humerus to snap across near the old site of injury. A private of the 42nd Regiment also had his humerus fractured by a shot in the same action. The missile in this case came from one of the old smooth-bore muskets used by the natives, and the fracture was of a trifling nature compared with that sustained by the officer previously mentioned. The broken bone was quickly united, and seemed to be quite strong when the man landed in England in April of the same year. On the 18th of June he had a struggle with a prisoner, when re-fracture of the bone occurred at the former place of injury. A private of the 10th Regiment was wounded in action at Perak in the Malay Peninsula, on the 7th of November 1875. The right humerus was fractured. He returned to England in March 1876 with the bone apparently firmly united, but with the elbow, wrist, and finger joints almost completely anchylosed. In October 1876 an attempt was made to reduce the anchylosis of the elbow under chloroform, and while. pressure was being made to bend the elbow, the humerus gave way and became broken again near the original wound. The re-fracture in these instances did not interfere in any way with a repetition of union.

Bones which have become firmly consolidated after gunshot comminuted fracture, and even in cases in which full power has seemed to have been restored, and in which the wounds in the soft parts have remained sound for years, are still liable to elimination of sequestra when detached splinters have been locked up in the new bone at the site of injury. I have elsewhere referred to the case of an officer who was under my care in the Crimea for a gunshot fracture of the thigh-bone in the upper third of the femur, who, though he had been on active duty and quite well for a period of nearly eleven years, suddenly at the end of that time became the subject of tenderness, without any external exciting cause, near the scar at the spot where the bullet had entered. The soreness increased, was followed by a small abscess, and from this abscess, when opened, a small sequestrum, one inch in length, evidently one of the original splinters, was extracted.* The wound of escape healed as soon as the piece of bone was got rid of, and no further trouble has been since experienced. Many examples of splinters locked up in the copious irregularly shaped new bone, by which some of the specimens of gunshot fractures have been united, are to be seen in the Museum at Netley. An examination of them will sufficiently show that such of them as by their form and situation were evidently completely detached at the time of the original injury are entirely necrosed; while others which had probably retained some amount of periosteal connection are also partially necrosed to a greater or less extent. As long as such fragments remain locked up in the new bony material, so long must the patient be liable to accidents connected

with them. Of these, the most favourable will be the occasional setting free of one or other of the fragments, its march to the surface, and final expulsion through the usual process of sequestral elimination. But under other circumstances the same series of unfavourable conditions may arise, which are apt to attend the presence of such inert substances as leaden or iron projectiles, when they are lodged in bone and subjected to disturbance. Many instances have been recorded in which such extraneous objects have remained dormant in bone for long periods of time, when an accidental violent injury has set up inflammatory action in their neighbourhood, and this has been followed by acute pain, abscess, constitutional irritation, and other ulterior results, sometimes of the gravest description.

CHAPTER III

ULTERIOR CONSEQUENCES OF GUNSHOT INJURIES IN PARTICULAR BODILY REGIONS

THE remote consequences of a gunshot wound in any particular region or anatomical system can only be properly estimated, so far as concerns an individual case, when the primary effects of the injury and the result of its treatment have been declared. But the general results of injuries, according to their situation in special regions of the body, and particularly those results which, as shown by experience, frequently lead to soldiers being disabled for further service, may be recapitulated without difficulty. A notice of them will sometimes point to ill effects which may be advantageously remembered, with a view to their mitigation and prevention as far as practicable, when wounds and injuries of a similar nature are in the course of their primary treatment. this purpose I will refer principally to the disabilities which have been noted among the men discharged from the service at the general invaliding hospitals at Chatham and Netley for the effects of gunshot injuries. A considerable proportion of these invalids have passed under my own observation.

For

Disabling consequences of gunshot injuries of the head.There are few cases of gunshot injuries of the head, whether contusions or contused wounds, and with or without fracture, which do not entail among their ultimate consequences some kind of cerebral disturbance. The little depth of the superficial coverings of the cranium, together with the contiguity and connections of the cranial contents, sufficiently explain the fact. These consequences are usually rendered more apparent in hot than in temperate climates. Numerous instances have occurred

among the invalids at Fort Pitt and Netley of men who were able to perform their duties in the ranks fairly well while in England, but who were found unable to continue at duty after they had moved with their regiments for service in India. The whole brain, as an organ, appears to be weakened after a sharp gunshot injury, for, as a general rule, it is rendered less able after one to bear any species of excitement that stimulates the cerebral circulation to increased action.

Wounds of the head, from the direct effects of which patients have recovered, leave behind them external marks which in many instances sufficiently indicate the nature of the injuries which have been inflicted. Not to mention scars from furrowed wounds limited to the scalp, others consist of cicatrices, often very irregular and extensive, adherent to bone beneath, but without alteration of the cranial outline; of cicatrices accompanied with more or less depression from loss of substance, when portions of the outer table, or of both tables of cranial bones, have been removed by the shot or subsequently by necrosis; and, lastly, of cicatrices with depression from fragments of bone having been driven inwards. Glancing wounds about the temporal region are occasionally followed by permanent dysecæa or complete deafness, perhaps with loss of a portion of the external ear, or with obliteration of the auditory canal in the cicatrix. Persistent cerebral disorder of less or greater intensity is usually met with in all these cases. Not unfrequently in some of the invalids there remains an expression of anxiety in the features of the face, or one of dulness and hebetude, which is very characteristic of cerebral trouble and incompetence.

