Chapter XII: On Shell Wounds

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

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

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

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

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

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

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

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

The larger fragments of such shells were responsible for the most serious mutilating injuries, while small fragments sometimes caused comparatively simple perforating wounds. I remember a fragment of the fused character not larger than a small nut which had perforated the front of the thigh of a Boer, and lodged near the inner surface of the femur. Removal of the fragment was followed by a free gush of 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.

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

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

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

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

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

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

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

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

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

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

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

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

OBLIQUE FRACTURE OF THE HUMERUS CAUSED BY A FRAGMENT OF A VICKERS-MAXIM OR POM-POM SHELL

The entire absence of comminution is very striking]

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

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

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

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

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

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

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

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

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

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

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

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

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

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

INDEX

Abdomen, injuries to, 407
General prognosis in, 470

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

Abscess of the brain, 287

Acetabulum, fracture of, 193

Acetylene light, 30

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

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

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

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

Anosmia, 348

Antrum, wounds of, 306

Aphasia:
Amnesic, 276
Ataxic, 273
Functional, 351

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

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

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

Biliary fistula, 467

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

Bones. See Fractures

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

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

Bread, 7

Buck wagon, 21

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

Cauda equina, injury to, 325, 330

Cellulitis, 34

Cervical nerve roots, injury to, 107
Plexus, 357

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

Cheek, wounds of, 309

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

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

Civil surgeons, 38

Climate, 8, 36, 71

Comparison of South African with other campaigns, 14

Compression of brain, 267
Spinal cord, 319

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

Contour wounds, 65

Contusion:
Nerves, 343
Spinal cord, 316

Costal cartilages, fractures of, 379

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

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

Deadliness of modern weapons, 16

Diaphragm, wounds of, 381

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

Drink, 8

Dust, 8, 35
Bacteriology of, 36

Empyema, 394, 396

Enteric fever, 9

Epilepsy, traumatic, 291

Equipment of foreign ambulances, 31
Surgical, 4

Erysipelas, 34

Expanding bullets, 91

Explosive bullets, 95

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

Eye, injuries to, 299

Facial paralysis:
Cortical, 273-277
Peripheral, 355

First field dressings, 107

Flies, 36

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

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

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

Fragmentation of bullets, 88

Fuses of shells, wounds by, 481

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

Genital organs, wounds of, 472

Guedes rifle, 65

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

Hæmarthrosis, 232

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

Hæmorrhoids, 10

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

Head, injuries to, 241

Health of the troops, 7

Heart, wounds of, 382
in neighbourhood of, 384

Hemianopsia, 276
Altitudinal, 277
Lateral, 276

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

Hospital ships, 24
Tents, 32
Trains, 23

Hydronephrosis, 464

Impact, irregular, 80, 82

Instruments, 4

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

Irregular wounds, 97

Itinerary, 2

Jam, 7

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

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

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

Joints, retained bullets in or near, 229, 230

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

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

Kidney, wounds of, 461

Krag-Jörgensen rifle, 65

Laminectomy, 335, 340

Larynx, wounds of, 312

Leaden bullets, 95

Lee-Metford rifle, 53, 64

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

Lightning stroke, 10

Liver, wounds of, 466

Local shock, 103
in fractures, 172

Lower jaw, fractures of, 306

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

Lyddite shells, 475

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

Malar bone, fractures, 305

Mandible, fractures, 306

Mantles, stability of, 51, 83

Martini-Henry rifle, 48
Wounds by, 96

Mastoid process, 299

Mauser rifle, 64

Meat, 7

Mediastinal wounds, 382, 384

Mesentery, wounds of, 420

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

'Modders, the,' 9

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:
Brachial, 357
Cervical, 347, 357
Lumbar, 359
Sacral, 359
Sacro-coccygeal, 360
Thoracic, 358

Neuritis:
Ascending, 350
Peripheral, 355
Traumatic, 349

Neurosis, traumatic 351

Nose, wounds of, 305, 348

Nurses, 38

Officers, mortality among, 14

Olecranon, fracture of, 183, 237

Omentum, wounds of, 420
Prolapse of, 420

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

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

Osteomyelitis in fractures, 174

Outfit, surgical, 3

Pain in wounds, 103

Paraplegia, functional, 337

Penetration of bullets, 49

Penis, wounds of, 472

Peritoneal infection, 412

Pharynx, wounds of, 311

Pleural 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

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

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:
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.:
Treatment of aneurism, 151

Stomach, wounds of, 424

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

Sunstroke, 10

Suppuration of wounds, 78
in fracture, 173

Synovitis, vibration, 226

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

Tents, 32

Testicle, wounds of, 472

Tetanus, 34

Thirst, 8

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

Thoracic vessels, wounds of, 384

Tonga, the, 19

Tongue, wounds of, 309

Trachea, wounds of, 312

Traction engines, 23

Trains, hospital, 23

Trajectory, 44

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

Traumatic aneurism. See Aneurism

Traumatic epilepsy, 291

Traumatic gangrene, 34

Traumatic neurosis, 107, 351

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

Trolly (McCormack-Brook), 19

Upper jaws, 306

Urethra, wounds of, 472

Urinary Bladder. See Bladder

Varix. See Aneurismal varix

Vegetables, 7

Veldt sores, 10

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

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

Vermiform appendix, wounds of, 437

Vibration synovitis, 226

Vickers-Maxim shell, 478

Vomiting in spinal injuries, 329

Wagons:
Ambulance, 20
Buck, 22
Ox, 20

Warfare, deadliness of, 40

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

Waxed bullets, 52

Wobble, 80, 81, 251

Wounded men, removal from the field, 18

Wounds, general:
Aperture of entry, 55, 72
Aperture of exit, 58, 74
Climate, influence on, 71
Clinical, course of, 69
Contour tracks, 65
Direct nature of tracks, 63
Directions of tracks, 66
Displacement of structures, 68
Explosive exit wounds, 97
Foreign bodies in, 71
First field dressing, 107
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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