wounds of the trunk 15.22 per cent. It will be seen that this percentage of wounds of the trunk, as compared with those of the head, face, and neck, is smaller than in any other war; and the peculiar circumstances, already mentioned, under which the fighting took place probably explain the difference. The wounds of the upper extremities are shown to be in greater excess over those of the lower extremities than in the war in New Zealand. It is probable that, in most wars in which bush-fighting predominates, similar proportions as regards wounds of the upper and lower extremities will be met with.

In the last part of the Surgical History of the War of the Rebellion, 43 there is a tabular statement of the relative frequency of wounds in the different regions of the body caused by shot. The figures are confined to wounds by projectiles, all other forms of injury being excluded. As regards the American Civil war, the total number of cases tabulated refer to the whole period from 1861 to 1865, and are 245,739 in amount. They do not include the cases of men killed in action. Of the total number mentioned, 26,400 were wounds of the head, face, and neck; 45,184 wounds of the trunk; 87,793 occurred in the upper extremities; and 86,413 in the lower extremities. The percentages were thus 10.7 in the head, face, and neck; 184 in the trunk; 35-7 in the upper extremities; and 351 in the lower extremities. The shot wounds of the upper extremities were therefore in the American war in excess of those of the lower extremities. This fact is thus explained in the text (p. 692): The protection afforded to the lower extremities and the trunk in the many siege operations by parapets, and in field operations, especially during the severe and extended campaign beginning with the battles of the Wilderness, Spottsylvania, Cold Harbor, and ending with the siege of Petersburg, by ditches, trenches, behind trees, &c., screened those parts to a large extent from injury, while the head and upper extremities were continually exposed to the practised eye of a vigilant foe.'

The American table also shows the distribution of wounds by shot, excluding other injuries, in twenty other wars and campaigns. The total number of cases recorded amount to 216,348, and of these 31,184 belong to the head, face, and neck; 45,583 to the trunk; 66,475 to the upper extremities; and 73,106 to the lower extremities; giving percentages of 144 to the head, face, and neck; 21.1 to the trunk; 307 to the upper, and 33.8 to the lower extremities. The large percentage of wounds of the extremities among the soldiers treated for shot wounds only, amounting in the United States hospitals to 70.8 per cent., is a noticeable fact. They also form a very considerable proportion of the shot wounds in the aggregate of cases treated during the twenty other wars quoted in the table, viz., 64.5 per cent. All

the statistics show, moreover, that there is not such a difference in the proportional numbers of shot wounds of the upper and lower extremities as might have been anticipated, merely judging from their difference in bulk and superficial target areas. On nearly every occasion the shot wounds of the upper and lower extremities closely approximate in their numbers, a fact sufficiently explained, as already pointed out, by the constant exposure to shot of the upper limbs, and the protection so frequently afforded to the lower limbs, in the ordinary procedures of warfare. Average regional distribution of wounds among hospital patients in time of war.-If the hitherto observed average percentage of deaths on the field to wounds inflicted, shown at page 703, be accepted as a basis, it may be assumed that in every 1000 casualties in warfare there will be about 200 deaths on the field; and that of the remaining 800, taking the proportions resulting from a general summary of all the statistics previously quoted, there will be admitted into hospital, in European warfare, about 110 wounds of the head, face, and neck; 154 of the chest, abdomen, and pelvis; 252 of the upper extremities; and 284 of the lower extremities. But, as before stated, whether, under the new conditions of warfare, the proportions of wounds will remain in accord with previous experience, can at present be only a matter of surmise.

CHAPTER VI

RELATIVE FATALITY OF GUNSHOT WOUNDS IN DIFFERENT BODILY

REGIONS

General causes which affect the ratios of mortality in gunshot injuries. It is not the purpose of the remarks in this chapter to estimate the ratios of mortality among wounded men according to the effects produced by different kinds of projectiles, but rather to observe how far certain ratios of mortality have been preserved in wounds of different regions of the body when the fire-arms and projectiles by which they have been caused, and the circumstances under which they have been inflicted, have apparently been alike. Even under these conditions there will always be variations in the absolute mortality consequent on wounds of corresponding kinds, as well as variations in the relative rates of mortality of wounds in the separate regions. The nature of the engagement, whether it is one on a large scale or one of minor importance; the plan on which the surgical arrangements are conducted, whether it is one by which early assistance

