A few hours later the man was seized with very severe pain in the ankle, and a day later I was asked to see him by Mr. Alexander. The man was anæsthetised, and I examined the wound with care, and also removed the retained bullet from the inner margin of the leg. The bullet was reversed, having no doubt suffered ricochet, hence the large aperture of entry, but it was in no way deformed. I could not certainly determine the presence of any fluid in the ankle-joint, and as the pain was apparently localised to the distribution of the musculo-cutaneous nerve, I decided not to freely open the joint. In this, however, I erred, and two days later, after consultation, the joint was freely incised by Mr. Alexander. It was then found that the bullet in its passage had just touched the posterior aspect of the tibia and wounded the ankle-joint. A localised collection of pus which had formed in the deep part of the wound had been diffused into the joint by the movements made when the splint was removed, in a similar manner to that described in the last case. This joint also did badly, and an amputation of the leg had to be performed by Mr. Alexander to save the man's life.
These two cases are particularly instructive as showing, first, how quietly a small amount of deep suppuration may sometimes take place; and, secondly, the importance of keeping the joints quiet on a splint when there is any reason to suspect their implication by wounds of this character.
The general treatment of the wounded joints was simple. The old difficulties of deciding on partial as against full excision, or amputation, were never met with by us. We had merely to do our first dressings with care, fix the joint for a short period, and be careful to commence passive movement as soon as the wounds were properly healed, to obtain in the great majority of cases perfect results. Careful light massage, if available, was used to promote absorption of blood.
If suppuration occurred, the choice between incision and amputation had to be considered. In the early stages this choice depended entirely on the nature of the injury to the bones. If this were slight, incision was the best plan to adopt. I saw several cases so treated which did well, although convalescence was often prolonged, and only a small amount of movement was regained. Amputation was sometimes indicated in cases of severe bone-splintering, when the shafts were implicated, but was as a rule only performed after an ineffectual trial to cut short general infection of the septicæmic type by incision.
I have dwelt at such length on the subject of suppuration on account of its importance, but I should add that, on the whole, suppuration of the joints was uncommon, except in the case of injuries far exceeding the average in primary severity.
Special joints.—Such deviations from the general type of injury as above described depended entirely on peculiarities of anatomical arrangement, and peculiarities in the situation of the joint clefts in the different parts of the body. A few words as to these are perhaps necessary.
Shoulder-joint.—Wounds of this articulation were by no means common. This depended, I think, on two points in the architecture of the joint: first, a bullet to enter the front of the cavity and traverse the joint needed to come with great exactitude from the immediate front; secondly, wounds received from a purely lateral direction calculated to pierce the head of the humerus and the glenoid cavity were naturally of very rare occurrence. Wounds of the prominent tip of the shoulder received while the men were in the prone position were not uncommon, but it was remarkable how rarely the shoulder-joint was implicated in these. The question of the narrow nature of the cleft exposed also comes up in this position. As far as my experience went, injuries to the lower portion of the capsule accompanying wounds of the axilla were those most often met with. The ease and neatness with which pure perforations of the head of the humerus can be produced was also an important element in the frequent escape of this joint. No case of fracture of the glenoid cavity happened to come under my notice.
I saw few instances in which the joint needed incision, and cannot recall or find in my notes any case in which serious trouble arose.
Elbow-joint.—Injuries to this joint came second in frequency in my experience to those of the knee. They were, in fact, comparatively common, especially in conjunction with fractures of the various bony prominences surrounding the articulation. Fractures of the lower end of the humerus were of worse prognostic significance than those of the ulna, on account of the greater tendency to splintering of the bone. I saw several cases of pure perforation of the olecranon without any signs of implication of the elbow-joint. In a case which has been utilised for the illustration of some of the types of aperture (fig. 20, p. 59), at the end of a week there was no sign of any joint lesion, although the bullet had obviously perforated the articulation.
Several cases of suppuration which came under my notice did well. I saw one of them a few days ago, six months after the injury, with perfect movement. In another of which I took notes, the bullet entered over the outer aspect of the head of the radius, to emerge just above the internal condyle anteriorly. A considerable amount of comminution of the olecranon resulted, and when the man came into hospital some ten days later the joint was suppurating. The joint was opened up from behind, and some fragments of bone removed by Mr. Hanwell. On the 26th day this joint was doing well, and considerable flexion and extension were possible without pain. There was a somewhat abundant discharge of bloody synovia during the first few days after the operation.