Fig. 94.—Pom-pom
Percussion Fuse, exact size
My friend Mr. Abbott removed a similar fuse from the substance of the lung
after the lapse of nine months, the patient having developed an empyema,
and a chronic fistula, which rapidly closed after the removal of the foreign
body.
Percussion Fuse, exact size
My friend Mr. Abbott removed a similar fuse from the substance of the lung
after the lapse of nine months, the patient having developed an empyema,
and a chronic fistula, which rapidly closed after the removal of the foreign
body.
Page 545
PLATE XXV.
Oblique Fracture of the Humerus caused by a Fragment of a
Vickers-Maxim or Pom-pom Shell
The entire absence of comminution is very striking
I will add one further case, that illustrated by plate XXV. In this a fragment
of a pom-pom shell entered the outer aspect of the right shoulder to escape
on the inner aspect of the arm, just below the confines of the axilla. An
oblique, non-comminuted fracture of the humerus resulted, which in spite
of moderate suppuration united well in the course of six weeks. The case is
Oblique Fracture of the Humerus caused by a Fragment of a
Vickers-Maxim or Pom-pom Shell
The entire absence of comminution is very striking
I will add one further case, that illustrated by plate XXV. In this a fragment
of a pom-pom shell entered the outer aspect of the right shoulder to escape
on the inner aspect of the arm, just below the confines of the axilla. An
oblique, non-comminuted fracture of the humerus resulted, which in spite
of moderate suppuration united well in the course of six weeks. The case is
Page 546
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.—Boer Segment Shell, or Shrapnel.
The large fragment is a piece of the case, the smaller are two of the
pieces of iron packed within
Fig. 95 illustrates a form of shrapnel employed by the Boers, the case of
which is of cast metal arranged in definite segments, while the interior is
filled with small fragments of iron so shaped as to pack in concentric layers.
As to the wounds produced by the contained fragments I have no
experience, since I never saw one of the pieces of iron removed. This no
doubt depended in part on the very unsatisfactory practice made by the
Boers with shrapnel generally. Even when they fired English shrapnel, the
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.—Boer Segment Shell, or Shrapnel.
The large fragment is a piece of the case, the smaller are two of the
pieces of iron packed within
Fig. 95 illustrates a form of shrapnel employed by the Boers, the case of
which is of cast metal arranged in definite segments, while the interior is
filled with small fragments of iron so shaped as to pack in concentric layers.
As to the wounds produced by the contained fragments I have no
experience, since I never saw one of the pieces of iron removed. This no
doubt depended in part on the very unsatisfactory practice made by the
Boers with shrapnel generally. Even when they fired English shrapnel, the
Page 547
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.
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.
Page 548
Fig. 96.—Normal, Deformed, and Fractured Leaden
Shrapnel Bullets
(212) Perforating shrapnel-wound of abdomen.—Boer wounded
at Graspan. Aperture of entry (shrapnel), opposite eighth left
costal cartilage, 1 inch external to nipple line. The opening was
circular, and surrounded by an area of ecchymosis 4 inches in
diameter; exit, 4½ 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.
Shrapnel Bullets
(212) Perforating shrapnel-wound of abdomen.—Boer wounded
at Graspan. Aperture of entry (shrapnel), opposite eighth left
costal cartilage, 1 inch external to nipple line. The opening was
circular, and surrounded by an area of ecchymosis 4 inches in
diameter; exit, 4½ 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.
Page 549
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.
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.
