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 view of the general lack of significance in these injuries it was interesting to note how very definite was the ill effect of early transport on the after course. This depended on the frequent development of parietal hæmothorax in patients who were not kept absolutely at rest.

The tracks produced in the lungs by the bullets were very minute, and in the few cases in which opportunity arose for their examination post mortem some little time after the infliction of the wound, there was great difficulty in localising them. The slight damage incurred by the pulmonary tissue is due to its elasticity and non-resistent character.

Pulmonary hæmothorax was distinctly rare. Reasoning from the analogous wounds of the liver, tracks scoring the surface of these organs might be much more to be feared than clean perforations. The elasticity of the lung tissue, however, must make such lesions rare. In point of fact, there is no reason why a perforation by a bullet of small calibre should be much more feared than a puncture from an exploring trocar, and the danger of the two wounds is probably very nearly the same.

The only points of importance as to the particular region of the lung traversed were the distance from the periphery as affecting the probable size of the vessels injured, and perhaps the implication of the base or apex of the organ respectively. I am under the impression that wounds in the apical region were somewhat more liable to be followed by the development of pneumothorax, and possibly hæmothorax, while wounds at the base gained their chief importance from the frequency of concurrent injury to the abdominal viscera. I had no experience of the immediate results of wound of the great vessels at the root of the lung, but assume that they led to speedy death.

Symptoms of wound of the lung.—I shall describe the whole complex usually observed, although it is obvious that the wound of the chest-wall is responsible for a large proportion of the signs.

The majority of these injuries were accompanied by a certain degree of systemic shock, and this was more marked in wounds received at a short range. The shock was, however, rather to be attributed to the injury to the chest-wall and thoracic concussion than to that to the lung itself. I think it may also be stated that few patients were inclined to walk or remain in the erect position after receiving these wounds; this feature was also noted in horses in whom a bullet passed through the lungs.

The remarks made as to the pain accompanying fractures of the ribs apply equally here. Pain was not a prominent symptom, except in so far as the actual impact caused temporary suffering. It was striking how often patients who received wounds through the arm prior to the same bullet traversing the chest appreciated the chest wound only, yet the chest might pass unnoticed when a still more sensitive part was struck later, as has been already mentioned in the section on wounds in general.

Dyspnœa was not a prominent primary symptom. The patients sometimes had 'all the wind knocked out of them' at the moment of impact, but when seen at the Field hospitals a short time later, the respirations were shallow, but easy and regular, and only moderately quickened; thus 24 was a not uncommon rate. Naturally if accumulation of blood in the pleura began early and continued, these remarks do not hold good; and again in some older men of full-blooded type and the subjects of recurrent attacks of bronchitis, a considerable degree of pain, dyspnœa, and even cyanosis was sometimes present soon after the injury. The complication of wound of the diaphragm has already been referred to in this relation.

Local respiratory immobility of the thoracic parietes and consequent asymmetry of movement were constant. This was especially a marked feature when the upper part of the chest was implicated on one side only. It rather corresponded, however, to the local shock observed in wounds of the limbs than to the instinctive immobility accompanying fractures of the ribs; since, as already explained, small-calibre bullet wounds of the ribs are not necessarily painful on movement, and the sign existed even when the bullet had passed by an intercostal space. This sign was naturally a transitory one.

Hæmoptysis was a fairly constant sign, but sometimes quite absent when no doubt could exist as to the perforation of the lung. As a rule, a considerable quantity of blood might be coughed up shortly after the injury; but I never knew this to be sufficient in amount to give rise to any misgivings as to danger from the hæmorrhage. After the first evacuation of blood from the wounded lung, the sign varied much; in the majority of instances the patients continued to expectorate small quantities of blood mixed with mucus, for some three or four days, the blood gradually assuming a coagulated condition. Sometimes only the primary hæmoptysis was noted, and still more rarely the expectoration of clots was continued for a week, or even longer. This probably depended partly on personal idiosyncrasy, partly on the size of the vessels which had been implicated in the track.