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, F.R.C.S.

SURGEON TO ST. THOMAS'S HOSPITAL, LONDON
JOINT LECTURER ON SURGERY IN THE MEDICAL SCHOOL OF ST. THOMAS'S HOSPITAL
MEMBER OF THE COURT OF EXAMINERS OF THE ROYAL COLLEGE OF
SURGEONS OF ENGLAND, AND LATE ONE OF THE CONSULTING SURGEONS
TO THE SOUTH AFRICAN FIELD FORCE


LONDON
SMITH, ELDER, & CO., 15 WATERLOO PLACE
1901

TO

SURGEON-GENERAL W. D. WILSON

PRINCIPAL MEDICAL OFFICER TO THE SOUTH AFRICAN FIELD FORCE

THE MEMBERS OF THE ROYAL ARMY MEDICAL CORPS
EMPLOYED IN SOUTH AFRICA

AND TO THE

CIVIL SURGEONS TEMPORARILY ATTACHED TO THAT CORPS

These Experiences are Dedicated

AS AN EXPRESSION OF APPRECIATION
OF THE INVARIABLE KINDNESS AND SYMPATHY EXTENDED
TO THE AUTHOR
WITHOUT WHICH THE BOOK COULD NOT
HAVE BEEN WRITTEN

PREFACE

The first two chapters have been added with a view to affording some information, first, as to the conditions under which a great part of the surgical work was done, and, secondly, as to the mechanism and causation of the injuries, which would not readily be at hand in the case of the general surgical reader. For much of the information contained in Chapter II. I must express my indebtedness to the work of MM. Nimier and Laval, so frequently quoted.

The only other object of this Preface is to express my thanks to the many who have aided me in the task of amplifying the observations on which the articles are founded, and I think no writer ever received more sympathetic and kindly help in such particulars than the author.

My first thanks, those due to the Members of the Royal Army Medical Corps, I endeavour to express by the dedication of this volume. Any attempt to make individual acknowledgment to either the Members of the Service, or to the Civil Surgeons temporarily attached, would be impossible. I have, however, tried to associate the names of many of those in charge of cases in the recital of histories and treatment throughout.

My thanks are not less due to the Military Heads of Departments at the War Office, who have helped me in the collection of details as to the subsequent course of many of the cases described, and in the acquisition of information regarding the weapons and ammunition treated of. I should particularly express my gratitude to Colonel Robb, of the Adjutant-General's Department, and Colonel Montgomery, of the Ordnance Department.

I am greatly indebted to my former colleague Mr. Cheatle for two of the illustrations of wounds, and for permission to quote some of his other experience, and to Mr. Henry Catling, to whose skill I owe the majority of the skiagrams of the fractures under my observation at Wynberg and elsewhere.

I must also express my thanks to Mr. Danielsson and his artist, Mr. Ford, for the trouble they have taken in converting my rough sketches into the illustrations contained in the volume.

Lastly, my warmest gratitude is due to my friends, Mr. Cuthbert Wallace, who has read some of my chapters, and to Mr. F. C. Abbott, who has read the whole book for the press and suggested many improvements and modifications.

47 Charles Street, Berkeley Square, W.

February 1901.

CONTENTS

PAGE
CHAPTER I

INTRODUCTORY

ItineraryLinen Holdall with surgical instrumentsSurgical outfit—Personal transport—General health of the troops—Climate—Consideration of the number of men killed and wounded—Transport of the wounded—Vehicles—Trains—Ships—Hospitals 1


CHAPTER II

MODERN MILITARY RIFLES AND THEIR ACTION

General type—Calibre, length, and weight of bullet—Velocity—Trajectory—Revolution—Varieties of rifle in common use by the Boers—Penetration—Comparison of bullets—Use of wax—Comparative efficiency of different types 40


