hideous and truly repulsive aspect. As even most extensive wounds of the face can be undergone without fatal results, these very sad cases have hitherto been by no means rare in the hospitals to which military invalids are sent. So far as facial wounds from the projectiles of portable fire-arms are concerned, these mutilations are not likely often to result when small-bore rifles are in general use their small dimensions and other qualities are sufficiently calculated to prevent such extensive disfigurements. Instances of facial deformities have been increased in number by the fact that the region of the face is that which most frequently suffers in cases of attempted but unsuccessful suicide by fire-arms among soldiers. In both polemical and suicidal wounds, important features of the face the eye and eyelids, the nose, parts of the cheeks, the lips, and of the bones of the face, including the lower jaw-may be more or less shot away, or may become detached by the after-effects of the injuries to which they have been subjected, and their functions proportionately impaired. The deformities and disabilities produced by these ablations are in many instances aggravated by the changes and contractions which take place during the process of cicatrisation, and the bridling influence exerted by cicatricial bands on parts not directly concerned in the wound though adjoining it, especially on the upper part of the neck. The natural expressions of all the features of the face are perverted in such cases, and not unfrequently a horribly mutilated and meaningless spectacle is presented instead. Men are sometimes rendered so repulsive in appearance from mutilations in this region that they find a difficulty in getting employment in civil life after their discharge from military service, and in other ways suffer from their objectionable aspect. In awarding pensions to soldiers who have been subjected to injuries of this nature in active service, these circumstances ought always to be taken into account.

In a few instances such deformities assume almost a grotesque character. In the case of one patient who had attempted suicide, the whole of one side of the face was mutilated, while the other was quite intact. On the mutilated side, the globe of the eye, the lower part of the orbit, and a great part of the cheek were gone, an opening in the cicatricial tissue led into the mouth through a gap in the upper maxillary bone, and the soft coverings over the lower maxilla were extensively lacerated. The view of the man in profile on the one side being perfectly normal, a spectator was quite unprepared for the horrible deformity presented when the other side was suddenly turned to him. In another case, also one of attempted suicide, half of the upper lip had been torn away from its connections, and had become united upwards towards the orbit in a line with the nose. The hair continued to grow as it had done when the lip was in its normal place. A huge gap, left by

the loss of the eye, the lower part of the orbit, the malar bone, and a large portion of the upper maxilla, was covered over by a plastic operation; but the lip could not be wholly returned to its normal position, and the hair still grew in this situation.

Worse even than the lamentable condition to which such patients are reduced by the effects of their wounds in regard to personal appearance, is the permanent loss of power of usefulness, enjoyment, and of general health, which they sometimes sustain from injury or destruction of some of the important organs connected with the region of the face. Dimness of vision, or complete loss of sight from direct wounds as the effects of concussion in one or both eyes; more or less injury of the bony orbit and ocular appendages, with resulting visual disorders, obliteration of lachrymal ducts, ectropium, &c.; dulness of hearing or complete deafness, on one or both sides, from wounds involving the opening of the Eustachian tube, from wounds of the external ear and meatus, and obliteration of the cavity by cicatrices; disfigurement from crush or ablation of the nose; loss of sense of smell; impairment or loss of power of speech, from wounds and cicatricial deviations of the tongue, destruction of the palate, &c.; defectiveness of articulation and pronunciation, from distortion or destruction of the upper dental arch, from loss of teeth, from partial loss or retractions of the lips; impairment of mastication, or total inability to masticate from loss of teeth; restraint of movement in the temporomaxillary articulation, or its complete fixation, from anchylosis; limitation of movements of the lower jaw as a result of fracture, or in consequence of cicatricial adhesions; loss of correlation between the upper and lower dental arches, so that they cannot be brought opposite to each other, from ununited or irregularly united fractures of the lower jaw, &c. ; interference with freedom of deglutition, from ablation of supporting structures and muscular deficiency, from cicatrices, openings of communication between the mouth and nasal fossæ, &c.; fistulous openings and loss of power of retaining the salivary secretions; fractures of various kinds of some of the bones of the face; loss of power of action in the facial muscles near the site of injury; facial neuralgia;-all these serious disabilities have resulted from gunshot wounds in the face, and may exist, either separately or combined, in a greater or less degree, according to the extent of the structures which have been involved in the original injury. In some wounds of this region, not only the part directly wounded suffers, but other parts associated with it, though not struck, are indirectly, or eventually become affected by the injury which has been inflicted. An eye wounded by a projectile will very often cause morbid irritation, and ultimately impaired, if not complete, loss of sight in the remaining eye. With some of the consequences previously mentioned, impairment of the function of digestion is almost necessarily asso

ciated; so that deterioration of general health may then be reckoned as one of the ultimate results of these wounds.

Wounds of the face, owing to the anatomical relations of this region, are sometimes associated with injuries to the base of the cranium, and thus some of the ultimate effects of injuries of the head are added to those peculiar to the region of the face itself. Even in cases where the facial lesion does not amount to a source of disability in itself, the effect of the cerebral concussion and disorder with which it was accompanied may be felt throughout life, sometimes becoming worse as time advances, and in the instances of soldiers may ultimately cause their discharge from the service. Such was the result of an injury, happily of an unusual kind, in the case of Private J. M'C., who suffered from a severe contusion of the right side of the face, together with a superficial wound which extended to the lower part of his right ear. He was struck at the final assault of Sebastopol by a man's leg that had been carried off by a round shot. Insensibility lasting for several days, and disturbance of mental faculties, followed the injury. He recovered, so far as the injury to the face was concerned, with the exception of deafness in the right ear, owing to the external meatus becoming occluded by cicatricial tissue, and in February 1856 he was sent to his regimental depôt.

mained at regimental duty for eleven years, subject, however, to frequently repeated attacks of giddiness, and always showing a certain amount of unsteadiness in the ranks. These symptoms increased in severity to such an extent on the man being sent to India that he was rendered unfit for his duties, and on this account he was discharged from further service.

