At the present day one is naturally not very familiar with a large

series of suppurating compound fractures, but during my whole experience

I have never seen so many cases of what might be regarded as fairly pure

instances of acute osteo-myelitis. The symptoms corresponded with the

main seat of the suppuration; only moderate swelling of the limbs

occurred, this mainly consisting in soft superficial oedema; often

there was no redness, and fluctuation was difficult to determine. At the

same time symptoms of constitutional infection, such as continued fever,

rapid pulse, restlessness, loss of strength, progressive anæmia, and

emaciation, were marked. Pyæmia, as evidenced by secondary deposits,

was, however, rare; I only saw two cases, both in fractures of the

femur; in both recovery followed secondary amputation.

_Prognosis._--This depended almost entirely on the nature of the injury

to the soft parts; given moderate injury to these, and the preservation

of the wound from infection, scarcely any degree of injury of the bones

precluded recovery, even if this were slow and prolonged. The existence

of perforations scarcely increased to an important extent the gravity of

a wound of the soft parts alone; in fact, this injury could not be

regarded as more severe than an ordinary surgical osteotomy, putting the

risks of infection of the wound under the special circumstances on one

side.

With regard to the functional results, these depended on the degree of

comminution; when this was extreme, union was slow and for a time weak,

and shortening was often considerable, but a fair result was as a rule

obtained.

Suppuration and osteo-myelitis were the dangerous features when they

occurred; still, even in the presence of these, I never saw a fatal

result in an upper extremity fracture, although in the lower extremity

a considerable mortality followed fractures both of the leg and thigh,

the deaths being most commonly from septicæmia, or from a combination of

this with secondary hæmorrhage.

_Treatment._--The general treatment was of a simple character. The

perforations may be at once dismissed, since nothing more was needed

than what has been already described under the heading of wounds of the

soft parts. Again, with regard to the co-existence of vascular injury,

or injury to the soft parts generally, the ordinary rules guiding us in

civil practice were followed.

The first point of importance, and needing consideration in the

treatment of severely comminuted fractures, was as to whether in these

it was better simply to try to obtain union of the wound with as little

disturbance as possible, or to anæsthetise the patient and explore the

wound, removing such fragments as were free or widely displaced. I think

the answer to this question depends entirely on the nature of the

external wounds. If these be of the small type forms, or if the exit

aperture is, at any rate, of only moderate size, a strictly conservative

attitude is the better when the risk of making an exploration under the

circumstances is borne in mind, the more so as an exploration, to be

safe and useful, ought to be done at once. If the exit wound is of the

large or explosive type, on the other hand, there is no doubt that the

best results are to be obtained by early exploration and the removal of

all loose fragments. I saw several excellent results obtained in this

way, even when the patients had to undergo the risk of transport

shortly, in some cases the very next day, after the operation. The loose

fragments are an immediate source of danger, and later may interfere

with the healing of the fracture, even if suppuration does not occur. In

all the cases that I saw the exit wound was dressed, but left freely

open, and I do not think any attempt to close it should ever be made.

The question of operative fixation rarely needs consideration; it

occasionally happens, however, that oblique fractures, such as one

mentioned on p. 166, are met with, in which screwing or wiring of the

bone ends is advisable. What has been said above as to fractures,

accompanied by loss of continuity, applies equally to cases of severe

wedge-fracture, where many loose fragments exist.

As to the disinfection of the limb, primary cleansing, mainly by soap

and water, of course precedes the exploration, and when the latter has

been carried out a second cleansing and disinfection, preferably with

spirit and carbolic acid lotion, are imperative.

Immobilisation is a more difficult problem. In practised hands

plaster-of-Paris splints answer most requirements except in the case of

the thigh; but the splints take time to apply and also to set firmly,

and, as sometimes needing frequent removal, are not altogether suitable

for Field hospital work. Of all the splints I saw in use, I think the

best were wire splints, and the Dutch cane folding splints for the thigh

and leg (figs. 56, 58); wire-gauze splints with steel at the margins

(fig. 54), or strips of ordinary cardboard applied with some variety of

adhesive bandage for the arm and forearm; and plain wooden of various

lengths for any situation.

A question of constant difficulty was that of frequency of dressing; in

a Stationary or Base hospital this is not difficult, as the same surgeon

has the patient continuously under his charge, and can readily decide as

to the proper moment for the renewal of the dressing. When the patient

is, however, being moved from the Field to the Stationary hospital, and

thence to the Base, a constant succession of surgeons has the case in

hand for short periods, the movements during transport disturb the

fixity of the dressing, and, in consequence, dressings are apt to be far

more frequent than is advisable. This question raises the larger one of

the advisability of _any_ transport beyond what may be an actual

necessity. There is only one answer to this. No fractures of the thigh

or leg, and few of the arm, can be transported for any distance without

material disadvantage. The risks attendant on disturbance of the

fracture and tissue injury, septic infection as a result of slipping of

the dressing and the impracticability of efficiently renewing it, far

more than counterbalance any advantage to be gained from the superior

comforts available at a Base hospital. For these reasons, if possible,

all fractures of the arm, thigh, or leg should be kept at a Stationary

hospital for a period of three or more weeks, and, as far as splints and

appliances are concerned, these should be as numerous and complete as at

a Base hospital. I have had a useful set made of aluminium. A word will

be added later as to the splints suitable for different regions of the

body.

The necessity for _primary amputation_ chiefly depends on the nature of

the injury to the soft parts, less commonly on the extent of the injury

to the bones, and should be decided on exactly the same lines as in

civil practice. So-called intermediate amputations are always to be

avoided if possible; the results were consistently bad, and the

operation should only be undertaken in cases of severe sepsis where

little can be hoped from it, or for secondary hæmorrhage. When the

operation could be tided over until the septic process had settled down

and localised itself, secondary amputation gave very fair results. In

either intermediate or secondary amputation for suppurating fractures,

it was necessary to bear in mind the special likelihood of the existence

of extensive osteo-myelitis. If this condition affected the upper

fragment, an amputation was of little use unless the whole bone was

removed, as septic infection continued and brought about a fatal issue,

or a fresh amputation was required in order to obtain a stump that would

heal.

SPECIAL FRACTURES

_Upper Extremity._--Fractures of the _scapula_ were not uncommon, but

were mostly of the perforative variety; thus perforations both of the

spine in longitudinal wounds of the back, and of the ala in perforating

wounds of the thorax, were tolerably frequent. They possessed little

practical interest; as a rule, the openings were not large, and the most

unexpected feature was the small interference with the movements of the

bone on the chest wall that resulted. It might be assumed that

comminuted fragments would project into the muscles and cause both pain

and interference with movement; but neither was the case. I saw grooving

of the crest of the spine, but never happened to meet with a fracture

of the acromion process. Many axillary tracks passed in the closest

proximity to the coracoid, but this again I never saw separated. One

practical point of importance with regard to the scapula was the

frequency with which bullets lodged in the venter, or the firmly

bound-down muscles of the supra- and infra-spinous fossæ. These retained

bullets often gave rise to remarkably little trouble in this situation;

thus I have a skiagram of a shrapnel bullet lying in the deepest part of

the subscapular fossa, which did not inconvenience its possessor.

[Illustration: FIG. 53. Head of Humerus, showing broken perforation. The

roof forms a hinged covering to a groove.]

Every variety of _fracture of the clavicle_ was met with, even

perforation of the most compact portion of the shaft; comminuted, wedge,

or notched fractures were, however, the more common, and were

accompanied by the development of very large masses of provisional

callus during the process of healing. An interesting skiagram is

reproduced in plate III., which shows a compound form of injury to the

clavicle. The bullet has passed obliquely beneath the acromial end,

rising to perforate the posterior compact margin, and producing one of

the diamond-shaped openings sometimes occurring in compact bone with the

passage of bullets at a low rate of velocity. No case of perforation of

the subclavian vein by comminuted fragments of the clavicle came under

my notice.

_Fractures of the humerus_ of every variety were common, and I think

when the statistics of the campaign are published, it will be shown that

the humerus was the most frequently injured individual bone in the whole

body. I remember to have seen thirteen fractures of the shaft of the

humerus in one pavilion alone at Wynberg after the battle of Paardeberg.

Perforations of the upper articular extremity were common, and as a rule

gave rise to wonderfully little trouble in the shoulder-joint. The outer

aspect of the head of the humerus is a common situation for the

production of a special form of broken canal or groove (fig. 53). The

slope from the greater tuberosity to the shaft naturally favours the

production of the injury in this position.

I saw only one case in which a vertical fissure extended from a fracture

of the shaft into the shoulder-joint; in this case the transverse

solution of continuity was at the upper part of the middle third of the

bone. Skiagram, plate IV., illustrates a well-marked stellate

comminution of the shaft with large fragments. Plate V. shows extreme

comminution with fragments blown out of the wound. Two plates, Nos. VI.

and VIII., illustrate well the difference resulting from the oblique

passage of a bullet at high and low rates of velocity respectively. In

both cases good results were obtained; in the more severe the resultant

mass of ensheathing callus was very large, temporarily interfered with

flexion of the elbow-joint, and consolidation was very slow (see plate

VII.). The patient was wounded at Belmont in November 1899, but he was

able to row at the end of the summer of 1900, although very prolonged

suppuration occurred, and the elbow movements became practically normal.

Plate IX. illustrates a transverse track, the bullet having undergone

considerable injury during its passage through the bone, as evidenced by

the presence of fragments both of mantle and lead in the limb. This

might be called an example of transverse fracture, and illustrates the

nearest approach to one seen when the bone is struck fairly plumb.

[Illustration: PLATE IV.

Skiagram by H. CATLING

Engraved and Printed by Bale and Danielsson, Ltd.

(24) COMMINUTED FRACTURE OF THE HUMERUS

Range about '300 yards.'

The wound track took a directly antero-posterior course. Impact

rectangular. The musculo-spiral nerve was completely divided.

The plate affords a good example of the so-called 'butterfly' fracture.

Two long doubly wedge-shaped lateral fragments, and pointed extremities

to both main fragments, are shown.

The fracture healed well, with the deposition of a large mass of

provisional callus. The musculo-spiral nerve was united by suture some

three months later.]

Plate VIII. exhibits an oblique fracture of the lower part of the shaft

produced by a bullet passing at a low rate of velocity. It does not

widely differ from a perforation, and the illustration possesses some

further interest as showing the deviation of a bullet likely to occur

when a bone lies in its course. Although the velocity with which this

bullet was travelling must have been very low, when the bone had been

traversed the deviation in its course was slight. A few bony fragments

from the compact tissue of the posterior surface of the humerus have

been carried into the distal portion of the track.

Fractures of the various prominences of the lower articular extremity

were not uncommon, but deviated little from the types with which we are

familiar in civil practice; the after results were good, both as to

union and movement of the elbow.

Explosive wounds of the soft parts were not infrequent in the arm, and

fig. 48, p. 158, exhibits an extreme example. The humerus in respect of

depth of covering, however, comes between the femur and the bones of the

leg and forearm; hence such injuries were not so easily produced as in

the latter segments of the limbs.

