 |
When admitted to the Herbert Hospital the patient complained chiefly of pains in the foot and leg. The aneurism was cured by ligation of the vein above and below the communication and proximal ligature of the popliteal artery.[15]
(16) 'Femoral arterio-venous aneurism.—A private of the West Yorkshire Regiment was hit on February 11, 1900, at Monte Christo by a bullet which passed through the inner border of his right thigh above its middle. On arrival at Woolwich the patient was found to have a varicose aneurism at the upper end of Hunter's canal. On May 31 the femoral artery was ligatured just above its communication with the vein, and as this stopped all pulsation in the vein, it was decided to postpone ligature of the latter to a subsequent occasion, if it should ever be necessary; such a procedure would, it was thought, interfere less with the circulation of the limb, and would therefore be less likely to be followed by gangrene, which is so frequent a result of high ligature of the femoral. But a few days after the operation the foot became cold and mummified, and there was no alternative but to amputate the limb through the condyles of the femur. From this operation the patient made a good recovery, and when discharged there was no sign of an aneurism of the vein.'
Case 16 is quoted from a paper in the Lancet by Lieut.-Colonel Lewtas, I.M.S. It illustrates a result with which I became acquainted in three other instances not under my own observation.
ANEURISMAL VARICES
(17) Axillary.—Wounded at Modder River. Entry (Mauser), at inner margin of front of left arm, just below level of junction of axillary fold. Exit, at about centre of hollow of axilla. A month later when the wound was healed a typical thrill and machinery murmur were noticed. The latter was audible down to the elbow and upwards into the neck. The radial pulse appeared normal. No swelling or pulsation existed. At the end of three months the condition was unaltered; the patient said he noticed nothing abnormal in his arm, except that it was sometimes 'sort of numb' at night.
(18) Popliteal.—Wounded at Magersfontein. Entry (Mauser), in centre of popliteal space. Exit, about centre of patella, which latter was cleanly perforated. Three weeks later the typical thickening of the knee-joint following haemarthrosis was present, also a well-marked thrill and machinery murmur in the popliteal vessels with no evidence of a tumour. The leg was normal except for slight enlargement of the internal saphenous vein and its branches, probably independent of the arterial lesion.
(19) Femoral.—Wounded at Magersfontein. Entry (Mauser), 7 inches below left anterior superior iliac spine. Exit, at inner aspect of thigh. One month later slight fulness without pulsation was discovered on the inner side of the femoral vessels just above the level of the wound track. Some blood-staining still remained in the fold between the scrotum and thigh. Machinery murmur and a well-marked thrill, most palpable to the inner side of the superficial femoral artery, were noted. No further symptoms developed and the patient was sent home.
Prognosis and treatment.—No one can help being struck with the disinclination shown by the older surgeons to interference in cases of either aneurismal varix or varicose aneurism, even after the time that ligation of the vessels had become a favourite and successful operation. The objections lay in the technical difficulties of local treatment, and the danger of gangrene after proximal ligature. Modern surgery has lightened the difficulties under which our predecessors approached these operations, but none the less the experience in this campaign fully supports the objections to indiscriminate and ill-timed surgical interference, as accidents have followed both direct local and proximal ligature.
In pure varix no doubt can exist as to the advisability of non-interference in the early stage, in the absence of symptoms. This is the more evident when we bear in mind that a stage in which an aneurismal sac exists can seldom be absent. In many cases an expectant attitude may lead to the conviction that no interference is necessary, especially in certain situations where the danger of gangrene has been fully demonstrated. In connection with this subject I cannot help recalling the first case of femoral varix that ever came under my own observation. I discovered the condition accidentally in a man admitted into the hospital for other reasons. The patient remarked: 'For heaven's sake, sir, do not say anything about that. I have had it many years, and it has never given any trouble. If it is known, I shall be worried to death by people examining it.'
None the less it must be borne in mind that beyond enlargement of the vein dilatation of the artery above the seat of obstruction does occur, and gives trouble in some situations. Again the disturbance of the general circulation already adverted to shows that the existence of this condition is sometimes of importance in its influence on the cardiac action.
Under these circumstances the treatment varies with regard to the vessels affected, and the degree of disturbance the condition gives rise to.
With regard to locality, experience appears to have shown clearly that communications between the carotid arteries and jugular veins usually give rise to so little serious trouble that, in view of the grave nature of the operation and its possible after consequences on the brain, interference is as a rule better avoided. I should, however, be inclined to draw a distinction between operations on the common and internal carotid arteries in this particular, and should regard varix of the latter vessel and the internal jugular vein as especially undesirable for interference.
The vessels at the root of the neck are probably to be regarded from the same point of view, as to surgical interference.
The arteries of the upper extremity are the most suitable for operation, and the axillary may perhaps be the vessel in which interference is most likely to be useful. In this relation it may be of interest to include here a case of a man who took part in the campaign when already the subject of an aneurismal varix of the axillary artery.
(20) Twenty years previously the patient suffered a punctured wound of the left axilla from a pencil. A varix developed, but was only discovered by accident ten years later. The patient was seen by several surgeons, and treatment was discussed; the balance of opinion was, however, in favour of non-interference, and nothing was done beyond giving injunctions as to care in the use of the limb. Up to the time of discovery of the varix no inconvenience had been felt, although the patient was of athletic habits. Subsequently, the patient himself was positive that a swelling existed, but he pursued his usual work. In 1899-1900 he took part in the operations in South Africa as a combatant, and during this time was subjected to very hard manual work. During this he was seized with sudden pain in the left side of the head and neck, and in consequence invalided. No restriction in the movements of the upper extremity, and no subcutaneous ecchymosis developed, but the patient was positive as to the tumour having greatly enlarged.
