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

Symptoms of fracture of the ribs.—Fractures accompanying transverse wounds of the chest were characterised by the insignificance of the symptoms produced. Every common sign of fracture of the rib was in fact absent. Neither pain, stitch on inspiration, nor crepitus, either audible or palpable, was, as a rule, present. This absence of signs was accounted for by the nature of the lesion: thus in perforations or notchings there was no loss of continuity, while in the freely comminuted fractures the loss of continuity was so absolute as to allow no possibility of the main fragments rubbing together. Again, part of the symptoms attending these injuries, as seen in civil practice, depends upon contusion and laceration of the surrounding structures—a condition precluded by the localised nature of the application of the violence by a bullet of small calibre. In order to establish a diagnosis, therefore, we were in many cases reduced to palpation, and occasionally to direct examination of the wound.

Fractures accompanying longitudinal tracks formed a class rather apart in the matter of symptoms. In these mere groovings might also be accompanied by no signs, or at the most by slight local pain and tenderness. When, however, the grooving was sufficiently deep to be accompanied by deformity, or a complete solution of continuity was effected, the signs were often severe. The tender salient angle, or, in the absence of this, a highly tender localised spot, often pointed to the less severe injuries, and when the fractures were complete or multiple, pain was a very prominent symptom, both constant and in the form of inspiratory stitch. The severity of the pain was probably to be in part ascribed to implication of the intercostal nerves, which in these injuries was direct and often multiple. Again, severe contusion or actual laceration of the nerves, with resulting anæsthesia, was less common than when the bullet directly implicated the nerves in transverse wounds. Free comminution and absolute solution of continuity were also less common than in the fractures accompanying transverse wounds; hence pain from rubbing of the fragments on inspiratory movement or palpation was more common, and crepitus, either on auscultation or palpation, was more often met with. Patients with this class of fracture often suffered greatly from painful dyspnœa, and were unable to assume the supine position.

External hæmorrhage of severity was rare from these thoracic wounds; in many cases it did not amount to more than local staining of the shirt; altogether I saw only one or two cases where any serious bleeding occurred. Internal hæmorrhage into the pleura, in consequence of the position of the intercostal arteries, was common, and often abundant; this will be treated of under the heading of hæmothorax.

Treatment of fractured ribs.—Transverse wounds of the thorax, with no symptoms of fractured ribs, needed to be dealt with as wounds of the soft parts alone.

In multiple fractures accompanying longitudinal tracks, bandaging or strapping for the purpose of fixation was necessary to relieve pain. A few fragments of bone sometimes needed primary removal, and occasionally small sequestra were removed at a later date; but necrosis was rare, unless some complication led to the development of a fistula.

Retained bullets were occasionally met with in the chest wall. In such cases the last remaining energy of the bullet often seemed to have been spent in diving under the margin of a rib and turning longitudinally up or down. Removal was sometimes necessary, either from the prominence produced, the presence of pain, or the continuance of suppuration. Some of the specimens removed offered interesting evidence of the capacity of the ribs to withstand considerable violence from a bullet. These were slightly bent, and marked by a half-spiral groove. I saw such bullets removed from the thoracic and the abdominal wall, and the evidence seemed rather against the groove having been produced prior to their entrance into the body.

Fig. 82.—Spirally grooved Mauser Bullet

Wounds of the diaphragm.—Perforations of the diaphragm were very frequent, and as a rule of small significance. When, however, the course taken by the bullet was parallel with that of the slope of the diaphragm, a more or less extensive slit was the result. I saw such a wound still gaping, and 2 inches in length, in the body of a patient who died three weeks after the infliction of a fatal abdominal injury.

In several other obliquely transverse thoracic wounds there was reason to assume the existence of similar slits. Certain signs were more or less constant under these circumstances. These consisted in shallow respiration, often accompanied by a groan or the slightest degree of hiccough on inspiration, and considerable increase in respiratory frequency. In one patient the respirations were at first 48, only dropping to 36 some seventy hours after the reception of the injury. In some of the cases in which the abdominal cavity was implicated, wound to the diaphragm seemed a more likely explanation of early, frequent, and painful vomiting than did visceral injury. The possibility of the later development of diaphragmatic herniæ in some of these patients will have to be borne in mind in the future.