The Project Gutenberg EBook of Surgical Experiences in South Africa, 1899-1900, by George Henry Makins This eBook is for the use of anyone anywhere at no cost and with almost no restrictions whatsoever. You may copy it, give it away or re-use it under the terms of the Project Gutenberg License included with this eBook or online at www.gutenberg.org Title: 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 Author: George Henry Makins Release Date: May 3, 2007 [EBook #21280] Language: English Character set encoding: ISO-8859-1 *** START OF THIS PROJECT GUTENBERG EBOOK SURGICAL EXPERIENCES *** Produced by Jonathan Ingram, Josephine Paolucci and the Online Distributed Proofreading Team at https://www.pgdp.net FRONTISPIECE. Photo, H. Kisch Ladysmith. Engraved and Printed by Bale and Danielsson, Ltd. 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 A word of explanation is perhaps necessary as to the form in which these experiences have been put together. The matter was originally collected with the object of sending a series of articles to the British Medical Journal. Various circumstances, however, of which the chief was the feeling that extending experience altered in many cases the views adopted at first sight, prevented the original intention from being carried into execution, and the articles, considerably expanded, are now published together. As to the illustrative cases introduced in support of various statements made in the text, only those have been chosen from my notes which were under my own observation for a considerable time, and many of these have been brought up to date since my return to England. I have, as a rule, avoided the inclusion of cases seen cursorily, and few simple ones have been quoted since their character is sufficiently indicated in the text. These remarks seem necessary since the mode of selection has resulted in the inclusion of a number of cases of exceptional severity, and any attempt to draw statistical conclusions from them would be most misleading. 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 [Pg vii] [Pg viii] 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 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 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 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 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 CHAPTER V [Pg ix] PAGE 1 40 [Pg x]55 112 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 extremity CHAPTER VI INJURIES TO THE JOINTS General character—Vibration synovitis—Wounds of joints—Classification—Course and symptoms—General treatment—Special joints 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 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—Treatment 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 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 hæmothorax CHAPTER XI INJURIES TO THE ABDOMEN 154 225 [Pg xi] 241 314 341 374 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 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 wounds Index of Contents ILLUSTRATIONS PLATES Varieties of Ammunition collected at Ladysmith 1. Section of Mauser Aperture of Entry 2. Section of Mauser Aperture of Exit 3. Punctured Fracture of Clavicle 4. Comminuted Fracture of Shaft of Humerus 5. Comminuted Fracture of Humerus accompanied by an Explosive Exit 6. Comminuted Fracture of Humerus due to Oblique Impact 7. Same Fracture healed 8. Low Velocity Fracture of Humerus With Retained Bullet 9. Localised Fracture of Humerus Showing Fragmentation of the Bullet 10. Wedge-shaped Fracture of the Radius 11. Fracture of the Metacarpus, showing Fragmentation of the Bullet 12. Finely Comminuted Fracture of the Femur 13. The same Fracture Healed 14. Stellate 'Butterfly' Fracture of the Femur 15. Lateral Impact of Bullet, with Comminution of the Femur 16. Rectangular Impact of Bullet, with highly Oblique Line of Fracture of the Femur 17. Punctured Fracture of the Femur with Exit Bone-flap [Pg xii] 407 474 487 [Pg xiii] Frontispiece To face p. 73 76 162 180 182 184 186 188 190 192 194 196 198 200 202 204 206 208 18. Fractured Patella 19. Oblique Comminuted Fracture of the Tibia 20. Transverse Fracture of the Tibia 21. Puncture of the Tibia, with an