Page 550
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:
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:
Page 551
Arm and forearm, 147
Effect on circulation, 134
Carotid, 146
Femoral, 147
Mode of development, 130
Popliteal, 147
Prognosis in, 144
Signs of, 131
Treatment of, 144
Anosmia, 348
Antrum, wounds of, 306
Aphasia:
Amnesic, 276
Ataxic, 273
Functional, 351
Arterial hæmatoma, 123
Prognosis in, 126
Treatment of, 126
Arteries:
Compression by cicatrices, 113
Contusion of, 112
Division of, 114
Perforation of, 114
Arterio-venous aneurism:
Arm and forearm, 150
Cervical, 149
Femoral, 150
Leg, 150
Popliteal, 151
Treatment of, 148
Effect on circulation, 134
Carotid, 146
Femoral, 147
Mode of development, 130
Popliteal, 147
Prognosis in, 144
Signs of, 131
Treatment of, 144
Anosmia, 348
Antrum, wounds of, 306
Aphasia:
Amnesic, 276
Ataxic, 273
Functional, 351
Arterial hæmatoma, 123
Prognosis in, 126
Treatment of, 126
Arteries:
Compression by cicatrices, 113
Contusion of, 112
Division of, 114
Perforation of, 114
Arterio-venous aneurism:
Arm and forearm, 150
Cervical, 149
Femoral, 150
Leg, 150
Popliteal, 151
Treatment of, 148
Page 552
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
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
Page 553
Composition of, 51
Deformities of, 81
Fragmentation, 88
Length, 41
Mantles of, 52, 82, 83
Penetration, 49
Revolution, 45
Ricochet, 82
Shape, 42
Stability, 51
Striking force, 50
Velocity of flight, 42
Weight, 42
Effect of resistance of bones on, 86, 87, 88, 93
Retention of, 71, 79
Indications for removal of, 110
in bladder, 110, 460
in chest, 381, 401
in nasal fossa, 244
in or near joints, 229, 230
in skull, 244, 249, 260, 266, 284, 298
in spinal canal, 337
Reversal of, 81
Varieties of:
Determination of, 105
Expanding, 91
Explosive, 95
Guedes, 48, 51
Krag-Jörgensen, 48, 51
Jeffreys, 94
Large leaden, 95
Lee-Metford, 52, 89
Mark IV., 94
Mauser, 52, 83
Soft-nosed, 93
Tampered, 95
Tweedie, 94
Deformities of, 81
Fragmentation, 88
Length, 41
Mantles of, 52, 82, 83
Penetration, 49
Revolution, 45
Ricochet, 82
Shape, 42
Stability, 51
Striking force, 50
Velocity of flight, 42
Weight, 42
Effect of resistance of bones on, 86, 87, 88, 93
Retention of, 71, 79
Indications for removal of, 110
in bladder, 110, 460
in chest, 381, 401
in nasal fossa, 244
in or near joints, 229, 230
in skull, 244, 249, 260, 266, 284, 298
in spinal canal, 337
Reversal of, 81
Varieties of:
Determination of, 105
Expanding, 91
Explosive, 95
Guedes, 48, 51
Krag-Jörgensen, 48, 51
Jeffreys, 94
Large leaden, 95
Lee-Metford, 52, 89
Mark IV., 94
Mauser, 52, 83
Soft-nosed, 93
Tampered, 95
Tweedie, 94
Page 554
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
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
Page 555
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
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
Page 556
Empyema, 394, 396
Enteric fever, 9
Epilepsy, traumatic, 291
Equipment of foreign ambulances, 31
Surgical, 4
Erysipelas, 34
Expanding bullets, 91
Explosive bullets, 95
Explosive wounds:
of abdomen, 414
of fractures, 155
of head, 245
of leg, 221
of soft parts, 97
of thigh, 197
Eye, injuries to, 299
Facial paralysis:
Cortical, 273-277
Peripheral, 355
First field dressings, 107
Flies, 36
Flockemann, Dr.:
Hæmothorax, 393
Injury to abdomen, 420
Enteric fever, 9
Epilepsy, traumatic, 291
Equipment of foreign ambulances, 31
Surgical, 4
Erysipelas, 34
Expanding bullets, 91
Explosive bullets, 95
Explosive wounds:
of abdomen, 414
of fractures, 155
of head, 245