Four months later the condition was little altered. A pulsating swelling 1-1/2 inch broad existed along the line of the upper two-thirds of the axillary artery, and along the subclavian in the neck, rising some 1-1/2 inch into the posterior triangle. Pulsation was visible; the murmur was audible when sitting beside the patient, and widely distributed over the whole chest, the neck, and upper extremity on auscultation. The pulse rate varied with the mental condition of the patient, which was excitable, between 96 and 120. There was neuralgic pain in the neck and scalp, and down the distribution of the brachial plexus. The pupils were equal, but flushing of the face and profuse sweating followed any exertion. I concluded the tumour in this case to be mainly due to dilatation of the trunk above the point of obstruction on account of its outline, the absence of any restriction of movement in the upper extremity, and the non-occurrence of subcutaneous ecchymosis at the time of the attack of severe pain. Difficulties arose as to undertaking any active form of treatment for this patient, which, to be satisfactory, needed an antecedent period of absolute rest, and he passed from my observation. I think, however, operation by ligature above and below the communication would have been possible. The case affords a good example of the course the condition may sometimes take if precaution is neglected.
The vessels of the arm or forearm may in almost all cases be interfered with, but in many instances an absence of any serious symptom renders operation unnecessary.
With regard to the femoral varices, I would refer to the remarks below, and those on the treatment of varicose aneurism as indicating that a certain amount of caution should be exercised in interfering with them.
The same remarks in a lesser degree apply to the popliteal vessels. In the leg the tibials may readily and safely be attacked, but it may be mentioned that the widespread and diffused nature of the thrill may in some cases give rise to considerable difficulty in sharp localisation of the varix to either of the vessels, or to any particular spot in their course. In one case in my experience the posterior tibial was cut down upon, when the varix was probably peroneal in situation.
The operation most in favour consists in ligation of the artery above and below the varix, the vein remaining untouched. Even this operation, however, in two cases of femoral varix failed to effect more than a temporary cessation of the symptoms, although the ligatures were placed but a short distance from the communication. Failure is due to the presence of collateral branches, which are not easy of detection. Even when the vessels lie exposed, the even distribution of the thrill renders determination of the exact point of communication difficult, and the difficulty is augmented by the temporary arrest of the thrill following the application of a proximal ligature to the artery. A successful case is reported by Deputy Inspector-General H. T. Cox, R.N., in which the ligatures were placed 1/2 an inch from the point of communication.[16] Single ligation, or proximal ligature, is useless.
If the vein cannot be spared, excision of a limited part of both vessels may be preferable, particularly in those of the upper extremity.
Proximal ligation of the artery combined with double ligature of the vein, as adopted in case 15 by Colonel Lewtas for a varicose aneurism, might offer advantages in some situations.
Given suitable surroundings and certain diagnosis, the ideal treatment of this condition, as of the next, is preventive—i.e. primary ligation of the wounded artery. Many difficulties, however, lie in the way of this beyond mere unsatisfactory surroundings. It suffices to mention the two chief: uncertainty as to the vessel wounded, and the necessity of always ligaturing the vein as well as the artery in a limb often more or less dissected up by extravasated blood, to show that this will never be resorted to as routine treatment.
Arterio-venous aneurism.—Many of the remarks in the last section find equal application here, but in the presence of an aneurismal sac non-intervention is rarely possible or advisable. In the early stages the proper treatment in any case consists in placing the patient in as complete a condition of rest as possible, and affording local support to the limb by a splint, preferably a removable plaster-of-Paris case. Should no further extension, or, what is more likely, should contraction and diminution occur, it will be well to continue this treatment for some weeks at least.
When the aneurism has reached a quiescent stage the question of further treatment arises, and whether this should consist in local interference or proximal ligature. The answer to this mainly depends on the size and situation of the vessels concerned. To take of the cases above described the five instances in which the cervical vessels were the seat of the aneurism. In No. 13 the symptoms appeared fairly conclusive of the injury being to the innominate artery and vein, or possibly innominate artery and jugular vein. Fortunately the aneurismal sac in this case was small and showed a tendency to decrease, but in any case no interference would have been justifiable. I think a similar opinion was unavoidable in No. 14, probably affecting the root of the right carotid. Here under any circumstances interference would have been most hazardous. The position of large aneurism made the route of approach to the wounded spot necessarily through the sac, exposing the patient to the double danger of immediate haemorrhage and of entrance of air into the great veins. Nos. 10, 11, and 12 fall into the same category, except that in No. 11 the immediate indication for interference was extension. In each, ligature of the artery above and below the point of communication would have necessitated so near an approach to the sac which must remain in communication with the vein as to have entailed injury to the latter, when both artery and vein must have been ligatured, probably risking serious cerebral trouble. In No. 11 I believe both the external and internal carotids were implicated; in No. 10 I believe the internal alone, close to its origin. The operation of proximal ligature ensured primary consolidation of the sac in both cases 10 and 11, but left the thrill unaltered, except in so far as it was temporarily weakened. It, in fact, converted these cases from arterio-venous aneurisms into pure aneurismal varices. In No. 10 a sac subsequently redeveloped. No. 12 stood on a different basis. No operation was done for him in South Africa, but the first portion of the carotid might have been ligatured in the episternal notch, or by aid of removal of a part of the sternum, and a second ligature placed above the sac. Here a ligature above and below the communication would have been comparatively easy.
