Fractures in the middle and lower thirds of the bone were more easy to treat successfully, but these also added to the list both of amputations and fatalities.

Punctured fractures of the lower articular extremity were usually of little importance, as they progressed without exception, as far as my experience went, favourably.

I can give no idea of the general results obtained during the whole campaign, but I am able to state the results of the fractures of the shaft treated at No. 1 General Hospital during my stay in South Africa. Thirty-two cases of fracture of the shaft of the bone came under treatment, and of these 6 or 18.7 per cent. needed amputation, and of the whole number 5 or 15.6 per cent. died. To emphasise the satisfactory nature of these figures I need only quote the results attained in the American War of the Rebellion; mortality in upper third, 46 per cent.; middle third, 40.6 per cent.; lower third, 38.2 per cent.

[Illustration: PLATE XVI.

Engraved and Printed by Bale and Danielsson, Ltd.

(34) OBLIQUE FRACTURE OF THE SHAFT OF THE FEMUR

Range '300 to 400 yards.'

Aperture of entry just above the centre of the outer aspect of the thigh. Exit, about 2 inches lower, at the junction of the inner and posterior aspects. The bullet was retained just within the wound, and when removed the mantle fell off in two parts. The leaden core was mushroomed. The bullet had passed through another soldier previous to entering the patient's thigh. Only two small fragments of the mantle were retained, as seen in the skiagram. These were in the substance of the great sciatic nerve, and were subsequently removed by Sir Thomas Smith.

It is difficult to determine how the bone was struck; reference to plate XXI. would suggest that the shaft may have been perforated, but no evidence of this remains in the skiagram taken, which was five months later.

The patient was standing at the moment of reception of the injury, and the obliquity of the fracture no doubt depended on his fall and the resulting influence of the weight of the body. The length of the fracture cleft was 9 inches.]

I need hardly dwell upon the difference between the nature of the injuries received in the American War of the Rebellion and in the present campaign, as in the former the old large bullets were employed, and shell injuries are possibly included; but I ought to add in this relation, that the numbers quoted from No. 1 General Hospital included, to my knowledge, at least three severe Martini-Henry wounds.

The first element for a favourable prognosis is a small wound, and opportunity for an efficient primary treatment of the same; the second the absence of necessity for transport of the patient. With regard to the second of these requirements, we were unfortunately situated in South Africa, and the majority of the cases which did badly were moved during the first few days and for a distance of between five and six hundred miles. On the other hand, as a rule, the external wounds were small.

As to functional result, the fractures did well. I think an average of an inch and a half would well cover the shortening, and in many the length was little altered. Considering the serious nature of many of these fractures, this was good.

Treatment.—In all punctured fractures of the lower extremity, dressing of the wounds like uncomplicated ones and a short period of immobilisation were all that was necessary. In oblique fractures, and those with slight comminution, closure of the wound by dressings, after it had been carefully cleansed, was all that was necessary prior to applying the splints for immobilisation.



In the highly comminuted fractures a more radical treatment was indicated, especially if the exit wound was large. In these, after careful preliminary cleansing of the limb, the wounds, especially the exit aperture, needed exploration and, if necessary, enlargement, and all free splinters needed removal. If interference with the entry wound could be avoided, this was always preferable, as it was rare for this not to heal by primary union unless free suppuration occurred. Under Field hospital conditions I think the exit wound should never be sutured, whatever its situation; and in the present campaign, where carbolic acid lotion was freely used, this step was manifestly inadvisable, in view of the abundant serous discharge always to be expected when this disinfectant has been employed. Except in cases manifestly infected at the time of exploration, the use of drainage tubes or plugs is not to be recommended. I would point out also that in the majority of cases it is quite hopeless to attempt to make the entry wound the safety-valve for drainage, as its natural tendency, even if enlarged, is to heal, while the condition of the tissues in the exit segment of the track usually renders primary union an impossibility.

The wound having been dealt with, the next indications were for the reduction of deformity, immobilisation of the limb, and the provision of a proper degree of extension. As to the reduction of the fracture, this was always a matter of ease, needing only slight axis traction. The provision of efficient means of extension and immobilisation was a very different matter. These questions had to be considered under two sets of conditions: (1) when it was possible to keep the patient at rest in the hospital he was first deposited in; (2) when it was necessary for him to be transported for a considerable distance, probably not less than 500 miles.

When transport is a necessity, the best method of immobilisation is the application of breeches of plaster of Paris, and a long outside splint. The latter we often had excellently made on emergency by the Ordnance Department or the Royal Engineers. A perineal band is the only form of extension possible under these circumstances. The Dutch ambulances were provided with a very excellent emergency splint for cases of fractured thigh, which is illustrated in fig. 56. I think something of this kind should be carried in one of the ambulances going on to every field of battle, as being far more suitable than a long outside splint for hasty and inaccurate application. This splint, fixed with some kind of firm bandage, is an excellent temporary one for use during transport.



In cases which can be treated at a Stationary hospital near at hand, a long outside splint supplemented by plaster breeches, and a well-applied American extension, is a very good method of treatment, the only point to bear in mind being frequent examination of the position of the limb to ensure the extension being efficient. As already mentioned, the shortening in the primary stages is often slight and easily combated, but in many of these cases if examined in a few days the limbs are found to have shortened considerably, principally as a result of recovery of tone by the muscles, and the absence of any help from the resting of the two fragments end to end. The weight, therefore, has often to be progressively increased and the fracture readjusted if necessary. Although this method of treatment is satisfactory in cases with a small wound, it is very troublesome to carry out, even when a bracket is inserted opposite the wound, when frequent dressing is necessary, as is generally at first the case when the wounds are large. For this purpose a much more satisfactory method is the use of Hodgen's splint. This allows of automatic adjustment of the degree of extension, and the dressing of the wound without interference with the position of the fracture. A continuous many-tailed bag is preferable to the strips usually employed for the suspension of the limb, as more easily adjustable and as offering a more even support to the limb.



While at Orange River, in conjunction with Major Knaggs, R.A.M.C., and Mr. Langmore, we treated several cases of fracture of the shaft of the femur by this method. The splints were made for us by the Ordnance Department, while the Royal Engineers erected a kind of gallows for us down the centre of a commissariat marquee in order to avoid the risk of using the tent poles for suspension. The patients were then ranged on each side of the tent in two rows so that the pull of the two sets of limbs opposed each other on the gallows from which they were suspended. Although these patients had to lie on the ground, they were really comfortable compared with those treated with long outside splints, and the results obtained were very good: in three cases which I had the opportunity of measuring later the bones were in good position and the shortening was less than one inch.

I have no doubt whatever that Hodgen's splint is by far the best method of treating all cases of fractured thigh in the Stationary field hospitals; and, more than this, I believe it is the only practicable and efficient one. It can be applied without the use of an anaesthetic without causing undue suffering to the patient, it allows of ready change of the dressing, it is comfortable and permits considerable range of movement on the part of the patient, it is as efficient with patients lying on the ground as in a bed, it keeps the limb in good position and allows of constant inspection on this point, and it is the only method which provides satisfactory extension without constant readjustment.



Cases in which operative fixation is indicated are rare, but a few oblique fractures may be treated with advantage in this manner if the conditions surrounding the patient admit of it. Screwing is generally preferable to wiring.

Lastly, we come to the cases in which primary amputation is necessary. I may say at once that I saw no case of wound from a bullet of small calibre in which this was indicated, and only one shell injury in which it was performed. I believe with small bullets that injury to the main blood-vessels is almost the only indication which is likely to be met with, and this by no means always indicates an amputation. First of all the question arises as to whether the wound in the vessel is caused by a bone fragment or by the bullet itself; reference to the chapter on blood-vessels would seem to prove that a bullet wound is by no means a necessary indication for amputation. Given favourable conditions, it might be treated locally by ligature at the time, while if haemorrhage is not proceeding, developments should be awaited before proceeding to amputation. In the case of bone fragment punctures, secondary haemorrhage is a more likely indication for amputation than primary.

Broadly, it may be laid down that very extensive injury to the soft parts is the only indication for primary amputation beyond primary haemorrhage, and it may be added that the condition is rare with wounds from small-calibre bullets. If a primary amputation is necessary the observations as to the transport of fractured thighs are equally applicable. I never saw a primary amputation do well that was moved during the first week; sloughing of flaps or haemorrhage followed as a rule, and often death.

Intermediate amputations were indicated in cases of septic infection and those of haemorrhage; they seldom did well, and should be avoided if possible. Secondary amputations for sepsis or haemorrhage were attended by fair results, but I can give no statistics. Unless extensive osteo-myelitis is evident, or very widespread cellulitis of the limb exists, I am strongly of opinion that the amputations when the fractures are above the middle of the thigh should be through the fracture, and not at the hip-joint, even if a subsequent secondary operation is risked.

[Illustration: PLATE XXI.

Skiagram by H. CATLING.