CHAPTER III

GENERAL CHARACTERS OF WOUNDS INFLICTED BY BULLETS OF SMALL CALIBRE

Type wounds—Nature of external apertures—Direct course of wound track—Multiple wounds—Small bore and sharp localisation of tracks—Clinical course—Mode of healing—Suppuration—Wounds of irregular type—Ricochet—Mauser bullet—Lee-Metford bullet—Expanding bullets—Altered bullets—Large sporting bullets—Symptoms—Psychical disturbance and shock—Local shock—Pain—Hæmorrhage—Diagnosis—Prognosis—Treatment 55

CHAPTER IV

INJURIES TO THE BLOOD VESSELS

Nature of lesions; contusion, laceration, perforation—Results of injuries—Primary hæmorrhage—Recurrent hæmorrhage—Secondary hæmorrhage—Treatment of hæmorrhage—Traumatic aneurisms—Arterial hæmatoma—True traumatic aneurism—Aneurismal varix and varicose aneurism—Conditions affecting development—Effects of aneurismal varix or varicose aneurism on the general circulation—Prognosis and treatment of aneurismal varix—Prognosis and treatment of varicose aneurism—Gangrene after ligation of arteries 112


CHAPTER V

INJURIES TO THE BONES OF THE LIMBS

Nature of wounds—Explosive wounds—Types of fracture of shafts of long bones—Stellate, wedge, notch, oblique, transverse, perforating—Fractures by old types of bullet—Lesions of the short and flat bones—Special character of the symptoms in gunshot fracture, and of the course of healing—Prognosis—Treatment—Special fractures—Upper extremity—Pelvis—Lower extremity154


CHAPTER VI

INJURIES TO THE JOINTS

General character—Vibration synovitis—Wounds of joints—Classification—Course and symptoms—General treatment—Special joints225


CHAPTER VII

INJURIES TO THE HEAD AND NECK

Anatomical lesions—Scalp wounds—Fracture of the skull without evidence of gross lesion of the brain—Fractures with concurrent brain injury—Classification—General injuries—Effect of ricochet—Vertical or coronal wounds in frontal region—Glancing or oblique wounds of any region—Gutter fractures—Superficial perforating fractures—Fractures of the base—Symptoms of fracture of the skull, with concurrent injury to the brain—Concussion—Compression—Irritation—Frontal injuries—Fronto-parietal and parietal injuries—Occipital injuries—Forms of hemianopsia—Abscess of the brain—General diagnosis—General prognosis—Traumatic epilepsy—General treatment—Wounds of the head not involving the brain—Mastoid process—Orbit—Globe of the eye—Nose—Malar bone—Upper jaw—Mandible—Wounds of the neck—Wounds of the pharynx, larynx, and trachea 241


CHAPTER VIII

INJURIES TO THE VERTEBRAL COLUMN AND SPINAL CORD

Fractures in their relation to nerve injury—Transverse processes—Spinous processes—Centra—Signs of fracture of the vertebra—Injuries to the spinal cord—Effects of high velocity—Concussion, slight, severe—Contusion—Hæmorrhage, extra-medullary, hæmatomyelia—Symptoms of injury to the spinal cord—Concussion—Hæmorrhage—Total transverse lesion—Diagnosis of form of lesion—Prognosis—Treatment314


CHAPTER IX

INJURIES TO THE PERIPHERAL NERVES

Anatomical lesions—Concussion—Contusion—Division or laceration—Secondary implication of the nerve—Symptoms of nerve injury—Traumatic neuritis—Scar implication—Ascending neuritis—Traumatic neurosis—Injuries to special nerves—Cranial nerves—Cervical, brachial, lumbar, and sacral plexuses—Cases of nerve injury—General prognosis and treatment 341


CHAPTER X

INJURIES TO THE CHEST

Non-penetrating wounds of the chest wall—Penetrating wounds, special characters of entrance and exit apertures—Fracture of the ribs, symptoms, treatment—Wounds of the diaphragm—Wounds of the heart—Wounds of the lung, symptoms—Pneumothorax—Hæmothorax— Empyema—Diagnosis, prognosis, and treatment of hæmothorax—Cases of hæmothorax374


