in one and the same soldier. The wounds which caused death on the field were observed in 118 instances during the last New Zealand war, and it was recorded that more than one wound had been inflicted in many of these fatal cases. The exact number of wounds inflicted was not noted. The observations were only made for compiling a table of the regions of the body wounded in men directly killed in action, and the wound which was most likely to have caused death in each case was the one put down in the table.33 Recoveries after multiple gunshot wounds with other injuries. The concurrence of multiple bullet wounds with injuries from other missiles, or with incised or stabbing wounds, is occasionally mentioned in the histories of particular cases of soldiers who have recovered, or who have survived and been invalided out of the army on account of them. I am not aware that they have been systematically collected in the history of any campaign. Dr. Chenu, in his history of the Italian campaign of 1859 (vol. ii. p. 294), gives the histories of a few remarkable cases, in which not only several bullet wounds, as many as five and even seven, occurred in the same soldier, but also some in which the patients, in addition, presented wounds from sabre cuts or bayonet or lance thrusts. In one case a soldier received four bullet wounds at Melignano, with two bayonet stabs, viz., a bullet wound of the left arm fracturing the ulna, another of the right side of the chest, a third through the left thigh, a fourth through the right thigh, and two bayonet stabs of the left thigh, and yet recovered. Another soldier recovered after a bullet wound of the left thigh, two others in the right thigh, a fourth bullet wound in the right side, and three bayonet stabs in the right shoulder, arm, and elbow. A third soldier survived after having had five bullet wounds, viz., one of the right shoulder fracturing the scapula, a second wound at the right axilla fracturing the upper part of the humerus, a third flesh wound of the lower part of the arm, a fourth wound of the left elbow, the bullet making its exit at the middle of the forearm, a fifth of the left hand fracturing the middle finger, and, in addition, a bayonet wound of the right forearm. Another soldier had two bullet wounds of the left leg, producing double fractures of the two bones, and five wounds in the right arm and right thigh from case-shot. An officer had a bullet wound of the left arm with fracture of the humerus, two others of the face and neck, a fourth of the left leg, and a fifth of the right thigh, with fracture of the femur, leading to amputation. Dr. Chenu mentions other instances of soldiers who had been pierced by several bullet wounds, and on whom other injuries had also been inflicted, and who yet made favourable recoveries. Many examples unhappily occur in war of men, knocked over by gunshot wounds, being stabbed by lances and bayonets in the fury of action. Some striking examples of this fact occurred during the Crimean war. Private J. Boxall, of the 4th Light Dragoons, was pensioned out of the service in April 1856, for a badly united fracture of the left femur caused by a gunshot wound at the action of Balaclava, He fell from his horse, and in the fall severely injured his right knee. While on the ground he received no less than twelve lance wounds. Private S. Weale, 38th Regiment, received a perforating bullet wound of the left hip, a shell wound of the same hip, and another of the head, and while on the ground received twelve bayonet wounds in various parts of the body. The official history of the Crimean war mentions the case of an officer who recovered after having been shot through the leg, and receiving seventeen bayonet stabs at the battle of Inkerman; and asserts that few men were bayonetted at that battle who had not already received one or more gunshot wounds which had partially or entirely disabled them.34 Multiple wounds from shell fragments.—Shells, when they happen to burst amid a group of men, or even near a single soldier when he is in the upright position, are particularly liable to inflict several severe wounds in the same individual. They not only cause injuries by their own fragments, but also by stones and other hard substances forced up at the moment of explosion. The instances of soldiers receiving more than one wound or injury at the same moment were particularly numerous in the trenches before Hebastopol, from the men being more or less confined in position, and from the effects of secondary projectiles derived from the parapets or surrounding objects. A remarkable instance of severe multiple wounds, which I saw under the care of my friend the late Mr. Rooke, was the following:-A private of the 77th Regiment, wounded by shell explosion, had an extensive part of the wall of the abdomen in the right hypogastric region removed, with laceration of the peritoneum and exposure of the intestines; a comminuted fracture of the crest and wing of the ilium; compound fracture of the right femur, and a fracture of both bones of the forearm, opening the wrist joint, together with extensive laceration of the soft parts in the neighbourhood of the broken bones. He was standing erect at the time he was struck. The forearm was amputated the second day after the injuries were received, and ultimately, after 133 days' treatment in the Crimea, this patient left for England. 35 Another terrible example of multiplicity of wounds in the Crimea was the following:-Lieutenant D., of the 3rd Buffs, was wounded on the 17th August 1855 by the fragments of an exploded shell. He had compound fracture of the thigh-bones on both sides, of both bones of the left leg, with great exposure and laceration of the muscular coverings, the right knee-joint opened, and simple, though comminuted, fracture of the right humerus. He also was standing up when wounded. No other than palliative treatment was practicable with such numerous and grave injuries. They did not cause death, however, until seven weeks after they were inflicted. But judging from the published histories of the results of accidental explosions of shells charged with some of the recently applied chemical explosives, multiplicity of wounds will be a complication of more general occurrence in future wars, and will entail greater difficulties for surgeons to contend against, than in any previous experience. The shells, which are usually made of cast-iron, are burst into such numerous fragments, and with such concentrated violence, by these high explosives, and the sharp and angular fragments are projected with such excessive force, that they frequently strike in a small shower, as it were, and penetrate the tissues very deeply. Some of the fragments are moderately large, but the majority are of small size, and some not bigger than peas, or even particles of sand. Thus, even though mortal wounds may be escaped from, and only the soft coverings of the body are penetrated, special risks may be expected from the mere number of wounds inflicted. The narrowness of the tracks, their sinuous character, their depth, the attrition of the tissues met by the hard and rugged projectiles in their path, must lead to impediments in the way of disinfection of the wounds, extraction of the lodged fragments, and the subsequent escape of discharges, and entail risks, in consequence, of various secondary complications. Multiple amputations from multiple wounds.