Oblique Fissure 22. Notched Fracture of the Tibia 23. Punctured Fracture of the Fibula 24. The same Fracture, Lateral View 25. Vickers-Maxim Fracture of the Humerus IN THE TEXT FIG. 1. Linen Hold-all with Instruments 2. Instrument Hold-all Rolled for Packing 3. Tin Water-bottle for Emergency Operations 4. Buggy on the Veldt 5. McCormack-Brook Wheeled Stretcher Carriage 6. Indian Tonga 7. Service Ambulance Wagon 8. Buck-wagon Loaded with Wounded Men 9. Interior of a Wagon of No. 2 Hospital Train 10. P. & O. Hospital Ship 'Simla' 11. Type of General Hospital 12. Type of Tortoise Tent Hospital 13. Single Tortoise Hospital Tent 14. Five Types of Cartridge in Common Use During the War 15. Sections of Four Bullets To Show Relative Thickness of Mantles 16. Entry and Exit Mauser Wounds 17. Gutter Wound of Shoulder 18. Oblique Gutter Exit Wound 19. Oval Entry, Starred Exit Wounds 20. Circular Entry, Slit Exit Wounds 21. Circular Entry, Starred Exit Wounds 22. Entry and Exit Wounds in Six Successive Spots made by same Bullet 208 210 212 214 216 218 220 482 [Pg xiv] PAGE 4 5 6 7 19 20 21 22 24 25 32 33 35 47 51 56 56 57 58 59 59 61 23. Four Successive Entry and Exit Wounds of same Bullet 24. Superficial Abdomino-thoracic Track 25. Superficial Linear Ecchymosis of Thigh 25a. Sections of Mauser Entry and Exit Wounds 25b. Prolapsed Omentum 26. Sections of Four Bullets 27. Normal Mauser Bullet 28. Four Mauser Ricochets 29. Mauser Ricochet, Disc Form 30. Fissured Mauser Mantle 31. Mausers Deformed by Impact on Femur 32. Apical Mauser Ricochet 33. Spiral Ricochet 34. Normal Lee-Metford Bullet 35. Apical Lee-Metford Ricochets 36. " " " 37. Four Types of Soft-nosed Bullets 38. 'Set-up' Soft-nosed Lee-Metford Bullets 39. Flattened, Solid-based Mantle From Ricochet 40. Mauser Bullet, Jeffreys-Tweedie Modification 41. Section of Mark IV. and Soft-nosed Mauser 42. Tampered Bullets 43. Large Leaden Sporting Bullets 44. Explosive Wound of Back 45. Dead Men on Field of Battle 46. Flattened Leaden Cores from Mantled Bullets 47. Explosive Exit Wound over Fractured Ulna 48. Explosive Exit Wound over Fractured Humerus 49. Explosive Exit and Entry Wounds of Legs 50. Types of Gunshot Fracture 51. Lower End of Fractured Femur 52. Oblique Perforation of Femur, Separation of Fragment at Exit Aperture in Bone 62 64 65 74 77 82 83 84 85 86 86 87 88 [Pg xv] 89 90 91 92 92 93 94 94 95 98 100 102 105 156 158 159 161 164 169 178 53. Gutter Fracture of Head of Humerus 53a. Diagram of 'Butterfly' Type 54. Wire Gauze Splint 55. Gutter Fracture of Pelvis 55a. Diagram of 'Butterfly' Type 56. Cane Field Splint for Lower Extremity 57. Tunnel Fracture at Surface of Tibia 58. Cane Field Splint for Leg 59. Skiagram of Injury to Interphalangeal Joint 60. Skiagram of Bullet in Nasal Fossa 61. Diagram of Aperture of Entry into Cranium 62. Aperture of Entry into Frontal Bone 63. Fragment of Inner Table Displaced from Opening seen in Fig. 62 64. Gutter Fracture of First Degree in Parietal Bone 65. Diagram of Gutter Fractures 66. Gutter Fracture of Second Degree in Parietal Bone 67. Diagrams of Gutter Fractures 68. Superficial Perforating Fracture of Parietal Region 69. Diagram of Superficial Perforating Fracture 70. Fragment Forming Floor of Temporal Gutter Fracture 71. Scale of External Table in Low Velocity Injury of Frontal Bone 72. Frontal Perforation, Aperture of Exit 73. Visual Field in Occipital Injury 74. " " " 75. " " " 76. " " " 77. " " " 78. " " " 79. Contused Spinal Cord 80. Divided Spinal Cord 81. Superficial Track in Anterior Body-wall 82. Spirally Grooved Bullet 178 180 187 191 200 209 219 222 237 244 245 252 253 255 256 257 258 259 260 260 [Pg xvi] 261 261 279 279 281 281 283 283 333 334 377 381 392 83. Ecchymosis in Fractured Ribs with Hæmothorax 84. Subcutaneous Division of Abdominal Muscles 85. Lateral Incomplete Wound of Small Intestine. Slit Form 86. Lateral Perforation of Small Intestine. Gutter Form 87. Entry and Exit Wounds in a Transverse Perforation of Intestine 88. Inner Aspect of Piece of Intestine Shown in Fig. 87 89. Impaction of Omentum in Exit Wound of Abdominal Wall 90. Fragments of Large Shells 91. Fragments of Percussion and Time Fuses 92. Complete 1-lb. Pom-pom Shell 93. Fragments of Exploded