CHAPTER XI

INJURIES TO THE ABDOMEN

Introductory remarks—Wounds of the abdominal wall—Penetration of the intestinal area without definite evidence of visceral injury—Wounds of explosive character—Anatomical characters of intestinal wounds—Wounds of the mesentery—-Wounds of the omentum—Results of intestinal wounds, fæcal extravasation, peritoneal infection, septicæmia—Reasons for the escape of severe injury in wounds traversing the abdomen—Wounds of the stomach—Wounds of the small intestine—Wounds of the large intestine—Prognosis in intestinal injuries—Treatment of intestinal injuries—Wounds of the urinary bladder—Wounds of the kidney—Wounds of the liver—Wounds of the spleen—General remarks on the prognosis in abdominal injuries—Wounds of the external genital organs—Wounds of the urethra 407


CHAPTER XII

ON SHELL WOUNDS

Varieties of shells employed—Large shells—Wounds produced by different varieties—Pom-Pom shells—Wounds produced by fragments and fuses—Shrapnel— Boer segment shells—Leaden shrapnel bullets—Treatment of shell wounds474


Index of Contents487

ILLUSTRATIONS

PLATES

Varieties of Ammunition collected at LadysmithFrontispiece

1. Section of Mauser Aperture of Entry To face p. 73

2. Section of Mauser Aperture of Exit 76

3. Punctured Fracture of Clavicle162

4. Comminuted Fracture of Shaft of Humerus180

5. Comminuted Fracture of Humerus accompanied by an Explosive Exit182

6. Comminuted Fracture of Humerus due to Oblique Impact184

7. Same Fracture healed186

8. Low Velocity Fracture of Humerus With Retained Bullet188

9. Localised Fracture of Humerus Showing Fragmentation of the Bullet190

10. Wedge-shaped Fracture of the Radius192

11. Fracture of the Metacarpus, showing Fragmentation of the Bullet194

12. Finely Comminuted Fracture of the Femur196

13. The same Fracture Healed198

14. Stellate 'Butterfly' Fracture of the Femur200

15. Lateral Impact of Bullet, with Comminution of the Femur202

16. Rectangular Impact of Bullet, with highly Oblique Line of Fracture of the Femur204

17. Punctured Fracture of the Femur with Exit Bone-flap206

18. Fractured Patella208

19. Oblique Comminuted Fracture of the Tibia210

20. Transverse Fracture of the Tibia212

21. Puncture of the Tibia, with an Oblique Fissure214

22. Notched Fracture of the Tibia216

23. Punctured Fracture of the Fibula218

24. The same Fracture, Lateral View 220

25. Vickers-Maxim Fracture of the Humerus 482

IN THE TEXT

FIG. PAGE
1.  Linen Hold-all with Instruments4

2.  Instrument Hold-all Rolled for Packing5

3.  Tin Water-bottle for Emergency Operations6

4.  Buggy on the Veldt7

5.  McCormack-Brook Wheeled Stretcher Carriage19

6.  Indian Tonga20

7.  Service Ambulance Wagon21

8.  Buck-wagon Loaded with Wounded Men22

9.  Interior of a Wagon of No. 2 Hospital Train24

10. P. & O. Hospital Ship 'Simla'25

11. Type of General Hospital 32

12. Type of Tortoise Tent Hospital 33

13. Single Tortoise Hospital Tent 35

14. Five Types of Cartridge in Common Use During the War47

15. Sections of Four Bullets To Show Relative Thickness of Mantles51

16. Entry and Exit Mauser Wounds56

17. Gutter Wound of Shoulder56

18. Oblique Gutter Exit Wound 57

19. Oval Entry, Starred Exit Wounds58

20. Circular Entry, Slit Exit Wounds59

21. Circular Entry, Starred Exit Wounds59

22. Entry and Exit Wounds in Six Successive Spots made by same Bullet61

23. Four Successive Entry and Exit Wounds of same Bullet62

24. Superficial Abdomino-thoracic Track64

25. Superficial Linear Ecchymosis of Thigh65

25a. Sections of Mauser Entry and Exit Wounds74

25b. Prolapsed Omentum77

26. Sections of Four Bullets82

27. Normal Mauser Bullet83

28. Four Mauser Ricochets 84

29. Mauser Ricochet, Disc Form 85

30. Fissured Mauser Mantle 86

31. Mausers Deformed by Impact on Femur 86

32. Apical Mauser Ricochet 87

33. Spiral Ricochet88


34. Normal Lee-Metford Bullet89

35. Apical Lee-Metford Ricochets90