Engraved and Printed by Bale and Danielsson, Ltd.

(39) PERFORATION OF THE SHAFT OF THE TIBIA, AND INCOMPLETE OBLIQUE FISSURE EXTENDING FROM THE LOWER PART OF THE OPENING TO THE CREST OF THE BONE.

Range medium. Entry and exit wounds at same level.

The patient was standing when struck, and fell backwards, his rifle falling at the same time and striking the shin. The fibula is intact.

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

The forking of the lower extremity of the cleft suggests the starting of the fissure from above. The fissure comes to the surface at the seat of election, but its position may possibly have been determined by the blow from the falling rifle.

The backward fall of the patient clearly explains the mechanism of production of the fissure, and throws light on the production of an oblique fracture such as shown in plate XVI.]

Fractures of the patella.—Punctured fractures of the patella were common with direct impact of the bullet; these were often difficult to palpate, and were only to be certainly diagnosed by attention to the direction of the track, and the development of haemarthrosis. I saw at least three or four in which the bullet, in addition to traversing the knee-joint, injured the popliteal vessels. I have notes of one case in which a bullet traversed the soft parts from above downwards and scored a vertical groove on the surface of the patella; this was readily palpable, but produced no solution of continuity. In several cases the margin of the patella was notched by a passing bullet.

I never saw a case of stellate fracture, and by this my experience in the case of the ilium was confirmed.

On two occasions I saw pure transverse fractures of the bone; in each the wound was produced by a Lee-Metford bullet. This is of some interest as denoting that the greater volume and weight, in conjunction with the blunter tip, of the Lee-Metford may produce more severe injury to the bones than the Mauser. I believe this to be the case, given an equal degree of velocity on the part of the bullet at the moment of impact; but it is probable that the position of the patella with regard to the condyles of the femur when struck is of far greater importance in relation to the production of transverse fractures. The skiagram represented in plate XVIII. shows an obliquely transverse fracture, which in this instance resulted from a crossing bullet, which grooved the surface of the bone.

With regard to the two cases of transverse fracture above referred to, I may add that one occurred in a youth under twenty, and a good result was obtained by treatment with splints, and later by massage. In the second the patient was a man over fifty, who had received other injuries. The wound over the patella healed and some union had occurred, when the patient fell and burst both the bone union and the skin cicatrix. Secondary suppuration of the knee-joint, necessitating an amputation of the thigh, followed, but the patient made a good recovery. The third case also did well.



The treatment of these injuries differed in no way from that adopted in civil practice, given satisfactory surroundings. Suture might be indicated in some cases of transverse fracture, but this would only be necessary if the fragments were widely separated. The punctured fractures needed treatment as for simple wounds, combined with a short period of rest and pressure for the condition of haemarthrosis. It was important not to prolong the period of rest beyond a week or ten days if the effusion was slight, in view of possible ulterior interference with range of movement in the knee-joint.

Fractures of the tibia.—Some remarks have already been made regarding fractures of the head of the tibia, and the importance of the overhanging prominent margins in the production of somewhat irregular injuries (p. 170). Putting these peculiarities on one side, the cancellous ends are subject to the type forms of injury; thus perforations either of the head of the bone or the malleolus were common injuries. The fractures of the shaft also deviated from the type in so far as the broad flat surfaces in the upper two thirds of the bone rendered it especially liable to the results of lateral impact, and to the production of the extreme wedge-shaped types of fracture. Plate XXII. illustrates the different result of a bullet striking the dense and strong spine at a low rate of velocity, a notch only resulting. If, on the other hand, the lateral surfaces were struck, a wedge with the base corresponding to the posterior surface was the most common injury, the spine in many cases remaining intact and maintaining the continuity of the bone. Wedge-shaped fractures of this bone were apt to show multiple secondary wave fissures concentric with the main line, and consequently free comminution. I saw several examples, the loose fragments being remarkably numerous. Plate XIX. is an example of an oblique fracture produced by a bullet which has ploughed across the bone, displacing large fragments anteriorly, but finely comminuting the bone in its course, and leaving small fragments of the mantle on its way. Plate XX. is an example of the rare condition of transverse fracture.



This fracture was produced by a bullet travelling at a high rate of velocity, which struck the posterior surface of the tibia, and caused a grooving, accompanied by a horizontal fissure through the whole thickness of the bone; later it struck the fibula more directly, and produced an ordinary comminuted fracture two inches above the malleolus. Perforations of the shaft were far more common than in the case of the femur, and I saw them in every part of the length of the bone (plate XXI.). Fig. 57 illustrates a form of peculiar interest as showing the gradual transition of the tunnel to the groove, and also as bringing fractures of the long bones into line with such fractures of the flat bones of the skull as are depicted in fig. 68.



Fractures of the fibula offered no special features of importance. Any form might occur. The plate No. XXIII. is of interest as showing a spurious form of perforation, and also the primary form of displacement of the fragments in stellate fractures. It was produced by a reversed ricochet, but undeformed, bullet, still seen in position in the skiagram; the bullet only possessed sufficient force to perforate the bone, and then appears to have turned on its transverse axis. The following plate, No. XXIV., is inserted to show the depth at which the bullet lay, and its distance from the surface of the tibia, which appears in the first plate to be nil. It is also of interest as showing the ease with which a false impression may be obtained from a single picture, as, beyond a spot of transparency, no obvious injury to the fibula, and certainly no displacement, is discernible.



Fractures of the bones of the leg possessed an unenviable degree of importance. First, on account of the very severe injuries to the soft parts that often accompanied them, without an apparently correspondingly serious damage to the bone. Secondly, on account of the frequency with which the vessels were implicated in these injuries to the soft parts, either by the bullet or bone fragments. Beyond this, fracture of either articular end of the tibia was certainly more frequently followed by troublesome joint complications than occurred in the case of any other bone.

In the matter of 'explosive' injuries, I think more were seen in the calf of the leg than in any other part of the body, and this often without solution of continuity of the bones, and sometimes without evidence even of contact of the bullet with either tibia or fibula. Some remarks on this subject have already been made in the chapter on wounds in general, and some sources of fallacy exposed. I believe that in practically all these so-called explosive injuries the wound was either caused by a ricochet, or a bullet which deformed with great ease on bony contact during its progress through the limb. A considerable number of the wounds which were referred by the men to the use of expanding bullets were probably the result of the use of Martini-Henry or large leaden sporting bullets, and evidence of this was often forthcoming on examination of the entry wounds. In other cases the irregularity of the opening plainly pointed to ricochet of a small bullet as the explanation of the character of the injury. The greater frequency of ricochet injuries in the leg and foot when the men were standing is readily understood.

Concurrent injury to the vessels of the leg was common, but primary haemorrhage, as was the case generally, usually ceased spontaneously. The importance of injury to the vessels was rather in view of secondary haemorrhage, which occurred with some frequency, and I think more commonly from the anterior than the posterior tibial vessels, usually occurring at the end of a week or ten days, and naturally most frequently in cases which suppurated.

Prognosis and treatment in fractures of the leg.—In fractures of the leg, except those of extreme severity, almost any form of splint sufficed to maintain the bones in position, but for field purposes the Dutch cane splint (fig. 58, p. 222) was certainly very convenient. For later use in cases that needed frequent dressing, a wooden back splint, with a foot-piece, or, if obtainable, a Neville's splint with a suspension cradle, was the best. Where the wounds were small and frequent dressing was not required, nothing was so good as plaster of Paris, especially when transport was a necessity.



In cases with large wounds suppuration was very frequent, and in connection with this secondary haemorrhage, or in the case of fractures near the articular ends, especially the upper, joint suppuration. The treatment of these cases varied: in many an amputation was the best or only treatment advisable; but I several times saw good results follow ligation of the anterior tibial artery for secondary haemorrhage, even when suppuration existed, and occasional good results after incision and drainage of joints if the infection was not of the most acute form.

Primary amputation was rarely needed for any case of injury from a bullet of small calibre, since it was only necessary either in the case of injury to both main arteries, and this was rare, or in cases of very extensive injury to the soft parts. I saw many of the latter make fair results when treated conservatively, even though the condition seemed almost hopeless at first sight. All the primary amputations that I saw were either for shell or large bullet injuries. A word may be inserted here as to the weight that ought to attach to nerve injuries in this relation. From the experience gained elsewhere it is clear that we should attach little importance to these unless the divided nerves are actually in sight, as far as deciding on amputation is concerned. On the other hand, there is little doubt that the presence of concurrent nerve injury, be it only concussion or contusion, exerts an important ulterior influence on the healing of the wound, whether the part be amputated or not. Amputation flaps in such cases possess a very considerably lowered degree of vitality.

Secondary amputations were often needed for sepsis, and on the whole did very well; both for the same cause and for haemorrhage intermediate amputations had occasionally to be performed; the results of these, as elsewhere, were bad.