-The occurrence of multiple wounds, when two or more fractures of bones have resulted from them, is sometimes shown in the classified returns of campaigns under the head of double amputations. Dr. Chenu, in his history of the Crimean war, tabulates forty cases of double amputations in individual soldiers for fractures caused by various projectiles, the larger proportion being by burst shells and grape; and, in the English history, nine similar cases are tabulated between April 1855 and the end of the war. More than one bone may be fractured in the same limb, and fractures of bones in separate limbs may be caused by a single projectile. Although, under ordinary circumstances, the bone or bones of one division of a limb only are broken by the stroke of a projectile, it can readily be understood how a man having his forearm bent on his arm at the moment he is hit, may have all three bones of the upper extremity fractured by one and the same passing bullet; or how a bullet striking one thigh sideways with sufficient force and breaking the femur, may pass on and fracture the bone of the adjoining thigh almost at the same instant of time. Drs. Ashton and Spanton mention the case of an officer who was wounded at Sedan in 1870 through both arms and both legs, and had all four limbs amputated. He was riding, when a ball passed through one of his legs, through the horse, and then through the other leg. At the same time a second bullet passed through both his arms. The horse was killed.36 Under the circumstances of such multiple fractures, it may often happen that the treatment, suitable for either fracture alone, is found to be no longer applicable for the two combined. Amputation may be necessary in some such cases where conservation might otherwise have been attempted with propriety; and operative interference, such as amputation, may be rendered impracticable without the risk of entailing immediate fatal results in others, where it might have been performed with reasonable hope of a good result, if either one of the multiple wounds had occurred alone. More precise information regarding this complication desirable in future wars. The probability of an increase in the frequency of the occurrence of multiplicity of wounds, and the very important influence exerted by it in increasing mortality in action; or, where immediately fatal effects are escaped from, its influence on the treatment that has to be adopted in particular cases, and on the effect of treatment; the additional shock to the system of the patients in all instances; the greatly increased and prolonged suffering entailed on them; together with the aggravated risks as regards the final results in many cases; these and perhaps other considerations make it extremely desirable that more marked notice should be taken of this complication than it seems to have attracted hitherto-that not only the number of officers and men wounded, but also the number of the wounds inflicted on them, should be shown in future professional field returns, in case of the necessity for their use unhappily arising. The importance becomes greater in proportion as the destructive force of the projectiles employed, and the facilities for multiplying the number of projectiles discharged within short periods of time, are increased. There is good reason for fearing that the preponderance in the number of wounds and injuries inflicted over that of the number of soldiers hit will be found to be much larger in wars of the future than it has ever been hitherto, owing, as regards small-arm ammunition, to the enormously increased penetrative energy of the modern narrow rifle bullets, the larger supplies of them that will be at the disposal of the troops, and the great rapidity with which they will be able to be discharged on particular occasions by the introduction of the magazine system; and at the same time, as regards the larger forms of projectiles, to the greater number of pieces into which they will be broken up, and to the greatly increased force with which the fragments will be armed, in consequence of the employment of the new chemical explosives as materials for the bursting charges. SECTION V AIDS TO THE DIAGNOSIS OF PARTICULAR FEATURES AND COMPLICATIONS OF GUNSHOT INJURIES THE characteristic appearances of bodily injuries from gunshot, and the primary symptoms and complications with which they are usually attended, have been described in preceding sections of the work. In the present section it is proposed to point out certain extraneous means by which a knowledge of some of the facts connected with them, especially the presence or absence of foreign bodies lodging in them, may frequently be obtained, or the judgment respecting these and other allied circumstances be assisted. The subject has lost some of its interest with respect to the present small-bore rifle bullets, from causes which will be explained, but still retains its importance as regards the spherical bullets of case and shrapnell, fragments of shells, and various secondary missiles of irregular forms. The evidence which may occasionally be obtained from an inspection of the clothing or accoutrements worn by soldiers, of substances carried by them, or from the projectiles themselves, in case of there being an opportunity of observing them, are more particularly alluded to in these remarks. CHAPTER I AID TO DIAGNOSIS DERIVED FROM COVERINGS OF WOUNDED Information afforded by clothing.-The diagnosis in respect to some of the circumstances connected with gunshot wounds may often be materially assisted by inspection of the uniform, accoutrements, or underclothing of a soldier. The value of this examination is particularly shown in the determination of doubts as to whether portions of some of these articles have or have not lodged in a wound; it will also occasionally solve questions as to the nearness or distance of a shot, the direction which a |