that the wound of the
chest-wall is responsible for a large proportion of the signs.

The majority of these injuries were accompanied by a certain degree of
systemic shock, and this was more marked in wounds received at a short
range. The shock was, however, rather to be attributed to the injury to
the chest-wall and thoracic concussion than to that to the lung itself.
I think it may also be stated that few patients were inclined to walk
or remain in the erect position after receiving these wounds; this
feature was also noted in horses in whom a bullet passed through the
lungs.

The remarks made as to the pain accompanying fractures of the ribs apply
equally here. Pain was not a prominent symptom, except in so far as the
actual impact caused temporary suffering. It was striking how often
patients who received wounds through the arm prior to the same bullet
traversing the chest appreciated the chest wound only, yet the chest
might pass unnoticed when a still more sensitive part was struck later,
as has been already mentioned in the section on wounds in general.

Dyspnoea was not a prominent primary symptom. The patients sometimes
had 'all the wind knocked out of them' at the moment of impact, but when
seen at the Field hospitals a short time later, the respirations were
shallow, but easy and regular, and only moderately quickened; thus 24
was a not uncommon rate. Naturally if accumulation of blood in the
pleura began early and continued, these remarks do not hold good; and
again in some older men of full-blooded type and the subjects of
recurrent attacks of bronchitis, a considerable degree of pain,
dyspnoea, and even cyanosis was sometimes present soon after the
injury. The complication of wound of the diaphragm has already been
referred to in this relation.

Local respiratory immobility of the thoracic parietes and consequent
asymmetry of movement were constant. This was especially a marked
feature when the upper part of the chest was implicated on one side
only. It rather corresponded, however, to the local shock observed in
wounds of the limbs than to the instinctive immobility accompanying
fractures of the ribs; since, as already explained, small-calibre bullet
wounds of the ribs are not necessarily painful on movement, and the sign
existed even when the bullet had passed by an intercostal space. This
sign was naturally a transitory one.

Haemoptysis was a fairly constant sign, but sometimes quite absent when