The deformities from wounds of the face may sometimes be partially rectified by suitable plastic operations, or masked by prothetic appliances, and in some instances functional impairments may be lessened. In other cases artificial substitutes for parts which have been destroyed, such as the nose or an eye, may be employed for counteracting disfigurement with advantage. Such remedial measures, however they may be applied, can only be expected to act as very imperfect substitutes for the natural parts which have been impaired or destroyed. Many ingenious contrivances were devised to replace deficiencies in parts of the upper maxilla and hard palate, and of portions of the lower jaw, among invalids at Fort Pitt after the Crimean war. Some of these substitutes for the lost natural parts did not only lessen the unsightly appearance of the men concerned, but they added to their power of mastication, deglutition, and articulation, thus increasing their means of preserving health, earning support, and so promoting their comfort. M. Legouest has recorded the cases, and has given drawings of some men at the Hôtel des Invalides at Paris, who survived many years after loss of the entire lower

jaw and floor of the mouth, which had been carried away by grape or massive gunshot. Their condition was rendered less intolerable by the use of a metallic chin and plate for supporting the tongue, and by masking the full extent of their deformity.

Disabling results of gunshot injuries of the neck.-Wounds of this region which escape a fatal termination, especially those which are caused by somewhat large fragments of shells, often leave behind them contortions and restricted movements of the neck, and also in some instances forced inflexions of the head from the loss of substance and cicatricial contractions to which they give rise. These effects vary in amount and persistency according to the extent and situation of the cicatrices; but though the restriction of movement is usually lessened with time, full freedom is rarely ever regained. Extensively lacerated wounds being generally fatal when they are inflicted in the anterior part of the neck, it is chiefly after wounds of the posterior or sternomastoid muscles that such ultimate effects are met with.

Both contusions and wounds of the lower and lateral parts of the neck may be attended with injury to the cervical nerves; so that paralysis of motion and sensation, atrophy, contractions, neuralgic pains, and other results of nerve lesions, may be manifested in the upper extremity on the side corresponding with that of the injury, and remain permanent consequences of gunshot wounds of the neck. Still more, extensive paralysis as a result of severe injury to some of the cervical vertebrae, with concussion of the spinal cord, and even, in a few rare instances, the effects of fractures of parts of some of the vertebræ, have been recorded as persistent consequences of wounds of this region.

Fistulous openings have sometimes remained when the larynx has been wounded, or the trachea penetrated without fatal results; and when such an opening could not be closed by a plastic operation, the permanent use of a cannula has become necessary. The usual consequences of tracheotomy and laryngotomy have persisted in cases where these operations have been performed in consequence of some of the primary effects of wounds implicating the larynx, and the patients have otherwise recovered. Aphonia may remain as the permanent result of a wound of the neck with simple contusion of the larynx. A young lieutenant who was under my care after having been shot from side to side through the œsophagus in the Crimea, recovered very favourably in all respects, with the exception of impaired vocal power. The bullet had evidently glanced against the posterior aspect of the larynx in its passage through the neck. It was hoped that this impairment might be lessened in time; but it was not, and he was eventually compelled, on rising to a higher rank, to quit the army solely in consequence of his inability to make himself heard at a sufficient distance. Many examples of deflection of projec

tiles which have struck against the anterior aspect of the larynx have been recorded, and these have generally been followed by persistent aphonia. Irritable cough and difficulty of respiration are other consequences occasionally met with as permanent results of injuries of the larynx and parts associated with this organ.

Disabling results of gunshot wounds of the chest.-As wounds in which the cavity of the chest has been penetrated, and particularly those in which the visceral contents of the cavity have been involved in the lesion, have hitherto been attended with fatal results in a very large majority of instances, either on the field of action itself, or within a few days after admission into hospital, the ulterior effects of chest injuries have been chiefly observed in those of the parietal or non-penetrating class. The survivals among patients who have been subjected to penetrating wounds of the chest will probably occur in a much larger proportion in future wars. This may be expected especially in wounds inflicted by the new rifle bullets. The slight resistance that can be offered against their passage when they are armed with their average force will cause perforating wounds of this region to occur in far larger numbers; it may fairly be expected that more men will be struck, and there will be a greater proportionate number of penetrating wounds to non-penetrating wounds of this region than has hitherto occurred in war; while the narrowness and other physical qualities of the new projectiles, it may be hoped, at the distances at which men are likely to be wounded by them in war, will render their effects less fatal by limiting the areas of the lesions inflicted by them. For these reasons such cases will probably come under hospital treatment far more frequently than has hitherto happened.

In many instances in which men have suffered a shot contusion of the chest without any open wound or injury to bone, whether by a fragment of shell, a bullet at high speed which has struck some resisting object, as a watch, coins, &c., or by a bullet at lowered speed, although there may at first have been signs of injury to a lung, such as hæmoptysis or painful dyspnoea. recovery after a time is almost complete. No ulterior consequences of a disabling kind remain. In other instances the ultimate issues are not so fortunate. The local contusion has been more severe, the commotion of the lung greater, there may have been laceration of the pulmonic substance, vessels ruptured, and as consequences, after these primary lesions have been repaired, there may remain pleuritic thickening and adhesions, permanently restrained movements of the chest-walls, with troubled respiration on any unusual or prolonged exertion. Cicatrices, with tendency to ulceration if pressed upon, or with contractions that permanently interfere with the full freedom of the chest-walls and adjoining arms, are among the disabilities occasionally met with in consequence