In connection with the subject of fractures of this bone, one word must

be added as to the occurrence of the most characteristic of its

complications, musculo-spiral paralysis. This was frequent in every

position of the fracture, and came on either immediately, or, at a

subsequent period, as a result of callus irritation or pressure. Its

frequency is only what would be expected when the nature of the fracture

is considered, but the chief interest of the condition lay in the

difficulty of certainly detecting it in the initial stages of the cases;

this depended on the fact that in many of them the local shock to the

limb was so severe that the function of the whole of the muscles was

lowered, or in some cases, although the musculo-spiral was the nerve

chiefly affected, the other large trunks had also suffered concussion or

contusion. In consequence of this difficulty the actual localised

paralysis often only became evident at the end of a week, or even more,

when there was difficulty in deciding as to whether the paralysis was

primary or due to secondary trouble. In the fracture illustrated by

skiagram, plate IV., the nerve suffered complete division, and was

united some three months later, improvement in the symptoms being very

slow. The latter was a common experience, and although not unusual in

civil practice, I think it is more marked in these injuries as a result

of the more widespread character of the nerve lesion.

[Illustration: PLATE V.

Skiagram by H. CATLING.

Engraved and Printed by Bale and Danielsson, Ltd.

(25) COMMINUTED FRACTURE OF THE HUMERUS

Range '50 yards.' Velocity extreme.

Impact somewhat oblique. The bullet entered anteriorly about 3 inches

above the elbow crease. The wound of exit was on the inner aspect of the

arm and explosive in character; it still measured 4 inches by 2 inches

three weeks after the injury was received.

The wounds suppurated locally, but at the end of six weeks fair union of

the bone had taken place and the wound of exit had contracted to a

sinus. The musculo-spiral nerve was concussed, but not divided.

The skiagram was taken three weeks after the reception of the injury.

Comparison with plate IV. demonstrates the effect of high velocity in

free comminution of the bone, the sharper radiation of the stellate

lines of fracture, and the propulsion of bone fragments.]

The _bones of the forearm_ were also often fractured. The principal

peculiarity of these fractures was the common localisation of the injury

to one bone, which is readily seen to be probable.

Each bone offered some special features dependent on its structural

character and anatomical position. In the case of the _ulna_, pure

perforation of the olecranon process, without obvious evidence of

implication of the elbow, was seen on several occasions. The other

important feature with regard to this bone depends on its subcutaneous

position, which accounted for the frequency with which highly developed

explosive exit wounds were met with. One is figured in the general

section (fig. 47, p. 156). This, however, is a very slight instance

compared with what was often seen in the upper and middle thirds of the

bone, where the lateral soft parts often protruded as a much larger

tumour, the particular illustration being mainly designed to show the

nature of the injury to the skin. The _radius_, as more deeply placed in

the upper part of its course, was less often the seat of such

well-marked explosive injuries; but when the lower end was struck this

character was sometimes very striking: thus in a track passing

antero-posteriorly through this bone, the whole lower end appeared

shattered, all the tendons at the back of the wrist being implicated in

the protruding mass, while the bone itself seemed shortened, so that the

hand took up the position common in Colles's fracture. It was found

impossible to place the bone in good position; nevertheless the patient

retained his hand, which is still of use in writing.

Plate X. is a good example of a high-velocity injury in which lateral

contact with the radius has produced local comminution, some slight

injury to the casing of the bullet, and the separation of a large wedge.

The case from which this was taken also illustrated well one of the

chief troubles of such fractures of the forearm; the degree of

splintering resulted in the formation of a large mass of callus, which

for a time rendered any degree of pronation and supination impossible.

[Illustration: PLATE VI.

Skiagram by H. CATLING.

Engraved and Printed by Bale and Danielsson, Ltd.

(26) COMMINUTED FRACTURE OF THE HUMERUS

Range '250 yards.'

Impact oblique. Wound of entry 1 inch below the insertion of the

deltoid; exit, on inner aspect of arm at a slightly lower level. The

bullet probably struck the bone laterally, and drove out the central

fragment.

Prolonged suppuration resulted, but the humerus healed well, and good

movement of the elbow was preserved.

The effect of oblique impact together with high velocity is well

illustrated. Had the resistance been greater, as in the case of the

femur, a nearer resemblance to the effect seen in plate XV. would have

been the result.]

Of _fractures of the hand_ I have little to say. In the case of the

_carpus_, the slight degree of resistance offered by the bones rendered

injuries of an explosive character rare. I never saw one. Fractures of

the _metacarpus_, on the other hand, presented exactly the opposite

features. The density of these small bones was well illustrated by the

frequency with which the bullet suffered injury, even amounting to

fragmentation, and the great comminution they themselves suffered. The

breaking up of the bullet in these fractures was a curious feature,

which may perhaps be explained by the tendency of the distal part of the

limb to be driven in the course of the bullet, with the result of

somewhat lengthening the period of contact of the projectile, or more

probably by somewhat frequently occurring irregular impact. Plate XI. is

a good example of an injury of this nature of moderate severity. The

soft parts suffered much in these injuries, the tendons were torn and

lacerated at the moment, and were very apt to acquire more or less

permanent adhesion. This latter condition was sometimes to be improved

by the removal of bone fragments, and I have freed tendons from actual

clefts in the bones where they had been carried in by the bullet. In

some cases very great deformity of the digits, due to shortening,

developed, even when no fragments were removed beyond those blown away

by the bullet.

One form of injury of some interest was multiple fracture of the

phalanges produced by a bullet travelling in a course parallel to the

length of the rifle when pointed by the patient. Occasionally several

digits were lost.

_Treatment of fractures of the upper extremity._--The general lines of

this have already been foreshadowed in the general section, the remarks

as to transport being applicable to all serious fractures of the shaft

of the humerus, and this is the only one of the bones of the upper

extremity on which anything special need be said, as the treatment of

all the other fractures exactly coincides with that of ordinary civil

practice.

[Illustration: PLATE VII.

Engraved and Printed by Bale and Danielsson, Ltd.

(26_a_) CONDITION OF THE SAME FRACTURE SHOWN IN PLATE VI., A YEAR AFTER

ITS PRODUCTION

The ensheathing callus is still very abundant, but less so than at an

earlier date. No trouble with the musculo-spiral nerve was noted, but

residual abscesses occurred from time to time in connection with the

fracture.]

[Illustration: FIG. 54.--German Wire Gauze Splint on steel wire

foundation.

(German Ambulance, Heilbron)]

The treatment of wounds should be on the lines already laid down:

thorough cleansing, and then an attempt to seal. In severely comminuted

fractures, however, the exit wound may be of very large size, and then

frequent dressings are necessary. Loose fragments, by which those freed

from their periosteal connections are meant, need removal. The question

which most interested me was the best method of fixation. This needs to

be sufficient to effect immobility, but on the other hand in many cases

the weight of the arm as a means of extension is very valuable. Some of

the most successfully treated cases that I saw were fixed by means of

simple strips of pasteboard, applied moist, and fixed with an adhesive

bandage. Ordinary book-muslin bandages are as good as anything for this

purpose, as they can be reinforced by a stronger form outside them.

Where necessary, an angular piece of cardboard can be applied on the

inner aspect, or a wooden angular splint may be substituted, if it is at

hand; but in this case most of the advantage of the weight of the arm as

a means of extension is lost. The cardboard cases possess the great

advantage of being readily cut off and reapplied much as is done with

plaster of Paris. During the period in which dressing may be necessary I

believe this form of splint is as good as can be got for use in Field

hospitals, the only point needing care being to ensure that the

bandaging is not too tight. It is much more reliable than are ordinary

splints if transport is unavoidable, and is much lighter and less

irksome to the patient. With such strips of cardboard, a few of the

gauze splints (fig. 54), and a few angular and wooden splints, I believe

a Field hospital is fully equipped for the treatment of any fractures of

the upper extremity.

[Illustration: PLATE VIII.

Skiagram by H. CATLING.

Engraved and Printed by Bale and Danielsson, Ltd.

(27) OBLIQUE FRACTURE OF THE HUMERUS OF THE NATURE OF A PERFORATION

Range more than '1,000 yards.'

The distance was probably much greater, as the bullet was retained and

undeformed, and the comminution of the bone was very slight. The wound

of entry was just below the elbow.

The bullet has cut its way through the inner half of the humerus,

producing little comminution and mere solution of continuity of the bone

without displacement]

_Fractures of the pelvis._--These, as a rule, were of so slight a nature

as to form a very insignificant part of the entire injury with which

they were associated, or when uncomplicated they were of little more

importance than simple wounds of the soft parts. The very great majority

were of the simple perforating type. I had the opportunity of examining

three at the brim of the pelvis, these all passing in a downward

direction. The openings were of about the same calibre as the bullet,

and at their entrance was a small amount of bone dust such as would be

found at the entry hole of a gimlet. It was these that made me consider

the possibility of the rifle grooves having some part in the ease with

which certain perforations are made. Of a large number of cases in which

bullets traversed the ilium, the openings in the bone, as a rule, were

with difficulty palpated. I must say that I was astonished that I never

met with an instance of an extensive stellate fracture in the case of

the ilium. Such may have occurred in some of the cases fatal on the

field or shortly afterwards, but I never came across one in the

hospital. It says much for the combined density and toughness of the

human pelvis.

Comminuted fractures were, however, occasionally met with when the

bullet passed in a track parallel to the plane of the bone. One such of

an unusual character has already been mentioned on p. 171. A still more

interesting form, and one highly characteristic of flat bone injuries,

is shown in fig. 55. The patient, a man wounded at Modder River, was

struck at a range of 300 to 400 yards. The bullet entered over about the

centre of the ilium and emerged in the anterior abdominal wall about 2

inches above the anterior-superior spine. As there was some doubt as to

penetration of the abdomen, and as the exit wound was of considerable

size, the wound was explored, an anæsthetic having been given. A

clean-cut track in the bone was discovered which allowed the middle

finger to be placed in it. There was little splintering of either inner

or outer table of the bone beyond the width of the track, but plates of

each table adhered on the one side to the origin of the gluteus medius,

and on the other to the iliacus, the latter muscle being somewhat widely

separated from the venter ilii by effused blood. There was no

perforation of the abdominal cavity.

[Illustration: PLATE IX.

Skiagram by H. CATLING.

Engraved and Printed by Bale and Danielsson, Ltd.

(28) LOCALISED COMMINUTED FRACTURE OF THE HUMERUS

Range '100 yards.'

The entry and exit wounds were on the front and back aspects of the arm,

about 3 inches above the elbow.

Fragmentation of the mantle of the bullet has occurred. It will be noted

that the fragments are lodged in both the proximal and distal segments

of the track. This may indicate that the bullet was damaged prior to

entry, or the recoil of fragments. I incline to the latter view. The

skiagram was taken a fortnight after the injury.

The large median fragment carried forwards, and the small degree of

comminution, suggest the decrease of resistance and prolongation of

impact by carriage back of the arm when struck.

The fracture is one of the nearest approaches to a transverse cleft that

I met with.

The plate may well be compared with No. XII., where the effect of

increased resistance in augmenting the degree of comminution is seen.]

Lesser degrees of the same kind of injury amounting to grooving of the

surface or notching of the crest of the ilium were not uncommon, and the

occasional large character of exit openings in buttock wounds pointed to

contact of travelling bullets with other parts of the external pelvic

wall.