36.         "         "         "         91

37. Four Types of Soft-nosed Bullets92

38. 'Set-up' Soft-nosed Lee-Metford Bullets92

39. Flattened, Solid-based Mantle From Ricochet93

40. Mauser Bullet, Jeffreys-Tweedie Modification94

41. Section of Mark IV. and Soft-nosed Mauser94

42. Tampered Bullets95

43. Large Leaden Sporting Bullets98

44. Explosive Wound of Back100

45. Dead Men on Field of Battle102

46. Flattened Leaden Cores from Mantled Bullets105

47. Explosive Exit Wound over Fractured Ulna156

48. Explosive Exit Wound over Fractured Humerus158

49. Explosive Exit and Entry Wounds of Legs159

50. Types of Gunshot Fracture161

51. Lower End of Fractured Femur164

52. Oblique Perforation of Femur, Separation of Fragment at Exit Aperture in Bone169

53. Gutter Fracture of Head of Humerus178

53a. Diagram of 'Butterfly' Type180

54. Wire Gauze Splint 187

55. Gutter Fracture of Pelvis 191

55a. Diagram of 'Butterfly' Type 200

56. Cane Field Splint for Lower Extremity 209

57. Tunnel Fracture at Surface of Tibia 219

58. Cane Field Splint for Leg 222

59. Skiagram of Injury to Interphalangeal Joint 237

60. Skiagram of Bullet in Nasal Fossa 244

61. Diagram of Aperture of Entry into Cranium 245

62. Aperture of Entry into Frontal Bone 252

63. Fragment of Inner Table Displaced from Opening seen in Fig. 62 253

64. Gutter Fracture of First Degree in Parietal Bone 255

65. Diagram of Gutter Fractures 256

66. Gutter Fracture of Second Degree in Parietal Bone 257

67. Diagrams of Gutter Fractures 258

68. Superficial Perforating Fracture of Parietal Region 259

69. Diagram of Superficial Perforating Fracture 260

70. Fragment Forming Floor of Temporal Gutter Fracture 260


71. Scale of External Table in Low Velocity Injury of Frontal Bone 261

72. Frontal Perforation, Aperture of Exit 261

73. Visual Field in Occipital Injury 279

74.          "         "         "          279

75.          "         "         "          281

76.          "         "         "          281

77.          "         "         "          283

78.          "         "         "          283

79. Contused Spinal Cord 333

80. Divided Spinal Cord 334

81. Superficial Track in Anterior Body-wall 377

82. Spirally Grooved Bullet 381

83. Ecchymosis in Fractured Ribs with Hæmothorax392

84. Subcutaneous Division of Abdominal Muscles409

85. Lateral Incomplete Wound of Small Intestine. Slit Form416

86. Lateral Perforation of Small Intestine. Gutter Form417

87. Entry and Exit Wounds in a Transverse Perforation of Intestine418

88. Inner Aspect of Piece of Intestine Shown in Fig. 87419

89. Impaction of Omentum in Exit Wound of Abdominal Wall421

90. Fragments of Large Shells 475

91. Fragments of Percussion and Time Fuses 477

92. Complete 1-lb. Pom-pom Shell 479

93. Fragments of Exploded Pom-pom Shells 480

94. Percussion Fuse From 1-lb. Pom-pom Shell481

95. Fragments of Boer Segment Shells 483

96. Normal and Deformed Leaden Shrapnel Bullets 485

TEMPERATURE CHARTS

1. Case of Axillary Hæmatoma, Blood Temperature 119

2. Case of Hæmothorax with Recurrent Hæmorrhages 395

3. Primary and Secondary Rises of Temperature in Hæmothorax, Recovering Spontaneously 402

4. Secondary Rise of Temperature in Hæmothorax 403

5. Falls of Temperature in Hæmothorax following Paracentesis 404

6. Secondary Hæmothorax, Spontaneous Fall of Temperature 405

SURGICAL EXPERIENCES

CHAPTER I

I think the general trend of the observations goes to show that the employment of bullets of small calibre is all to the advantage of the men wounded, except in so far as the increased possibilities of the range of fire may augment the number of individuals hit; also that such variations as exist between wounds inflicted by bullets of the Martini-Henry and Mauser types respectively, depend rather on the form and bulk of the projectile than on any inherent difference in the nature of the injuries. Thus in the chapter devoted to the general characters of the wounds, it will be seen that most of the older types of entry and exit aperture are produced in miniature by the small modern bullet, and that the main peculiarity of the deeper injuries is the frequent strict localisation of the direct damage to an area of no greater width than that crossed by narrow structures of importance such as arteries or nerves.