Pom-pom Shells 94. Percussion Fuse From 1-lb. Pom-pom Shell 95. Fragments of Boer Segment Shells 96. Normal and Deformed Leaden Shrapnel Bullets TEMPERATURE CHARTS 1. Case of Axillary Hæmatoma, Blood Temperature 2. Case of Hæmothorax with Recurrent Hæmorrhages 3. Primary and Secondary Rises of Temperature in Hæmothorax, Recovering Spontaneously 4. Secondary Rise of Temperature in Hæmothorax 5. Falls of Temperature in Hæmothorax following Paracentesis 6. Secondary Hæmothorax, Spontaneous Fall of Temperature SURGICAL EXPERIENCES IN SOUTH AFRICA CHAPTER I INTRODUCTORY The following pages are intended to give an account of personal experience of the gunshot wounds observed during the South African campaign in 1899 and 1900. For this reason few cases are quoted beyond those coming under my own immediate observation, and in the few instances where others are made use of the source of quotation is indicated. It will be noted that my experience was almost entirely confined to bullet wounds, and in this respect it no doubt differs from that of surgeons employed in Natal, where shell injuries were more numerous. This is, however, of the less 392 409 416 417 418 419 421 475 477 479 480 481 483 485 119 395 402 403 404 405 [Pg 1] moment for my purpose as there is probably little to add regarding shell injuries to what is already known, while, on the other hand, the opportunity of observing large numbers of injuries from rifle bullets of small calibre has not previously been afforded to British surgeons. 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. [Pg 2] [Pg 3] [Pg 4] Fig. 1. Fig. 1.—Linen Holdall with surgical instruments My departure for the seat of war was rather hurried, hence my surgical equipment was not of an extensive nature. It may be of interest, however, to shortly recount what it consisted in, since it proved an ample one, and yet was carried in a small satchel. The plan of selection adopted consisted in carefully going through the equipment of the British Field Hospital, and then adding such other instruments as seemed to me likely to be useful. With few exceptions, therefore, designed to meet emergencies, my set of instruments formed a supplement to the actual necessities carried by the Service hospitals, and was as follows:—4 trephines, Horsley's elevator, brain knife and seeker. 2 pairs of Hoffman's and 1 pair of Lane's fulcrum gouge forceps, 3 bone gouges, 1 pair straight 1 curved necrosis forceps, 1 pair bone forceps. 1 Wood's 1 Horsley's skull saws, 18 Gigli's saws with an extra handle, and two Podrez' directors for the same. 1 set Lane's bone drills, broaches, screw-drivers, and counter-sink with eight ounces of screws: silver patella wire, and 1 pair Peter's bone forceps. 2 aneurism needles, 1 bullet probe, 1 pair Egyptian Army pattern bullet forceps. 4 Lane's and 3 pairs Makins's bowel clamps, Nos. 3 4 and 5 Laplace's bowel forceps, 6 Murphy's buttons, 1 pair Morris's retractors, 6 dozen intestine needles, 2 Macphail's needle-holders, Nos. 4 5 6 Thomas's slot-eyed needles, 1 mouth gag, 1 Durham's double raspatory, 3 strong plated raspatories, 1 pair tongue forceps, 1 tracheal dilator, 1 pair hernia needles, 1 hernia and 1 ordinary steel director, 1 transfusion set with metal funnel, and a stock of Messrs. Burroughes and Wellcome's compound saline infusion soloids. 1 antitoxin syringe. 6 scalpels, 2 blunt-pointed curved bistouries, 6 forcipressure forceps, 1 pair Jordan Lloyd's retractors, 1 pair ordinary retractors, 2 pairs of forceps, 3 pairs of Scissors, 1 skin-grafting razor and roll of perforated tin foil, 1 metal pocket case, and 1 hypodermic syringe with tabloids. A stock of silkworm gut, horsehair and silk ligatures, the latter prepared and sterilised for me by Miss Taylor, the Theatre Sister at St. Thomas's Hospital. Some pairs of McBurney's india-rubber, and cotton-thread operating gloves. Fig. 2. Fig. 2.—Instrument Holdall rolled The instruments were packed in sets in small linen holdalls suggested and made by Messrs. Down Bros., who also devised my satchel. In the light of the experience gained I should have preferred a tin case to the satchel, as it never [Pg 5] Fig. 3. Fig. 3.