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

Cough was not commonly the troublesome symptom noted in the contused wounds of the lung seen in civil practice accompanying fracture of the ribs. Moist sounds were usually audible on auscultation, but in many cases over a very limited area and only on the first few days.

Cellular emphysema was distinctly rare, and usually limited in extent: thus I saw it in the posterior triangle of the neck alone in an apical wound; over about a third of the upper part of the thorax in another wound through the second intercostal space, and in this case oddly enough the emphysema was the only sign of injury to the lung; and very occasionally widely distributed—in the latter case there were also usually multiple fractures of the ribs. Neither issue of air from the external wound nor frothy blood was ever seen with small-calibre wounds, but I saw one instance in a case of Martini-Henry wound.

Pneumothorax was also rare. I saw pneumothorax three times out of about half a dozen Martini-Henry wounds, but I do not think it occurred as often in 100 small-calibre wounds. The Martini-Henry wounds all recovered; but convalescence was very prolonged, and the same remark to a less degree holds good in the small-calibre cases.

That the slow recovery in cases of pneumothorax in the Martini-Henry wounds was due mainly to the size of the opening in the thoracic parietes was, I think, proved by the fact that in the small-calibre bullet wounds, followed by the development of pneumothorax, the external wounds were usually large and irregular in type; also, that in the only pneumothorax which I saw produced during an extraction operation, the air was very rapidly absorbed. In the latter case, however, there was little reason to conclude that wound of the lung had occurred primarily, and certainly no opening existed at the time the thorax was incised.

Hæmothorax.—This was the most frequent and also the most interesting of the complications of wound of the chest. In 90 per cent. or more of the cases, the hæmorrhage was of parietal source, and due either to direct injury to the intercostal vessels by the bullet or to laceration by spicules of comminuted ribs. For this reason, the passage of the bullet whether by an intercostal space, or through a rib, provided the wound was not at the posterior part of the space where the artery crosses, was a point of considerable prognostic importance. Exclusion of the lung as the source of hæmorrhage was, I think, amply justified by the absence of continuous recurrent or progressive hæmoptysis in the majority of the cases, and by the very small trace of injury found in the lungs of patients who died some weeks after the injury. In such it was difficult to discriminate the tracks at all. I only happened to see one case where free hæmoptysis, during the course of development of a hæmothorax, pointed to the lung as the source of the blood.

Hæmorrhage into the pleural cavity occurred in some degree in a very large proportion of the chest wounds, but it was especially interesting to note how greatly its extent was influenced by the amount of transport to which the patients were subjected in the early stages after the injury. During the early part of the campaign, on the western side, I saw a large number of chest wounds, and had I been asked my opinion as to the relative frequency of occurrence of hæmothorax I should have placed it at about 30 per cent. The patients in these early battles needed little wagon transport, and when sent down to the Base travelled in comfortable ambulance trains. After the commencement of the march from Modder River to Bloemfontein, however, these conditions were changed, and all the chest as other cases were exposed to the necessity of three days and nights' journey to the Stationary hospitals and afterwards to the long journey to Cape Town. Of these patients, at least 90 per cent. suffered with hæmothorax of varying degrees of severity.

In some cases, the least common, signs of considerable intra-pleural hæmorrhage immediately followed the wound; in others, the accumulation of blood was gradual, and only manifest in any degree at the end of three or four days, when it became stationary if the patient was kept at rest. In a second series the hæmorrhage was of the recurrent variety; these cases differing little in character from those of slight continuous hæmorrhage. In a third, the bleeding was definitely of a secondary character, corresponding with one of the classes of secondary hæmorrhage described in Chapter IV., and occurring on the eighth or tenth day from giving way of an imperfectly closed wounded vessel. In either of the two latter classes the development of the hæmothorax often corresponded with a journey, or with allowing the patient to get up.

The general course of these effusions was towards spontaneous absorption and recovery. Coagulation of the blood took place early, the fluid serum separated, and tended to undergo absorption with some rapidity, leaving a small amount of coagulum at the base, which evidenced its presence for many weeks by a persistence of a certain degree of dulness on percussion. Early coagulation, I think, accounted for the usual absence of gravitation ecchymosis as a sign.

The course to recovery was sometimes broken by signs of slight pleuritic inflammation, which, as affecting the amount of effusion, will be spoken of under the heading of symptoms. In some cases the amount of blood was so great as to necessitate means being taken for its removal; in these a reaccumulation often took place. Occasionally an empyema followed in cases thus treated.

The nature of the blood evacuated on tapping varied much. In very early aspirations unchanged blood was often met with, but clot sometimes made evacuation difficult and necessitated a second puncture. In the tappings done at the end of a week or more a dark porter-like fluid was common, while when suppuration was imminent a brick-red-coloured grumous fluid replaced normal blood. In the cases where early incision was resorted to, blood both fluid and in clots was often mixed with a certain proportion of lymph flakes, perhaps indicating the part taken by inflammatory reaction to the irritation of the clot in producing the rise of temperature.