George Henry Makins

“ The course of the nerve is preserved by its intact connective-tissue framework, and ultimate recovery by a regeneration of the nerve fibres is more likely to be complete, and will be just as rapid, if nature be relied on and the nerve be left untouched by the hand of the surgeon.
It is, I think, undeniable that nerve trunks may escape severe or irrecoverable injury by lateral displacement. The mere fact that the trunk itself may be perforated by a slit in its long axis would suggest the possibility of displacement of the whole structure, and this no doubt occurred with some frequency. ”

“ A ricochet bullet, on the other hand, may upset all our calculations, if size alone be taken as an indication; but here the irregularity of the wound often serves to exclude one of the larger varieties as the cause. The appearances of the exit wound are less useful in determining the nature of the bullet employed, as irregularities of outline are so much more common whatever projectile may have emerged; but examination of this wound often gives us useful information as to the existence of an injury to the bones not involving loss of continuity. ”

“ Suppuration.—While the occurrence of deep suppuration or septic phlegmon was rare, local suppuration of the apertures of entry and exit was seen in a considerable proportion of the wounds. This was referable to infection from the skin itself, or to infection from without subsequent to the infliction of the injury. Infection from the skin, difficult to obviate at all times, is especially likely to occur in wounds the first dressing of which is often delayed, and which happen to men sweating freely into clothes the condition of which is at least undesirable for contact with a recent wound. ”

“ I discovered the condition accidentally in a man admitted into the hospital for other reasons. The patient remarked: 'For heaven's sake, sir, do not say anything about that. I have had it many years, and it has never given any trouble. If it is known, I shall be worried to death by people examining it.'
None the less it must be borne in mind that beyond enlargement of the vein dilatation of the artery above the seat of obstruction does occur, and gives trouble in some situations. ”

“ As a civilian, one cannot but recognise that the conditions of modern warfare are much altered from those of the past. Prisoners are well cared for and kindly treated, the sick and wounded are respected by both sides, and except in the actual horrors of fighting the condition of the soldier is a happier one. Under these circumstances the limitation of the transport facilities of a department so closely concerned with the well-being of all, and which has been organised on a most moderate scale, must soon become a tradition of the past in civilised armies. ”

“ Experience of the character of the lesions observed after severe concussion by the ordinarily somewhat coarser forms of violence common to civil life, fully explains the severity of the damage to the brain tissue met with in injuries due to bullets of small calibre. Viewing the elaborate arrangements which exist for the preservation of the central nervous system from the moderate vibration incidental to ordinary existence, it is easy to appreciate the harmfulness of such exquisite vibratory force as that transmitted by a bullet of small calibre travelling at a high rate of velocity. ”

“ While at work in the Field hospital alone I gained the impression that the musculo-spiral nerve would not retain the unenviable character of being the most vulnerable nerve of the upper extremity, since the chances of each individual nerve seemed about equal, putting the question of the long course of the musculo-spiral nerve against the humerus out of question. ”

“ Visceral injuries.—The frequent escape of the thoracic viscera from injury, putting aside the lungs which fill so great a part of the cavity, was very remarkable. I never saw a case in which I could assume injury to any of the posterior mediastinal viscera, although such may have occurred on the field of battle. An injury to the œsophagus, for instance, would almost of necessity be accompanied by wound of either one of the large vessels, even the thoracic aorta, or the spinal column. ”

“ Swelling of the limb was often very great, and vascular injury definitely far more common than in the fractures of civil practice, in consequence, no doubt, not only of the number and sharpness of the fragments, but also of the force with which they were driven into the surrounding tissues. The exit segment of the track was out of all proportion in size to the entry, as a result of the propulsion of bone fragments through it. ”

“ The mode of displacement of the lateral fragments when a wide shaft such as that of the femur is struck, throws some light on that of the displacement of soft tissues such as the component parts of a perforated nerve or artery. The bullet, passing through, expends the chief part of its energy in driving before it the fragments produced in its direct course, while a minor part of the energy is expended on displacing the lateral fragments, which are pushed to either side without becoming separated from their periosteal attachment. ”

“ Transport.—The importance of transport is felt from the moment of the injury till the time of arrival of the patient in the mother country. To the surgeon it is of the same vital importance as the carrying of food for the troops is to the combatant general. ”

“ The most striking instances of local enlargement of the track are of course seen when a bone lies in the course of the bullet, but we must here bear in mind the introduction of a new element—the propulsion of comminuted fragments together with the bullet itself. In cases of fracture the distal portion of the track is in consequence many times larger than the proximal. The most striking examples of small even tracks are seen, on the other hand, in punctures of the elastic and practically homogeneous lung tissue, where the wounds are extremely small. ”

“ During the period in which dressing may be necessary I believe this form of splint is as good as can be got for use in Field hospitals, the only point needing care being to ensure that the bandaging is not too tight. It is much more reliable than are ordinary splints if transport is unavoidable, and is much lighter and less irksome to the patient. With such strips of cardboard, a few of the gauze splints (fig. 54) , and a few angular and wooden splints, I believe a Field hospital is fully equipped for the treatment of any fractures of the upper extremity. ”