of leg, 221
of soft parts, 97
of thigh, 197
Eye, injuries to, 299
Facial paralysis:
Cortical, 273-277
Peripheral, 355
First field dressings, 107
Flies, 36
Flockemann, Dr.:
Hæmothorax, 393
Injury to abdomen, 420
Page 557
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
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
Page 558
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:
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:
Page 559
of bladder, 458
of bones, 231
of intestine, 417
of joints, 231
of liver, 466
of pelvis, 189
of scalp, 242
of skull, 255
of soft parts, 157
Hæmarthrosis, 232
Hæmorrhage, 104, 114
Control by bullets, 116
by loop of nerve, 116
Deaths from, 116
Fever dependent upon, 118
Internal, 116
Interstitial, 118
Primary, 114
Recurrent, 117
Secondary, 117
Treatment of, 120
Hæmorrhoids, 10
Hæmothorax, 386, 389
Behaviour of blood in, 390
Course of, 390, 394
Diagnosis of, 398
Effect of transport on, 389
Empyema after, 394
Pleuritic effusion in, 390
Prognosis in, 399
Recurrent bleeding in, 393
Parietal, 389, 398
of bones, 231
of intestine, 417
of joints, 231
of liver, 466
of pelvis, 189
of scalp, 242
of skull, 255
of soft parts, 157
Hæmarthrosis, 232
Hæmorrhage, 104, 114
Control by bullets, 116
by loop of nerve, 116
Deaths from, 116
Fever dependent upon, 118
Internal, 116
Interstitial, 118
Primary, 114
Recurrent, 117
Secondary, 117
Treatment of, 120
Hæmorrhoids, 10
Hæmothorax, 386, 389
Behaviour of blood in, 390
Course of, 390, 394
Diagnosis of, 398
Effect of transport on, 389
Empyema after, 394
Pleuritic effusion in, 390
Prognosis in, 399
Recurrent bleeding in, 393
Parietal, 389, 398
Page 560
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:
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:
Page 561
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
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
Page 562
Joints, special:
Ankle, 239
Elbow, 236
Hand, 237
Hip, 238
Knee, 238
Shoulders, 236
Tarsus, 240
Ker, J. E., cases of aneurism, 152
Kidney, wounds of, 461
Krag-Jörgensen rifle, 65
Laminectomy, 335, 340
Larynx, wounds of, 312
Leaden bullets, 95
Lee-Metford rifle, 53, 64
Lewtas, Col. I. M. S., cases of aneurism, 144
Lightning stroke, 10
Liver, wounds of, 466
Local shock, 103
in fractures, 172
Lower jaw, fractures of, 306
Lungs, wounds of, 385
Ankle, 239
Elbow, 236
Hand, 237
Hip, 238
Knee, 238
Shoulders, 236
Tarsus, 240
Ker, J. E., cases of aneurism, 152
Kidney, wounds of, 461
Krag-Jörgensen rifle, 65
Laminectomy, 335, 340
Larynx, wounds of, 312
Leaden bullets, 95
Lee-Metford rifle, 53, 64
Lewtas, Col. I. M. S., cases of aneurism, 144
Lightning stroke, 10
Liver, wounds of, 466
Local shock, 103
in fractures, 172
Lower jaw, fractures of, 306
Lungs, wounds of, 385
Page 563
Diagnosis, 398
Effect of velocity on, 385
Prognosis, 399
Retained bullets in, 401
Symptoms of, 386
Treatment of, 400
Lyddite shells, 475
MacCormac, Sir W.:
Aneurism, 150
Fractures, 167
Malar bone, fractures, 305
Mandible, fractures, 306
Mantles, stability of, 51, 83
Martini-Henry rifle, 48
Wounds by, 96
Mastoid process, 299
Mauser rifle, 64
Meat, 7
Mediastinal wounds, 382, 384
Mesentery, wounds of, 420
Mills-Roberts, Mr. H. R.:
Spinal hæmorrhage, 321
'Modders, the,' 9
Effect of velocity on, 385
Prognosis, 399
Retained bullets in, 401
Symptoms of, 386
Treatment of, 400
Lyddite shells, 475
MacCormac, Sir W.:
Aneurism, 150
Fractures, 167
Malar bone, fractures, 305
Mandible, fractures, 306
Mantles, stability of, 51, 83
Martini-Henry rifle, 48
Wounds by, 96