—Tin Water-bottle for the march (Military Equipment Company) needed to be carried on horseback. For dressings I trusted entirely to the Royal Army Medical Corps, and at my request Colonel Gubbins, R.A.M.C., sent out to the Cape a quantity of sterilised sponges and pads made by Messrs. Robinson & Co. Ltd. of Chesterfield, which fully met all requirements in this direction. This equipment was superfluous at the Base hospitals, but when in the field with the troops proved very useful. In the early part of the campaign I was able to do all my travelling by train, but later I travelled by road only. I received the greatest kindness and help in this particular. General Sir William Nicholson, Chief Director of Transport, provided me with a buggy, a pair of horses, and a driver, and Prince Francis of Teck, the Chief Remount Officer, selected a pony suitable to my equestrian powers. The buggy proved a very great success; the box seat carried my instruments and dressings, the front a 4-gallon tin water-bottle for emergency operations, and the rear shelf my personal belongings. The water-bottle was lent to me by the Portland Hospital. (Fig. 3.) The cart was able to cross any drifts or dongas, and when an engagement was in progress was able to accompany the Ambulance wagons, so that I had all my necessaries on the spot, even at the first dressing station. In point of fact when with the Highland Brigade, on some occasions, we did all necessary operations on the spot during the progress of fighting; a most useful performance, since fighting on several days did not cease till dark, and the evenings were much too cold to allow of operations being done with safety to the patients. The great advantage of the buggy was its lightness and smallness. On one occasion it accompanied me between 500 and 600 miles without a single accident, beyond the fact that one night I was relieved of both my horses by some troopers whose own were worn out. Fig. 4. Fig. 4.—My Buggy on the veldt at Bloemfontein. (Photo by Mr. Bowlby) With regard to the general health of the troops as subjects of surgical wounds, I suppose a better class of patient could scarcely be found. The men were young, sound, well set and nourished, and hard and fit from exercise in the open air. Beyond this, in spite of the scarcity of vegetables, a certain amount of fruit, rations of jam, and lime juice made any sign of scurvy a rare occurrence—I never saw a case during the whole of my wanderings. The meat was good, especially in the early part of the campaign, when it was for the most part brought from Australia and New Zealand, and we enjoyed the two collateral advantages of getting plenty of the ice which had been used for the preservation of the meat, in the camps, and the still greater one of having no butchers' offal to need destruction or prove a source of danger. When bread was to be got it was fairly good, and the biscuit was at all times excellent. Except on the advance from Modder River to Bloemfontein, as far as I could judge, no large bodies of the men ever really suffered from shortness of food, and then only for a few days. Drink was a more serious problem: in the early days beer was to be got at the canteens, but with the increase of numbers and difficulties of transport this ceased to be the case, and water was the sole fluid [Pg 6] [Pg 7] [Pg 8] available. This was often muddy, and the soldiers would take very little care what they drank unless under constant supervision; hence a great quantity of very undesirable water was drunk. None the less I think the water was more often the cause of sand diarrhœa than of enteric fever. A large quantity of fluid was by no means a necessity if the men would only have exercised some self-control. During the first week I spent at Orange River, I drank lime juice and water all day, but after that time, by a very slight amount of determination, I thoroughly broke myself of the habit, and drank at meal-times only. Most of the men however emptied their water-bottles during the first hour of the march, and the rest of the day endured agony, seizing the first opportunity of drinking any filthy water they met with. When, for instance, we camped near a vlei, and the General took the greatest care that the mules and horses should be watered at one spot only, in