“ There can be no doubt that a considerable number of the most severe injuries we saw were produced by the various soft-nosed or expanding forms of bullet, also that others of an equally serious nature were produced by Martini-Henry or large leaden sporting bullets. Allowing for this, however, I think a considerable proportion were the result of deformation from bony impact, or ricochet deformities external to the body acquired by regulation Mauser bullets, and I think these bullets can be quite as formidable as any of the sporting varieties met with. ”

“ Under ordinary circumstances, moreover, the indications for removal of a bullet are not likely to be sufficiently imperative to necessitate the operation being undertaken until the patient can be placed under the best conditions that can be secured. This is the more advisable since such operations need the infliction of an additional wound, require great delicacy, and may be very prolonged in performance. The experience of civil practice has already sufficiently proved the small amount of inconvenience likely to follow the retention of a bullet in the skull. ”

“ A patient in the German Ambulance in Heilbron, under Dr. Flockemann, died as a result of suppuration and hæmorrhage secondary to an injury to the colon. At the autopsy a portion of the omentum was found adherent in the wound of exit, but it had not reached the external surface. The chief interest of the observation lies in the light it throws on the mechanism of these injuries. It is impossible to conceive that a small-calibre bullet coming into direct contact with the omentum could do anything but perforate it. ”

“ I think it must be a rare occurrence for pressure from bone fragments to be able to be regarded as a favourable prognostic condition, since in the very large majority of cases the velocity of the bullet causing the injury will have been such as to inflict irreparable damage on the cord. Still, cases may occasionally be met with where the velocity has been sufficiently low, or contact with the bone slight enough, to allow of the comparative escape of the cord. ”

“ The frequent association of wounds of the thoracic cavity with those of the abdomen afforded many of the most striking examples of immunity from serious consequences as a result of wound of the pleura. It must be conceded that in a large number of such injuries only the extreme limits of the pleural sac were encroached upon, yet in some the tracks passed through the lungs, although without serious consequences. Under the heading of injury to the large intestine a somewhat special form of pleural septicæmia will be referred to. ”

“ It should be added that for 'explosive' features to reach their strongest development, it is necessary that the bone affected should lie near the surface of the body; hence the most characteristic explosive wounds were met with in the forearm or leg, over the metacarpus or metatarsus, or in the arm. In the thigh, on the other hand, where the femur in a great part of its course not only lies deeply, but is also protected by particularly strong and resistent skin and fascia, another type of wound was met with. ”

“ In cases in which the injury has been produced by a bullet fired at a short range, or in which contact with the nerve has been close, the return of functional activity is very slow. In such instances the condition probably resembles that in which a divided nerve has been sutured, with the additional disadvantage that a considerable portion of the nerve, both above and below the point actually struck, has been destroyed as far as the conduction of nervous impulses is concerned. ”

“ 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. ”

“ It is one which might be of much use in Base hospitals if the patients were brought directly into them, but in the Field hospitals, in face of the rush with which the first dressings have to be done, I think it is seldom applicable, and consider the interference with the wound as rather likely to increase the danger of infection than to decrease it.
Dressings should not be too frequent; two should suffice for simple wounds with type forms of entry and exit; there is little discharge and usually no bleeding: hence the more the dry scab form of healing can be simulated the better. ”

“ Until recent times gunshot injuries of the joints formed a class entailing the gravest anxiety to the surgeon, both in regard to the selection of primary measures of treatment and in the conduct of the after progress of the cases. The external wounds were severe, comminution of the bones was great, and retention of the bullet within the articulation was not uncommon. Operative surgery therefore found a large field in the extraction of bullets, removal of bone fragments, excision of the joints, or even amputation of the limbs. ”

“ In tracks crossing the chest transversely the injury to the ribs might consist in notching, perforation, or complete solution of continuity, sometimes with fine comminution. In the incomplete injuries some importance attached to the localisation of the lesion to the upper or lower border of the rib, in so far as the intercostal artery was concerned. Comminution at the wound of entry was, as a rule, not so extensive as at the aperture of exit, and in any case was less apparent, since the fragments were driven inward. ”

“ Fig. 33 shows a form not uncommon when the bullet comes into contact with the ribs. It is produced in bullets travelling at a low rate of velocity and striking by their side. I several times met with it when the bullet was retained, and also without fracture of the rib. In some variety it might occur after impact with any narrow margin of bone, and some importance attaches to the form, since it affords evidence as to the ease with which alterations in symmetry can be produced in Mauser bullets. ”

“ This question raises the larger one of the advisability of any transport beyond what may be an actual necessity. There is only one answer to this. No fractures of the thigh or leg, and few of the arm, can be transported for any distance without material disadvantage. The risks attendant on disturbance of the fracture and tissue injury, septic infection as a result of slipping of the dressing and the impracticability of efficiently renewing it, far more than counterbalance any advantage to be gained from the superior comforts available at a Base hospital. ”