Fractures of the tarsus.—Wounds of these short bones were as a rule of slight importance, given fairly direct impact on the part of the bullet. They then consisted of either simple perforations or surface grooving. A single bone might be implicated or several might be tunnelled; in the latter case the implication of the joints very considerably influenced the prognosis, since the addition of the joint injury caused much more prolonged weakening of the foot.

Wounds of the foot were common from the fact that when the men lay out in the prone position, the foot was often the part least protected by the cover chosen, and particularly the heel. In these circumstances the os calcis was the bone most frequently implicated, and that by tracks taking an oblique course downwards from the leg to the sole. Again the foot was often struck by ricochet bullets, as a result of its position when the erect attitude was assumed. The latter fact was of much importance with regard to the nature of the injury sustained by the bones, as under these circumstances the mode of impact was irregular, and consequently comminution was often produced.

The behaviour of the different bones of the tarsus varied somewhat. On the whole the prognosis in cases of injury to the os calcis was the best, since the injury was more often individual and did not implicate any joint, and also because of the comparatively regular architecture of the bone. In the smaller bones concurrent injury to a joint was more frequent. In the astragalus the central hard core extending upwards from the interosseous groove, as increasing resistance, I think accounted for the fact that comminution was more marked in this bone than in any other. The effect of wound of bones of the tarsus in producing a certain degree of laxity in the mediotarsal joint resulting in a slightly flexed position of the fore part of the foot and some projection of the head of the astragalus did not seem to me easy of explanation, but it occurred with some regularity.

The injuries to the metatarsus corresponded so nearly to those already spoken of in the case of the metacarpus that they need no further mention. They were less common, however, and I am under the impression that fragmentation of the bullet was not such a marked feature, probably on account of the lower degree of density of the bones, and their greater fixity of position.

FOOTNOTES:

[18] Col. W. F. Stevenson. Loc. cit. p. 69.



CHAPTER VI

INJURIES TO THE JOINTS

Until recent times gunshot injuries of the joints formed a class entailing the gravest anxiety to the surgeon, both in regard to the selection of primary measures of treatment and in the conduct of the after progress of the cases. The external wounds were severe, comminution of the bones was great, and retention of the bullet within the articulation was not uncommon. Operative surgery therefore found a large field in the extraction of bullets, removal of bone fragments, excision of the joints, or even amputation of the limbs.

The introduction of bullets of small calibre has robbed these injuries of much of the importance they possessed in earlier days and during the present campaign direct clean wounds of the joints were little more to be dreaded than uncomplicated wounds of the soft parts alone. No more striking evidence of the aseptic nature of the wounds, and the harmless character of the projectile as a possible infecting agent, than that offered by the general course of these injuries in this campaign, is to be found in the whole range of military surgery.

The aseptic nature of the wounds, and the slight and localised character of the bone lesions, have in fact justified the opinion previously expressed by Von Coler, that these injuries in the future would be less feared than fractures of the diaphyses of the bones.

Not less important than the localised character of the bone lesion itself is the fact that the accompanying wounds of the soft parts retain the small or type forms. Thus I occasionally observed more troublesome results from minor shell wounds in the neighbourhood of joints, but not implicating the synovial cavity, than in actual perforating injuries produced by bullets of small calibre.

Vibration synovitis.—Before proceeding to the consideration of wounds of the joints, a short account is necessary of a condition of some importance which is, I believe, more or less special to injuries from bullets of small calibre travelling at high rates of velocity. This condition, if not novel, at any rate excited little comment in the descriptions of the older forms of injury, although this may have depended on the more serious nature of the primary local lesions accompanying wounds from the larger bullets, among which it formed a comparatively unimportant element.

The condition referred to was the occurrence of considerable synovial effusion into the joints of limbs in which the articulation itself was primarily untouched. These effusions sometimes occurred even when the soft parts alone were perforated, especially when the wounds were situated above or below the knee-joint. They were apparently the direct result of vibratory concussion of the entire limb dependent on the blow received from the bullet.

The effusions were most strongly marked in cases of fractures of the diaphyses, although this was more noticeable in some situations than others. Thus with fractures of the shaft of the femur anywhere below the junction of the upper and middle thirds of the bone, and in some cases even higher, effusion into the knee-joint was very common, and sometimes extreme. On the other hand, similar effusions into the hip-joint were less marked, since I failed to determine their existence in the majority of cases. I am inclined to ascribe this to the different anatomical arrangement of the two joints, particularly to the fact that the head of the femur is included in a bony cup, into the hollow of which it is accurately fixed by the resilient cotyloid fibro-cartilage. The latter by its firm grasp of the head allows of little play in the joint; hence vibrations are conveyed directly to the acetabulum in continuous waves, and rocking of the articular surfaces is prevented. Beyond this no doubt the difficulty of detecting small effusions in this joint is an element which must be taken into consideration.

I do not think that wrenches of the knee-joint in the act of falling can be suggested as an explanation of the frequency of effusions into that articulation, since the fractures of the femur were not always received while the erect position was maintained, and effusion was most marked when the diaphysis was the part affected, the latter point illustrating the greater resistance offered by compact bone. Again, when fracture had taken place, the solution of continuity rendered the directly injured point the most mobile, and tended to prevent lateral strain from falling on the joints.

Effusion into the knee or ankle, or sometimes both joints, was common in fractures of the shaft of the tibia.

In the articulations of the upper extremity the condition was also common, but somewhat less marked than in the lower limb. Effusions into the shoulder or elbow occurred. In the former these were less striking; again, perhaps, as a result of the difficulty of detecting small effusions in this situation. The elbow was to a certain extent protected by the possession of a degree of fixity somewhat resembling that already mentioned in the case of the hip-joint, although here depending on the conformation of the bones alone. I think this explained the absence of free effusion in many cases of fracture of the humeral shaft, but when the latter affected the lower third effusion into the elbow was usually abundant.

The lighter weight and greater mobility of the upper extremity as a whole, as decreasing the resistance to the bullet, were also probably an element in the fact that these effusions were less severe than those in the joints of the lower limb.

The nature of the effusions was apparently simple, since they were rapidly reabsorbed, and little thickening of the synovial membrane remained to suggest either a marked degree of inflammation, or the deposition of blood-clot on the inner aspect of the same.

The only treatment indicated was a short period of rest, accompanied in the early stages by pressure and slight fixation, followed later by massage and movement if necessary.

Before dismissing this subject, I should like to particularly emphasise the fact, that in the cases described there was no reason to suspect the extension of fissures from the point of fracture in the shafts into the articular ends of the bones. This was as far as possible excluded by clinical examination, and in the cases where wounds of the soft parts only were present, the rapid return of the patients to active duty, with absence of remaining joint trouble, negatived the possibility of such fractures.

I only saw one case in which a longitudinal fracture actually extended for any considerable distance into a neighbouring joint. In this a comminuted fracture occurred just above the centre of the shaft of the humerus. At the time of examination and putting up of the fracture there was considerable swelling of the whole arm, and nothing special was noticed about the shoulder-joint. Three weeks later, however, when the fracture was consolidating, difficulty in abduction of the shoulder was noted, and the arm could not be placed closely in contact with the trunk. There was no evident displacement of the head of the humerus forwards. A skiagram, which I much regret I have not been able to insert, showed that a longitudinal fissure extended from the seat of fracture upwards in such a manner as to divide the upper fragment into two parts, of which the outer bore the greater tuberosity, the inner the articular surface of the head. The latter fragment had become somewhat displaced downwards, and had united in such a manner that the head rested on the lower part of the glenoid cavity. Abduction of the limb therefore brought the greater tuberosity into contact with the acromion process, and movement was checked. This case passed out of my observation shortly afterwards, and I have no knowledge of the final result as to movement.

Fractures of the bony processes surrounding the elbow-joint, and of the malleoli of the tibia and fibula, were not infrequent, but offered no special features.

One other form of injury indirectly affecting the joints is perhaps worthy of mention, but I observed it only once, and that in the case of the shoulder, the only joint where it is likely to be marked. I refer to the displacement of the head of the humerus by the force of gravity, when the circumflex nerve is injured. In the instance I refer to, a fracture of the surgical neck of the humerus was accompanied by complete motor paralysis of the deltoid and very rapid wasting of the muscle. Circumflex sensation was impaired, but not absent at the time the condition of the muscle was noted—a favourable prognostic sign of much importance. At the end of five weeks, when the fracture of the bone was consolidated, the head of the humerus had dropped vertically at least an inch, but could be replaced with ease. Shortly afterwards an improvement in the condition of the muscle commenced, and with this the head of the humerus was gradually raised. This patient later recovered his power in great part, but not completely.