order to preserve the cleanliness of the rest of the pool, the men would often go and fill their water-bottles amongst the animals' feet rather than take the trouble to walk the few necessary yards round. In such particulars they needed constant supervision. The climate on the western side was a great element no doubt both in the general healthiness of the men and in the general good results seen in the healing of wounds. The days were often hot; thus even in November at Orange River the thermometer registered 115°F. in the single bell tents, but on the other hand the nights were cool and refreshing. The air was very pure and exceedingly dry, while the constant sunshine not only kept up the spirits, but also proved the most efficient disinfector of any ground fouled to less than a serious extent. Dust was our principal bugbear; and when a camp had been settled for a few days, flies; both of these evils increasing rapidly as the stay on any one spot was prolonged. My personal experience of rain was small, but I was twice in camp, once at Orange River and once at Bloemfontein, when very heavy rain fell, and this was sufficient to make the camps terribly uncomfortable for a few days. Under these conditions, as might be expected, until the outbreak of enteric fever the health of the men was remarkably good, minor ailments alone prevailing. One of the most troublesome of these was diarrhœa, which gained the appellation of 'the Modders,' already a classical name as far as South Africa is concerned. This most frequently, I think, depended on errors of diet, combined with the swallowing of a large amount of sand with the food as dust, and in the water drunk. Cases of severe dysentery, however, were also not very uncommon. Rheumatic pains were a common ailment, which, considering the dryness of the atmosphere, would hardly have been expected. Continued fever of a somewhat special type was not uncommon, and was sometimes spoken of under the name of the district, sometimes as veldt fever—of this I will say nothing, as others better fitted to point out its peculiarities will no doubt deal with it. Enteric fever, our chief scourge, I will pass over for the same reason. I might, however, remark from the point of view of one not very experienced in this disease, that in a large number of the fatal cases I happened to see, the actual cause of death seemed to me to be septicæmia from absorption from the mouth. The mouths were unusually bad, even allowing for the often insufficient cleansing that was able to be carried out, and I was inclined to attribute these in some degree to the dryness of the atmosphere, which very quickly and effectively dried up the mucous membrane of the mouth in patients not breathing through the nose, and encouraged the formation of large cracks. Pneumonia was rare, and this was rendered the more striking from the comparatively large number of men who contracted the disease on board ship on the voyage out from England. As will be gathered from the above, medical disease seldom called for the aid of the surgeon. Abdominal section was occasionally considered in cases of perforation in enteric fever, and was, I believe, a few times performed, but as far as I know without success. It was also proposed to treat some of the severe dysentery cases by colotomy, but I never saw the method tried. As far as I was concerned I never met with a case of either disease I thought suitable for the treatment. I saw one case in which an abscess of the liver had followed an attack of enteric, which had been successfully treated by incision, and a few cases of tropical abscess which probably came into the country were also subjected to operation. Some cases of appendicitis, as would be expected, also needed surgical treatment. In a few instances empyema followed influenza, and a few cases of mastoid suppuration had to be dealt with. Of surgical diseases the one most special to the campaign, although not of great importance, was the veldt sore. This was a small localised suppuration most common on the hands and neck, but sometimes invading the whole trunk, more particularly the lower extremities however, when the covered parts of the body were attacked. The sores were no doubt the result