can be given to the wounded, or one under which the first aid is delayed, or, in other words, the length of time the wounded are left on the field unattended to; the distance which has to be traversed before systematic surgical help can be reached; the nature of the ground and of the means of transport; the kinds of hospitals employed, whether tents, huts, or buildings, together with their forms and position; the number of the wounded collected in the separate hospitals; the amount of surgical attention and nursing care available; the state of general health of the troops as influenced by length of service in the field, circumstances in respect to diet, exposure, season, climate, temperature, and other conditions which I may have omitted to mention; all these matters exert an influence on the ratios of mortality from gunshot wounds shown in statistical returns, irrespective of differences in the wounds themselves. Some illustrations of the effects of a few of these circumstances follow.

As regards the future, there is every reason to expect that among the wounded who will come under hospital treatment the ratio of mortality will be considerably less than it has been hitherto, especially as regards men suffering from rifle-shot wounds. Not only will the nature of the wounds, from the narrowness of the projectiles, render very many of them less hazardous to life, but the improved means and methods of treatment will also, under ordinary circumstances, conduce to a far larger proportion of recoveries among the patients.

Effects of increase in dimensions of battles.-The absolute mortality among the wounded is always increased in vast battles like those of Königgrätz, Solferino, Gravelotte, and others. The wounded are so numerous, and fall within such comparatively short periods of time, that it becomes physically impossible, with the amount of hospital and sick-transport staff usually available, either to afford the necessary surgical aid, or to carry the wounded away to places where it can be obtained. Under such circumstances many men die from simple want of attention. It is an old remark that the percentage of mortality among men wounded in battle increases as their number is increased. It is obvious that this must arise from the fact that in small engagements the whole of the wounded can receive attention quickly; but that in large battles surgical care, adequate in amount, can hardly be given to any, while a large number must remain without any attention at all, or, at least, cannot receive it until too long a time has elapsed for it to be of much avail. The late Surgeon-General Dr. Loeffler of the Prussian army, basing his observations on experience gained in the slighter engagements and larger battles during the war between Prussia and Austria in 1866, proved that in almost every instance the mortality among the wounded of that campaign was increased concurrently with an increase in their numbers. The

44

following is Leoffler's table showing the number of wounded in certain engagements, and the percentages of mortality among them :

-

When the dimensions of the battles, and the numbers of the wounded, that may be expected in case of another European war are considered, owing to the probable masses of the opposing forces, the power and rapidity of the discharges of artillery and rifle projectiles, together with the increase, beyond all experience, in the difficulties of reaching the wounded owing to the enormous distances over which the rain of projectiles will extend, the general fact just described assumes a most serious aspect.

Increased ratio of mortality from aggregation of wounded. -The increased mortality which occurs from wounds when large numbers of wounded soldiers are collected together for treatment, in consequence of the morbid conditions generated by aggregation, is now fully recognised. The steps which have been taken to prevent accumulations of wounded, for combined treatment in large and often unsuitable buildings, have constituted one of the greatest improvements effected of late years in military medical administration. Nothing has more tended to diminish the preventible mortality among wounded men than the plan of treating them in separate and freely aërated huts or tents, while limiting the numbers collected in one locality as far as economical and transport considerations would allow. Circumstances will still occur in warfare which render an accumulation of wounded, at least for some time, unavoidable; but whenever this does happen, an increase in the absolute mortality among them may be expected to result, whatever pains may be taken to obviate it.

Apparent increase in ratios of mortality in certain wounds. —The following fact serves to illustrate the difference which there may appear to be in the fatality of certain wounds on different occasions among hospital patients, when the different mortality results are not due to any peculiarities in the wounds themselves, but are wholly attributable to extrinsic circumstances. During the Crimean war the percentage of fatality of chest wounds, all kinds being taken together, in the French military hospitals was 30-7 per cent. This ratio of mortality was almost the same as it was in the Crimean hospitals of the British army. In the French hospitals during the Italian campaign of 1859, however, the mortality was only 18.9 per cent. The altered rate of mortality shown in the hospital returns of the latter war cannot be said to have been due