In a few cases bullets lodged in the neighbourhood of joints in such positions as to limit movement by mechanical impact with the bones. Thus I saw one case in which a bullet lay between the radius and ulna just below the lesser sigmoid cavity; in another the bullet lay in front of the ankle-joint, and limited the possibility of flexion; and in a case related to me by Mr. Bowlby, a bullet was removed by him from the wall of the acetabulum where it was tightly fixed in the substance of the bone. In two other cases I saw bullets lying deeply on the anterior surface of the hip capsule and so limiting flexion. In all such cases the indication for removal of the bullet was sufficiently strongly marked.

WOUNDS OF THE JOINTS

These may be divided into several classes, varying much in comparative severity, and in prognostic importance.

1. The comparatively rare instances in which a wound implicated a joint cavity, without accompanying lesion of any bone.

2. Perforating wounds in which the bullet was retained within the articular cavity. These were also rare.

3. Wounds of the joints accompanied by grooving of the articular extremities of the bones.

4. Complete perforating tracks through the articular ends of the bones, crossing the joint cavity in various directions.

5. Comminuted fractures of the terminal parts of the diaphyses extending into joints.

Of these several classes, the first was of the least prognostic importance. In the absence of bone injury the wounds usually healed without any obvious ill effect beyond the transient effusion into the joints of a mixture of blood and synovial fluid. When suppuration of the wound in the soft parts occurred, however, the remarks made as to the injuries classed under the third heading also apply here in a lesser degree.

With regard to the retention of the bullet, in the case of bullets of small calibre this was a distinctly rare occurrence. I never happened to see an instance of retention of either a Mauser or Lee-Metford bullet in an articulation. It is only possible with bullets practically spent, or travelling at a very low rate of velocity and making irregular impact.

The influence of both volume and velocity of flight was well illustrated by my own small experience of retained bullets. In one case a Martini-Henry was found impacted between the femoral condyles, having slipped in beneath the margin of the patella. It caused a semiflexed position to be assumed by the joint, and was removed by Mr. Brown in No. 1 General Hospital at Wynberg. The second instance I saw in the Portland Hospital at Bloemfontein in a patient of Mr. Bowlby's. The bullet was a Guedes, a form which has been already described as possessing low velocity and deficient power of penetration; beyond this, in the particular instance irregular impact was evidenced by the presence of a large irregular contused wound of entry over the tuberosity of the tibia.

The presence of the bullet in the knee-joint was later determined by the X-rays, and Mr. Bowlby removed it successfully. Seven months later the range of movement was nearly normal.

I may add that I saw several instances of large leaden bullets lodging in the popliteal space, and a comparatively insignificant number of bullets of small calibre in the same situation. This was very striking, in view of the immense relative frequency of use of the latter forms. There is no doubt, moreover, that small bullets rarely lodge even in the neighbourhood of joints, unless at the distal end of a long track. To take the extreme example of large bullets, those employed as shrapnel, in comparison with the frequency with which wounds were produced by them, bullets lying at the bottom of short tracks in the neighbourhood of joints were not uncommon. Thus I saw one lying over the hip-joint, and another in close proximity to the shoulder capsule.

Wounds of the third class, where the bones had been superficially grooved, were in some respects the most serious. This was especially so in the knee and ankle joints, and some cases will be quoted later under the heading of the special joints to illustrate this point. Danger only arose in the event of suppuration; and here the presence of the long oblique superficial track in a neighbourhood liable to comparatively free movement was the important element. Such tracks usually opened the synovial sac more extensively than direct perforating wounds, and if suppuration occurred in any portion of the track, the pus was very liable to be sucked into the joint on any free movement. The presence of fine splinters of the bone displaced in the production of the groove was also a special character of wounds of this class. Another point worthy of mention is that in these cases it was not always easy to be quite certain whether the joint cavity had been implicated or not, since cases often occurred in which, although the bones had been grooved, the joint cavity escaped. The indication, however, was to consider any wound in the immediate proximity of a joint as perforating until it was healed. This course was the more easy to take, since a large proportion of such wounds were accompanied by some degree of synovial effusion, even when the neighbouring joint had escaped puncture.

Wounds of the fourth class, although the most highly characteristic of the form of accident, were in many instances the most favourable in regard to their course. The tracks might course directly across the joint in any direction, or they might course obliquely, traversing either one or both the component bones. In the latter case the exit might be in the diaphysis, and be accompanied by the separation of an exit fragment such as is illustrated in fig. 52, p. 169. The particularly favourable character of the direct transverse and antero-posterior wounds depended on the slight amount of splintering of the bones, the limited nature of the opening into the joint, and the shortness of the tracks in the soft parts, which ensured that, even if infection did occur, the resulting pus was near the surface, and generally spread in that direction and escaped.

Wounds of the fifth class were the most dangerous, but the danger was entirely a secondary one, dependent on the occurrence of infection. These injuries were liable to be accompanied by the presence of extensive irregular wounds of the soft parts, in which suppuration was frequent, and the suppuration of the joint frequently meant subsequent amputation, if not a worse result.

Course and symptoms of wounds of the joints.—The immediate result of any perforation of a joint was the development of intra-articular effusion. This consisted of synovial fluid admixed with a varying proportion of blood. The degree of synovitis was apt to vary with the amount of force expended in the production of the injury; for this reason both high velocity and irregular impact were of importance in this relation.

The constant feature, however, depended on the effusion of blood; this was not rapid, or, as a rule, very abundant, but tended to increase during the first twenty-four hours. It resulted in a swelling of the joint, which possessed some peculiar features. At first elastic and resilient, it slowly decreased in volume with the assumption of a soft doughy character on palpation. In the case of the knee, where readily palpated, it very much resembled a tubercular synovial membrane, except for its extreme regularity of surface; still more closely the condition noted in a haemophilic knee of some duration. Absorption took place with some rapidity, and except for slight thickening, the joints might appear almost normal, in a period of from two to four weeks. With the development of the effusion there was local rise in temperature of the surface, and in a considerable number of the cases a general rise of temperature.

This latter was sometimes very marked, as in the case of all the other traumatic blood effusions, but not quite so regular in occurrence. It was important, as I have seen it give rise to the suspicion of suppuration, when tapping resulted in nothing more than the evacuation of turbid synovia mixed with blood. Pain was rarely a prominent symptom in consequence of the generally moderate degree of distension.

As a rule, these injuries were characterised by the small tendency to the development of adhesions; but this in great part depended on the care expended on their treatment. If kept too long quiet, either from necessity when the effusion was followed by much thickening, or when the external wound was large and so situated as to be harmfully influenced by movement, or in the ordinary course of treatment, troublesome stiffness, even amounting to firm anchylosis, sometimes followed. I saw several such cases, some of the most confirmed being wounds of the knee-joint complicated by injury to the popliteal vessels or nerves. The latter complication I saw altogether six times, but only once with a thoroughly bad knee, and in this case the injury had affected both the vessels and the internal popliteal nerve. The joint in that case was straightened out by continuous extension by Major Lougheed, when it came under his charge some six weeks after the primary injury, but I hear has again relapsed, and the popliteal paralysis is not much improved.

The small tendency to formation of adhesions in uncomplicated cases probably depended on the coagulation of a layer of blood over the whole internal lining of the joint. This kept the synovial surfaces apart at the lines of reflection of the membrane, and, given sufficiently active treatment, mobility was restored before any firm union could take place.

The primary escape of synovial fluid was rarely observed, as the wounds of the soft parts were too small and valvular to permit of it. Synovia in some abundance, mixed with pus, sometimes escaped in considerable quantity when infection had opened up the tracks.

Primary suppuration in any joint as a result of small and direct wounds was very rare. I observed it only on one occasion. On the other hand, a considerable number of cases in which secondary suppuration occurred came under my notice. In some of these the suppuration was secondary to comminuted fractures of the shaft of the tibia, in which the articular extremity was implicated. These offered no special peculiarity. In others infection of the joint was secondary to infection and suppuration in the deep part of long oblique wound tracks, and these were of sufficient interest to warrant the insertion of two illustrative cases.

(43) In a man wounded at Paardeberg the bullet entered the leg to the inner side of the crest of the tibia, about 3 inches below the tubercle; thence it coursed upwards to emerge about 2 inches above the cleft of the knee-joint on the outer side. Regulation dressings were applied, and a week later the man arrived at the Base, with little apparent mischief in the knee-joint. He was placed in bed and warned against movement; on the second day, however, he got up and walked to the latrine. When bending his knee to sit down he was seized with agonising pain in the joint, and had to call out for help; he was then carried back to bed in a more or less collapsed condition. The knee commenced to swell; there was rise of temperature and great pain, together with extreme restlessness. I was asked to see him two days later, and after a consultation, Major Burton, R.A.M.C., freely incised the knee-joint bi-laterally. One opening was closed, the second plugged for drainage, as there was a large quantity of pus. No improvement followed, and a week later Major Burton amputated through the thigh. An attack of secondary haemorrhage a few days later, combined with the degree of septic infection, ended the man's life. On examination of the joint, a groove forming three-fourths of a tunnel was found in the external tuberosity of the tibia, leading into the knee-joint beneath the external semilunar cartilage. The bullet had then passed upwards over the outer border of the cartilage, bruised the margin of the external condyle of the femur in such a manner as to depress the outer compact layer, and finally escaped from the joint near the upper reflection of the synovial membrane. The synovial membrane was granular in appearance and reddened, but there was no suppuration outside the confines of the joint, except in a cavity corresponding to 2 inches of the track before it actually perforated the tibia. A localised abscess had evidently formed here and been diffused into the joint by the movement of flexion already described.