of local infections; they reminded me most of the sores seen on the hands of plasterers, and I think there is no doubt the dust was responsible for them. I think piles were somewhat more prevalent than they should have been among the men, but this was probably dependent on the strain involved in defæcation in the squatting position, since the soldiers were for the most part regularly attentive to the calls of nature. I saw a good many cases of lightning stroke, and some were fatal. Sunstroke was not common, and, considering the heat, it was very remarkable how little the men suffered from this condition. This was no doubt in part attributable to the absence of the possibility of getting alcoholic drinks, but it is not common for any one in South Africa to suffer in this way, probably as a result of the continuous nature of the sunshine. In spite of the labours of hospital surgeons at home, it was rather instructive to see the number of men who suffered with hernia, varicocele, and varicose veins to a sufficient degree to necessitate going to the base. The experience quite sufficed to explain the trouble which is taken to prevent men with these complaints entering the service. General Consideration of the Number of Men Killed and Wounded I will now pass to the question of the proportionate frequency with which the men were killed or wounded during the [Pg 9] [Pg 10] [Pg 11] present campaign. I propose to take only one series of battles, with which I was personally acquainted throughout, to illustrate this point. This seems the more satisfactory course to follow, since the number of casualties is still undergoing continuous gradual increase, and besides this the warfare has assumed a peculiar and irregular form, statistics from which scarcely possess general application. The battles included, those of the first Kimberley Relief Force, were fought under fair average conditions as to the nature of the ground. In the first two the defending enemy occupied heights, in the two following the ground advanced over by our men was comparatively even; thus at Modder River there was only a gradual slope upwards, and at Magersfontein the advanced trenches of the Boers were only slightly above the level of the ground over which the advance was made. At the same time, at the latter battle a great number of the Boers engaged were on the sides of the hill well above the advanced trenches. In no case were the Boers in such a position as to have to fire upwards, to them a considerable advantage. It must also be noted that throughout the Boers were able to rest their rifles; hence the fire should have been at any rate of an average degree of accuracy. In the advances of our own men, anthills and stones were practically the only cover to be obtained, and little or no help was given by variations in the general surface. All these points seem to favour a large proportional number of hits on the part of the riflemen. I very much regret that I am unable to say what was the proportional number of shell wounds among the men hit, but I can say with some confidence that among the wounded it was not as great as ten per cent. I should be inclined to place it as low as five per cent. Again, I cannot fix the proportionate occurrence of wounds from bullets of large calibre such as the Martini-Henry, but this was certainly not large. I think if ten per cent. is deducted to represent the number of hits from either of these forms of projectile, that we may fairly assume the remaining 90 per cent. of the wounds to have been produced by bullets of small calibre. The numbers of the opposing forces were probably fairly even. Taking all these circumstances together, and bearing in mind that our army was always in the position of having to make frontal attacks on men well protected in strong positions, I think it must be allowed that a fair idea should be possible of the effectiveness of the modern weapons. Only one circumstance, one inseparable from any fighting with the Boers, seems to affect the numbers in an important manner. This consists in the fact that the Boer rarely fights to the bitter end, hence the greater proportion of his hits are obtained at long distances. TABLE I Number of troops engaged Killed Wounded Missing Total Percentage of killed and wounded to number of men engaged Belmont: Officers 297 3 23 0 26 8.75 Non.