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 exact.i.tude 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 p.r.o.ne 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 ill.u.s.tration 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 b.l.o.o.d.y synovia during the first few days after the operation.

[Ill.u.s.tration: FIG. 59.--Ill.u.s.trates the very neat and limited injury to the Phalanges over the dorsal aspect of the first inter-phalangeal joint of the Middle Finger, accompanying a gutter wound received by the patient while holding a rifle.]

I never saw any troublesome results from perforations of the _carpus_.

The joints of the _fingers_ also offered little special interest, except in so far as they afforded astonishing examples of the extreme neatness of the injuries which a small-calibre bullet can produce. Fig.

59 is a good example of such an injury.

_Hip-joint._--I can only repeat with regard to this joint what I have already said as to the injuries to the head of the femur. I had practically no experience of small-calibre bullet injuries to the femoral const.i.tuent, 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 a.s.sociation of popliteal aneurisms with wounds of the knee-joint has already been spoken of in relation to anchylosis. Wounds of the popliteal s.p.a.ce 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 ma.s.sage and pa.s.sive 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 pa.s.sing 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 pa.s.sing 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 repet.i.tion 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 att.i.tude 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 pa.s.sed 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 a.s.sume 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 cla.s.sical 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 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 cla.s.ses.

[Ill.u.s.tration: FIG. 60.--Mauser Bullet in Nasal Fossa. (Skiagram by H.

Catling.) Case No. 47]

1. Extensive sagittal tracks pa.s.sing _deeply_ through the brain, and vertical wounds pa.s.sing 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 cla.s.ses 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 cla.s.s 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 a.s.sume 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.

[Ill.u.s.tration: FIG. 61.--Diagram of Aperture of Entry in Occipital Bone, showing radiating fissures exact length. The exit in the frontal region was of typical explosive character. Range '100 yards'.]

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 ill.u.s.trating 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 gla.s.s set in a frame. I saw several apertures in the thick gla.s.s of the windows of the waterworks building at Bloemfontein produced by Mauser bullets. They differed little from the opening seen in an ordinary plate-gla.s.s 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 gla.s.s. 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.