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 pa.s.sed 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 sh.e.l.l 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.

[Ill.u.s.tration: PLATE XVII

Skiagram by H. CATLING.

Engraved and Printed by Bale and Danielsson, Ltd. (35) PERFORATION OF THE SHAFT OF THE FEMUR. FLAP OF BONE RAISED AT THE APERTURE OF EXIT IN THE POPLITEAL SURFACE OF THE SHAFT.

Range 'over 1,000 yards.'

Compare with fig. 52, p. 169.]

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

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

When transport is a necessity, the best method of immobilisation is the application of breeches of plaster of Paris, and a long outside splint.

The latter we often had excellently made on emergency by the Ordnance Department or the Royal Engineers. A perineal band is the only form of extension possible under these circ.u.mstances. The Dutch ambulances were provided with a very excellent emergency splint for cases of fractured thigh, which is ill.u.s.trated 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.

[Ill.u.s.tration: PLATE XVIII.

Skiagram by H. CATLING.

Engraved and Printed by Bale and Danielsson Ltd.

(36) OBLIQUELY TRANSVERSE FRACTURE OF THE PATELLA

Range 'short.'

The entry and exit wounds were small, and a distinct grooving from loss of substance of the bone was palpable superficial to the actual cleft of the fracture.]

[Ill.u.s.tration: FIG. 56.--Dutch Cane Field Emergency Splint for Thigh or Lower Extremity. (Dutch Ambulance, Winberg)]

In cases which can be treated at a Stationary hospital near at hand, a long outside splint supplemented by plaster breeches, and a well-applied American extension, is a very good method of treatment, the only point to bear in mind being frequent examination of the position of the limb to ensure the extension being efficient. As already mentioned, the shortening in the primary stages is often slight and easily combated, but in many of these cases if examined in a few days the limbs are found to have shortened considerably, princ.i.p.ally 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.

[Ill.u.s.tration: PLATE XIX.

Skiagram by H. CATLING.

Engraved and Printed by Bale and Danielsson Ltd.

(37) OBLIQUE COMMINUTED FRACTURE OF THE TIBIA

Range '600 yards.'

The entrance wound was large and the exit also. The fracture may have been caused by a Mannlicher (8 mm.) soft-nosed bullet, or possibly a ricochet. The fragmentation is somewhat coa.r.s.e at the periphery, but very fine in the track of the bullet. Several fragments of the mantle are visible.

The fracture affords a good example of obliquity due to cutting by the bullet, and contrasts well with those due to rectangular impact such as are shown in plates IV. and XIV.]

While at Orange River, in conjunction with Major Knaggs, R.A.M.C., and Mr. Langmore, we treated several cases of fracture of the shaft of the femur by this method. The splints were made for us by the Ordnance Department, while the Royal Engineers erected a kind of gallows for us down the centre of a commissariat marquee in order to avoid the risk of using the tent poles for suspension. The patients were then ranged on each side of the tent in two rows so that the pull of the two sets of limbs opposed each other on the gallows from which they were suspended.

Although these patients had to lie on the ground, they were really comfortable compared with those treated with long outside splints, and the results obtained were very good: in three cases which I had the opportunity of measuring later the bones were in good position and the shortening was less than one inch.

I have no doubt whatever that Hodgen's splint is by far the best method of treating all cases of fractured thigh in the Stationary field hospitals; and, more than this, I believe it is the only practicable and efficient one. It can be applied without the use of an 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.

[Ill.u.s.tration: PLATE XX.

Skiagram by H. CATLING.

Engraved and Printed by Bale and Danielsson Ltd.

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

Range '300 yards.'

Wound of soft parts nearly transverse, entry on tibial aspect. The bullet crossed and grooved the posterior aspect of the tibia, but struck the fibula full. This is the only instance of a transverse cleft which came under my notice.

The wound suppurated, and a number of fragments of the fibula needed removal; hence the amount of callus present.]

Cases in which operative fixation is indicated are rare, but a few oblique fractures may be treated with advantage in this manner if the conditions surrounding the patient admit of it. s.c.r.e.w.i.n.g 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 sh.e.l.l 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.

[Ill.u.s.tration: 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.