numbness, by more or less loss of sensibility in the part, that the primary symptom of pain is forgotten. A feeling of heaviness, often likened to the parts concerned having been stunned, is usually complained of, and this sensation may extend to a considerable distance from the site of injury, perhaps to the whole limb, if the wound be in the upper extremity. The following is the only instance I have met with in which there appears to have been consciousness of pain throughout the course of the bullet— at the entrance, along the track, and at the exit. The patient was a medical officer, Dr. Chalmers Miles, who was shot during the Sepoy Mutiny in an attack on a fortified place not far from Neemuch. The description of the wound is in Dr. Miles's own language. Just about this time I was shot through the thigh by a bitten musket bullet-one of those implements of war which cause immensely unpleasant and jagged wounds. The feeling when you are hit is peculiar: it is just as if a red-hot iron was suddenly plunged into your thigh, and the channel it formed filled with molten lead; then a scalding, unpleasant pain passes through you; and then there is a sensation of faintness, yet relief, and the ball is out.'4

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Pain of bullet contusions.-When a bullet does not penetrate the flesh, but simply inflicts a contusion, the pain caused by the injury is often described by patients as having been more severe than the pain spoken of by patients in whose bodies the bullet has effected an entrance. In such cases, in addition to the direct injury to the sentient nerves of the skin, and to the sub-tegumentary tissues, at the particular spot struck, the extent to which the impetus is communicated to the parts surrounding the point of impact of the bullet, and the great stretching to which these parts must be subjected, must also be taken into account in explaining the severity of the pain complained of. In a wound made by a bullet moving at full speed this strain upon the surrounding tissues can hardly take place, for the resistance of the parts opposed to the projectile is instantaneously overcome and a passage freely opened to it. The sensitiveness of the skin at the wound itself is at the same moment numbed, or, it may be, even annihilated, by destruction of its vitality.

Special sensory effects from injuries to nerves.-Occasionally, when the trunks of nerves are directly injured--not divided, but violently pushed aside-the wound will be accompanied with intense pain, but none will be experienced locally; the pain which is felt will be referred far away from the track of the projectile to some distant part to which the nerves are distributed, or for an instant a portion of the limb will be thought to have been completely carried away by the shot. I have known a wounded officer in the Crimea so deceived from the cause mentioned as to support an unwounded arm a considerable distance, on the supposition

that his hand and forearm had been shattered by a shot. He had been wounded through the neck, but was not aware of having been struck in that situation. It has happened that a patient who has sustained a wound, in which nerves have been implicated, in one limb, has thought that the wound was in the opposite limb. Dr. Mitchell, of the United States, has mentioned two cases in which wounds of one leg seemed to the patients to be really in the unwounded limbs,5 and has referred to other cases of a similar nature. Less rare cases are those in which pain is not only felt in the wounded limb, but reflex pain is also felt at the same time in the opposite uninjured limb, in parts corresponding in function with those at the true seat of injury.

CHAPTER II

(B.) ON 'SHOCK' AS A PRIMARY SYMPTOM OF GUNSHOT INJURIES

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Description of shock. When a large bone is suddenly shattered, a cavity penetrated, an important viscus wounded, a part of the body struck by a heavy fragment of a shell, or a limb carried off by a shot, one of the most common features of the injury is a general disturbance of the nervous system, which shows itself by strongly marked bodily and mental depression. In most cases this perturbation supervenes instantaneously on the injury. This symptom is generally described as the 'shock' of a gunshot wound. The patient trembles, totters, is pale, depressed and faint, perhaps vomits. The surface of his body has lost its natural warmth. His features exhibit the vacancy of stupor, and more or less anxiety and distress. His circulation is weak, irregular, and agitated; the respiration feeble, slow, and labouring. seems as if every mental and bodily function of the patient had received a sudden check. A somewhat similar emotion or state of agitation and apparent stupor may be observed in a horse which has received a serious or deadly wound in action, just the same as in his rider. It may be regarded as an expression of sympathy of the whole frame with a part suddenly subjected to serious injury. The prostration of shock must not be confounded with the prostration or collapse which results from copious loss of blood. The instant tottering and trembling condition of the body, the direct depression, and the immediate stunning of the senses which are so characteristic of shock, are hardly noticeable among the early symptoms of faintness from hæmorrhage. At the same time, as both drain of blood and nervous shock produce many similar results, though by different paths, on the centre of circulation, there are necessarily many symptoms in common between them.

Neither should the effects of shock be confused with those produced by direct injuries of the brain or spinal cord.

