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

During the course of healing some other peculiarities are worthy of mention. First of all, union was tardy and often not strong. On the other hand, an abundance of provisional callus was common, which formed large swellings apt to implicate neighbouring nerves, and sometimes to interfere with the movements of joints. The slowness of healing was particularly noticeable in those cases where the degree of local shock had been marked, and was probably to some extent dependent on disturbance of the general nutrition of the tissues of the affected limb. Beyond this, however, it was in many cases a direct result of the degree of comminution and displacement of the fragments, which necessitated the formation of a large amount of provisional callus, and time for the proper consolidation and contraction of the same. In many cases a large ball-like mass of callus surrounding the fragments was developed, into which the actual ends of the broken bone only dipped, and hence union was weak and insecure. As to those cases in which the wounds closed by primary union, we must bear in mind in this relation the tardy union often observed in civil practice, when the irritation of suppuration and consequent inflammation are absent.

Another peculiarity of a similar nature was the occasional late necrosis of fragments; the wounds apparently healed well, only to break down weeks or months later for the discharge of a sequestrum. Such cases were quite distinct from those in which primary suppuration had occurred. I saw one or two instances in fractures of the humerus, the trouble arising with commencing use of the limb, and I suppose that fragments which suffered death at the time of the injury had been enclosed, and only caused irritation as foreign bodies when the muscles again came into action. In the absence both of evident necrosis and suppuration, however, in some cases the exit portion of the track in the soft parts was extremely slow in healing. Although no discharge beyond a small quantity of blood-tinged serum escaped, the wounds remained open for many weeks, even when the fracture consolidated well. I ascribed this to slow separation of aseptic sloughs, a point which has already been mentioned under the heading of wounds in general.

Superabundance of callus, as far as I had an opportunity of judging, comparatively seldom gave rise to permanent mechanical trouble. This was no doubt due to the infrequency of extension of the comminuted fractures beyond the junction of diaphysis and epiphysis.

Lastly, with regard to suppuration, only a small proportion of the fractures, accompanied by the presence of large wounds, escaped infection. When infection did occur, the results offered some special features dependent on the small relative amount of damage to the soft tissues, compared with that suffered by the bone. In an ordinary compound fracture, such as we meet with in civil practice, whether the result of direct or indirect violence, a considerable amount of contusion or laceration, as the case may be, accompanies the injury to the bone. The result of this is a widespread effusion of blood into the limb, which tears and strips up the various layers of soft parts, and opens up the way to the spread of infection, often into the whole length of the segment of the limb affected. In fractures produced by bullets of small calibre, even when the exit portion of the track is large, the injury to the soft parts is far more localised, except in extreme cases, while the bone itself is the tissue which has suffered the most severe violence and contusion. When infection occurred, its spread corresponded with this anatomical feature of the lesion, and the bone itself and its immediate neighbourhood suffered the most severely.

At the present day one is naturally not very familiar with a large series of suppurating compound fractures, but during my whole experience I have never seen so many cases of what might be regarded as fairly pure instances of acute osteo-myelitis. The symptoms corresponded with the main seat of the suppuration; only moderate swelling of the limbs occurred, this mainly consisting in soft superficial œdema; often there was no redness, and fluctuation was difficult to determine. At the same time symptoms of constitutional infection, such as continued fever, rapid pulse, restlessness, loss of strength, progressive anæmia, and emaciation, were marked. Pyæmia, as evidenced by secondary deposits, was, however, rare; I only saw two cases, both in fractures of the femur; in both recovery followed secondary amputation.

Prognosis.—This depended almost entirely on the nature of the injury to the soft parts; given moderate injury to these, and the preservation of the wound from infection, scarcely any degree of injury of the bones precluded recovery, even if this were slow and prolonged. The existence of perforations scarcely increased to an important extent the gravity of a wound of the soft parts alone; in fact, this injury could not be regarded as more severe than an ordinary surgical osteotomy, putting the risks of infection of the wound under the special circumstances on one side.

With regard to the functional results, these depended on the degree of comminution; when this was extreme, union was slow and for a time weak, and shortening was often considerable, but a fair result was as a rule obtained.

Suppuration and osteo-myelitis were the dangerous features when they occurred; still, even in the presence of these, I never saw a fatal result in an upper extremity fracture, although in the lower extremity a considerable mortality followed fractures both of the leg and thigh, the deaths being most commonly from septicæmia, or from a combination of this with secondary hæmorrhage.

Treatment.—The general treatment was of a simple character. The perforations may be at once dismissed, since nothing more was needed than what has been already described under the heading of wounds of the soft parts. Again, with regard to the co-existence of vascular injury, or injury to the soft parts generally, the ordinary rules guiding us in civil practice were followed.

The first point of importance, and needing consideration in the treatment of severely comminuted fractures, was as to whether in these it was better simply to try to obtain union of the wound with as little disturbance as possible, or to anæsthetise the patient and explore the wound, removing such fragments as were free or widely displaced. I think the answer to this question depends entirely on the nature of the external wounds. If these be of the small type forms, or if the exit aperture is, at any rate, of only moderate size, a strictly conservative attitude is the better when the risk of making an exploration under the circumstances is borne in mind, the more so as an exploration, to be safe and useful, ought to be done at once. If the exit wound is of the large or explosive type, on the other hand, there is no doubt that the best results are to be obtained by early exploration and the removal of all loose fragments. I saw several excellent results obtained in this way, even when the patients had to undergo the risk of transport shortly, in some cases the very next day, after the operation. The loose fragments are an immediate source of danger, and later may interfere with the healing of the fracture, even if suppuration does not occur. In all the cases that I saw the exit wound was dressed, but left freely open, and I do not think any attempt to close it should ever be made.