[Illustration: FIG. 55.--Clean Gutter Fracture of the Ilium (range

placed by patient at 300 yards. Highland Brigade, Magersfontein). The

gutter was clean cut, and admitted the forefinger. The inner and outer

tables of the bone were in part blown out of a large irregularly

circular exit opening about 1-1/2 in. above the crest of the ilium. The

cancellous tissue was probably entirely blown out. Plates of the outer

and inner tables still remained connected by their periosteum to the

deep aspects of the iliacus and gluteus medius muscles. The peritoneal

cavity was not opened. The patient did well. Compare with the gutter

fractures of the skull shown in figs. 64, 66.]

Certain portions of the pelvis were subject to more severe comminution;

thus in one case in which the bladder was wounded, a very much

comminuted fracture of the horizontal ramus of the pubes was produced by

a bullet which subsequently lodged in the thigh behind the femoral

vessels. In this case the track was so oblique as to have necessitated

almost pure lateral impact on the part of the bullet; hence the form of

injury was nearly allied to the comminutions of the ilium already

described.

[Illustration: PLATE X.

Skiagram by H. CATLING

Engraved and Printed by Bale and Danielsson, Ltd

(29) Wedge-shaped Fracture of the Radius

Range 'a few yards.'

The officer shot the man, his assailant, with a revolver. The entry

wound was on the posterior aspect of the forearm at the junction of the

middle and lower thirds. The exit wound was on the anterior aspect of

the forearm, 1 inch below the elbow crease, and of moderate size.

Some fine fragmentation of the mantle of the bullet is indicated, and

very fine comminution of the bone. The fracture healed well, but the

resulting mass of callus at the end of three months prevented any

movements of pronation or supination.]

I never observed a fracture of the floor of the acetabulum by a bullet

which had entered from the back of the pelvis, although tracks entering

by the great sciatic notch were not infrequent. I saw one case in which

a bullet which traversed the upper part of the shoulder and emerged at

the axilla entered a second time an inch behind and above the anterior

superior spine, and split off a layer of the outer table of the ilium of

the extent of two square inches, which involved the upper portion of the

rim of the acetabulum. No displacement upwards of the femur resulted;

but external rotation was accompanied by crepitus. The wound suppurated,

and some general infection resulted, but six weeks later there was no

evidence of fluid in the hip-joint, the limb was adducted and slightly

rotated outwards, and some movement in each direction could be made

without causing any great amount of pain. I can say nothing of the

further course of this case, as I neglected to take the patient's name.

I saw one or two instances of perforation of the sacrum. One is

mentioned in the chapter on injuries to the abdomen, in which a central

puncture at the level of the fourth vertebra was accompanied by

temporary incontinence of fæces.

Fractures of the _femur_ were fairly numerous and formed one of the most

serious classes of case we had to treat, as well as one of the most

fertile sources of mortality in the Base hospitals. In spite of the last

observation, however, it is probable that the results in this campaign

will be far better than in any previous war, both as to the smaller

proportion in which amputation was needed and as to recovery.

[Illustration: PLATE XI.

Skiagram by H. CATLING.

Engraved and Printed by Bale and Danielsson, Ltd.

(30) COMMINUTED FRACTURE OF THE SECOND METACARPAL BONE

Large fragments of the mantle of the bullet.

Fragmentation of the bullet was comparatively common when the metacarpal

bones were struck, also free comminution of a somewhat coarser variety

than that seen when bones offering greater resistance were struck.

This may be a result of the more frequent lateral impact of the bullet

on these small bones.]

In spite of a considerable experience, I never saw a case of perforation

of either the head or neck of the thigh bone. I saw numerous tracks

emerging at the side of the femoral vessels and entering at the buttock

or vice versa, but never one accompanied either by effusion into the

hip-joint or impairment of movement. Considering the regularity with

which hæmarthrosis occurred when the other joints were crossed, and also

the nature of the compact tissue of the neck of the femur, which must

have ensured some splintering, I do not think I can have overlooked an

injury of this nature. No doubt also the escape of the neck of the bone

was explained in some of the cases by the fact that the injuries were

received while the hip-joint was in a position of flexion, the bullet

passing over the neck of the femur. In two cases of extensive

comminution of the upper third of the femur that I saw, the fissures

stopped short at the inter-trochanteric line anteriorly, but in one of

them a large angular fragment was torn out of the posterior surface of

the neck.

Excepting transverse fracture every form was met with in the shaft,

although I saw only two instances of perforation. One has been already

alluded to and was situated in the broadening portion of the lower

third, the bullet taking an antero-posterior course. The second is seen

in plate XVII.

Plate XII. shows an instance of extreme comminution of the upper third

accompanied by the presence of two typical elongated fragments. The

course taken by the bullet was almost directly antero-posterior, and the

wounds were of moderate size even in the case of the exit one. This

seems to preclude the possibility of the injury having been produced by

a ricochet bullet, while the fact of perforation and escape of the

bullet in spite of the serious damage suffered by the mantle points to

the injury having been produced at a short range of fire. The patient

himself owns to being quite unable to give any estimate of the distance.

Although no suppuration occurred, this fracture was very slow in

consolidating, and the free comminution with consequent inaccurate

apposition led to the development of four inches shortening of the limb.

The skiagram was taken about six weeks after the occurrence of the

injury, a few days after I first saw the patient; I have, however, had

the opportunity of seeing a second skiagram taken some four months

later. This is of considerable interest, as throwing light on the mode

of union of such fractures. The two elongated fragments in the later

skiagram are widened to three times their original breadth, and form

buttresses on either side of the point of union, while the irregular

ends of the shaft are rounded off, and the mass of fine fragments behind

is consolidated. Beyond this the second skiagram shows that the upper

fragment, apparently intact in the first, was really split

longitudinally, and therefore was far less useful as a point of support

than might have been assumed from the earlier skiagram, plate XIII. The

case illustrates well the chief difficulty in the treatment of such

fractures: that of maintaining the fragments in line, since absolutely

no help is received from the apposition of the two ends, and artificial

traction alone must be relied upon.

[Illustration: PLATE XII.

Skiagram by H. CATLING.

Engraved and Printed by Bale and Danielsson, Ltd.

(31) HIGHLY COMMINUTED FRACTURE OF THE UPPER THIRD OF THE SHAFT OF THE

FEMUR

Range 'short.'

Impact fairly direct. The wounds were of moderate size and at nearly the

same level. The exit wound near the buttock fold was of moderate size,

and presented no special features.

Considerable fragmentation of the bullet occurred. The comminution of

the bone is very fine, suggesting high velocity, and great resistance by

the bone. The skiagram was taken five weeks after the injury was

received, and at that time no union had occurred.

Reference to plate XIII. will explain more fully the difficulty

experienced in maintaining this fracture in position. The upper fragment

is seen to be split into fragments, beyond the separation of the long

splinter on the inner side; hence no aid was to be obtained from the

apposition of the ends. About 2 inches of the shaft were actually

pulverised; the fine fragments seen in a mass to the inner side of the

bone in the exit portion of the back, eventually formed a large mass of

callus, and the fracture united, with considerable shortening.]

Plate XIV. offers a good contrast; the fracture here presents a typical

stellate form, and a good result without shortening was readily

obtained. I assume that the difference in character of these two

fractures depended mainly on the rate of velocity with which the bullet

was travelling, since it passed fairly directly across the limb in each.

I think it is clear, however, that the bullet struck the femur rather

nearer the centre of the width of the shaft and therefore more directly,

in the more severe injury.

This brings me to the question of explosive exit wounds in the thigh. In

spite of the great tendency to comminution of the shaft, these were rare

in a severe form. This depended simply on the depth and thickness of the

coverings of the bone, and, as already mentioned, although the skin

openings were often comparatively small, a large cavity or area of

destroyed soft tissues may be contained within the limb. I do not think

I ever saw an exit wound in the thigh exceeding 1-1/2 inch in diameter.

The oblique fracture illustrated by plate XVI. has been already referred

to, and the influence of the weight and movement of the trunk on its

production has been considered.

Plate XV. illustrates an obliquely comminuted fracture of another

character. The bullet has here been stripped of its mantle, which has

undergone fragmentation, but the leaden core is little altered in shape.

This is of much interest, since it shows that the bullet struck the bone

by its side. The effect of such lateral impact on the part of the

projectile is well shown: there is great bone comminution of a less

regular character than usual, and the bullet is retained. Retention in

this case was probably not a result of low velocity of flight, but of

the increased resistance offered by the broad area of bone struck, and

the check exerted on the axial rotation of the bullet by the lateral

contact.

[Illustration: PLATE XIII.

Engraved and Printed by Bale and Danielsson, Ltd.

(31_a_) THE FRACTURE SHOWN IN PLATE XII., SIX MONTHS AFTER RECEPTION OF

THE INJURY

The amount of callus furnished around the loose fragments is very

striking.

The upper end of the bone is shown to have been divided into at least

two fragments, hence one of the difficulties of maintaining the ends in

apposition. The stoppage of the fissuring short of the epiphysis is

characteristic.]

Slighter injuries to the femur in which the shaft was chipped or grooved

without loss of continuity were not uncommon, and showed well the

capacity of the bone to withstand the lateral shock transmitted by small

bullets. Two figures inserted in the chapter on wounds in general (figs.

22, 23, pp. 61, 62) are of cases in which, from the appearance of the

wound of exit, the bullet probably underwent deformation, or was so

deflected as to escape on a considerably altered axis. Beyond the nature

of the exit wound in the case depicted in fig. 22, some thickening

beneath the femoral vessels denoted bone injury, but unfortunately no

skiagram was taken.

I saw no case in which a transverse fracture of the shaft accompanied

such injuries, but am under the impression that, if they had been

produced by bullets of greater volume and weight, transverse solution of

continuity would have been more common. In point of fact, no case of

pure transverse fracture of the femur ever came under my notice.

The diagram depicted in fig. 51, p. 164, is from a sketch made of the

lower end of a femur in which a severely comminuted fracture followed by

suppuration necessitated an amputation of the thigh, performed by Major

Lougheed, R.A.M.C. It is inserted as an illustration of the tendency of

the fissures to stop short above the actual articular extremities of the

bones. In this case the comminution was extreme and accompanied by the

usual long lateral fragments, one of which measured five inches in

length and might well have extended into the knee-joint had that been an

ordinary occurrence.

Perforations of the lower extremity of the bone were very common. These

were sometimes transverse and limited to the articular extremity itself,

or the same limitation occurred to the antero-posterior tracks. These

were the slightest forms of injury, putting on one side incomplete

tunnels and grooves on the surface of the bone. With regard to the

latter, however, when they invaded the joint cavity the injury was

liable to be more severe than a complete perforation, in consequence of

the projection of comminuted fragments into the joint cavity near the

line of reflection of the synovial capsule and ulterior interference

with freedom of movement.

[Illustration: FIG. 55_a_.--Diagram of 'Butterfly' type.]

[Illustration: PLATE XIV.

Skiagram by H. CATLING.

Engraved and Printed by Bale and Danielsson Ltd.

(32) TYPICAL STELLATE (BUTTERFLY) COMMINUTED FRACTURE OF THE FEMUR

Range 'short.'

Wounds small, impact direct, very little fine comminution. The bone

united without shortening of the limb.]

Other tracks took a direction of longitudinal obliquity, and then

implicated both epiphysis and diaphysis. Fig. 52, p. 169, shows an

example, and also the peculiarity likely to be assumed by the exit

aperture in the bone, especially if the bullet was travelling at a low

rate of velocity, a considerable plate of the compact bone being driven

out. In some cases these oblique tracks involved both femur and tibia.