As a general rule proximal ligature is to be reserved for those cases alone in which double ligature is either impracticable or inadvisable, and it can only be expected to convert a varicose aneurism into the less dangerous condition of aneurismal varix.
In the case of arterio-venous aneurisms in the limbs the possibilities of treatment are enlarged, and here the alternatives of (a) local interference with the sac and direct ligature of the wounded point, (b) simple ligature above and below the sac, (c) proximal ligature (Hunterian operation), come into consideration.
Direct incision of the sac is suitable, and the best method of treatment for aneurisms in the calf, forearm, and probably arm. Several cases in the two former situations were successfully treated by this method. On the other hand, the only case I saw in which a proximal ligature had been applied for an arterio-venous aneurism of the leg resulted most unsatisfactorily. The sac in the calf suppurated at a later date, and for many weeks the escape of small quantities of blood from the remaining sinus kept up the fear of a severe attack of secondary haemorrhage until the sinus closed.
In the case of femoral and popliteal aneurisms the method of Antyllus is often unsuitable. A case of arterio-venous aneurism of the femoral artery quoted in the Lancet[17] will illustrate the difficulty which may be met with in determining the actual bleeding point in the irregular cavity laid open. In any case the necessary ligature of both artery and vein is a serious objection to the direct method either in the thigh or ham, and more particularly if adopted before the damage dependent on the dissection of the limb by extravasated blood has been repaired.
Proximal ligature (Hunterian) even, offers dangers under these circumstances. In one case with which I became acquainted, it was followed by gangrene, necessitating amputation. The lesion in this instance was a perforating one of the femoral artery and vein.
For either femoral or popliteal arterio-venous aneurisms ligature of the artery above and below the aneurism is the best and safest treatment. In view of the healthy state of the vascular wall in most of these cases, the advantage of placing the ligatures as near to the wounded spot as can be managed without interference with the sac is afforded. A number of popliteal cases treated in this way did perfectly. In the femoral cases a considerable period of rest to allow of consolidation of the sac, and readjustment of the circulation, should always be allowed to elapse.
In the case of popliteal arterio-venous aneurisms a number were successfully treated by proximal (Hunterian) ligature, and by single ligature immediately above the sac. In a considerable proportion of the latter both artery and vein were tied. This was apparently the result of the difficulty of isolating the vessels in the tangled mass of clot and cicatricial tissue surrounding them, and is a strong argument against too early interference. The late Sir William Stokes expressed himself as in favour of ligature of the artery in Hunter's canal, combined with that of the great anastomotic branch, and quoted some successful cases to me. I have grave doubts, however, whether the varix can often be permanently cured by this operation.
I can give no useful statistics on this subject, but with regard to the popliteal aneurisms I may state that in three instances gangrene of the leg followed early operative interference in the popliteal space.
My own opinion on this subject is strong, and to the effect that none of these operations should be undertaken before a period of from two to three months after the injury, unless there is evidence of progressive enlargement. In every case which came under my own observation progressive contraction and consolidation took place up to a certain point under the influence of rest. When this process has become stationary, and the surrounding tissues have regained to a great extent their normal condition, the operations are far easier, and beyond this more likely to be followed by success.
It appears to me that one argument only can be raised against the above opinion, viz. the possibility of healing of the recent wound in the vessels when the force of the circulation is lowered by proximal ligature. Such experience as that quoted from Sir W. Stokes and two of Mr. Ker's cases, mentioned below, support this possibility, but in all the reported results were recent. Against them I can only advance my knowledge of several mishaps following early operation.
In concluding these observations on injuries to the arteries and aneurisms, a few general remarks as to the occurrence of gangrene after operation must be added. This was not uncommon, and in the main was no doubt attributable—(1) to the lowering of the vitality of the surrounding tissues by creeping blood extravasation, and sometimes to actual pressure by the extravasation on the vessels necessary for the establishment of the collateral circulation. (2) To the frequency with which both artery and vein required to be ligatured.
Beyond these common causes, however, others must be advanced, dependent on the general and local condition of the nervous system in these cases. In general mental state many of the patients were much shaken, and in others the condition spoken of as local shock in a former chapter had been marked. In a third series obvious individual nerve lesions were co-existent with those to the vessels. Beyond this a fourth nervous element of unknown quantity, the effect of the form of injury on the vaso-motor nerves accompanying the great vessels, must be taken into consideration.
I believe all these factors were of importance, since it appeared to me that gangrene occurred more often than I should have expected. In one case which I have heard of, gangrene followed a very slight injury to the foot in a patient who had apparently made an excellent recovery after ligature of the femoral artery.
The nervous factor seems another element in favour of reasonable delay in active interference with traumatic aneurisms of the above varieties in the absence of threatening symptoms.
It is worthy of remark that no case of gangrene due to aneurism came under my notice, except subsequently to operation.
Since the above chapter was written, my friend, Mr. J. E. Ker, has sent me his experience in the treatment of four aneurisms, which is of such interest that I insert it as an addendum.
Arterial haematomata.—(1) Popliteal, treated by local incision. Both artery and vein completely divided. Ligature of the four ends. Cure. (2) Traumatic aneurism of upper third of forearm. Treated by rest and pressure by bandage. On the eighth day pulsation and bruit ceased spontaneously, and the remains of the sac steadily consolidated until the man's discharge on the twenty-sixth day.
Arterio-venous aneurisms.—(1) At junction of brachial and axillary arteries. Proximal ligature. Cure. (2) Arterio-venous aneurism at the bend of the elbow. Ligature of the brachial at the junction of the middle and lower thirds of the arm. Cure.
