Surgical Experiences in South Africa, 1899-1900 / Being Mainly a Clinical Study of the Nature and Effects of Injuries Produced by Bullets of Small Calibre

by George Henry Makins

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 hæmorrhage, as was the case generally, usually ceased spontaneously. The importance of injury to the vessels was rather in view of secondary hæmorrhage, 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.

Fig. 58.—Dutch Cane Field Emergency Splint for Leg

In cases with large wounds suppuration was very frequent, and in connection with this secondary hæmorrhage, 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 hæmorrhage, 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 hæmorrhage 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.