They will be referred to again under the heading of injuries to the

joints, and some remarks will also be found there regarding the synovial

effusion so often occurring into the knee-joint in cases of fracture of

the shaft of the bone.

It may be of interest to insert here a few remarks as to the clinical

characteristics of fractures of the femur. First with regard to the

primary signs and symptoms. A very considerable degree of general or

constitutional shock usually accompanied them, and this was perhaps more

constant than in the case of any other injury in the body. This was,

moreover, no doubt increased by the unfavourable conditions in which

patients on the field of battle are situated in regard to transport.

When the patients were brought into hospital some delay in the primary

treatment was often necessary until reaction took place. Local shock to

the part was also a prominent feature. Abnormal mobility was very free

in the badly comminuted cases. Crepitus was often loose, and of 'the bag

of bone' variety. The result of local shock and consequent flaccidity of

the muscles was to reduce the development of primary shortening; in some

cases of severe comminution this was practically nil during the first

day or two, when, with return of tone in the muscles, it sometimes

became very considerable. Swelling of the limb was often very great, and

vascular injury definitely far more common than in the fractures of

civil practice, in consequence, no doubt, not only of the number and

sharpness of the fragments, but also of the force with which they were

driven into the surrounding tissues. The exit segment of the track was

out of all proportion in size to the entry, as a result of the

propulsion of bone fragments through it. This often made the closure of

the exit wound a very protracted event, the track continuing to

discharge a small quantity of bloody serum and fragments of necrosed

tissue for many weeks.

[Illustration: PLATE XV.

Skiagram by H. CATLING.

Engraved and Printed by Bale and Danielsson, Ltd.

(33) COMMINUTED FRACTURE OF THE FEMUR

Range 'short.'

Normal entry wound of slightly oval form.

Oblique lateral impact on the part of the bullet, the mantle of which

burst into numerous fragments. The bullet is seen to the inner side of

the shaft, almost devoid of its mantle, and little deformed at the tip.

The comminution of the upper portion of the fracture is very fine; the

bullet has merely cut its way down the lower portion, and one or two

long fragments are separated. The skiagram shows well the result of

lateral impact by the side of the bullet.

Compare this plate with No. VI. as illustrating lesser resistance, and

No. VIII. as illustrating the effect of lower velocity.]

In a large proportion of the cases which were transported for any

distance suppuration occurred; this must have been the case in at least

60 per cent. of the fractures. Suppuration was of the character already

described in the general section, affecting particularly the bone

itself, and accompanied by very marked signs of general infection.

_Prognosis in fractures of the femur._--As regards mortality fractures

in the upper third of the bone proved one of the most formidable

injuries which came under treatment. Suppuration was common, at least 60

per cent. of the wounds becoming infected. This depended on several

reasons, often inseparable from the injuries, or from their treatment in

Field hospitals: such as (1) the exit wound being situated in the

dangerous region of the thigh; (2) ineffective dressing and fixation;

(3) the impossibility of ensuring primary cleansing and removal of

detached fragments of bone; (4) the necessity of the early transport of

patients to the Stationary or Base hospitals, often for great distances;

(5) the comparatively long period that often had to elapse before the

opportunity of doing the first efficient dressing arrived.

Fractures in the middle and lower thirds of the bone were more easy to

treat successfully, but these also added to the list both of amputations

and fatalities.

Punctured fractures of the lower articular extremity were usually of

little importance, as they progressed without exception, as far as my

experience went, favourably.

I can give no idea of the general results obtained during the whole

campaign, but I am able to state the results of the fractures of the

shaft treated at No. 1 General Hospital during my stay in South Africa.

Thirty-two cases of fracture of the shaft of the bone came under

treatment, and of these 6 or 18.7 per cent. needed amputation, and of

the whole number 5 or 15.6 per cent. died. To emphasise the satisfactory

nature of these figures I need only quote the results attained in the

American War of the Rebellion; mortality in upper third, 46 per cent.;

middle third, 40.6 per cent.; lower third, 38.2 per cent.

[Illustration: PLATE XVI.

Engraved and Printed by Bale and Danielsson, Ltd.

(34) OBLIQUE FRACTURE OF THE SHAFT OF THE FEMUR

Range '300 to 400 yards.'

Aperture of entry just above the centre of the outer aspect of the

thigh. Exit, about 2 inches lower, at the junction of the inner and

posterior aspects. The bullet was retained just within the wound, and

when removed the mantle fell off in two parts. The leaden core was

mushroomed. The bullet had passed through another soldier previous to

entering the patient's thigh. Only two small fragments of the mantle

were retained, as seen in the skiagram. These were in the substance of

the great sciatic nerve, and were subsequently removed by Sir Thomas

Smith.

It is difficult to determine how the bone was struck; reference to plate

XXI. would suggest that the shaft may have been perforated, but no

evidence of this remains in the skiagram taken, which was five months

later.

The patient was standing at the moment of reception of the injury, and

the obliquity of the fracture no doubt depended on his fall and the

resulting influence of the weight of the body. The length of the

fracture cleft was 9 inches.]

I need hardly dwell upon the difference between the nature of the

injuries received in the American War of the Rebellion and in the

present campaign, as in the former the old large bullets were employed,

and shell injuries are possibly included; but I ought to add in this

relation, that the numbers quoted from No. 1 General Hospital included,

to my knowledge, at least three severe Martini-Henry wounds.

The first element for a favourable prognosis is a small wound, and

opportunity for an efficient primary treatment of the same; the second

the absence of necessity for transport of the patient. With regard to

the second of these requirements, we were unfortunately situated in

South Africa, and the majority of the cases which did badly were moved

during the first few days and for a distance of between five and six

hundred miles. On the other hand, as a rule, the external wounds were

small.

As to functional result, the fractures did well. I think an average of

an inch and a half would well cover the shortening, and in many the

length was little altered. Considering the serious nature of many of

these fractures, this was good.

_Treatment._--In all punctured fractures of the lower extremity,

dressing of the wounds like uncomplicated ones and a short period of

immobilisation were all that was necessary. In oblique fractures, and

those with slight comminution, closure of the wound by dressings, after

it had been carefully cleansed, was all that was necessary prior to

applying the splints for immobilisation.

[Illustration: PLATE XVII

Skiagram by H. CATLING.

Engraved and Printed by Bale and Danielsson, Ltd. (35) PERFORATION OF

THE SHAFT OF THE FEMUR. FLAP OF BONE RAISED AT THE APERTURE OF EXIT IN

THE POPLITEAL SURFACE OF THE SHAFT.

Range 'over 1,000 yards.'

Compare with fig. 52, p. 169.]

In the highly comminuted fractures a more radical treatment was

indicated, especially if the exit wound was large. In these, after

careful preliminary cleansing of the limb, the wounds, especially the

exit aperture, needed exploration and, if necessary, enlargement, and

all free splinters needed removal. If interference with the entry wound

could be avoided, this was always preferable, as it was rare for this

not to heal by primary union unless free suppuration occurred. Under

Field hospital conditions I think the exit wound should never be

sutured, whatever its situation; and in the present campaign, where

carbolic acid lotion was freely used, this step was manifestly

inadvisable, in view of the abundant serous discharge always to be

expected when this disinfectant has been employed. Except in cases

manifestly infected at the time of exploration, the use of drainage

tubes or plugs is not to be recommended. I would point out also that in

the majority of cases it is quite hopeless to attempt to make the entry

wound the safety-valve for drainage, as its natural tendency, even if

enlarged, is to heal, while the condition of the tissues in the exit

segment of the track usually renders primary union an impossibility.

The wound having been dealt with, the next indications were for the

reduction of deformity, immobilisation of the limb, and the provision of

a proper degree of extension. As to the reduction of the fracture, this

was always a matter of ease, needing only slight axis traction. The

provision of efficient means of extension and immobilisation was a very

different matter. These questions had to be considered under two sets of

conditions: (1) when it was possible to keep the patient at rest in the

hospital he was first deposited in; (2) when it was necessary for him to

be transported for a considerable distance, probably not less than 500

miles.

When transport is a necessity, the best method of immobilisation is the

application of breeches of plaster of Paris, and a long outside splint.

The latter we often had excellently made on emergency by the Ordnance

Department or the Royal Engineers. A perineal band is the only form of

extension possible under these circumstances. The Dutch ambulances were

provided with a very excellent emergency splint for cases of fractured

thigh, which is illustrated in fig. 56. I think something of this kind

should be carried in one of the ambulances going on to every field of

battle, as being far more suitable than a long outside splint for hasty

and inaccurate application. This splint, fixed with some kind of firm

bandage, is an excellent temporary one for use during transport.

[Illustration: PLATE XVIII.

Skiagram by H. CATLING.

Engraved and Printed by Bale and Danielsson Ltd.

(36) OBLIQUELY TRANSVERSE FRACTURE OF THE PATELLA

Range 'short.'

The entry and exit wounds were small, and a distinct grooving from loss

of substance of the bone was palpable superficial to the actual cleft of

the fracture.]

[Illustration: FIG. 56.--Dutch Cane Field Emergency Splint for Thigh or

Lower Extremity. (Dutch Ambulance, Winberg)]

In cases which can be treated at a Stationary hospital near at hand, a

long outside splint supplemented by plaster breeches, and a well-applied

American extension, is a very good method of treatment, the only point

to bear in mind being frequent examination of the position of the limb

to ensure the extension being efficient. As already mentioned, the

shortening in the primary stages is often slight and easily combated,

but in many of these cases if examined in a few days the limbs are found

to have shortened considerably, principally as a result of recovery of

tone by the muscles, and the absence of any help from the resting of the

two fragments end to end. The weight, therefore, has often to be

progressively increased and the fracture readjusted if necessary.

Although this method of treatment is satisfactory in cases with a small

wound, it is very troublesome to carry out, even when a bracket is

inserted opposite the wound, when frequent dressing is necessary, as is

generally at first the case when the wounds are large. For this purpose

a much more satisfactory method is the use of Hodgen's splint. This

allows of automatic adjustment of the degree of extension, and the

dressing of the wound without interference with the position of the

fracture. A continuous many-tailed bag is preferable to the strips

usually employed for the suspension of the limb, as more easily

adjustable and as offering a more even support to the limb.

[Illustration: PLATE XIX.

Skiagram by H. CATLING.

Engraved and Printed by Bale and Danielsson Ltd.

(37) OBLIQUE COMMINUTED FRACTURE OF THE TIBIA

Range '600 yards.'

The entrance wound was large and the exit also. The fracture may have

been caused by a Mannlicher (8 mm.) soft-nosed bullet, or possibly a

ricochet. The fragmentation is somewhat coarse at the periphery, but

very fine in the track of the bullet. Several fragments of the mantle

are visible.

The fracture affords a good example of obliquity due to cutting by the

bullet, and contrasts well with those due to rectangular impact such as

are shown in plates IV. and XIV.]

While at Orange River, in conjunction with Major Knaggs, R.A.M.C., and

Mr. Langmore, we treated several cases of fracture of the shaft of the

femur by this method. The splints were made for us by the Ordnance

Department, while the Royal Engineers erected a kind of gallows for us

down the centre of a commissariat marquee in order to avoid the risk of

using the tent poles for suspension. The patients were then ranged on

each side of the tent in two rows so that the pull of the two sets of

limbs opposed each other on the gallows from which they were suspended.