(44) A man wounded during General Hamilton's advance on Heilbron was struck on the outer aspect of the heel. An oval opening of some size led down to a track in the os calcis; the bullet was retained. The foot was dressed, and put up later in a plaster-of-Paris splint. On the tenth day the splint was removed to see to the wound, which looked satisfactory and was re-dressed.

A few hours later the man was seized with very severe pain in the ankle, and a day later I was asked to see him by Mr. Alexander. The man was anaesthetised, and I examined the wound with care, and also removed the retained bullet from the inner margin of the leg. The bullet was reversed, having no doubt suffered ricochet, hence the large aperture of entry, but it was in no way deformed. I could not certainly determine the presence of any fluid in the ankle-joint, and as the pain was apparently localised to the distribution of the musculo-cutaneous nerve, I decided not to freely open the joint. In this, however, I erred, and two days later, after consultation, the joint was freely incised by Mr. Alexander. It was then found that the bullet in its passage had just touched the posterior aspect of the tibia and wounded the ankle-joint. A localised collection of pus which had formed in the deep part of the wound had been diffused into the joint by the movements made when the splint was removed, in a similar manner to that described in the last case. This joint also did badly, and an amputation of the leg had to be performed by Mr. Alexander to save the man's life.

These two cases are particularly instructive as showing, first, how quietly a small amount of deep suppuration may sometimes take place; and, secondly, the importance of keeping the joints quiet on a splint when there is any reason to suspect their implication by wounds of this character.

The general treatment of the wounded joints was simple. The old difficulties of deciding on partial as against full excision, or amputation, were never met with by us. We had merely to do our first dressings with care, fix the joint for a short period, and be careful to commence passive movement as soon as the wounds were properly healed, to obtain in the great majority of cases perfect results. Careful light massage, if available, was used to promote absorption of blood.

If suppuration occurred, the choice between incision and amputation had to be considered. In the early stages this choice depended entirely on the nature of the injury to the bones. If this were slight, incision was the best plan to adopt. I saw several cases so treated which did well, although convalescence was often prolonged, and only a small amount of movement was regained. Amputation was sometimes indicated in cases of severe bone-splintering, when the shafts were implicated, but was as a rule only performed after an ineffectual trial to cut short general infection of the septicaemic type by incision.

I have dwelt at such length on the subject of suppuration on account of its importance, but I should add that, on the whole, suppuration of the joints was uncommon, except in the case of injuries far exceeding the average in primary severity.

Special joints.—Such deviations from the general type of injury as above described depended entirely on peculiarities of anatomical arrangement, and peculiarities in the situation of the joint clefts in the different parts of the body. A few words as to these are perhaps necessary.

Shoulder-joint.—Wounds of this articulation were by no means common. This depended, I think, on two points in the architecture of the joint: first, a bullet to enter the front of the cavity and traverse the joint needed to come with great exactitude from the immediate front; secondly, wounds received from a purely lateral direction calculated to pierce the head of the humerus and the glenoid cavity were naturally of very rare occurrence. Wounds of the prominent tip of the shoulder received while the men were in the prone position were not uncommon, but it was remarkable how rarely the shoulder-joint was implicated in these. The question of the narrow nature of the cleft exposed also comes up in this position. As far as my experience went, injuries to the lower portion of the capsule accompanying wounds of the axilla were those most often met with. The ease and neatness with which pure perforations of the head of the humerus can be produced was also an important element in the frequent escape of this joint. No case of fracture of the glenoid cavity happened to come under my notice.

I saw few instances in which the joint needed incision, and cannot recall or find in my notes any case in which serious trouble arose.

Elbow-joint.—Injuries to this joint came second in frequency in my experience to those of the knee. They were, in fact, comparatively common, especially in conjunction with fractures of the various bony prominences surrounding the articulation. Fractures of the lower end of the humerus were of worse prognostic significance than those of the ulna, on account of the greater tendency to splintering of the bone. I saw several cases of pure perforation of the olecranon without any signs of implication of the elbow-joint. In a case which has been utilised for the illustration of some of the types of aperture (fig. 20, p. 59), at the end of a week there was no sign of any joint lesion, although the bullet had obviously perforated the articulation.

Several cases of suppuration which came under my notice did well. I saw one of them a few days ago, six months after the injury, with perfect movement. In another of which I took notes, the bullet entered over the outer aspect of the head of the radius, to emerge just above the internal condyle anteriorly. A considerable amount of comminution of the olecranon resulted, and when the man came into hospital some ten days later the joint was suppurating. The joint was opened up from behind, and some fragments of bone removed by Mr. Hanwell. On the 26th day this joint was doing well, and considerable flexion and extension were possible without pain. There was a somewhat abundant discharge of bloody synovia during the first few days after the operation.



I never saw any troublesome results from perforations of the carpus. The joints of the fingers also offered little special interest, except in so far as they afforded astonishing examples of the extreme neatness of the injuries which a small-calibre bullet can produce. Fig. 59 is a good example of such an injury.

Hip-joint.—I can only repeat with regard to this joint what I have already said as to the injuries to the head of the femur. I had practically no experience of small-calibre bullet injuries to the femoral constituent, and beyond the single case of injury to the acetabular margin mentioned on p. 193 I saw no obvious wounds of the joint at all.

The knee, as usual, proved itself par excellence the joint most commonly injured, no doubt as a result of its size, the extent of its capsule anteriorly, and its exposed position. In spite, however, of the frequency with which it suffered injury, and the opportunities it afforded for observation of the progress of the effusions towards absorption, the injuries to the joint gave less anxiety and attained a more favourable prognostic character than is the case in civil practice. This depended on the very favourable course observed in the frequent pure perforations following a direct line. These occurred in every direction, the accompanying haemarthrosis usually disappearing completely in an average period of little over a month. The extremes can be fairly placed at a fortnight and six weeks. Limitation of movement was slight or non-existent in many cases; in others it was of a very moderate character, and I only remember to have seen one case in which a really serious anchylosis developed. In this the man was struck from a distance of 300 yards, and a considerable amount of bone dust from the femur was found in the lips of the exit aperture. The wounds healed per primam, but when I saw the man two months later anchylosis in the straight position was apparently complete.

The comparatively frequent association of popliteal aneurisms with wounds of the knee-joint has already been spoken of in relation to anchylosis. Wounds of the popliteal space from larger bullets sometimes caused more troublesome after-stiffness than wounds of the articulation itself. Again I remember a small pom-pom wound at the inner margin of the ligamentum patellae without obvious wound of the joint, which was accompanied by synovitis from contusion, and was followed by very considerable limitation of movement. This had only been partially improved when the patient returned home, in spite of prolonged massage and passive movement.

The general remarks on the joints cover all that need be said as to suppuration of the knee-joint.

The ankle-joint maintained the undesirable character which it has always held as a subject for gunshot injuries. This is entirely a question of sepsis, and in great measure depends on the fact that the foot, as enclosed in a boot, is invested with skin particularly difficult to thoroughly cleanse; while the socks are an additional source of infection to the wounds before the patients come under proper treatment.

Of seven cases of suppurating ankle-joint, of which I have notes, only two retained the foot, and one of these after a very dangerous illness. This case was one of special interest as exemplifying the results dependent on variations in velocity on the part of the bullet. The patient was struck at a distance of twenty yards. The bullet entered the front of the right ankle-joint and emerged through the internal malleolus, just behind its centre, causing no comminution of the latter. It then entered the left foot by a type wound one inch behind and below the tip of the internal malleolus, traversed and comminuted the astragalus, and emerged one inch below the tip of the external malleolus. The first joint healed per primam. The second produced by the bullet when passing at a lower rate of velocity was accompanied by considerable comminution of the bone. It suppurated, and gave rise to great anxiety both for the fate of the foot and the life of the patient. It is probable that the more abundant haemorrhage which took place from the second wound was in part responsible for the occurrence of infection.

The second of the two cases is of some interest in relation to the doctrine of chances as to the position in which a wound may be received. The man was wounded in one of the earlier engagements, a bullet passing transversely through his leg immediately behind the bones and about half an inch above the level of the ankle-joint. He recovered, and rejoined his regiment, only to receive at Paardeberg a second wound, about an inch lower, which traversed the ankle-joint. On his return to Wynberg he happened to be sent to the same pavilion, and occupied the same bed he had left on returning to the front.

The subject of the result of wounds of the joints of the foot has received sufficient consideration under the heading of wounds of the tarsus.

