Surgical Experiences in South Africa, 1899-1900 Part 3

Pure septicaemia, especially in connection with abdominal injuries, severe head injuries and secondary to acute traumatic osteo-myelitis, was the form most commonly seen. Pyaemia with secondary deposits was uncommon, and often of a somewhat subacute form; thus I saw several patients recover after secondary abscesses had been opened, or the primary focus of infection removed. The only really acute case of joint pyaemia I heard of, developed in connection with a blistered toe followed by cellulitis of the foot.

Cutaneous erysipelas I never happened to see, and really acute phlegmonous inflammation was rare.

I may mention the occurrence of acute traumatic gangrene in two cases.

This developed in each instance with gunshot fracture of the femur; in one amputation was performed, and the process extended upwards on to the abdomen. The cases occurred with the army in the field in the neighbourhood of Thaba-nchu and not in a stationary hospital.

Acute traumatic teta.n.u.s occurred only in one instance to my knowledge.

In this case the primary injury was a sh.e.l.l wound of the thigh, and the patient developed the disease and died within ten days.

To the civil surgeon the performance of operations, and the dressing of severe wounds at the front, proved on occasions a somewhat trying ordeal.

When operations were necessary in the field, during the daytime, it was often possible to perform them in the open air, provided tolerable protection could be obtained from the sun. A number of cases were so operated upon during the march of the Highland Brigade from Wynberg to Heilbron, and gave excellent results, the patients deriving considerable benefit from the early cleansing and closure of the wounds.

[Ill.u.s.tration: FIG. 13.--Tortoise Hospital Tent. Portland Hospital.

(Photo by Mr. C. S. Wallace)]

In camp, in the Field, or Stationary hospitals, the difficulties were often much greater. The operations were necessarily performed under shelter for reasons of privacy. In the tents the draught carrying the dust from the camp was one of the commonest troubles. The exclusion of dust was impossible, and it not only found its way into open wounds, but permeated bandages with ease. Often when a bandage was removed, an even layer of dust moistened by perspiration covered the whole area included with a coating of mud. Again, in dust storms a similar layer of mud sometimes covered the whole of the exposed parts of the bodies of patients lying on the ground in the tents.

It is of some interest to remark with regard to this dust, that Dr. L.

L. Jenner lately kindly examined a specimen collected at Modder River after the camp had been more than two months established, and discovered no pathogenic organisms in it. As a period of seven months had elapsed since this dust was collected, the fact is of no practical import, beyond showing that, if such organisms had existed, at any rate they were not of a resistent nature.

Insects, particularly common house-flies, were an intolerable pest at times. In a fresh camp they were sometimes not abundant, but after two or three days they multiplied enormously. Not only hospital tents, but living and mess tents, swarmed with them, the canvas appearing positively black at night. Even when dressing a wound, without unceasing pa.s.sage of the hand across the part, it was impossible to keep them from settling, and during operations the nuisance was much greater.

Storms of rain were occasionally as troublesome as, though perhaps less harmful than, those of dust. On one occasion a whole Field hospital was flooded only a few hours after a number of important operations had been performed, and the patients were practically washed out of the tents. It was somewhat remarkable that none of the men suffered any serious ill as a result.

At times the temperature was sufficiently high to make either dressing or operating a most exhausting process to the surgeon. The heat of the day was not on the whole so disadvantageous from the point of view of the operator, as the cold of the nights during the winter in Orange River Colony. On one or two occasions serious operations had to be left undone, as it was only possible to consider them in camp, where, as we arrived at night only, the temperature was too low to justify the necessary exposure.

Water for use at operations was often a great difficulty. Even at Orange River, where, though muddy, the water was wholesome, it was impossible to get water suitable for operations unless it had previously gone through the complicated processes of precipitation by alum, boiling, and filtration. At Orange River a small room in the house of one of the railway servants was obtained and fitted as a rough operating room by the Royal Engineers. The necessary utensils were provided by Colonel Young, Commissioner of the Red Cross Societies. Here a stock of prepared water was kept for emergencies.

The remaining difficulties mainly consisted in those we are familiar with in civil practice, such as the securing of suitable a.s.sistance in the handling of instruments and dressing, when the rush of work was very great.

At the Base hospitals accommodation for operating in properly equipped rooms obviated many of the difficulties above referred to.

In concluding this introduction I should sum up in a few words my experience of the general working of the hospital system during my stay in South Africa.

The excellence of the Field hospitals for their purpose has been already alluded to, and, as far as I could ascertain, won the confidence and approval of patients, military commanders, and civilians such as myself.