When a portion of a cranial bone has been completely carried away, whether by the direct impact of the projectile or by the results of necrosis, the loss is not naturally repaired by the formation of new bone. A tough cicatricial membranous tissue, representing the integuments and the dura mater in close combination, is presented, varying in thickness in different cases, and this occupies the place of the bone that has been lost. If the membranous cicatrix is of considerable dimensions, some protecting cover has to be permanently worn over it as a safeguard against accidental injury. Not unfrequently this membrane may be seen to move with the movements of the brain. These movements are more obvious if some fluid, as when the parts are bathed, is allowed to lie in the depressed cicatrix.

The manner in which the cerebral disturbance is manifested varies very greatly in different instances. Headache is one of the most common symptoms, and this is sometimes intermittent, sometimes continuous. It varies in degree in different cases - from occasional pains of the most intense character to merely slight uneasiness. The injury to the brain may also exhibit

its effects in weakness, or loss of function, of one or more of the organs of hearing, sight, smell, and speech; or in simply diminished muscular power and sensory acuteness; in functional spasms; in dizziness on turning the head downwards or in stooping; or in more or less complete paralysis of the face or particular muscles, hemiplegia or paraplegia, or general paralysis. Epilepsy or convulsions of an epileptiform character are developed in some instances. Such seizures may, however, cease if an exciting cause can be discovered and removed. There are in the Museum at Netley the parts of a rifle bullet and some small fragments of bone which were removed from the interior of the lateral ventricle of a soldier wounded in the head, who had long suffered from attacks of the kind; the seizures gradually stopped after the extraction of the foreign bodies from the brain. And in an invalid at Netley who had been long suffering from the chronic effects of a cranial gunshot wound, epileptiform convulsions of extreme severity were stopped by the removal of a minute piece of bone, about the size of a grain of wheat, which was exerting pressure within a small opening in the dura mater. In other cases lessened mental power and intellectual activity are manifested, evidenced by defective memory, dulness of apprehension, depression of spirits without due cause, difficulty in forming and slowness in expressing ideas, and inability to fix or concentrate thought on subjects. The temperament of the individual is sometimes changed. The development of an excitable disposition is a common result. Slight causes produce irritation, and not unfrequently paroxysms of anger, in persons who were previously of a comparatively calm and easy temper. More or less loss of self-control is usually marked in such cases. In one case, an officer, with whom I was intimately acquainted, of thoughtful and rather reticent habits, after a severe contusion, became conspicuous for his talkative disposition and tendency to risibility on occasions when there appeared to be little to excite laughter. In this instance the injury was received on the vertex, but there was no open wound. In the early period of the case there was some suspicion that a fracture of the base of the skull might have occurred.

The brain, through the nerves connected with it, is rendered inordinately sensitive. Over-stimulation of the organs of hearing by excessive noise, of the eyes by bright dazzling light, or disturbance of sight by rapid cross movements of objects, cause cerebral uneasiness, and generally more or less mental bewilderment. Hence the brightness of objects in tropical countries, no less than the solar heat, cannot be so well tolerated as it may have been before the injury. Anything that interferes with the freedom and regularity of the general circulation, and so increases the impulse or disturbs the circulation of blood within the head,

speedily produces exaggerated cerebral excitement. Constipation, fatigue, anxiety, pressure of business, speedily give rise to confusion of ideas and headache. The use of stimulants in a similar manner leads to very deleterious effects. The amount of alcoholic stimulant that could be taken before the wound with impunity, if now taken, speedily produces evidence of intoxication, such as loss of muscular control, and not unfrequently induces violent outbreaks of ill-temper or delirium, and this condition generally continues during the remainder of life. Tight pressure about the head is ill borne, because it tends to impede the freedom of return of venous blood from the surface, and to produce more or less internal congestion.

In the few exceptional instances of men who have recovered after bullets have passed completely through the cranium and brain, the consecutive disabilities of a permanent nature have presented wide variations, both in kind and degree. It is scarcely possible that any such case can happen among soldiers, without permanent cerebral disturbance occurring to an extent to prevent the man from earning a livelihood. The most prominent disabilities will be loss of mental power, particularly in general intelligence, judgment, or the faculty of memory, impairment of some of the sensory functions, or disorders of motion or sensation. The sense of sight has been totally lost by a transverse passage through the cranium of a bullet without any other persistent disability. Major H., of the 90th Light Infantry, who was for a long time a patient at Netley, was wounded in action at Kambulla Hill, South Africa, in March 1879, by a bullet which entered at the right temple and passed out at the left temple, one inch posterior to the outer angular process of the corresponding orbit on each side. Both optic nerves were destroyed by the bullet in its passage, and sight was at once and for ever extinguished. Major H. recovered completely in all other respects-hearing and all other senses, as well as intelligence, being quite unimpaired. The occurrence of the wound itself remained a perfect blank in his recollection; but every incident of the action, up to the moment of its infliction, was clearly remembered.

Disabling results of gunshot injuries of the face. As gunshot wounds of the face are only followed by fatal results in a relatively small proportion of their number, their remote consequences may be frequently seen among military invalids who have been the subjects of them. One of the most noticeable effects of wounds of this region after cicatrisation is the alteration and deformity of features which they often leave behind them. Such disfigurements are generally very conspicuous and often distressing, if the wounds have been severe; occasionally, when they have been caused by fragments of shell and are extensive, they present a