The repetition of the fact that, among the whole series of cases on which this chapter is founded, not a single instance of primary or secondary excision of a joint, either partial or complete, is recorded, forms an apt conclusion to my remarks on this subject.



CHAPTER VII

INJURIES TO THE HEAD AND NECK

Injuries to the head formed one of the most fruitful sources of death, both upon the battlefield and in the Field hospitals. It has been suggested that the mere fact of wounds of the head being readily visible ensured all such being at once distinguished and correctly reported, while wounds hidden by the clothing often escaped detection. When the external insignificance of many of the fatal wounds of the trunk is taken into consideration this is possible; but, on the other hand, it must be borne in mind that the head is in any attitude the most advanced, and often the most exposed, part of the body, and even when the soldier had taken 'cover,' it was frequently raised for purposes of observation. For the latter reasons I believe injury to the head fully deserved the comparative importance as a fatal accident with which it was credited.

A number of somewhat sensational immediate recoveries from serious wounds of the head have been placed upon record. Observation, however, shows that these, with but few exceptions, belonged either to certain groups of cases the relatively favourable prognosis in which is familiar to us in civil practice, or that the wounds were received from a very long range of fire, and hence the injuries were strictly localised in character.

ANATOMICAL LESIONS

Wounds of the scalp.—Nothing very special is to be recorded with regard to these; they either formed the terminals of perforating wounds, or were the result of superficial glancing shots. The glancing wounds were of the nature of furrows, varying in depth from mere grazes to wounds laying bare the bone. Their peculiarity was centred in the fact that a definite loss of substance accompanied them, the skin being actually carried away by the bullet; hence gaping was the rule. Every gradation in depth was met with, but the only situations in which wounds of considerable length could occur were the frontal region in tranverse shots, or, when the bullet passed sagitally, the sides of the head, or the flat area of the vertex.

The danger of overlooking injuries to the bone was of special importance in the short subcutaneous tracks occasionally met with at the points at which the surface of the skull makes sharp bends. In all such wounds it was a safe rule to assume a fracture of the skull until this was excluded by direct examination. In some of the gutter wounds and subcutaneous tracks crossing the forehead and sides of the head, signs of intracranial disturbance were occasionally observed in the absence of external fracture, such as transient muscular weakness, unsteadiness in movements, giddiness, diplopia, or loss of memory and intellectual clearness. In connection with such symptoms the classical injury of splintering of the internal table of the skull, the external remaining intact, had to be borne in mind, but I observed no proven instance of this accident. I am of opinion, moreover, that its occurrence with small bullets travelling at a high degree of velocity must be very rare, since little deflection is probable unless the contact has been sufficiently decided to fracture the external table; while in the cases of spent bullets the injury is unlikely, as requiring a considerable degree of force.

Injuries to the cranial bones, without evidence of gross lesion to the brain.—It may be premised that these were of the rarest occurrence, and they may be most readily described by shortly recounting the conditions observed in a few cases I noted at the time. The injuries resulted from blows with spent bullets, from bullets barely striking the skull directly, or those striking over the region of the frontal sinuses. Wounds of the mastoid process will not be considered in this connection as being of a special nature (see p. 299).

I saw only one case of escape of the internal, with depressed fracture of the external, table of the skull.

(45) In marching on Heilbron a man in the advance guard was struck by a bullet at right angles just within the margin of the hairy scalp. The regiment was at the time to all intents and purposes outside the range of rifle fire, and the patient was the only individual struck among its number. When brought into the Highland Brigade Field Hospital, a single typical entry wound was discovered; examination with the probe gave evidence of a slight depression in the external table of the frontal bone just above the temporal ridge. Although no perforation was detectible by the probe, and this was positively excluded on the raising of a flap (Major Murray, R.A.M.C.), it was considered advisable to remove a 1/4-inch trephine crown, the pin of the instrument being applied to the margin of the depression. No depression or splintering of the internal table was discovered, nor any injury to the dura, nor blood upon the surface of that membrane. The man made an uninterrupted recovery.

(46) A case of frontal injury was shown to me at Wynberg, in which a distinct furrow could be traced across the upper part of the frontal sinuses. There had been no symptoms beyond temporary diplopia, and the wound was healed; no surgical interference had been deemed necessary.

(47) In a man wounded at Poplar Grove, a single typical wound of entry was found 3/4 of an inch above the right eyebrow and the same distance from the median line. No primary symptoms were observed, but on the evening of the second day the temperature rose above 100 deg. F., and the man seemed somewhat heavy and dull. The patient was examined by Major Fiaschi and Mr. Watson Cheyne, and it was decided to explore the wound. Mr. Cheyne removed fragments both of external and internal tables, one of the latter having made a punctiform opening, not admitting the finest probe, in the dura-mater. The bullet was traced into the nasal fossae, where it was subsequently localised with the aid of the Roentgen rays when the patient came under my observation at Wynberg some days later (fig. 60).

Gunshot fracture of the skull with concurrent brain injury.—This was the commonest form of head injury, and possessed two main peculiarities; firstly, the large amount of brain destruction compared with the extent of the bone lesion; secondly, the fact that any region of the skull was equally open to damage. In consequence of the second peculiarity, the position and direction of secondary fissures are not so dependent on anatomical structure as in the corresponding injuries of civil practice. Thus, fractures of the base, for instance, were less constant in their course and position. The cases as a whole are best divided into four classes.



1. Extensive sagittal tracks passing deeply through the brain, and vertical wounds passing from base to vertex or vice versa, in the posterior two thirds of the skull. These will be referred to as general injuries.

2. Vertical or coronal wounds in the frontal region.

3. Glancing or obliquely perforating wounds of varying depth in any part of the head.

4. Fractures of the base.

Of these classes the first was nearly uniformly fatal; the second relatively favourable, and with low degrees of velocity often accompanied by surprisingly slight immediate effects; while the third had perhaps the best prognosis of all, but this varied as to the defects that might be left, and with the region of the head affected.

1. General injuries.—Fractures of this class may be treated of almost apart. For their production the retention of a considerable degree of velocity on the part of the bullet was always necessary, and the results were consequently both extensive and severe.

The aperture of entry was comparatively small, since to take so direct and lengthy a course through the skull the impact of the bullet needed to be at nearly an exact right angle to the surface of the bone. Any disposition to assume the oval form, therefore, depended mainly upon the degree of slope of the actual area of the skull implicated. In size the aperture of entry did not greatly exceed the calibre of the bullet; in outline it was seldom exactly circular, but rather roughly four-sided, with rounded angles, slightly oval, or pear-shaped. The margin of the opening consisted of outer table alone, the inner being always considerably comminuted. Fragments of the latter, together with the majority of those corresponding to the loss of substance of the outer table, were driven through the dura mater and embedded in the brain. These bony fragments were more or less widely distributed over an area of a square inch or more, and not confined to a narrow track.



The amount of fissuring at the aperture of entry was often not so extensive as I had been led to expect. Fig. 61 is a diagram illustrating a fairly typical instance; in some cases no fissuring existed. As a rule the nearer to the base, the greater was the amount of fissuring observed. The fissures were sometimes very extensive in this position, probably as a result of the lesser degree of elasticity in this region of the skull. Again, when the aperture of entry was near the parts of the vertex where sudden bends take place, considerable fissuring of the same nature as that seen in the superficial tracks (fig. 68) was produced in the flat portion of the skull above the point of entrance.

Radial fissuring around the aperture of entry in the skull scarcely corresponds in degree with that seen when the shafts of the long bones are struck, and is far less marked and regular than when one of these small bullets strikes a thick sheet of glass set in a frame. I saw several apertures in the thick glass of the windows of the waterworks building at Bloemfontein produced by Mauser bullets. They differed little from the opening seen in an ordinary plate-glass window resulting from a blow from a stone, except perhaps in the regularity and multiplicity of the radial fissures. As in the skull, the opening was a little larger than the calibre of the bullet, and the loss of substance on the inner aspect considerably exceeded that on the outer.

The degree of fissuring is probably affected by the resistance offered by the particular skull, or the special region struck, but as a rule the elasticity and capacity for alteration in shape possessed by the bony capsule, is opposed to the production of the extreme radial starring observed in the long bones or a fixed sheet of glass. Corroborative evidence of the influence of elasticity in the prevention of starring is seen in the limited nature of the comminution of the ribs in cases of perforating wounds of the thorax.

In the most severe cases we can only speak of the 'aperture' of exit in a limited sense in so far as the opening in the scalp is concerned; this was often comparatively small, not exceeding 3/4 of an inch in diameter. Beneath this limited opening in the soft parts, the bone of the skull was smashed in a most extensive manner. The portion exactly corresponding to the point of exit of the bullet was carried altogether away, but around this point a number of large irregularly shaped fragments of bone, from 3/4 to 1 inch in diameter, were found loose, and often so displaced as to expose a considerable area of the dura-mater. Beyond the area of these loose fragments, fissures extended into the base and vertex, in the latter case often being limited in their extent by the nearest suture.