It is to be regretted that I am unable to furnish any important statistical details, but incomplete numbers, such as are at my disposal, would be of little value. In view, however, of the considerable interval which must elapse before the Royal Army Medical Corps is able to arrange and publish the large material which will have accumulated, it has seemed unwise to defer publication until the completion of a report which will deal with such matters thoroughly.

It may be of interest to premise the opportunities which I enjoyed of gaining experience during the campaign. I arrived in South Africa on November 19, 1899; two days later I proceeded to Orange River with Surgeon-General Wilson, and on the day three weeks after leaving home performed some operations in the field hospitals on patients from the battle of Belmont. I remained at Orange River during the three next engagements, Graspan, Enslin, and Modder River, and on the day of Magersfontein I went forward to the Field hospitals at Modder River, arriving during the bringing in of the patients from the field of battle. I returned to Orange River with the patients and remained there a further period of three weeks, during which time the patients were gradually transferred to the Base hospitals at Wynberg. At Christmas I followed the patients down to the base, and thus was able to observe the course of the cases from their commencement to convalescence. I remained at Wynberg six weeks, during which time a number of cases from the neighbourhood of Rensburg and some from Natal were received. On February 7, I left Wynberg, following Lord Roberts up to my old quarters at Modder River, where I saw a few wounded men brought in from the engagements at Koodoosberg Drift. On Lord Roberts's departure for Bloemfontein he requested me to return to Wynberg to await the wounded who might be sent down from the fighting which might occur during his advance. I therefore had the disappointment of seeing the start of the army, and then returning to Wynberg, where I remained for another six weeks in attendance at Nos. 1 and 2 General Hospitals.

During this period a very large number of the wounded from Paardeberg Drift and other battles were sent down and treated, after which surgical work began to flag.

On April 14, I was recalled to the front and journeyed to Bloemfontein, where I stayed three weeks, making one journey out to the Bearer Company of the IX. Division at the Waterworks.

On May 4, I left Bloemfontein with Lord Roberts's army, and shortly after joined the IX. Division, with which I journeyed until the commencement of June, seeing a good deal of scattered work in the field and Field hospitals, and in the small temporary improvised hospitals in the towns of Winberg, Lindley, and Heilbron. Early in June I left Heilbron with Lord Methuen's division, and spent the next four weeks with this division in the field. Thence I journeyed to Pretoria and Johannesburg, seeing a small number of wounded in each town, and on July 10, with Lord Roberts's consent, I started for home, visiting a number of the hospitals in the Orange River Colony and Natal on my way down to Cape Town. During the movements briefly recorded above, which absorbed a period of nine months, my time was fairly evenly divided between Field, Stationary, and Base hospitals; hence I had opportunities of observing the patients in every stage of their illnesses, and in all some thousands of men came under my notice.