FOOTNOTES:
[14] The murmur is still present at the expiration of one year, but no other change.
[15] Lieut.-Colonel Lewtas, I.M.S. See Lancet, 1900, vol. ii. p. 1073.
[16] Lancet, 1900, vol. ii. p. 1074.
[17] Sir W. MacCormac, Lancet, vol. i. 1900, p. 876.
CHAPTER V
INJURIES TO THE BONES OF THE LIMBS
Injuries to the bones of the limbs formed a very large proportion of the accidents we were called upon to treat, and afforded as much interest as any class, since they possessed many special features. I shall hope to show, however, as in some of the other injuries, that these features differed only in degree from those exhibited by injuries from the old leaden bullets of larger calibre, although with few exceptions they were of a distinctly more favourable character.
It is of considerable interest to note that, taking the fractures as a whole, there was a somewhat striking change in their nature during the earlier and later portions of the campaign. In the earlier stages I think there is no doubt that punctured fractures were proportionately more common than in the later, when comminuted fractures were much more often seen. There was, I believe, a source of error in this opinion, as far as I myself was concerned, in that the first cases I saw were at Capetown and had come from Natal. There is no doubt that the punctured fractures were earlier fit to travel, and hence a larger number of them found their way to the Base hospitals at a period when the comminuted fractures were still in the Field or Stationary hospitals. I do not, however, rely on the cases seen at Capetown alone for my opinion, as while at the front I saw the same large proportion of clean punctures in the early engagements of the Kimberley relief force.
I am inclined to attribute the change to two reasons: first, I believe that the use of regulation weapons was more universal in the earlier part of the war, while later, as more men were engaged, the Martini-Henry came more into evidence, and the Boers took more freely to the use of sporting rifles and ammunition. Another element also in the less clean punctures of the short and cancellous bones was probably the less accurate and hard shooting of the Mauser rifles as they became worn; the bullets seemed to evidence this by the comparative shallowness of their rifle grooves, which, I take it, would mean less velocity and accuracy in flight. This would be of importance, since the clean puncture of cancellous bone was no doubt favoured by a high rate of velocity.
The special features of the fractures caused by the small-calibre bullets were: (1) The nature of the exit wound, which in a certain proportion of the cases exhibited the so-called 'explosive' character. (2) The presence, in a marked degree in the severe cases, of the condition spoken of in Chapter III. as 'local shock.' (3) The striking contrast of clean perforation and extreme comminution in different cases. (4) The occasional occurrence of fractures of a very high degree of longitudinal obliquity. (5) The rarity of any that could be termed transverse fractures. (6) The general tendency of longitudinal fissuring when it occurred to stop short of the articular extremities of the bones.
It will perhaps be most convenient to consider first the explanation of the development of the so-called explosive apertures, and then to pass on to a general consideration of the types of fracture commonly met with, before proceeding to the description of the injuries to the separate bones.
Explosive wounds in connection with fractures.—The aperture of entry in these injuries presented little or no deviation from the normal, unless it was due to the passage of ricochet bullets, when it might be very irregular, but usually not of great size.
The aperture of exit offered special features beyond simple increase in size. First of all, as in the small type wounds, the actual extent of destruction of the skin was small, this having been projected outwards by the passing bullet and then either burst or torn by the bullet and accompanying bony fragments. Fig. 47 well illustrates this feature. A triangular tongue of skin was lifted by the passing bullet and probably by the lower end of the upper fragment of the fractured ulna; through the resulting opening a mass of soft tissues and bone fragments, bound together by an infiltration of coagulated blood, was extruded, separating the lateral lips of the aperture, while the original tongue has shortened and retracted up to the top of the wound.
The small extent of skin actually destroyed is an important element in the rapid contraction often seen in these wounds when they progress favourably. Thus the large wound portrayed in fig. 48 contracted to one-fourth its original size ten days after the diagram and measurements were made. The large mass of protruded tissue was often most striking when a muscle such as the biceps in fig. 48 had been divided; but the herniae were more persistent when the mass projected in regions where tendons formed a large integral constituent, as at the wrist or lower third of the forearm. The protruding tissues naturally consisted of many varieties, according to what lay in the track of any particular wound.
It should be added that for 'explosive' features to reach their strongest development, it is necessary that the bone affected should lie near the surface of the body; hence the most characteristic explosive wounds were met with in the forearm or leg, over the metacarpus or metatarsus, or in the arm. In the thigh, on the other hand, where the femur in a great part of its course not only lies deeply, but is also protected by particularly strong and resistent skin and fascia, another type of wound was met with. The explosive exit aperture, although large, was still only moderate in extent, sometimes, as in the front of the lower third, exposing a somewhat angular large track walled by the divided quadriceps extensor cruris. In other cases, on introducing the finger through a moderate exit opening on the inner aspect of the thigh, a large cavity, sometimes 4 or 5 inches in diameter, was discovered, full of clot and shreds of destroyed tissue and lined by a layer of similar material. In either of these latter cases the fractured bone ends were situated too deeply to take part in the actual laceration of the skin, while the force transmitted to the bone fragments, although sufficient to cause them to widely destroy the first soft tissues met with, did not suffice to cause them to burst or lacerate the skin widely.
With regard to the theories of the production of these phenomena, that of the transmission of a part of the force of the bullet to the comminuted fragments, which thus themselves acquire the characters of secondary projectiles, seems quite adequate.[18] Examination of any of the skiagrams in which considerable comminution has taken place, shows that the fragments are carried forward and perforate the tissues distal to the fracture.