Over extensive fractures of this nature general oedema and infiltration of the scalp, due to extravasation of blood, were present. When the exit was situated in the frontal region ecchymosis often extended to the eyelids and down the face, while in the occipital region similar ecchymosis was often seen at the back of the neck.

The opening in the dura mater at the aperture of entry was either slitlike, or more often irregular from laceration by the fragments of bone driven in by the bullet. At the point of exit a similar limited opening corresponded with the spot at which the bullet had passed, while separate rents of larger size were often seen at some little distance. The latter were the result of laceration of the outer surface of the membrane by the margins of the large loose fragments of bone above described.

Injury to the brain more than corresponded in extent to the fractures of the bone. Pulping of its tissue existed over a wide area both at the points of entrance and of exit. In the former position the amount of damage was the less, the gross changes roughly corresponding with the tissue directly implicated by the bullet itself, and the fragments of bone carried forward by it. The degree of splintering of the skull therefore in great part determined the severity of the lesion. At the exit aperture much more widespread destruction existed, while masses of brain tissue, small shreds of the membranes, fragments of bone, and debris from the scalp were found occasionally bound together by coagulated blood and protruding from an exit opening of some size. The largest masses of such debris were most often seen in instances in which the bullet had entered by the base to escape at the vertex of the skull.

The brain in the line of injury suffered comparatively slightly, but small parenchymatous haemorrhages into its tissue indicated in lesser degree the same type of injury undergone by the mass of brain pulp and small blood-clots found at the external limits of the wound. Beyond this extensive haemorrhages at the base of the skull were common.

With regard to the extensive character of the brain destruction in the region of the aperture of exit, it must be borne in mind that this lesion corresponds in position with one which would exist even if the injury were of a non-penetrating degree. A large proportion of the contusion and destruction is therefore explained by violent impact of the projected brain with the skull prior to the passage of the bullet, and not to the direct action of the bullet on the tissues.

These cases of 'general injury' afford a marked example of the lesions to which the term 'explosive' has been applied, and as such have an important bearing on the theories held as to the mode of production of explosive effect. The increased area of tissue damage at the aperture of exit favours the theory of direct transmission of a part of the force with which the bullet is endowed, to the molecules of tissue bounding the track made by the projectile. Thus the area of destruction corresponds with the cone-like figure which one would expect to be built up by the vibrations spreading from the primary point of impact. The exit region of the skull is subjected not alone to the force of the travelling bullet, but also to that exerted over a much wider area by the tissue to which secondary vibrations have been communicated. The brain itself is, in fact, dashed with such violence against the bone as to cause a great part of the injury.

No doubt the brain in its reaction to the bullet forms as near an approach to a fluid as any solid tissue in the human body, and experimental observation has shown how greatly its presence or absence in the skull affects the degree of comminution on the exit side; hence the fondness for the so-called hydraulic theory that has been always exhibited in the case of these injuries. The localisation of the injury in its highest degree to the neighbourhood of the exit aperture, however, shows that in any case the main wave takes a definite direction in a course corresponding to that of the bullet.

The real importance of the presence of the brain within the skull in increasing the amount of damage at the exit end of the track, is as a medium for the ready transmission of forcible vibrations. That the latter are to some extent conveyed as by a fluid is evidenced by the occasional presence of brain matter and fragments of bone in the aperture of entry, which suggests recoil or splash such as would be expected from a fluid wave.

Experience of the character of the lesions observed after severe concussion by the ordinarily somewhat coarser forms of violence common to civil life, fully explains the severity of the damage to the brain tissue met with in injuries due to bullets of small calibre. Viewing the elaborate arrangements which exist for the preservation of the central nervous system from the moderate vibration incidental to ordinary existence, it is easy to appreciate the harmfulness of such exquisite vibratory force as that transmitted by a bullet of small calibre travelling at a high rate of velocity.

Effect of ricochet in the production of severe forms of injury.—In connection with the lesions above described mention must be made of cases in which the aperture of entry reaches a large size, or a portion of the skull is actually blown away.

Examples of the former class were not uncommon; I will briefly relate one.

(48) A Highlander while lying in the prone position at Rooipoort, was struck by a bullet probably at a distance of about 1,000 yards. A large entry wound in the scalp was produced, while the defect in the skull was coarsely comminuted and was capable of admitting three fingers into a mass of pulped brain. Both brain matter and fragments of bone were found in the external wound, which was situated just anterior to the right parietal eminence. The bullet passed onwards through the base of the skull, crossing the external auditory meatus, fracturing the zygoma and probably the condyle of the mandible, and eventually lodged beneath the masseter muscle. Blood and brain matter escaped from the external auditory meatus.

The patient was brought off the field in a semi-conscious condition, the pupils moderately contracted but equal, the pulse 66, very small and irregular in beat, the respiration quiet and easy, and with paralysis of the left side of the body. The faeces had been passed involuntarily.

The wound was cleansed and bone fragments removed. The patient had to travel in a wagon for the next three days until the column halted. The progress of the case was unsatisfactory, as the wound became infected, and the man eventually died on the 14th day of general septicaemia, but with little evidence of local extension of septic inflammation.

In this instance the head was no doubt struck by a bullet which had previously made ricochet contact with the ground. I saw several such cases.

Closely connected with such injuries are those in which large portions of the skull and scalp were actually blown away. I never witnessed one of these myself, but I recall two instances described to me by officers who lay near the wounded men on the field. In one the frontal region was carried away so extensively that, to repeat the familiar description given by the officer, 'he could see down into the man's stomach through his head.' In a second case the greater part of the occipital region was blown away in a similar manner, and this was of especial interest as the wounded man was seen to sit up on the buttocks and turn rapidly round three or four times before falling apparently dead. The observation offers interesting evidence of the result of an extensive gross lesion of the cerebellum.

In the absence of exact information, it may well be that such injuries as the two latter were produced by some special form of bullet, but as both were produced while the patients were lying on the ground, and therefore especially liable to blows from ricochet bullets, I am inclined to attribute both to this cause.

In considering injuries of the above nature, one cannot help speculating on the possible influence of a head-over-heels ricochet turn on the part of the bullet while traversing the long sagittal axis of the skull. It is not uncommon for apical target ricochets to present evidence of damage to the apex and base of the mantle alone. This must depend on a rapid turn on impact, which might well be imitated in the case of the skull, and would then go far to explain the production of some of the most severe forms of explosive exit wounds met with. See cases 48, 54, 68.

Short of ricochet, the influence of simple wobbling must also be considered in shots from a long range. The entry wound may be large as a result of this condition, but as the velocity possessed by the bullet is low, the injuries would probably not be of a very severe nature.

In connection with the subject of wobbling, reference should be made to the form suggested by Nimier and Laval, in which the wobble, as the result of resistance to the apex of the revolving bullet, assumes the form of movement seen when the spin of a top is failing. This would explain a peculiarity in some wounds of entry over the skull first pointed out to me by Mr. J. J. Day. When such wounds were explored, as well as the presence of brain in the entry aperture, a number of fragments of the external table of the skull were found everted and fixed in the tissues of the scalp. As already suggested, this may be mere evidence of splash, but it may be equally well explained by a process of wobble around the axis of revolution of the bullet. This might, no doubt, also be invoked to explain the displacement of some of the fragments in fractures of the long bones, where considerable resistance to the passage of the bullet is offered.

II. Vertical or coronal wounds in the frontal region.—These injuries were common, and offered some of the most interesting illustrations of the variations in symptoms and effects following apparently exactly identical lesions, judging from the condition of the external soft parts alone; since the latter sometimes gave little indication of the force (dependent on the rate of velocity) which had been applied.

With the lower degrees of velocity simple punctured fractures of the skull resulted, without extensive lesion of the frontal lobes as evidenced by immediate symptoms. The nature of the fractures differed in no way from the punctured fractures we are familiar with in civil practice. The openings of entry in the bone were irregularly rounded, corresponding in size to the particular calibre of the bullet concerned. The margin consisted of outer table alone, while the inner table was either considerably comminuted, or a large piece was depressed, wounding the dura-mater and projecting into the brain substance (see fig. 63). The aperture of exit presented exactly the opposite characters, the splintering comminution or separation of a large fragment affecting the outer table, while the inner presented a simple perforation. The latter condition is represented in figs. 71 and 72, and I will here give short notes of four illustrative cases, as being the shortest and most satisfactory method of conveying a correct idea of the nature of such injuries.