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Variations in degree of shock. The shock of a gunshot wound is more or less marked in degree according to various circumstances. Examples show that it may occasionally be altogether suppressed for a time, even in very severe injuries, by moral and nervous action of another kind, or by a state of mental tension; but this rarely happens when the injury is a vital one. One difficulty in estimating the amount of shock in particular cases is that panic, when induced suddenly, leads to symptoms which closely simulate those of traumatic shock.' A soldier having his thoughts carried away from himself, his whole frame stimulated to the utmost height of excitement by the continued scenes and circumstances of the fight, when he becomes conscious of being wounded, is instantaneously recalled to a sense of personal danger; and if he be seized with doubt whether his wound is mortal, depression as low as his previous excitement was high may immediately follow. This alarm, and the depression induced by it, will vary in degree according to individual character and intelligence, state of general health, the structural condition of the heart, whether vigorous or weak, and other personal peculiarities. In persons enfeebled from any cause, from previous illness, the injurious effects of a prolonged campaign, unhealthy surroundings, as when men have been shut up for a long time in a besieged place, from bad and insufficient food, over-fatigue, and other such causes of physical depression, the shock of a gunshot wound when it occurs will be more profound, and the reaction from it more delayed and difficult. If the emotion be as intense as it is sudden, it alone will sometimes induce a rapidly fatal result. In others of a different temperament, the alarm and depression will be controlled, and even extraordinary energy be manifested in its stead for a time. Numerous examples occur in every action of men walking long distances to field hospitals for assistance, unsupported and with comparatively little signs of distress, after a gunshot fracture or even the loss of an arm, a perforating flesh wound of the thigh, or some other such severe injury, and only, after arrival at a dressing station or field hospital, exhibiting the usual symptoms of shock. Among the collection of drawings by Sir Charles Bell at Netley, is one of a sergeant of cavalry who had his left arm completely carried off near the shoulder by a large cannon shot at Waterloo; yet in this condition he started off and rode upright all the way from the field of battle to Brussels, a distance of fifteen miles. Such a remarkable feat could only have been accomplished under the influence of extreme nervous excitement. On reaching a ward in the Elizabeth Hospital, he became utterly prostrate, and remained insensible for half-an-hour. His collapsed condition was readily

explained by the fact that the stimulus which had urged him onwards had suddenly ceased, and that the exertion he had undergone in his wounded condition would necessarily be followed by extreme bodily fatigue. On the other hand, examples might readily be quoted of men with comparatively slight wounds who have been quite overcome and have had to be carried from the field. It is not easy in many of these latter cases to determine how much of the symptoms presented is due to alarm, and how much to true 'shock.'

Duration of shock.-The duration of shock, when it exists as a temporary condition-that is, when it is not associated with any fatal shot wound-is as varied as is the degree in which it is met with at the onset of the injury. It may pass off in ten or fifteen minutes; it may remain four or five hours, or even longer, and then pass away. Nor can the period during which it will last be calculated from the amount in which it is exhibited immediately after an injury. Excessive shock will sometimes pass off with comparative quickness, while the persistence of moderate shock is often very prolonged. These differences, again, seem to depend upon constitutional peculiarities; perhaps on the extent to which the centre of circulation is susceptible to the influence of the nervous system, perhaps to the fineness of the sympathy which exists in the ganglionic system. They cannot always be explained by the relative degrees of gravity of the wounds themselves.

Recovery from shock.-As the shock is disappearing, the pulse gradually resumes its regularity; the paleness changes to the natural hue as the capillary circulation of the surface of the body is restored; the mind gradually regains its power, awaking, as it were, from a state of abstraction and of general undefined apprehension to take a discriminative interest in the local injury which has been sustained, and to consider its nature and consequences with judgment. Even moderate uneasiness and pain at the seat of injury become noticed by the patient. In short, a gradual improvement, bodily and mental, takes place until the normal state of tranquillity is restored, and nothing remains beyond the particular local disturbance which has been directly produced by the violence of the shot.

Effects of shock on hæmorrhage. One effect of shock is to lessen the impulse of the heart's action, and thus for a time, like fainting, to lessen the risk of fatal hæmorrhage in case of an important artery having been opened. But equally with what happens in fainting, as the heart recovers its vigour, and the circulation recovers its usual force, so the danger of a return of hæmorrhage is increased. The reaction of shock is very similar to the reaction of faintness, though arising in different ways. The necessity for watching the return of bleeding under such circumstances, and for being prepared on the instant to check it, is

a matter that should not be forgotten when a wounded man has to be intrusted to imperfectly trained bearers during removal from one place to another, or is left in the hands of inexperienced hospital attendants.

Relation of shock to amount of injury.-As a general rule, the graver the injury the greater and more persistent is the amount of shock. A rifle bullet which splits up a long bone into many longitudinal fragments inflicts a much more serious injury than the fracture which was ordinarily produced by the ball of the smooth-bore musket; and the amount of constitutional shock usually bears a like proportion. When a portion of one or of both lower extremities is carried away by a gunshot, the higher towards the trunk the injury is inflicted, the greater may be expected to be the shock, independently of the loss of blood, panic, or other depressing circumstances. Not only the local, but also the constitutional injury is greater.

The following case is, however, well suited to illustrate the fact that shock may occasionally induce a speedily fatal result after an injury which in itself could hardly be regarded as one of extreme gravity. The late Professor De Chaumont, when serving during the Crimean war with the Rifle Brigade, was with a party of men in one of the ravines leading to Sebastopol, when two of them were struck by a gunshot from the great Redan. The first man struck was killed immediately. In the case of the second, who was by the side of the first, the shot passed along the upper arm, between the shoulder and elbow joints. The arm was near to the rocky side of the ravine at the time, but, so far as external evidence was concerned, there was nothing to show that it had been crushed by the shot against the rock. The integuments were sound, and as normal in appearance as if no projectile had passed near them. On examination, however, the shaft of the humerus was found shattered to pieces. The injury was followed immediately by symptoms of shock so extreme in degree that all attempts to rally the soldier from them failed, and the man died almost without power to speak a word from the moment the shot struck him. No internal organ had been damaged-this was ascertained by examination of the cavities of the body after death; nor was there any reason to believe that any part had been injured in addition to the arm already mentioned.

It seems probable that in uncomplicated flesh wounds by modern small-bore projectiles the symptom of shock will sometimes be entirely absent. This may be explained by the small area of bodily tissue traversed by one of these bullets, the extreme rapidity of its passage, and the trifling resistance encountered owing to its immense penetrative energy. Even when the speed of one of these narrow projectiles is much reduced, so long as only soft textures are involved in the injury, the wound may still