Fig. 49, although a poor delineation of the actual condition, shows well the possible action of projected fragments, even after they have been driven from the wound. In this case either a large or a ricochet bullet entered on the outer aspect of the upper third of the left tibia; it produced a severe comminuted fracture, the fragments from which, together with the deformed bullet, then struck and perforated the upper third of the right tibia. A large irregular entry wound 5 inches in transverse diameter was produced in the second limb together with a comminuted fracture of the bone. The right limb had eventually to be amputated for secondary haemorrhage, but I am unacquainted with the later history of the patient.
The mode of displacement of the lateral fragments when a wide shaft such as that of the femur is struck, throws some light on that of the displacement of soft tissues such as the component parts of a perforated nerve or artery. The bullet, passing through, expends the chief part of its energy in driving before it the fragments produced in its direct course, while a minor part of the energy is expended on displacing the lateral fragments, which are pushed to either side without becoming separated from their periosteal attachment. The appearance, in fact, somewhat suggests what might be expected were a small charge of dynamite introduced into the centre of a small tunnel made across the shaft of the bone. Examination of some of the skiagrams also illustrates another point of interest, viz. that a certain degree of recoil on the part of the bone results from the blow, since in many of them portions of the mantle of the bullet and bone fragments are seen in that portion of the track proximal to the fractured bone.
The importance of 'setting up' of the bullet is at once evident in relation to the production of wounds of an explosive type in connection with fractures of the bones. There can be no doubt that a considerable number of the most severe injuries we saw were produced by the various soft-nosed or expanding forms of bullet, also that others of an equally serious nature were produced by Martini-Henry or large leaden sporting bullets. Allowing for this, however, I think a considerable proportion were the result of deformation from bony impact, or ricochet deformities external to the body acquired by regulation Mauser bullets, and I think these bullets can be quite as formidable as any of the sporting varieties met with. The soft-nose varieties of small calibre may not set up enough to cause severe injury, while the large leaden bullets often flatten out so completely as to lose all penetrating power. As far as my impressions went, the small soft-nosed bullets needed to be travelling at a very considerable rate of velocity to be dangerous. In the form of soft-nose Mauser employed, the soft-nose was too short to allow of as successful a mushrooming of the bullet as often occurred with the regulation projectile, because, as already explained, the mantle acquires increased stability from its closed base.
FRACTURES OF THE SHAFTS OF THE LONG BONES
Types of fracture.—The common types of fracture of shafts of the long bones are illustrated diagrammatically in fig. 50. Of the whole series comminuted fractures were by far the most frequently met with, while the various wedge-shaped forms were the most strongly characteristic of the special form of injury in which we are interested.
[Illustration: FIG. 50.—Five Types of Fracture: A. Primary lines of stellate fracture; wedges driven out laterally and pointed extremities left to main fragments. B. Development of same lines by a bullet travelling at a low degree of velocity; suppression of two left-hand limbs and substitution of a transverse line of fracture; a spurious form of perforation. See plate XXIII. C. Typical complete wedge. See plate VII. D. Incomplete wedge; impact of bullet, lateral or oblique, and two left-hand lines seen in A are suppressed. E. Oblique single line, one right and one left hand line seen in A, suppressed. The influence of leverage from weight of the body probably acts here. Compare plates XVI. and XXI.]
1. Stellate comminuted fractures.—A shows the primary nature of the lesion in all comminuted fractures of compact bone, consisting in the production of a number of radiating fissures, which assume a stellate form of which the point of impact corresponds to the centre. B shows an incomplete development of this form, the fragments being simply displaced laterally with slight loss of substance, so as to simulate a real punctured fracture. An illustration of this fracture produced by a bullet travelling at a low degree of velocity is seen in plate XXIII., which also shows the unaltered bullet lying in close proximity to the injured fibula.
The degree of comminution in these fractures depends first on the range of fire and consequent striking force retained by the bullet, a high degree of velocity producing extreme comminution of compact bone. The severity of the latter again may be influenced by the measure of resistance dependent on the density and brittleness of any individual bone, or on the possession of the same characters as a special property by the tissues of the man struck. Thus plate IV. shows a fracture of the humerus produced by a bullet shot from a short range, and the fragments are comparatively large and of even dimensions, while plate XIV. shows extreme comminution of the portion of the femur exposed to direct impact, with elongated large fragments at the sides of the track. Plate XIX. shows less extreme comminution and less separation of the fragments, and was probably produced by a bullet from a longer range of fire.
The separation of elongated lateral fragments is a special feature, and best marked when the portion of bone struck is considerably wider than the bullet, as in the case of the shaft of the femur. These fragments correspond in the method of their production to those seen in the wedge fractures described below, while their separation leaves a pointed extremity to either segment of the shaft. This fracture in its purest type is, I believe, spoken of as the 'butterfly fracture.'
With regard to the spread of the fissures in the long axis of the bone into neighbouring articulations I think fractures produced by bullets of small calibre differ considerably from those produced by larger projectiles, in that their general tendency is not to extend beyond the commencement of the cancellous bone forming the joint end. This is perhaps capable of explanation on several grounds: first, the smaller area of impact results in the assumption of a strongly marked stellate figure, the radiating fissures of which rapidly reach the lateral limits of the shaft, producing a solution of continuity in the bone which interrupts the continuance of the action of the wedge represented by the bullet. Secondly, the small size of the wedge itself is opposed to the wide separation of the parts directly implicated, which is necessary for the continued progress of the process of fissuring, and again the rapidity of passage minimises the period during which the force is exerted. It is in these points that I believe the chief differences between the modern and old gunshot fractures find their explanation, since with the larger bullets fractures extending from some distance into the joints were a somewhat special feature. In addition it is probable that the alteration in structure at the junction of the shafts with the cancellous ends also tends to check the regular extension of the fissures, as a similar limitation is illustrated even in some fractures by Snider bullets. Fig. 51 of the lower end of the femur illustrates a not uncommon lower limit to a comminuted injury in this region.