(49) Vertical perforation of frontal bone.—Wounded at Belmont, while in the prone position. Aperture of entry (Mauser), at the anterior margin of the hairy scalp on the left side; course, through the anterior part of the left frontal lobe, roof of the left orbit, cutting the optic nerve and injuring the back of the eyeball, floor of the orbit, the antrum, the hard palate, and tongue. Exit, in mid line of the submaxillary region. No cerebral symptoms were noted, and on the fifth day the man was sent to the Base hospital without operation; the pulse was then 70 and the temperature normal. The movements of the eyeball were perfect, but blindness was absolute. At the Base hospital the eye suppurated and was removed. The patient was then sent home apparently well. He has since been discharged from the service, and is now employed as a painter in Portsmouth Dockyard.

(50) Vertical perforation of frontal bone.—Wounded at Paardeberg while in the prone position. Range, 600-700 yards. Aperture of entry (Mauser), at the fore margin of the hairy scalp above the centre of the right eyebrow; course, through the anterior third of the right frontal lobe, roof of orbit, front of eyeball, margin of floor of orbit making a distinct palpable notch, and cheek; exit through the red margin of the upper lip, 1/2 an inch from the right angle of mouth. The bullet slightly grooved the lower lip.

The patient rose almost immediately after being struck, and walked about a mile, although feeling dizzy and tired. The wounds, which both bled considerably, were then dressed. After three days' stay in a Field hospital, the patient was sent in a bullock wagon three days and nights' journey to Modder River and thence to the Base.

There was anaesthesia over the area supplied by the outer branch of the supra-orbital nerve, extending from the supra-orbital notch backwards into the parietal region, but none over the area supplied by the second division of the fifth nerve.

On the tenth day there were no signs of cerebral disturbance except a pulse of 48. The eyeball was suppurating, and the temperature rose to 99 deg. at night. The lids were still swollen and closed.

A few days later the eyeball was removed and at the same time a flap was raised and the fracture explored (Major Burton, R.A.M.C.). An opening somewhat angular, 1/3 of an inch in diameter, was found with a thin margin in the outer table of the skull (fig. 62); when this was enlarged with a Hoffman's forceps, an opening in the dura was discovered, and cerebro-spinal fluid escaped. A piece of the inner table of the skull (fig. 63), 3/4 by 1/3 an inch in size, was discovered projecting downwards vertically into the brain. This latter was removed and the wound closed. Healing by primary union followed, and no further symptoms were observed.



(51) Transverse frontal wound.—Wounded at Paardeberg. The man was sitting down at the time he was struck, in the belief that he was out of the range of fire. The entry and exit wounds were almost symmetrical, placed on the two sides of the forehead at the margin of the hairy scalp, 2-1/4 inches above the level of the external angular processes of the frontal bone. The patient lost consciousness for about half an hour, then rose and walked half a mile to the Field hospital. The wounds were dressed, and after a stay of three days in hospital, the man was sent the three days' journey to Modder River; during the journey he got in and out of the wagon when he wished. After two days' stay at Modder, a journey was again made by rail to De Aar (122-1/2 miles). The wounds were healed. The man stayed at De Aar nearly a month, and then, rejoining his regiment, made a two days' march of some 22 miles on hot days. He had to fall out twice on the way by reason of headache, feeling dizzy, and 'things looking black.' He did not own to any loss of memory or intellectual trouble, but was invalided to England. This patient returned to South Africa later, and is now on active service.

(52) Transverse frontal wound.—Within a few days an almost identical symmetrical wound in the frontal region occurred in the same district, from a near range. The patient became immediately unconscious, and remained so until his death some four days later, his symptoms being in no way alleviated by operation and the removal of a quantity of bone fragments and cerebral debris. At the post-mortem examination, extensive destruction of both hemispheres of the brain was revealed, and large fissures extended into the base of the skull.

III. Glancing or oblique perforating wounds of varying depth in any portion of the cranium.—These injuries were the most common, the most highly characteristic of small-calibre bullet wounds, the most interesting from the point of view of diagnosis, prognosis, and treatment, and beyond this they formed the variety most unlike any that we meet with in civil practice.

They were met with in every region of the cranium, and in every degree of depth and severity. The lesser are best designated as gutter fractures, the deeper are perforating and gradually approximate themselves to the type of injury described as class 1.

When the bullet struck a prominent or angular spot on the skull a considerable oval-shaped fragment was occasionally carried away, leaving an exposed surface of the diploe (case 60, p. 274). Under these circumstances the apparent lesion on raising a flap was slight, but exploration often showed extensive intra-cranial mischief. Thus in the case referred to both dura and brain were wounded, and continuing haemorrhage led to the development of progressive paralysis, relieved only by operation.

From the more deeply passing bullets a more or less oval opening resulted, in which both tables were freely comminuted and displaced. These cases differed from the typical gutter fracture only in length and outline, and the nature of the accompanying intra-cranial lesion was identical, while in the latter particular they differed much from fractures in which the impact of the bullet was direct, in spite of a near resemblance in the appearances in the osseous defect.

I saw one instance in which a circular fissure about 1-1/2 inch from the actual opening of entry surrounded the latter, the area of bone within the circle being somewhat depressed, though radial fissures were absent.

In several of these cases fragments of lead were either found on the fractured surface of the bone or within the cranial cavity, showing that the bullets had undergone fissuring of the mantle, or had actually broken up on impact.

Gutter fractures.—The nature of the injury to the bones in these is best illustrated by a series of diagrams of sections such as are shown below.



In the most superficial injuries the outer table was grooved and depressed, usually with loss of substance from small fragments directly shot away: these latter had either been driven through the wound in the soft parts, or remained embedded on the deep aspect of the enveloping scalp (fig. 64). In the less common variety the scalp was slit to a length corresponding with the injury to the bone, but more often oval openings in the skin existed at either end of the track. The inner table was practically never intact, but the amount of comminution naturally varied with the depth to which the outer table was implicated (fig. 65 A, and B).

The following is an illustrative example of this degree, and also emphasises the consequences which may follow primary non-interference.



(53) Superficial gutter fracture in parietal region. Convulsive twitchings. Secondary paralysis.—Wounded at Modder River. Range, 400 yards. A scalp wound 3 inches in length ran vertically downwards, commencing 1 inch from the median line, and situated immediately over the upper third of the right fissure of Rolando. The patient was unconscious for several hours after the injury, and later suffered with severe headache, and twitchings in the left shoulder and arm.

The wound healed, but a well-marked groove was palpable in the bone beneath, and the twitchings persisted. The latter came on about every twenty minutes, and loss of power in the left upper extremity, and to a less degree in the lower, developed. The memory was defective, and the patient suffered at times with headache. The pupils were equal but sluggish in action. No changes were discovered in the fundus beyond a well-developed myopic crescent at the lower and outer part of the left disc (Mr. Hanwell).

The twitchings became more frequent and latterly were accompanied by somewhat severe muscular contractions in the upper extremity, while the loss of power in the lower extremity became more marked. Headache was also more troublesome.

The patient throughout refused any operation, saying he would rather go home first, and at the end of a month he left for England.

In the deeper injuries more and more of the outer table was cut away, and the inner became gradually more depressed, fractured, or comminuted (fig 66).



Bevelling at the expense of the outer table at both entry and exit ends of the course existed, but in either case a portion of the inner table was also detached and depressed. Sometimes the depressed portion of the inner table was mainly composed of one elongated fragment; this was either when the bullet had not implicated a great thickness of the outer table, or had passed with great obliquity through especially dense bone (see fig. 70). When the bullet had passed more deeply the inner table was comminuted into numberless fragments. I have frequently seen 50 or 60 removed. Where such tracks crossed convex surfaces of the skull, the two conditions were often combined; thus at one portion of the track, usually the centre, the comminution was extreme, while at either end a considerable elongated fragment of inner table was often found, the latter perhaps more commonly at the distal or exit extremity (fig. 67).



The nature of the injury to the bone when the flight of the bullet actually involved the whole thickness of the calvarium was comparable to that seen in the case of the long bones when struck by a bullet travelling at a moderate rate (see plate XIX. of the tibia, or what is illustrated in the case of the pelvis in fig. 55). In point of fact, a clean longitudinal track appeared to have been cut out. The length of these tracks naturally depended upon the region of the skull struck. When a point corresponding to a sharp convexity, or a sudden bend in the surface, was implicated, an oval opening of varying length in its long axis was the result; when a flat area, as exists in the frontal or lateral portions of the skull, was the seat of injury, a long track was cut.

Superficial perforating fractures.—These formed the next degree; the chief peculiarity in them was the lifting of nearly the whole thickness of the skull at the distal margin of the entry, and the proximal edge of the exit, openings; the flatter the area of skull under which the bullet travelled the more extensive was the comminution. In some cases nearly the whole length of the bone superficial to the track would be raised; in fact, the bullet having once entered, the force is applied from within in exactly the same way that it operates on the inner table in the gutter fractures. A corresponding injury is met with in the case of the bones of the extremities (see fig. 57 of the tibia), and again the resemblance between these injuries of the skull and such perforations of the long bones as are illustrated by skiagrams Nos. III. and XXIII. of the clavicle and fibula is a close one.