The Stationary hospitals (by which I intend to indicate those receiving the patients directly from the Field hospitals before the establishment of advanced Base hospitals), as already indicated, were not in my opinion so perfectly conceived or organised. The requirements of these are, however, far greater than those of the Field hospitals, and they of all others are dependent on the possession of facilities for rapid transport. In South Africa the difficulties of supplying them were enormous, and no doubt the conditions of the campaign in this, as so many other particulars, were novel and unusual. None the less the experience gained will no doubt be utilised in the future. With regard to the extravagant criticisms levelled at the Field hospitals serving as Stationary hospitals at the time of the early period of the occupation of Bloemfontein, it may be pointed out that the only proper ground for comparison was not between the patients at Bloemfontein and those in hospital at the base, but between the men in hospital and those in the field at that time, since the conditions were equally adverse to both.

Besides, it must not be forgotten that a large proportion of the patients, at that time, were really comfortably housed in the Raadzaal and other buildings, the preparation of which entailed a very great amount of both labour and resource.

The difficulties experienced at that time will, it is hoped, go far towards securing greater facilities and rights of transport to the Royal Army Medical Corps in the future. 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 circ.u.mstances 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.

As to the efficiency of the organisation of the General hospitals, either at the advanced or actual base, I have already testified.

Naturally the working of these hospitals varied with the personal equation of the officer in charge of them, but as a whole the service has every reason to be proud of their success. As far as surgical results are concerned, and with these I had special acquaintance, the success of the hospitals was amply demonstrated.

Adverse criticism was not however wanting, and often expressed in the strongest terms by persons totally unacquainted with hospital methods, and apparently unconscious that such excellence as is exhibited in a London hospital is the result of continuous work and development for some centuries, and that such inst.i.tutions are worked by committees and staffs of permanent const.i.tution.

The proportion of female nurses employed in these hospitals underwent steady increase from the commencement of the campaign, and the immense value of the nursing reserve was fully proved. There is no doubt that in Base hospitals the actual nursing should always be entrusted to women.

The demands of the campaign necessitated the employment of a large number of civil surgeons in the various hospitals. These gentlemen accommodated themselves with true British apt.i.tude to the conditions under which they were placed, and in all positions their sterling work contributed in no small degree to the success that was attained.

One cla.s.s of hospital still remains for mention. I refer to the improvised hospitals prepared in the Boer towns prior to the British occupation. They were met with in all the smaller towns, and also in the larger ones such as Johannesburg and Pretoria.

The Burke hospital in Pretoria, started by a private citizen and his daughter, and the Victoria hospital in Johannesburg, presided over by Dr. and Mrs. Murray, were two of the largest, but each and all deserve due recognition.

I am sure that many of our wounded officers and men who were cared for in these hospitals while prisoners in the hands of the Boers, will never lose their sense of grat.i.tude to those inhabitants who spared no effort to render their position as happy as possible under the circ.u.mstances; and the existence of these hospitals was no small boon to the service when called upon to take charge of the sick and wounded therein contained.

I cannot close this chapter without recognition of the immensity of the task which has fallen on the Royal Army Medical Corps in the treatment of the sick and wounded during the course of the campaign and full appreciation of the manner in which that task has been met. The strain thrown upon this department of the service, originally organised for the needs of an army less than half the magnitude of that eventually taking the field, was incalculably great, and the medical profession may well be proud of the efforts made by its military representatives to do the best possible work under the circ.u.mstances.

FOOTNOTES:

[1] 3,328 men of the IX. Brigade present are not included, as they never came into action.

[2] The high mortality was due to deaths amongst the officers of the Naval Brigade.

[3] To obtain this total the numbers of killed, wounded, and missing, after the three earlier battles, have been ma.s.sed, and added to the total number of men known to have taken part in the battle of Magersfontein. The inaccuracy dependent on the fact that some of the men reported as wounded or missing in the earlier battles had already returned to their regiments, and are included in the total of 11,447, must be disregarded.

[4] Numbers quoted from Fischer, _Handbuch der Kriegschirurgie_, vol. i.

p. 22, 1882.

CHAPTER II

MODERN MILITARY RIFLES AND THEIR PROJECTILES IN RELATION TO INJURIES PRODUCED BY THEM ON THE HUMAN BODY

Before proceeding to the actual description of the wounds inflicted by modern military rifles, it is necessary to prefix a few remarks on the mechanism and mode of production of these injuries.