The degree and nature of the comminution also vary with the directness of impact on the part of the bullet. The more nearly this approaches at a right angle, the more severe is the local comminution, but probably a lesser area of the shaft is implicated. Plate V. shows an example of this: all trace of continuity is lost, a wide gap separates the bone ends, while the fragments themselves have been for the most part driven altogether out of the wound. Oblique impact, on the other hand, may widen the comminuted area at the point of impact, while, if the bullet retains sufficient force and regularity of outline, it may then travel 'cutting its way' through the remainder of the bone in an oblique direction. It will be of course recognised that the exact impact of the bullet depends not alone on the direction of the projectile, but also on the nature of the slope offered by the surface of bone struck.
2. Wedge fractures.—This form (C and D, fig. 50) is equally characteristic of gunshot injury with pure perforation; it is met with in two varieties. C illustrates the more strongly marked type; in it the bullet makes passing lateral impact with the shaft, and from the point struck radiating fissures extend to the opposite margin, so that a wedge-shaped piece of bone often secondarily comminuted is separated from the remainder of the shaft; see plate X. of the radius.
The second variety, D, is an incomplete development of the stellate fracture in which the fissures pass to one margin of the bone only. The explanation of this variation is probably to be sought in the direction of impact on the part of the bullet, since the main fissure is often accompanied by secondary lines which run a somewhat parallel course to the main one, and suggest the dispersion of the force in the form of concentric waves. Such fractures were most strongly marked in the tibia, the breadth of the surfaces of this bone presenting especially favourable conditions for their production.
3. Notched fractures.—These may be a slight degree of the form of wedge fracture last described; such a one is depicted in plate XXII. where a portion of the spine of the tibia has been carried away by a passing bullet. Other notched fractures approximate themselves more nearly to perforations, the notch being a groove secondary to the opening up of such a track as is shown in the illustration of a perforation of the lower third of the shaft of the tibia (fig. 57 on p. 219). Notching or grooving is naturally much more common in the cancellous portions of bones.
4. Oblique fractures.—These also occur in two varieties: the first has been already alluded to; in it the bullet actually cuts an oblique track in the bone; the main line of fracture is often considerably comminuted, usually at the proximal end of the track (see plates XV. and XIX.).
The second variety (E, fig. 50) is less common; in it two of the main limbs of the simple stellate figure are suppressed, while the remaining two form a continuous line from one margin of the shaft to the other, the point of impact lying approximately in the centre of the line of fracture. Such a fracture is illustrated by the skiagram of a femur in plate XVI. in which the bullet traversed the soft parts transversely at the level of the centre of the fracture, which was 9 inches in length. In another case the line of fracture occupied the lower third of the femur, passing from the inner border of the shaft, the lower end of the upper fragment was formed by the compact tissue forming the outer wall of the external condyle. This latter perforated the vastus externus and lay beneath the skin; as it could not be disentangled, an incision was made over it, and the fragments when reduced were screwed together by Mr. S. W. F. Richardson. In neither fracture was there any comminution. Such fractures most nearly resemble the oblique or spiral ones met with in civil practice as the results of falls. In all the instances I observed the patients were supported on the lower extremities at the time of the accident, and one can only assume that a twist of the trunk consequent on the fall of the body diverts the most forcible vibrations resulting from the impact of the bullet into one line, and thus produces a solution of continuity of a simple oblique nature. In both the cases mentioned above the bullet was probably travelling at a low degree of velocity; in the first it was a ricochet and was retained. I never saw one of these fractures in the upper extremity.
Plate XXI. affords an excellent example of this mechanism. The patient was standing when struck, and then fell backwards. An incomplete fissure 7 inches in length is seen to extend from an otherwise pure perforation of the shaft of the tibia.
5. Transverse fractures.—Throughout these were of very rare occurrence. Plate XX. illustrates a pure transverse fracture produced by passing contact of a bullet probably fired at a distance not exceeding 400 yards, and which subsequently struck the fibula plumb and produced considerable comminution. No fissure extended into the ankle-joint. Comminutions such as that illustrated by plate V. more or less simulated transverse fractures, but I saw no examples of transverse tracks comparable to the oblique ones described above 'cut through' the shaft of a bone.
6. Perforations.—Although these were common in cancellous bone, they were comparatively rare in the compact shafts. I saw, however, complete pure perforations of the shafts of the tibia, femur, clavicle, and other bones. These perforations were, I believe, always the result of low degrees of velocity, and they took the place of simple transverse fractures of the 'cut' variety. The apertures of entry and exit in the bones resembled in character those seen in the soft parts, or in the bones of the skull in low-velocity injuries (see figs. 71 and 72, p. 261). The entry was more or less cleanly cut, while at the exit a plate of bone was raised, and either separated or turned back on a hinge by the bullet (fig. 52), (plate XVII.) Such a projecting hinged fragment was sometimes a source of some trouble; thus in a case of postero-anterior perforation of the lower third of the shaft of the femur, the long exit fragment projected into the substance of the quadriceps extensor muscle, and interfered with flexion of the knee-joint. Fig. 57 of a superficial tunnel of the lower third of the tibia is especially interesting as bringing such injuries of the long bones into line with fractures of the flat bones of the skull, such as are illustrated in fig. 68, p. 259.