Although these patients had to lie on the ground, they were really

comfortable compared with those treated with long outside splints, and

the results obtained were very good: in three cases which I had the

opportunity of measuring later the bones were in good position and the

shortening was less than one inch.

I have no doubt whatever that Hodgen's splint is by far the best method

of treating all cases of fractured thigh in the Stationary field

hospitals; and, more than this, I believe it is the only practicable and

efficient one. It can be applied without the use of an anæsthetic

without causing undue suffering to the patient, it allows of ready

change of the dressing, it is comfortable and permits considerable range

of movement on the part of the patient, it is as efficient with patients

lying on the ground as in a bed, it keeps the limb in good position and

allows of constant inspection on this point, and it is the only method

which provides satisfactory extension without constant readjustment.

[Illustration: PLATE XX.

Skiagram by H. CATLING.

Engraved and Printed by Bale and Danielsson Ltd.

(38) TRANSVERSE FRACTURE OF THE TIBIA, COMMINUTED FRACTURE OF THE FIBULA

Range '300 yards.'

Wound of soft parts nearly transverse, entry on tibial aspect. The

bullet crossed and grooved the posterior aspect of the tibia, but struck

the fibula full. This is the only instance of a transverse cleft which

came under my notice.

The wound suppurated, and a number of fragments of the fibula needed

removal; hence the amount of callus present.]

Cases in which operative fixation is indicated are rare, but a few

oblique fractures may be treated with advantage in this manner if the

conditions surrounding the patient admit of it. Screwing is generally

preferable to wiring.

Lastly, we come to the cases in which primary amputation is necessary. I

may say at once that I saw no case of wound from a bullet of small

calibre in which this was indicated, and only one shell injury in which

it was performed. I believe with small bullets that injury to the main

blood-vessels is almost the only indication which is likely to be met

with, and this by no means always indicates an amputation. First of all

the question arises as to whether the wound in the vessel is caused by a

bone fragment or by the bullet itself; reference to the chapter on

blood-vessels would seem to prove that a bullet wound is by no means a

necessary indication for amputation. Given favourable conditions, it

might be treated locally by ligature at the time, while if hæmorrhage is

not proceeding, developments should be awaited before proceeding to

amputation. In the case of bone fragment punctures, secondary hæmorrhage

is a more likely indication for amputation than primary.

Broadly, it may be laid down that very extensive injury to the soft

parts is the only indication for primary amputation beyond primary

hæmorrhage, and it may be added that the condition is rare with wounds

from small-calibre bullets. If a primary amputation is necessary the

observations as to the transport of fractured thighs are equally

applicable. I never saw a primary amputation do well that was moved

during the first week; sloughing of flaps or hæmorrhage followed as a

rule, and often death.

Intermediate amputations were indicated in cases of septic infection and

those of hæmorrhage; they seldom did well, and should be avoided if

possible. Secondary amputations for sepsis or hæmorrhage were attended

by fair results, but I can give no statistics. Unless extensive

osteo-myelitis is evident, or very widespread cellulitis of the limb

exists, I am strongly of opinion that the amputations when the fractures

are above the middle of the thigh should be through the fracture, and

not at the hip-joint, even if a subsequent secondary operation is

risked.

[Illustration: PLATE XXI.

Skiagram by H. CATLING.

Engraved and Printed by Bale and Danielsson, Ltd.

(39) PERFORATION OF THE SHAFT OF THE TIBIA, AND INCOMPLETE OBLIQUE

FISSURE EXTENDING FROM THE LOWER PART OF THE OPENING TO THE CREST OF THE

BONE.

Range medium. Entry and exit wounds at same level.

The patient was standing when struck, and fell backwards, his rifle

falling at the same time and striking the shin. The fibula is intact.

The perforation indicated by the well-marked translucent spot is small.

The forking of the lower extremity of the cleft suggests the starting of

the fissure from above. The fissure comes to the surface at the seat of

election, but its position may possibly have been determined by the blow

from the falling rifle.

The backward fall of the patient clearly explains the mechanism of

production of the fissure, and throws light on the production of an

oblique fracture such as shown in plate XVI.]

_Fractures of the patella._--Punctured fractures of the patella were

common with direct impact of the bullet; these were often difficult to

palpate, and were only to be certainly diagnosed by attention to the

direction of the track, and the development of hæmarthrosis. I saw at

least three or four in which the bullet, in addition to traversing the

knee-joint, injured the popliteal vessels. I have notes of one case in

which a bullet traversed the soft parts from above downwards and scored

a vertical groove on the surface of the patella; this was readily

palpable, but produced no solution of continuity. In several cases the

margin of the patella was notched by a passing bullet.

I never saw a case of stellate fracture, and by this my experience in

the case of the ilium was confirmed.

On two occasions I saw pure transverse fractures of the bone; in each

the wound was produced by a Lee-Metford bullet. This is of some interest

as denoting that the greater volume and weight, in conjunction with the

blunter tip, of the Lee-Metford may produce more severe injury to the

bones than the Mauser. I believe this to be the case, given an equal

degree of velocity on the part of the bullet at the moment of impact;

but it is probable that the position of the patella with regard to the

condyles of the femur when struck is of far greater importance in

relation to the production of transverse fractures. The skiagram

represented in plate XVIII. shows an obliquely transverse fracture,

which in this instance resulted from a crossing bullet, which grooved

the surface of the bone.

With regard to the two cases of transverse fracture above referred to, I

may add that one occurred in a youth under twenty, and a good result was

obtained by treatment with splints, and later by massage. In the second

the patient was a man over fifty, who had received other injuries. The

wound over the patella healed and some union had occurred, when the

patient fell and burst both the bone union and the skin cicatrix.

Secondary suppuration of the knee-joint, necessitating an amputation of

the thigh, followed, but the patient made a good recovery. The third

case also did well.

[Illustration: PLATE XXII.

Skiagram by H. CATLING. Engraved and Printed by Bale and Danielsson,

Ltd.

(40) NOTCH FRACTURE OF THE CREST OF THE TIBIA

Range 'short.'

The raising of the margins of the notch suggests a perforation. Compare

with figs. 51 and 57 in the text.]

The treatment of these injuries differed in no way from that adopted in

civil practice, given satisfactory surroundings. Suture might be

indicated in some cases of transverse fracture, but this would only be

necessary if the fragments were widely separated. The punctured

fractures needed treatment as for simple wounds, combined with a short

period of rest and pressure for the condition of hæmarthrosis. It was

important not to prolong the period of rest beyond a week or ten days if

the effusion was slight, in view of possible ulterior interference with

range of movement in the knee-joint.

_Fractures of the tibia._--Some remarks have already been made regarding

fractures of the head of the tibia, and the importance of the

overhanging prominent margins in the production of somewhat irregular

injuries (p. 170). Putting these peculiarities on one side, the

cancellous ends are subject to the type forms of injury; thus

perforations either of the head of the bone or the malleolus were common

injuries. The fractures of the shaft also deviated from the type in so

far as the broad flat surfaces in the upper two thirds of the bone

rendered it especially liable to the results of lateral impact, and to

the production of the extreme wedge-shaped types of fracture. Plate

XXII. illustrates the different result of a bullet striking the dense

and strong spine at a low rate of velocity, a notch only resulting. If,

on the other hand, the lateral surfaces were struck, a wedge with the

base corresponding to the posterior surface was the most common injury,

the spine in many cases remaining intact and maintaining the continuity

of the bone. Wedge-shaped fractures of this bone were apt to show

multiple secondary wave fissures concentric with the main line, and

consequently free comminution. I saw several examples, the loose

fragments being remarkably numerous. Plate XIX. is an example of an

oblique fracture produced by a bullet which has ploughed across the

bone, displacing large fragments anteriorly, but finely comminuting the

bone in its course, and leaving small fragments of the mantle on its

way. Plate XX. is an example of the rare condition of transverse

fracture.

[Illustration: PLATE XXIII

Skiagram by H. CATLING.

Engraved and Printed by Bale and Danielsson, Ltd.

(41) SPURIOUS PERFORATION OF THE FIBULA

Moderate range, 'about 1,000 yards.'

The injury was caused by an 8 mm. bullet, which entered base foremost

and lodged in the calf. The fracture is really an incomplete stellate

form, two well-marked transverse fissures extending from the point

struck. The position of the bullet suggests its entry into the limb base

foremost, and as it is retained low velocity may be assumed.]

This fracture was produced by a bullet travelling at a high rate of

velocity, which struck the posterior surface of the tibia, and caused a

grooving, accompanied by a horizontal fissure through the whole

thickness of the bone; later it struck the fibula more directly, and

produced an ordinary comminuted fracture two inches above the malleolus.

Perforations of the shaft were far more common than in the case of the

femur, and I saw them in every part of the length of the bone (plate

XXI.). Fig. 57 illustrates a form of peculiar interest as showing the

gradual transition of the tunnel to the groove, and also as bringing

fractures of the long bones into line with such fractures of the flat

bones of the skull as are depicted in fig. 68.

[Illustration: FIG. 57.--(42) Perforation of lower third of Tibia,

showing lifting and fissuring of the compact roof of the tunnel. Compare

with fig. 68, p. 259, of a fracture of the cranial vault.]

_Fractures of the fibula_ offered no special features of importance. Any

form might occur. The plate No. XXIII. is of interest as showing a

spurious form of perforation, and also the primary form of displacement

of the fragments in stellate fractures. It was produced by a reversed

ricochet, but undeformed, bullet, still seen in position in the

skiagram; the bullet only possessed sufficient force to perforate the

bone, and then appears to have turned on its transverse axis. The

following plate, No. XXIV., is inserted to show the depth at which the

bullet lay, and its distance from the surface of the tibia, which

appears in the first plate to be nil. It is also of interest as showing

the ease with which a false impression may be obtained from a single

picture, as, beyond a spot of transparency, no obvious injury to the

fibula, and certainly no displacement, is discernible.

[Illustration: PLATE XXIV.

Skiagram by H. CATLING.

Engraved and Printed by Bale and Danielsson, Ltd.

(41_a_) This skiagram is inserted to show the depth at which the bullet

lay from the surface. It is also interesting to note the insignificance

of the fracture of the fibula from this aspect. Without the second

skiagram the injury might have passed for a simple perforation or a

transverse fracture.]

Fractures of the bones of the leg possessed an unenviable degree of

importance. First, on account of the very severe injuries to the soft

parts that often accompanied them, without an apparently correspondingly

serious damage to the bone. Secondly, on account of the frequency with

which the vessels were implicated in these injuries to the soft parts,

either by the bullet or bone fragments. Beyond this, fracture of either

articular end of the tibia was certainly more frequently followed by

troublesome joint complications than occurred in the case of any other

bone.

In the matter of 'explosive' injuries, I think more were seen in the

calf of the leg than in any other part of the body, and this often

without solution of continuity of the bones, and sometimes without

evidence even of contact of the bullet with either tibia or fibula. Some

remarks on this subject have already been made in the chapter on wounds

in general, and some sources of fallacy exposed. I believe that in

practically all these so-called explosive injuries the wound was either

caused by a ricochet, or a bullet which deformed with great ease on bony

contact during its progress through the limb. A considerable number of

the wounds which were referred by the men to the use of expanding

bullets were probably the result of the use of Martini-Henry or large

leaden sporting bullets, and evidence of this was often forthcoming on

examination of the entry wounds. In other cases the irregularity of the

opening plainly pointed to ricochet of a small bullet as the explanation

of the character of the injury. The greater frequency of ricochet

injuries in the leg and foot when the men were standing is readily

understood.