-com. officers and men 8,396 55 206 4 265 3.15 Total 8,693 58 229 4 291 3.34 Graspan: Officers 326 3 7 0 10 3.06 Non.-com. officers and men 8,213 18 163 7 188 2.29 Total 8,539 21 170 7 198 2.31 Modder River: Officers 335 3 19 0 22 6.56 Non.-com. officers and men 9,856 67 377 18 462 4.68 Total 10,191 70 396 18 484 4.74 Magersfontein: Officers 379 18 48 2 68 17.94 Non.-com. officers and men 11,068 148 669 101 918 8.29 Total[1] 11,447 166 717 103 986 8.43 Table I. gives the number of men engaged, and also that of the killed and wounded at each of four battles. Table III. shows for comparison the relative number of killed and wounded in some former campaigns while older forms of weapon were in use. With regard to the numbers in Tables I. and II. it should be at once said that they are only to be regarded as approximate, since they do not exactly tally with those officially reported in the 'Times' at a later date. Sources of error [Pg 12] [Pg 13] may, however, have crept into both, and as there is little difference in the gross numbers, I have preferred to retain the series compiled by Major Burtchaell, R.A.M.C., as Table II. contains interesting information as to the proportionate number of men who died during the first 48 hours, after being wounded. TABLE II Showing Proportion of Mortality amongst Men Hit, (a) on the Field, (b) during the First Forty-eight Hours Percentage mortality Number of troops engaged Total number of men hit Killed Died within forty- eight hours Total To men hit To force employed Belmont: Officers 297 26 3 3 6 23 2.02 Non.-com. officers and men 8,396 265 55 8 63 23.77 0.75 Total 8,693 291 58 11 69 23.71 0.79 Graspan: Officers 326 10 3 1 4 40[2] 1.22 Non.-com. officers and men 8,213 188 18 3 21 11.17 0.25 Total 8,539 198 21 4 25 12.62 0.29 Modder River: Officers 335 22 3 1 4 18.18 1.19 Non.-com. officers and men 9,856 462 67 9 76 16.45 0.77 Total 10,191 484 70 10 80 16.53 0.78 Magersfontein: Officers 379 68 18 4 22 32.35 5.80 Non.-com. officers and men 11,068 918 148 20 168 18.30 1.51 Total 11,447 986 166 24 190 19.26 1.66 The high death rate among the officers will at once arrest attention, but this has been noticed in other campaigns, particularly in the Franco-German war. It is mainly attributable to the circumstance that the officers, as leading, are always in the front and most exposed position. I much doubt whether at the end of the campaign the entire abandonment of distinctive badges will be found to have had any very important result in decreasing the relative number of casualties as between officers and men. At close quarters distinctive uniform is no doubt a danger, but at the common ranges of 1,000 yards and upwards the enemy's fire is rather directed to cover a zone than to pick out individuals. The especially high mortality among the officers at the battle of Graspan was attributable to the casualties among the naval officers, and the men of the brigade suffered most severely also. It will be noted that the most expensive battles were those of Belmont and Magersfontein. If the numbers of the men actually taking part in the fighting in these battles as given in Table I. are massed, we get an approximate total of 12,420.[3] Of this number, 1,959 or 15.06 per cent. were reported as killed, wounded, or missing. Thus: killed, 315 or 2.53 per cent.; wounded, 1,512 or 12.17 per cent.; missing, 132 or 1.06 per cent. Reference to Table III. shows that these percentages almost exactly correspond with those obtaining in the entire Crimean campaign, and are greater than those observed in the German army during the entire Franco-German campaign. The mortality statistics given in Table II. are of great interest, since to those dying on the field are added all men dying within the first 48 hours in the Field hospitals. From the surgical point of view these men all received mortal injury, and are therefore properly included among the fatalities. Their inclusion, moreover, makes an appreciable difference in the percentage proportion of mortal injuries to wounds. Thus, if the numbers are massed (omitting the 'missing'), we find [Pg 14] [Pg 15]