Plate XXI. affords an excellent example of perforation of the shaft of the tibia, although complicated by the secondary fissure.
Plates XXIII., VIII., and III., of the fibula, humerus, and clavicle, exhibit examples of what may be called spurious perforations of the shafts of bones, since comminution or loss of continuity accompanies all three.
Subsequently to writing the above paragraphs, I took the opportunity of re-examining the magnificent series of gunshot fractures collected during the Franco-German campaign by Sir William MacCormac, and afterwards presented by him to the museum of St. Thomas's Hospital.
The close approximation in type between the main features in these and those in the fractures produced by the modern bullet is very striking. In the case of the shafts of the long bones, the same stellate, oblique, wedge-shaped, and even perforating injuries are illustrated on a coarser scale. In a specimen of a patella, a perforation of the lower half, implicating also the tendon of the quadriceps muscle is, though large, almost as pure as a Mauser perforation.
The difference in the nature of the lesions of the bones is seen to be, firstly, one of pure magnitude, corresponding to the size of the large Snider bullet by which they were produced. Thus the fragments generally are larger, and occupy a wider area of the shafts, the first character depending on the lesser degree of velocity of the bullet, the latter on its volume and weight. Fine comminution, however, the most striking feature of the modern injury, is throughout absent.
The effect of the larger size of the wedge provided by the bullet in increasing the length of secondary longitudinal fissures is well marked, and for the same reason the perforations are usually accompanied by fissures of considerable extent. It is interesting to note, however, that even in the case of the large bullets, and the special tendency shown by them to cause the extension of fissures into the joints, one or two specimens still show that these fissures incline to stop short when the point of junction between the portion of the shaft occupied by the medullary canal and that built on a foundation of cancellous tissue is reached.
LESIONS OF THE SHORT AND FLAT BONES
The above types of fracture are those common to the shafts of the long bones, but the difference in structure of the articular ends and the short and flat bones endows lesions of these with somewhat different characters, the nature of which varies between grooving, perforation, and great comminution.
The most typical injury consists in the production of a clean perforation of the cancellous bone; this was common both in the articular ends and in the short bones. The tunnel differed little in character from those already described, a tendency always existing to the lifting of a lid of compact tissue at the exit end of the track.
For the production of the cleanest forms of injury I believe high rates of velocity were distinctly favourable, although I am unable to maintain this statement by proof in the case of injuries received at the shortest ranges of fire. When the velocity was lower, yet with force still sufficient to produce a perforating injury, the separation of an extensive scale of bone at the exit aperture was a marked feature not seen in perforations produced by higher degrees of velocity. Fig. 52, of a perforation of the lower end of the femur, well exhibits this feature; but it must be borne in mind in this case that the illustration is not a pure one, both shaft and epiphysis taking part in the walls of the track, and the exit opening is in the former, where a thicker layer of compact bone exists than would cover any epiphysis, and hence the fragment is larger. I use the example, however, because it so forcibly illustrates the effect of increased resistance on the part of the bone struck in widening the area of the lesion. When the track was entirely limited to the articular ends the small amount of damage at either aperture was shown by clinical evidence in the rarity of subsequent limitation of joint movements due to bony deformity.
Again, it was rare for fissuring to extend from these tunnels to the articular surfaces; thus many instances could be given of perforation of the head of the humerus, the olecranon, or the femoral condyles, in which no evidence of joint fissure was discoverable. The slight amount of resistance offered by the cancellous ends was also clinically illustrated by the absence of severe synovial effusions when they were struck. When the joint cavity was not crossed, slight effusion only resulted, while in the case of fractures of the femoral shaft great effusion into the knee-joint, resulting from the forcible vibration transmitted to the limb, was a common feature, even when the point fractured was situated above the centre of the bone. Again, when the joint cavity was crossed a moderate degree only of haemarthrosis was the most common result.
With regard to the implication of joints, either primary or secondary, in connection with fractures of the articular ends, I am inclined to place the lesions of the upper end of the tibia in a more important position than those of any other bone. Evidence of this implication was in my experience more frequent here than in any other situation. This may in part be attributable to the complexity of structure of this epiphysis, and perhaps more correctly to the influence of its irregular outline in favouring lateral forms of impact on the part of the bullet and consequent increase in the area of damage.
Next to tunnelling, grooving was the most common form of injury to the short bones. In the case of superficial tracks the compact tissue might be considerably comminuted, but not, as a rule, over a width greatly exceeding the calibre of the bullet.
Comminution and crushing of a single or several bones were rare in proportion to the occurrence of similar injuries produced by Martini-Henry or large leaden bullets. When the condition was produced by bullets of small calibre, I believe it was in the majority of cases the result of irregular impact on the part of the projectile. In support of this view it may be added that such injuries were most common in the bones of the tarsus, bones especially liable to be struck by ricochet bullets.
It was generally believed that bullets travelling at a very high degree of velocity were liable to cause severe comminution of the short bones, but I never saw any cases supporting this opinion; in point of fact, all the short-range lesions of this nature that I saw were of the clean perforating variety. I believe that this is capable of satisfactory explanation on the ground of the thin character of the layer of compact tissue which for the most part ensheaths the short bones; this decreases the resistance offered to the bullet and so tends to localise the lesion. This statement may be supported by two observations with regard to the long and flat bones. First, if the shaft of a long bone be hit above the junction of diaphysis and epiphysis, the cancellous tissue in and extending from the medullary cavity is pulverised, and examination of fragments from such fractures gives the impression of the inner aspect having been scraped clean. Secondly, I saw one fracture of the ilium produced by a bullet taking a course between its compact layers for 3 inches from the notch between the anterior superior and anterior inferior spines; the bone to the extent of 2-1/2 square inches was pulverised, the cancellous tissue blown away as dust, and the compact tissue only represented by scales still adhering by their periosteum to the muscles attached to the two surfaces of the bone. This injury was produced from a rifle fired at five yards distance, and was an extreme example; but, on the other hand, it illustrates only what we are thoroughly well acquainted with in the case of flat bones, such as those of the cranium, where the compact element is abundant in comparison with the cancellous, and the resistance offered to the bullet is consequently great.