Mastoid process, 299
Mauser rifle, 64
Meat, 7
Mediastinal wounds, 382, 384
Mesentery, wounds of, 420
Mills-Roberts, Mr. H. R.:
Spinal hæmorrhage, 321
'Modders, the,' 9
Page 564
Mortality, general, 11
amongst officers, 14
in battles of Kimberley Relief Force, 12
Nasal fossæ, bullet in, 244
Neck, wounds of, 309
Nerves, injuries to, 341
Concussion, 341, 343, 346
Contusion, 343, 347
Displacement of, 342
Laceration, 344, 348
Perforation, 345
Prognosis in, 370
Scar, implication of, 345, 350
Section, 344
Symptoms of, 346
Treatment of, 371
Velocity in relation to, 341
Nerves, special:
Cranial:
Fifth, 353
Fourth, 353
Eighth, 353, 354
Eleventh, 356
Olfactory, 352
Optic, 352
Seventh, 354, 372
Sixth, 353
Tenth, 356
Third, 353
Twelfth, 357
Spinal:
amongst officers, 14
in battles of Kimberley Relief Force, 12
Nasal fossæ, bullet in, 244
Neck, wounds of, 309
Nerves, injuries to, 341
Concussion, 341, 343, 346
Contusion, 343, 347
Displacement of, 342
Laceration, 344, 348
Perforation, 345
Prognosis in, 370
Scar, implication of, 345, 350
Section, 344
Symptoms of, 346
Treatment of, 371
Velocity in relation to, 341
Nerves, special:
Cranial:
Fifth, 353
Fourth, 353
Eighth, 353, 354
Eleventh, 356
Olfactory, 352
Optic, 352
Seventh, 354, 372
Sixth, 353
Tenth, 356
Third, 353
Twelfth, 357
Spinal:
Page 565
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
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
Page 566
Pain in wounds, 103
Paraplegia, functional, 337
Penetration of bullets, 49
Penis, wounds of, 472
Peritoneal infection, 412
Pharynx, wounds of, 311
Pleural septicæmia, 437
Pleurisy, 390, 398
Pneumonia, 9, 398
Pneumo-thorax, 388
Pom-pom shells, 478
Portland Hospital, 34
Psychical disturbance, 101
Rain, 9, 36
Range of fire:
Difficulty of judging influence on mortality, 17
Rectum, wounds of, 443, 444
Removal of wounded from the field, 18
Paraplegia, functional, 337
Penetration of bullets, 49
Penis, wounds of, 472
Peritoneal infection, 412
Pharynx, wounds of, 311
Pleural septicæmia, 437
Pleurisy, 390, 398
Pneumonia, 9, 398
Pneumo-thorax, 388
Pom-pom shells, 478
Portland Hospital, 34
Psychical disturbance, 101
Rain, 9, 36
Range of fire:
Difficulty of judging influence on mortality, 17
Rectum, wounds of, 443, 444
Removal of wounded from the field, 18
Page 567
Respiration in spinal injuries, 329
Retained bullets. See Bullets
Reversed bullets, 81
Revolution of bullet, 45, 46
Ribs, fractures of, 377
Signs of, 379
Ricochet, 82
Effect on wound type, 249
Lee-Metford, 89
Mauser, 84
Within body,
Abdomen, 415
Skull, 249
Rifles:
Bore, 41
Guedes, 47, 54
Krag-Jörgensen, 47, 54
Lee-Metford, 47, 64
Martini-Henry, 47, 97
Mauser, 47, 64
Modern principles of, 40
Trajectory, 44
Varieties employed, 47, 48
Scalp wounds, 242, 264
Scapula, fractures of, 177, 379
Scrotum, wounds of, 472
Retained bullets. See Bullets
Reversed bullets, 81
Revolution of bullet, 45, 46
Ribs, fractures of, 377
Signs of, 379
Ricochet, 82
Effect on wound type, 249
Lee-Metford, 89
Mauser, 84
Within body,
Abdomen, 415
Skull, 249
Rifles:
Bore, 41
Guedes, 47, 54
Krag-Jörgensen, 47, 54
Lee-Metford, 47, 64
Martini-Henry, 47, 97
Mauser, 47, 64
Modern principles of, 40
Trajectory, 44
Varieties employed, 47, 48
Scalp wounds, 242, 264
Scapula, fractures of, 177, 379
Scrotum, wounds of, 472
Page 568
Septic disease, 34
Septicæmia:
General, 34
in enteric fever, 9
Peritoneal, 421
Pleural, 437
Shells, 474
Varieties of, 475
Vickers-Maxim, 478
Lyddite, 476
Shrapnel, 483
Shell wounds:
of abdomen, 480, 485
Proportionate occurrence of, 11
Shell fuse wounds, 481
