however, cleaner, and is a good substitute for a poultice. At this period there is always great danger of secondary hæmorrhage; a tourniquet should be loosely applied to the limb when the wound is in the vicinity of a large artery, so that it can be tightened when required, and the patient should be carefully watched. Should hæmorrhage take place, the artery must be tied at the wound, if possible, or at the most suitable place above it. Should the bleeding still continue, the limb must be amputated. Necrosis, abscesses, and sinuses often remain for years, producing serious injury to the patient's health, and, in some cases, ending fatally from pyæmia.

Balls, or a portion of shell, occasionally lodge and become encysted in the muscles or bone without producing much inconvenience. As it is impossible to know what injuries they may cause if not removed at once, every endeavour should be made on the part of the surgeon to accomplish their extraction, along with any other foreign body which may have been driven in with them, if this can be done without producing any serious mischief to some important organ or vessels, as in the case of Private Thomas Boulger, 84th Regiment, under gunshot wound of the lower extremities.

In cases where the ball remains unextracted a sinus continues, which occasionally heals and breaks out again from time to time, producing inflammation and suppuration in the sac, when encysted, or in its neighbourhood, necessitating continued attention and treatment. Patients in whom the ball is lodged complain of weakness, weight, and wandering pains in the limb, which is easily affected by change of weather.

.

Balls, and especially the old round ball, occasionally take very extraordinary courses, according to the angle at which they strike the structure, whether it is bone, tendon, or aponeurosis, and also upon the position of the body at the time.

The extraction of balls and other foreign bodies lodged is, in general, accomplished without much difficulty, if done before inflammation and swelling have come on, and if attention is paid to placing the patient in the same position as he was when injured, and putting the same muscles into action, and questioning the patient as to his ideas and feeling as to where the ball

is situated; examining the clothes as to whether any part has been carried in, as the ball may only have gone a short distance, and then dropped out under the clothes. Two apertures on opposite sides of the limb cannot be taken as decisive evidence of the ball having perforated, as they may be caused by two separate balls; occasionally, also, one ball makes several aper

tures.

The different kinds of forceps which have been invented for the extraction of bullets are innumerable, but it appears to me that the simplest are the best-viz., the common lever, with finger acting as probe and director, and the common dressing or polypus forceps. There are also some other more complicated instruments, which are, in some difficult cases, of great service, such as Coxeter's or Read's forceps.

Patients, soon after being wounded, seldom object to the extraction of the bullet, however reluctant they may be after months or years of a state of things of which they have become accustomed to, with all the attendant evils, such as pains, gleety discharges, &c.; still, when they have been persuaded to have the ball extracted, they express themselves as very much delighted.

CHAPTER II.

GUNSHOT WOUNDS OF THE HEAD.

WOUNDS of the substance of the brain, and also those of the cranium and scalp, are of a most serious character, and require very great attention and skill on the part of a surgeon engaged in civil practice, but more especially that of a military surgeon.

After an action wounds of the head do not form the greatest proportion of the cases, as very many of them are killed instantly, or die before they can receive medical assistance. Wounds of the head are much more frequent when soldiers are employed in trenches during a siege, or in cavalry engagements, than in action amongst infantry.

These injuries may be divided into

I. Gunshot Injuries producing Concussion or Compression with Contusion or Fracture of the Cranium without depression, and with or without any Scalp Wound.

Concussion.

Compression.

Suppuration.

Necrosis.

Extravasation.

Fracture without depression; also Fissure, or counter-frac

ture.

Fracture of the external table only.

Fracture of the inner or vitreous table only.

II. With Contusion or Fracture of the Cranium, with depression or displacement of both tables.

III. Penetrating or Perforating the Cranium and its contents.

IV. Sabre and Bayonet Wounds.

Simple incised, punctured, or lacerated wounds of the scalp, caused by sabre cut or by the bayonet, but without Fracture of the Skull.

Simple incised, punctured, or lacerated wounds, caused by sabre or bayonet, and with Fracture of the Cranium.

V. Circumstances under which the trephine should be employed.

VI. Operation of Trephining.

VII. Hernia Cerebri.

VIII. Abscesses of the Liver consequent on Gunshot Wounds of the Head.

IX. Treatment of Gunshot Injuries of the Head.

I. GUNSHOT INJURIES PRODUCING CONCUSSION OR COMPRESSION WITH CONTUSION OR FRACTURE OF THE CRANIUM, AND WITH OR WITHOUT ANY SCALP WOUND.

CONCUSSION.

The brain is occasionally merely temporarily disturbed in its function by external injuries, without any appreciable lesion to its structure. Its function is at first impaired, and is ultimately restored, more or less completely, should it escape inflammation of the membranes or substance.

The entire brain undergoes a number of vibrations and momentary compressions, of various degrees of amount, in every case of concussion where the cranium remains entire, and without any depressed portion of bone. Concussion may be either caused by a direct blow on the head, or from falling on the feet, the shock being communicated to the brain. The circulation and functions of the brain are generally only suspended for a short time, but on some occasions the patient remains insensible for several hours. The concussion may be so severe as

be

to cause instant death, although on post-mortem examination no lesion of structure can be ascertained; or the brain may found soft and pulpy, and yet no rupture may be discerned; or the accident may be so severe as to cause a very distinct rupture of the cerebral substance.

In any severe injury of the head causing concussion the surface of the body is cold, the patient lies motionless and insensible, or only answering when spoken to, pulse feeble, pupils contracted and sphincters relaxed, and muscular power lost; this is the first stage, viz., depression marked by feeble circulation and insensibility, which generally lasts from a few minutes to two or three hours, and occasionally proves fatal. The second stage commences by the re-establishment of the circulation, the pulse becoming stronger and the surface warmer; vomiting generally takes place, which greatly assists the patient in regaining his consciousness. The third stage is that of extensive reaction with inflammatory symptoms. In some severe cases the patient remains for hours in the first stage, and as if completely moribund, and finally he either recovers slowly or death takes place at once from failure of the heart's action, or it may terminate in inflammation of the membranes or substance of the brain, which is called the third or inflammatory stage. On some occasions an irritable state of the brain remains, rendering the patient liable to be easily excited by any excess in living, and frequently terminating fatally within twelve months, or even more, after the injury. In other cases the memory, speech, hearing, and vision are very much impaired, or perhaps there is amaurosis or squinting. When the injury is inflicted upon the posterior part of the head, there may be loss of the muscular and virile powers.

The treatment is very different in the three stages of concussion, and also according to its severity.

In the first stage we assist reaction, if need be, by giving some slight stimulant, or remain, in many cases, a passive spectator, waiting for reaction and consciousness to take place. When there is great depression, warmth should be applied to the surface, and friction over the chest and abdomen, and, if necessary, stimulant enemata, &c. As soon as reaction is established we stop these restorative measures and trust more to the effort of nature.