Concurrent injury to the vessels of the leg was common, but primary

hæmorrhage, as was the case generally, usually ceased spontaneously. The

importance of injury to the vessels was rather in view of secondary

hæmorrhage, which occurred with some frequency, and I think more

commonly from the anterior than the posterior tibial vessels, usually

occurring at the end of a week or ten days, and naturally most

frequently in cases which suppurated.

_Prognosis and treatment in fractures of the leg._--In fractures of the

leg, except those of extreme severity, almost any form of splint

sufficed to maintain the bones in position, but for field purposes the

Dutch cane splint (fig. 58, p. 222) was certainly very convenient. For

later use in cases that needed frequent dressing, a wooden back splint,

with a foot-piece, or, if obtainable, a Neville's splint with a

suspension cradle, was the best. Where the wounds were small and

frequent dressing was not required, nothing was so good as plaster of

Paris, especially when transport was a necessity.

[Illustration: FIG. 58.--Dutch Cane Field Emergency Splint for Leg]

In cases with large wounds suppuration was very frequent, and in

connection with this secondary hæmorrhage, or in the case of fractures

near the articular ends, especially the upper, joint suppuration. The

treatment of these cases varied: in many an amputation was the best or

only treatment advisable; but I several times saw good results follow

ligation of the anterior tibial artery for secondary hæmorrhage, even

when suppuration existed, and occasional good results after incision

and drainage of joints if the infection was not of the most acute form.

Primary amputation was rarely needed for any case of injury from a

bullet of small calibre, since it was only necessary either in the case

of injury to both main arteries, and this was rare, or in cases of very

extensive injury to the soft parts. I saw many of the latter make fair

results when treated conservatively, even though the condition seemed

almost hopeless at first sight. All the primary amputations that I saw

were either for shell or large bullet injuries. A word may be inserted

here as to the weight that ought to attach to nerve injuries in this

relation. From the experience gained elsewhere it is clear that we

should attach little importance to these unless the divided nerves are

actually in sight, as far as deciding on amputation is concerned. On the

other hand, there is little doubt that the presence of concurrent nerve

injury, be it only concussion or contusion, exerts an important ulterior

influence on the healing of the wound, whether the part be amputated or

not. Amputation flaps in such cases possess a very considerably lowered

degree of vitality.

Secondary amputations were often needed for sepsis, and on the whole did

very well; both for the same cause and for hæmorrhage intermediate

amputations had occasionally to be performed; the results of these, as

elsewhere, were bad.

_Fractures of the tarsus._--Wounds of these short bones were as a rule

of slight importance, given fairly direct impact on the part of the

bullet. They then consisted of either simple perforations or surface

grooving. A single bone might be implicated or several might be

tunnelled; in the latter case the implication of the joints very

considerably influenced the prognosis, since the addition of the joint

injury caused much more prolonged weakening of the foot.

Wounds of the foot were common from the fact that when the men lay out

in the prone position, the foot was often the part least protected by

the cover chosen, and particularly the heel. In these circumstances the

os calcis was the bone most frequently implicated, and that by tracks

taking an oblique course downwards from the leg to the sole. Again the

foot was often struck by ricochet bullets, as a result of its position

when the erect attitude was assumed. The latter fact was of much

importance with regard to the nature of the injury sustained by the

bones, as under these circumstances the mode of impact was irregular,

and consequently comminution was often produced.

The behaviour of the different bones of the tarsus varied somewhat. On

the whole the prognosis in cases of injury to the os calcis was the

best, since the injury was more often individual and did not implicate

any joint, and also because of the comparatively regular architecture of

the bone. In the smaller bones concurrent injury to a joint was more

frequent. In the astragalus the central hard core extending upwards from

the interosseous groove, as increasing resistance, I think accounted for

the fact that comminution was more marked in this bone than in any

other. The effect of wound of bones of the tarsus in producing a certain

degree of laxity in the mediotarsal joint resulting in a slightly flexed

position of the fore part of the foot and some projection of the head of

the astragalus did not seem to me easy of explanation, but it occurred

with some regularity.

The injuries to the _metatarsus_ corresponded so nearly to those already

spoken of in the case of the metacarpus that they need no further

mention. They were less common, however, and I am under the impression

that fragmentation of the bullet was not such a marked feature, probably

on account of the lower degree of density of the bones, and their

greater fixity of position.

FOOTNOTES:

[18] Col. W. F. Stevenson. _Loc. cit._ p. 69.

CHAPTER VI

INJURIES TO THE JOINTS

Until recent times gunshot injuries of the joints formed a class

entailing the gravest anxiety to the surgeon, both in regard to the

selection of primary measures of treatment and in the conduct of the

after progress of the cases. The external wounds were severe,

comminution of the bones was great, and retention of the bullet within

the articulation was not uncommon. Operative surgery therefore found a

large field in the extraction of bullets, removal of bone fragments,

excision of the joints, or even amputation of the limbs.

The introduction of bullets of small calibre has robbed these injuries

of much of the importance they possessed in earlier days and during the

present campaign direct clean wounds of the joints were little more to

be dreaded than uncomplicated wounds of the soft parts alone. No more

striking evidence of the aseptic nature of the wounds, and the harmless

character of the projectile as a possible infecting agent, than that

offered by the general course of these injuries in this campaign, is to

be found in the whole range of military surgery.

The aseptic nature of the wounds, and the slight and localised character

of the bone lesions, have in fact justified the opinion previously

expressed by Von Coler, that these injuries in the future would be less

feared than fractures of the diaphyses of the bones.

Not less important than the localised character of the bone lesion

itself is the fact that the accompanying wounds of the soft parts retain

the small or type forms. Thus I occasionally observed more troublesome

results from minor shell wounds in the neighbourhood of joints, but not

implicating the synovial cavity, than in actual perforating injuries

produced by bullets of small calibre.

_Vibration synovitis._--Before proceeding to the consideration of wounds

of the joints, a short account is necessary of a condition of some

importance which is, I believe, more or less special to injuries from

bullets of small calibre travelling at high rates of velocity. This

condition, if not novel, at any rate excited little comment in the

descriptions of the older forms of injury, although this may have

depended on the more serious nature of the primary local lesions

accompanying wounds from the larger bullets, among which it formed a

comparatively unimportant element.

The condition referred to was the occurrence of considerable synovial

effusion into the joints of limbs in which the articulation itself was

primarily untouched. These effusions sometimes occurred even when the

soft parts alone were perforated, especially when the wounds were

situated above or below the knee-joint. They were apparently the direct

result of vibratory concussion of the entire limb dependent on the blow

received from the bullet.

The effusions were most strongly marked in cases of fractures of the

diaphyses, although this was more noticeable in some situations than

others. Thus with fractures of the shaft of the femur anywhere below the

junction of the upper and middle thirds of the bone, and in some cases

even higher, effusion into the knee-joint was very common, and sometimes

extreme. On the other hand, similar effusions into the hip-joint were

less marked, since I failed to determine their existence in the majority

of cases. I am inclined to ascribe this to the different anatomical

arrangement of the two joints, particularly to the fact that the head of

the femur is included in a bony cup, into the hollow of which it is

accurately fixed by the resilient cotyloid fibro-cartilage. The latter

by its firm grasp of the head allows of little play in the joint; hence

vibrations are conveyed directly to the acetabulum in continuous waves,

and rocking of the articular surfaces is prevented. Beyond this no doubt

the difficulty of detecting small effusions in this joint is an element

which must be taken into consideration.

I do not think that wrenches of the knee-joint in the act of falling

can be suggested as an explanation of the frequency of effusions into

that articulation, since the fractures of the femur were not always

received while the erect position was maintained, and effusion was most

marked when the diaphysis was the part affected, the latter point

illustrating the greater resistance offered by compact bone. Again, when

fracture had taken place, the solution of continuity rendered the

directly injured point the most mobile, and tended to prevent lateral

strain from falling on the joints.

Effusion into the knee or ankle, or sometimes both joints, was common in

fractures of the shaft of the tibia.

In the articulations of the upper extremity the condition was also

common, but somewhat less marked than in the lower limb. Effusions into

the shoulder or elbow occurred. In the former these were less striking;

again, perhaps, as a result of the difficulty of detecting small

effusions in this situation. The elbow was to a certain extent protected

by the possession of a degree of fixity somewhat resembling that already

mentioned in the case of the hip-joint, although here depending on the

conformation of the bones alone. I think this explained the absence of

free effusion in many cases of fracture of the humeral shaft, but when

the latter affected the lower third effusion into the elbow was usually

abundant.

The lighter weight and greater mobility of the upper extremity as a

whole, as decreasing the resistance to the bullet, were also probably an

element in the fact that these effusions were less severe than those in

the joints of the lower limb.

The nature of the effusions was apparently simple, since they were

rapidly reabsorbed, and little thickening of the synovial membrane

remained to suggest either a marked degree of inflammation, or the

deposition of blood-clot on the inner aspect of the same.

The only treatment indicated was a short period of rest, accompanied in

the early stages by pressure and slight fixation, followed later by

massage and movement if necessary.

Before dismissing this subject, I should like to particularly emphasise

the fact, that in the cases described there was no reason to suspect the

extension of fissures from the point of fracture in the shafts into the

articular ends of the bones. This was as far as possible excluded by

clinical examination, and in the cases where wounds of the soft parts

only were present, the rapid return of the patients to active duty, with

absence of remaining joint trouble, negatived the possibility of such

fractures.

I only saw one case in which a longitudinal fracture actually extended

for any considerable distance into a neighbouring joint. In this a

comminuted fracture occurred just above the centre of the shaft of the

humerus. At the time of examination and putting up of the fracture there

was considerable swelling of the whole arm, and nothing special was

noticed about the shoulder-joint. Three weeks later, however, when the

fracture was consolidating, difficulty in abduction of the shoulder was

noted, and the arm could not be placed closely in contact with the

trunk. There was no evident displacement of the head of the humerus

forwards. A skiagram, which I much regret I have not been able to

insert, showed that a longitudinal fissure extended from the seat of

fracture upwards in such a manner as to divide the upper fragment into

two parts, of which the outer bore the greater tuberosity, the inner the

articular surface of the head. The latter fragment had become somewhat

displaced downwards, and had united in such a manner that the head

rested on the lower part of the glenoid cavity. Abduction of the limb

therefore brought the greater tuberosity into contact with the acromion

process, and movement was checked. This case passed out of my

observation shortly afterwards, and I have no knowledge of the final

result as to movement.

Fractures of the bony processes surrounding the elbow-joint, and of the

malleoli of the tibia and fibula, were not infrequent, but offered no

special features.

One other form of injury indirectly affecting the joints is perhaps

worthy of mention, but I observed it only once, and that in the case of

the shoulder, the only joint where it is likely to be marked. I refer to

the displacement of the head of the humerus by the force of gravity,

when the circumflex nerve is injured. In the instance I refer to, a

fracture of the surgical neck of the humerus was accompanied by

complete motor paralysis of the deltoid and very rapid wasting of the

muscle. Circumflex sensation was impaired, but not absent at the time

the condition of the muscle was noted--a favourable prognostic sign of

much importance. At the end of five weeks, when the fracture of the bone

was consolidated, the head of the humerus had dropped vertically at

least an inch, but could be replaced with ease. Shortly afterwards an

improvement in the condition of the muscle commenced, and with this the

head of the humerus was gradually raised. This patient later recovered

his power in great part, but not completely.