Ships, hospital, 24
Shock:
General, 101
Local, 103
Treatment of, 110
Shrapnel, 483
Simla, 25
Skull. See Fractures
Fractures independent of gross brain lesion, 242
with brain lesion, 248
Spinal column:
Septicæmia:
General, 34
in enteric fever, 9
Peritoneal, 421
Pleural, 437
Shells, 474
Varieties of, 475
Vickers-Maxim, 478
Lyddite, 476
Shrapnel, 483
Shell wounds:
of abdomen, 480, 485
Proportionate occurrence of, 11
Shell fuse wounds, 481
Ships, hospital, 24
Shock:
General, 101
Local, 103
Treatment of, 110
Shrapnel, 483
Simla, 25
Skull. See Fractures
Fractures independent of gross brain lesion, 242
with brain lesion, 248
Spinal column:
Page 569
Injuries to, 314
Fractures of centra, 317
Spinous processes, 315
Transverse processes, 314
Spinal cord, injuries to, 315
Compression by bullets, 319
Concussion, 319
Contusion, 320
Diagnosis, 335
Hæmato-myelia, 322
Section of, 323
Shock accompanying, 328
Signs of, 323
Transport of, 339
Treatment of, 339
Spinal hæmorrhage:
Epidural, 321
Hæmato-myelia, 322
Peri-pial, 321
Spleen, wounds of, 469
Splints:
Aluminium, 177
Field cane, 209, 221
Hodgen's, 211
Wire gauze, 187
Sternum, fractures of, 379
Stevenson, Col. W. F.:
Local shock, 106
Explosive wounds, 159
Stokes, Sir W.:
Fractures of centra, 317
Spinous processes, 315
Transverse processes, 314
Spinal cord, injuries to, 315
Compression by bullets, 319
Concussion, 319
Contusion, 320
Diagnosis, 335
Hæmato-myelia, 322
Section of, 323
Shock accompanying, 328
Signs of, 323
Transport of, 339
Treatment of, 339
Spinal hæmorrhage:
Epidural, 321
Hæmato-myelia, 322
Peri-pial, 321
Spleen, wounds of, 469
Splints:
Aluminium, 177
Field cane, 209, 221
Hodgen's, 211
Wire gauze, 187
Sternum, fractures of, 379
Stevenson, Col. W. F.:
Local shock, 106
Explosive wounds, 159
Stokes, Sir W.:
Page 570
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
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
Page 571
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
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
Page 572
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:
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:
Page 573
Character of, 8, 36
Transport of, 5
Waxed bullets, 52
Wobble, 80, 81, 251
Wounded men, removal from the field, 18
Wounds, general:
Aperture of entry, 55, 72
Aperture of exit, 58, 74
Climate, influence on, 71
Clinical, course of, 69
Contour tracks, 65
Direct nature of tracks, 63
Directions of tracks, 66
Displacement of structures, 68
Explosive exit wounds, 97
Foreign bodies in, 71
First field dressing, 107
Hæmorrhage, 104
Irregular types of, 80, 97
Mode of healing, 72
Multiple character, 67
Nature of tracts, 68
Pain, 103
Prognosis, 106
Psychical disturbance, 101
Shock, 101
Small bore, 67
Superficial tracts, 65
Suppuration, 69, 78
Symptoms, 100
Tracks, nature of, 68
Treatment, 107
Transport of, 5
Waxed bullets, 52
Wobble, 80, 81, 251
Wounded men, removal from the field, 18
Wounds, general:
Aperture of entry, 55, 72
Aperture of exit, 58, 74
Climate, influence on, 71
Clinical, course of, 69
Contour tracks, 65
Direct nature of tracks, 63
Directions of tracks, 66
Displacement of structures, 68
Explosive exit wounds, 97
Foreign bodies in, 71
First field dressing, 107
Hæmorrhage, 104
Irregular types of, 80, 97
Mode of healing, 72
Multiple character, 67
Nature of tracts, 68
Pain, 103
Prognosis, 106
Psychical disturbance, 101
Shock, 101
Small bore, 67
Superficial tracts, 65
Suppuration, 69, 78
Symptoms, 100
Tracks, nature of, 68
Treatment, 107
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