Some remarks on transverse fractures of the patella will be found under the heading devoted to that bone.
Lesions of the flat bones are considered at some length in Chapter VII., which deals with injuries to the head, and their special features are there described; some further remarks on these injuries will be found under the headings of the individual bones.
Special characters of the symptoms observed, and of the course of healing of the fractures.—Peculiarities in the initial signs may be rapidly passed over. The first depended on the large number of lesions of the bone which were unaccompanied by loss of continuity. In the case of perforations attention to the course of the track, external palpation, and possibly the detection of bone dust in the aperture of exit, were usually sufficient to indicate injury to the bones. When these did not suffice the introduction of a probe would usually set the question at rest; but this is always to be avoided if possible, as adding a fresh item of risk to the wound. The X rays were not always to hand, and are not always capable of giving reliable information in the matter of perforations, although very useful in detecting grooves or notching. The latter injuries are those in which information as to the condition of the bones is often of most interest in view of the characters of the external wounds.
Fractures with solution of continuity were, as a rule, easy of detection, but the relative prominence of the classical signs varied somewhat from what we are accustomed to see in civil practice.
The first striking peculiarity noted in comminuted fractures of the long bones was the degree of local shock; the limbs were often quite powerless, the muscles flaccid, and common sensation lowered. This was of importance in two ways; firstly, shortening of the limb was often absent as a sign, and, secondly, pain was sometimes not at all pronounced even when the patient was moved. The primary absence of shortening, even persisting for the first two or three days, was a phenomenon always important to bear in mind, as it affected the degree of extension needed in the treatment of the fracture, which, if sufficient at the moment, often proved quite inadequate with the return of tone in the muscles. Secondly, abnormal mobility was usually strongly marked, and this sometimes without very definite crepitus, as a result of the fine nature of the comminution and the displacement of the small fragments.
During the course of healing some other peculiarities are worthy of mention. First of all, union was tardy and often not strong. On the other hand, an abundance of provisional callus was common, which formed large swellings apt to implicate neighbouring nerves, and sometimes to interfere with the movements of joints. The slowness of healing was particularly noticeable in those cases where the degree of local shock had been marked, and was probably to some extent dependent on disturbance of the general nutrition of the tissues of the affected limb. Beyond this, however, it was in many cases a direct result of the degree of comminution and displacement of the fragments, which necessitated the formation of a large amount of provisional callus, and time for the proper consolidation and contraction of the same. In many cases a large ball-like mass of callus surrounding the fragments was developed, into which the actual ends of the broken bone only dipped, and hence union was weak and insecure. As to those cases in which the wounds closed by primary union, we must bear in mind in this relation the tardy union often observed in civil practice, when the irritation of suppuration and consequent inflammation are absent.
Another peculiarity of a similar nature was the occasional late necrosis of fragments; the wounds apparently healed well, only to break down weeks or months later for the discharge of a sequestrum. Such cases were quite distinct from those in which primary suppuration had occurred. I saw one or two instances in fractures of the humerus, the trouble arising with commencing use of the limb, and I suppose that fragments which suffered death at the time of the injury had been enclosed, and only caused irritation as foreign bodies when the muscles again came into action. In the absence both of evident necrosis and suppuration, however, in some cases the exit portion of the track in the soft parts was extremely slow in healing. Although no discharge beyond a small quantity of blood-tinged serum escaped, the wounds remained open for many weeks, even when the fracture consolidated well. I ascribed this to slow separation of aseptic sloughs, a point which has already been mentioned under the heading of wounds in general.
Superabundance of callus, as far as I had an opportunity of judging, comparatively seldom gave rise to permanent mechanical trouble. This was no doubt due to the infrequency of extension of the comminuted fractures beyond the junction of diaphysis and epiphysis.
Lastly, with regard to suppuration, only a small proportion of the fractures, accompanied by the presence of large wounds, escaped infection. When infection did occur, the results offered some special features dependent on the small relative amount of damage to the soft tissues, compared with that suffered by the bone. In an ordinary compound fracture, such as we meet with in civil practice, whether the result of direct or indirect violence, a considerable amount of contusion or laceration, as the case may be, accompanies the injury to the bone. The result of this is a widespread effusion of blood into the limb, which tears and strips up the various layers of soft parts, and opens up the way to the spread of infection, often into the whole length of the segment of the limb affected. In fractures produced by bullets of small calibre, even when the exit portion of the track is large, the injury to the soft parts is far more localised, except in extreme cases, while the bone itself is the tissue which has suffered the most severe violence and contusion. When infection occurred, its spread corresponded with this anatomical feature of the lesion, and the bone itself and its immediate neighbourhood suffered the most severely.
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 anaemia, and emaciation, were marked. Pyaemia, 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 septicaemia, or from a combination of this with secondary haemorrhage.
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 anaesthetise 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 haemorrhage. 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 fossae. 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.
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.
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.
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.
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 anaesthetic 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.
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 faeces.
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.
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 haemarthrosis 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.
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.
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. |
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