In a few cases bullets lodged in the neighbourhood of joints in such

positions as to limit movement by mechanical impact with the bones. Thus

I saw one case in which a bullet lay between the radius and ulna just

below the lesser sigmoid cavity; in another the bullet lay in front of

the ankle-joint, and limited the possibility of flexion; and in a case

related to me by Mr. Bowlby, a bullet was removed by him from the wall

of the acetabulum where it was tightly fixed in the substance of the

bone. In two other cases I saw bullets lying deeply on the anterior

surface of the hip capsule and so limiting flexion. In all such cases

the indication for removal of the bullet was sufficiently strongly

marked.

WOUNDS OF THE JOINTS

These may be divided into several classes, varying much in comparative

severity, and in prognostic importance.

1. The comparatively rare instances in which a wound implicated a joint

cavity, without accompanying lesion of any bone.

2. Perforating wounds in which the bullet was retained within the

articular cavity. These were also rare.

3. Wounds of the joints accompanied by grooving of the articular

extremities of the bones.

4. Complete perforating tracks through the articular ends of the bones,

crossing the joint cavity in various directions.

5. Comminuted fractures of the terminal parts of the diaphyses extending

into joints.

Of these several classes, the first was of the least prognostic

importance. In the absence of bone injury the wounds usually healed

without any obvious ill effect beyond the transient effusion into the

joints of a mixture of blood and synovial fluid. When suppuration of the

wound in the soft parts occurred, however, the remarks made as to the

injuries classed under the third heading also apply here in a lesser

degree.

With regard to the retention of the bullet, in the case of bullets of

small calibre this was a distinctly rare occurrence. I never happened to

see an instance of retention of either a Mauser or Lee-Metford bullet in

an articulation. It is only possible with bullets practically spent, or

travelling at a very low rate of velocity and making irregular impact.

The influence of both volume and velocity of flight was well illustrated

by my own small experience of retained bullets. In one case a

Martini-Henry was found impacted between the femoral condyles, having

slipped in beneath the margin of the patella. It caused a semiflexed

position to be assumed by the joint, and was removed by Mr. Brown in No.

1 General Hospital at Wynberg. The second instance I saw in the Portland

Hospital at Bloemfontein in a patient of Mr. Bowlby's. The bullet was a

Guedes, a form which has been already described as possessing low

velocity and deficient power of penetration; beyond this, in the

particular instance irregular impact was evidenced by the presence of a

large irregular contused wound of entry over the tuberosity of the

tibia.

The presence of the bullet in the knee-joint was later determined by the

X-rays, and Mr. Bowlby removed it successfully. Seven months later the

range of movement was nearly normal.

I may add that I saw several instances of large leaden bullets lodging

in the popliteal space, and a comparatively insignificant number of

bullets of small calibre in the same situation. This was very striking,

in view of the immense relative frequency of use of the latter forms.

There is no doubt, moreover, that small bullets rarely lodge even in the

neighbourhood of joints, unless at the distal end of a long track. To

take the extreme example of large bullets, those employed as shrapnel,

in comparison with the frequency with which wounds were produced by

them, bullets lying at the bottom of short tracks in the neighbourhood

of joints were not uncommon. Thus I saw one lying over the hip-joint,

and another in close proximity to the shoulder capsule.

Wounds of the third class, where the bones had been superficially

grooved, were in some respects the most serious. This was especially so

in the knee and ankle joints, and some cases will be quoted later under

the heading of the special joints to illustrate this point. Danger only

arose in the event of suppuration; and here the presence of the long

oblique superficial track in a neighbourhood liable to comparatively

free movement was the important element. Such tracks usually opened the

synovial sac more extensively than direct perforating wounds, and if

suppuration occurred in any portion of the track, the pus was very

liable to be sucked into the joint on any free movement. The presence of

fine splinters of the bone displaced in the production of the groove was

also a special character of wounds of this class. Another point worthy

of mention is that in these cases it was not always easy to be quite

certain whether the joint cavity had been implicated or not, since cases

often occurred in which, although the bones had been grooved, the joint

cavity escaped. The indication, however, was to consider any wound in

the immediate proximity of a joint as perforating until it was healed.

This course was the more easy to take, since a large proportion of such

wounds were accompanied by some degree of synovial effusion, even when

the neighbouring joint had escaped puncture.

Wounds of the fourth class, although the most highly characteristic of

the form of accident, were in many instances the most favourable in

regard to their course. The tracks might course directly across the

joint in any direction, or they might course obliquely, traversing

either one or both the component bones. In the latter case the exit

might be in the diaphysis, and be accompanied by the separation of an

exit fragment such as is illustrated in fig. 52, p. 169. The

particularly favourable character of the direct transverse and

antero-posterior wounds depended on the slight amount of splintering of

the bones, the limited nature of the opening into the joint, and the

shortness of the tracks in the soft parts, which ensured that, even if

infection did occur, the resulting pus was near the surface, and

generally spread in that direction and escaped.

Wounds of the fifth class were the most dangerous, but the danger was

entirely a secondary one, dependent on the occurrence of infection.

These injuries were liable to be accompanied by the presence of

extensive irregular wounds of the soft parts, in which suppuration was

frequent, and the suppuration of the joint frequently meant subsequent

amputation, if not a worse result.

_Course and symptoms of wounds of the joints._--The immediate result of

any perforation of a joint was the development of intra-articular

effusion. This consisted of synovial fluid admixed with a varying

proportion of blood. The degree of synovitis was apt to vary with the

amount of force expended in the production of the injury; for this

reason both high velocity and irregular impact were of importance in

this relation.

The constant feature, however, depended on the effusion of blood; this

was not rapid, or, as a rule, very abundant, but tended to increase

during the first twenty-four hours. It resulted in a swelling of the

joint, which possessed some peculiar features. At first elastic and

resilient, it slowly decreased in volume with the assumption of a soft

doughy character on palpation. In the case of the knee, where readily

palpated, it very much resembled a tubercular synovial membrane, except

for its extreme regularity of surface; still more closely the condition

noted in a hæmophilic knee of some duration. Absorption took place with

some rapidity, and except for slight thickening, the joints might appear

almost normal, in a period of from two to four weeks. With the

development of the effusion there was local rise in temperature of the

surface, and in a considerable number of the cases a general rise of

temperature.

This latter was sometimes very marked, as in the case of all the other

traumatic blood effusions, but not quite so regular in occurrence. It

was important, as I have seen it give rise to the suspicion of

suppuration, when tapping resulted in nothing more than the evacuation

of turbid synovia mixed with blood. Pain was rarely a prominent symptom

in consequence of the generally moderate degree of distension.

As a rule, these injuries were characterised by the small tendency to

the development of adhesions; but this in great part depended on the

care expended on their treatment. If kept too long quiet, either from

necessity when the effusion was followed by much thickening, or when the

external wound was large and so situated as to be harmfully influenced

by movement, or in the ordinary course of treatment, troublesome

stiffness, even amounting to firm anchylosis, sometimes followed. I saw

several such cases, some of the most confirmed being wounds of the

knee-joint complicated by injury to the popliteal vessels or nerves. The

latter complication I saw altogether six times, but only once with a

thoroughly bad knee, and in this case the injury had affected both the

vessels and the internal popliteal nerve. The joint in that case was

straightened out by continuous extension by Major Lougheed, when it came

under his charge some six weeks after the primary injury, but I hear has

again relapsed, and the popliteal paralysis is not much improved.

The small tendency to formation of adhesions in uncomplicated cases

probably depended on the coagulation of a layer of blood over the whole

internal lining of the joint. This kept the synovial surfaces apart at

the lines of reflection of the membrane, and, given sufficiently active

treatment, mobility was restored before any firm union could take place.

The primary escape of synovial fluid was rarely observed, as the wounds

of the soft parts were too small and valvular to permit of it. Synovia

in some abundance, mixed with pus, sometimes escaped in considerable

quantity when infection had opened up the tracks.

Primary suppuration in any joint as a result of small and direct wounds

was very rare. I observed it only on one occasion. On the other hand, a

considerable number of cases in which secondary suppuration occurred

came under my notice. In some of these the suppuration was secondary to

comminuted fractures of the shaft of the tibia, in which the articular

extremity was implicated. These offered no special peculiarity. In

others infection of the joint was secondary to infection and suppuration

in the deep part of long oblique wound tracks, and these were of

sufficient interest to warrant the insertion of two illustrative cases.

(43) In a man wounded at Paardeberg the bullet entered the leg

to the inner side of the crest of the tibia, about 3 inches

below the tubercle; thence it coursed upwards to emerge about 2

inches above the cleft of the knee-joint on the outer side.

Regulation dressings were applied, and a week later the man

arrived at the Base, with little apparent mischief in the

knee-joint. He was placed in bed and warned against movement;

on the second day, however, he got up and walked to the

latrine. When bending his knee to sit down he was seized with

agonising pain in the joint, and had to call out for help; he

was then carried back to bed in a more or less collapsed

condition. The knee commenced to swell; there was rise of

temperature and great pain, together with extreme restlessness.

I was asked to see him two days later, and after a

consultation, Major Burton, R.A.M.C., freely incised the

knee-joint bi-laterally. One opening was closed, the second

plugged for drainage, as there was a large quantity of pus. No

improvement followed, and a week later Major Burton amputated

through the thigh. An attack of secondary hæmorrhage a few days

later, combined with the degree of septic infection, ended the

man's life. On examination of the joint, a groove forming

three-fourths of a tunnel was found in the external tuberosity

of the tibia, leading into the knee-joint beneath the external

semilunar cartilage. The bullet had then passed upwards over

the outer border of the cartilage, bruised the margin of the

external condyle of the femur in such a manner as to depress

the outer compact layer, and finally escaped from the joint

near the upper reflection of the synovial membrane. The

synovial membrane was granular in appearance and reddened, but

there was no suppuration outside the confines of the joint,

except in a cavity corresponding to 2 inches of the track

before it actually perforated the tibia. A localised abscess

had evidently formed here and been diffused into the joint by

the movement of flexion already described.

(44) A man wounded during General Hamilton's advance on

Heilbron was struck on the outer aspect of the heel. An oval

opening of some size led down to a track in the os calcis; the

bullet was retained. The foot was dressed, and put up later in

a plaster-of-Paris splint. On the tenth day the splint was

removed to see to the wound, which looked satisfactory and was

re-dressed.

A few hours later the man was seized with very severe pain in

the ankle, and a day later I was asked to see him by Mr.

Alexander. The man was anæsthetised, and I examined the wound

with care, and also removed the retained bullet from the inner

margin of the leg. The bullet was reversed, having no doubt

suffered ricochet, hence the large aperture of entry, but it

was in no way deformed. I could not certainly determine the

presence of any fluid in the ankle-joint, and as the pain was

apparently localised to the distribution of the

musculo-cutaneous nerve, I decided not to freely open the

joint. In this, however, I erred, and two days later, after

consultation, the joint was freely incised by Mr. Alexander. It

was then found that the bullet in its passage had just touched

the posterior aspect of the tibia and wounded the ankle-joint.

A localised collection of pus which had formed in the deep part

of the wound had been diffused into the joint by the movements

made when the splint was removed, in a similar manner to that

described in the last case. This joint also did badly, and an

amputation of the leg had to be performed by Mr. Alexander to

save the man's life.

These two cases are particularly instructive as showing, first, how

quietly a small amount of deep suppuration may sometimes take place;

and, secondly, the importance of keeping the joints quiet on a splint

when there is any reason to suspect their implication by wounds of this

character.

_The general treatment_ of the wounded joints was simple. The old

difficulties of deciding on partial as against full excision, or

amputation, were never met with by us. We had merely to do our first

dressings with care, fix the joint for a short period, and be careful to

commence passive movement as soon as the wounds were properly healed, to

obtain in the great majority of cases perfect results. Careful light

massage, if available, was used to promote absorption of blood.

If suppuration occurred, the choice between incision and amputation had

to be considered. In the early stages this choice depended entirely on

the nature of the injury to the bones. If this were slight, incision was

the best plan to adopt. I saw several cases so treated which did well,

although convalescence was often prolonged, and only a small amount of

movement was regained. Amputation was sometimes indicated in cases of

severe bone-splintering, when the shafts were implicated, but was as a

rule only performed after an ineffectual trial to cut short general

infection of the septicæmic type by incision.

I have dwelt at such length on the subject of suppuration on account of

its importance, but I should add that, on the whole, suppuration of the

joints was uncommon, except in the case of injuries far exceeding the

average in primary severity.

_Special joints._--Such deviations from the general type of injury as

above described depended entirely on peculiarities of anatomical

arrangement, and peculiarities in the situation of the joint clefts in

the different parts of the body. A few words as to these are perhaps

necessary.

_Shoulder-joint._--Wounds of this articulation were by no means common.

This depended, I think, on two points in the architecture of the joint:

first, a bullet to enter the front of the cavity and traverse the joint

needed to come with great exactitude from the immediate front; secondly,

wounds received from a purely lateral direction calculated to pierce the

head of the humerus and the glenoid cavity were naturally of very rare

occurrence. Wounds of the prominent tip of the shoulder received while

the men were in the prone position were not uncommon, but it was

remarkable how rarely the shoulder-joint was implicated in these. The

question of the narrow nature of the cleft exposed also comes up in this

position. As far as my experience went, injuries to the lower portion of

the capsule accompanying wounds of the axilla were those most often met

with. The ease and neatness with which pure perforations of the head of

the humerus can be produced was also an important element in the

frequent escape of this joint. No case of fracture of the glenoid cavity

happened to come under my notice.

I saw few instances in which the joint needed incision, and cannot

recall or find in my notes any case in which serious trouble arose.

_Elbow-joint._--Injuries to this joint came second in frequency in my

experience to those of the knee. They were, in fact, comparatively

common, especially in conjunction with fractures of the various bony

prominences surrounding the articulation. Fractures of the lower end of

the humerus were of worse prognostic significance than those of the

ulna, on account of the greater tendency to splintering of the bone. I

saw several cases of pure perforation of the olecranon without any signs

of implication of the elbow-joint. In a case which has been utilised for

the illustration of some of the types of aperture (fig. 20, p. 59), at

the end of a week there was no sign of any joint lesion, although the

bullet had obviously perforated the articulation.

Several cases of suppuration which came under my notice did well. I saw

one of them a few days ago, six months after the injury, with perfect

movement. In another of which I took notes, the bullet entered over the

outer aspect of the head of the radius, to emerge just above the

internal condyle anteriorly. A considerable amount of comminution of the

olecranon resulted, and when the man came into hospital some ten days

later the joint was suppurating. The joint was opened up from behind,

and some fragments of bone removed by Mr. Hanwell. On the 26th day this

joint was doing well, and considerable flexion and extension were

possible without pain. There was a somewhat abundant discharge of bloody

synovia during the first few days after the operation.

[Illustration: FIG. 59.--Illustrates the very neat and limited injury to

the Phalanges over the dorsal aspect of the first inter-phalangeal joint

of the Middle Finger, accompanying a gutter wound received by the

patient while holding a rifle.]

I never saw any troublesome results from perforations of the _carpus_.

The joints of the _fingers_ also offered little special interest,

except in so far as they afforded astonishing examples of the extreme

neatness of the injuries which a small-calibre bullet can produce. Fig.

59 is a good example of such an injury.

_Hip-joint._--I can only repeat with regard to this joint what I have

already said as to the injuries to the head of the femur. I had

practically no experience of small-calibre bullet injuries to the

femoral constituent, and beyond the single case of injury to the

acetabular margin mentioned on p. 193 I saw no obvious wounds of the

joint at all.

_The knee_, as usual, proved itself _par excellence_ the joint most

commonly injured, no doubt as a result of its size, the extent of its

capsule anteriorly, and its exposed position. In spite, however, of the

frequency with which it suffered injury, and the opportunities it

afforded for observation of the progress of the effusions towards

absorption, the injuries to the joint gave less anxiety and attained a

more favourable prognostic character than is the case in civil practice.

This depended on the very favourable course observed in the frequent

pure perforations following a direct line. These occurred in every

direction, the accompanying hæmarthrosis usually disappearing completely

in an average period of little over a month. The extremes can be fairly

placed at a fortnight and six weeks. Limitation of movement was slight

or non-existent in many cases; in others it was of a very moderate

character, and I only remember to have seen one case in which a really

serious anchylosis developed. In this the man was struck from a distance

of 300 yards, and a considerable amount of bone dust from the femur was

found in the lips of the exit aperture. The wounds healed _per primam_,

but when I saw the man two months later anchylosis in the straight

position was apparently complete.

The comparatively frequent association of popliteal aneurisms with

wounds of the knee-joint has already been spoken of in relation to

anchylosis. Wounds of the popliteal space from larger bullets sometimes

caused more troublesome after-stiffness than wounds of the articulation

itself. Again I remember a small pom-pom wound at the inner margin of

the ligamentum patellæ without obvious wound of the joint, which was

accompanied by synovitis from contusion, and was followed by very

considerable limitation of movement. This had only been partially

improved when the patient returned home, in spite of prolonged massage

and passive movement.

The general remarks on the joints cover all that need be said as to

suppuration of the knee-joint.

_The ankle-joint_ maintained the undesirable character which it has

always held as a subject for gunshot injuries. This is entirely a

question of sepsis, and in great measure depends on the fact that the

foot, as enclosed in a boot, is invested with skin particularly

difficult to thoroughly cleanse; while the socks are an additional

source of infection to the wounds before the patients come under proper

treatment.

Of seven cases of suppurating ankle-joint, of which I have notes, only

two retained the foot, and one of these after a very dangerous illness.

This case was one of special interest as exemplifying the results

dependent on variations in velocity on the part of the bullet. The

patient was struck at a distance of twenty yards. The bullet entered the

front of the right ankle-joint and emerged through the internal

malleolus, just behind its centre, causing no comminution of the latter.

It then entered the left foot by a type wound one inch behind and below

the tip of the internal malleolus, traversed and comminuted the

astragalus, and emerged one inch below the tip of the external

malleolus. The first joint healed _per primam_. The second produced by

the bullet when passing at a lower rate of velocity was accompanied by

considerable comminution of the bone. It suppurated, and gave rise to

great anxiety both for the fate of the foot and the life of the patient.

It is probable that the more abundant hæmorrhage which took place from

the second wound was in part responsible for the occurrence of

infection.

The second of the two cases is of some interest in relation to the

doctrine of chances as to the position in which a wound may be received.

The man was wounded in one of the earlier engagements, a bullet passing

transversely through his leg immediately behind the bones and about half

an inch above the level of the ankle-joint. He recovered, and rejoined

his regiment, only to receive at Paardeberg a second wound, about an

inch lower, which traversed the ankle-joint. On his return to Wynberg he

happened to be sent to the same pavilion, and occupied the same bed he

had left on returning to the front.

The subject of the result of wounds of the joints of the _foot_ has

received sufficient consideration under the heading of wounds of the

tarsus.

The repetition of the fact that, among the whole series of cases on

which this chapter is founded, not a single instance of primary or

secondary excision of a joint, either partial or complete, is recorded,

forms an apt conclusion to my remarks on this subject.

CHAPTER VII

INJURIES TO THE HEAD AND NECK

Injuries to the head formed one of the most fruitful sources of death,

both upon the battlefield and in the Field hospitals. It has been

suggested that the mere fact of wounds of the head being readily visible

ensured all such being at once distinguished and correctly reported,

while wounds hidden by the clothing often escaped detection. When the

external insignificance of many of the fatal wounds of the trunk is

taken into consideration this is possible; but, on the other hand, it

must be borne in mind that the head is in any attitude the most

advanced, and often the most exposed, part of the body, and even when

the soldier had taken 'cover,' it was frequently raised for purposes of

observation. For the latter reasons I believe injury to the head fully

deserved the comparative importance as a fatal accident with which it

was credited.

A number of somewhat sensational immediate recoveries from serious

wounds of the head have been placed upon record. Observation, however,

shows that these, with but few exceptions, belonged either to certain

groups of cases the relatively favourable prognosis in which is familiar

to us in civil practice, or that the wounds were received from a very

long range of fire, and hence the injuries were strictly localised in

character.

ANATOMICAL LESIONS

_Wounds of the scalp._--Nothing very special is to be recorded with

regard to these; they either formed the terminals of perforating wounds,

or were the result of superficial glancing shots. The glancing wounds

were of the nature of furrows, varying in depth from mere grazes to

wounds laying bare the bone. Their peculiarity was centred in the fact

that a definite loss of substance accompanied them, the skin being

actually carried away by the bullet; hence gaping was the rule. Every

gradation in depth was met with, but the only situations in which wounds

of considerable length could occur were the frontal region in tranverse

shots, or, when the bullet passed sagitally, the sides of the head, or

the flat area of the vertex.

The danger of overlooking injuries to the bone was of special importance

in the short subcutaneous tracks occasionally met with at the points at

which the surface of the skull makes sharp bends. In all such wounds it

was a safe rule to assume a fracture of the skull until this was

excluded by direct examination. In some of the gutter wounds and

subcutaneous tracks crossing the forehead and sides of the head, signs

of intracranial disturbance were occasionally observed in the absence of

external fracture, such as transient muscular weakness, unsteadiness in

movements, giddiness, diplopia, or loss of memory and intellectual

clearness. In connection with such symptoms the classical injury of

splintering of the internal table of the skull, the external remaining

intact, had to be borne in mind, but I observed no proven instance of

this accident. I am of opinion, moreover, that its occurrence with small

bullets travelling at a high degree of velocity must be very rare, since

little deflection is probable unless the contact has been sufficiently

decided to fracture the external table; while in the cases of spent

bullets the injury is unlikely, as requiring a considerable degree of

force.

_Injuries to the cranial bones, without evidence of gross lesion to the

brain._--It may be premised that these were of the rarest occurrence,

and they may be most readily described by shortly recounting the

conditions observed in a few cases I noted at the time. The injuries

resulted from blows with spent bullets, from bullets barely striking the

skull directly, or those striking over the region of the frontal

sinuses. Wounds of the mastoid process will not be considered in this

connection as being of a special nature (see p. 299).

I saw only one case of escape of the internal, with depressed fracture

of the external, table of the skull.