Recent tendency in the construction of military rifles has been in the direction of reduction of bore, and a corresponding one in the calibre of the bullet, the resulting loss of weight in the latter as an element in striking power being compensated for by the attainment of an augmentation of velocity in the flight of the projectile, and a comparatively flat trajectory.

Changes in this direction have endowed the weapons with increase both in range and accuracy of fire; while the greater rapidity with which magazine rifles can be discharged and, in consequence of reduction in weight, the greater number of cartridges which can be carried by each man, also form important factors in the possible deadliness of warfare at the present day. None the less the experience of the present campaign has scarcely justified the early prognostications expressed as to a great increase in the number and severity of wounds amongst the combatants.[5] This comparative immunity is to be explained mainly on two grounds. The increased distance which for the most part separated the two bodies of men, a feature no doubt accentuated by the mode of warfare adopted by the Boer, and his strong sense of the folly of close combat on equal terms, tended to efface one of the chief characters, velocity of flight, on the part of the projectile. The want of effectiveness of the small-calibre bullet as an instrument of serious mischief also kept down the mortality.

Since the year 1889 the calibre of the bullet in our own army has been reduced from that of the Martini-Henry (.450 in.) to one of .309 in. in the Lee-Metford, and a consequent reduction in weight from 480 to 215 grains. To allow of the satisfactory a.s.sumption of the more complicated rifling by the more rapidly projected bullet, the lead core has been ensheathed in a mantle of denser metal. The bullet itself is of an original calibre (.309 in.) somewhat exceeding the bore of the rifle barrel (.303 in.), in which way a species of 'choke' is obtained and deep rifling of the surface ensured. Beyond this the comparative transverse and longitudinal measurements and shape have been altered in order to maintain weight, preserve a proper balance during flight, and increase the power of penetration. These alterations with slight differences in detail embody the general principles that underlie the construction of each of the weapons adopted by European nations. It will be well here to consider the influence of each alteration from the point of view of the surgeon.

_Calibre._--The effect of the diminution of calibre is (_a_) to reduce the area of impact of the bullet on the part impinged upon, and hence to lower the degree of resistance offered by the tissues; this to a certain extent tends to neutralise the augmented striking force resulting from the increased velocity of flight. (_b_) To limit considerably the destructive powers of the bullet, as a smaller area of tissue is exposed to its action. (_c_) To allow of the production of very 'neat' injuries and the frequent escape of important structures, also the production of remarkably prolonged subcutaneous tracks in positions where such would be regarded as scarcely possible, and in point of fact were impossible with the older and larger projectiles.

_Length._--The comparative increase in length of the bullet is, from the surgical point of view, only of material importance in increasing the weight and therefore the striking power, and in so far as it is a mechanical necessity for the flight of the projectile on an axis parallel to its long diameter, and so tends to ensure impact on the body by the tip of the bullet. This latter is, however, surgically favourable as ensuring a smaller wound.

_Weight._--The decrease in weight must be regarded on the whole as altogether to the advantage of the wounded individual, since it cannot be considered to be entirely compensated for by the resulting increased velocity of flight, unless the range of fire is moderately close.

_Shape._--The ogival tip and general wedge-like outline, while decreasing the aerial resistance to and increasing the power of penetration possessed by the bullet, at the same time allow the escape of some structures by displacement, while others are saved from complete destruction by undergoing perforation. Beyond this the sharper the tip, the smaller is the area of the body primarily impinged upon, the less the resistance offered to perforation, and to some degree the less the destruction of surrounding tissues.

_Increased velocity of flight._--This multiplies the striking force, and compensates in part for decrease in volume and weight of the bullet. It is customary to speak of the velocity as 'initial' and 'remaining.'

Initial velocity is the term employed to express the velocity at the time of the escape of the bullet from the barrel; this is also designated as 'muzzle velocity.' 'Remaining velocity' expresses that obtaining during any subsequent portion of the flight of the projectile.

The greatest initial velocity is obtained with the use of bullets of the smallest calibre, but this is not of the practical importance which might be a.s.sumed, since the remaining velocity of flight of such projectiles falls more rapidly than that of those of slightly greater ma.s.s. Thus, although there may be a difference of a hundred metres per second in initial velocity between two rifles of calibres varying from 6.5 to 8 millimetres (.303-.314 in.), at the end of 1,000 metres the discrepancy is greatly reduced, while at 2,000 metres it hardly exists.

Under such circ.u.mstances the projectile of greater weight and volume, as possessing the greater striking force, is considerably the more formidable of the two. This is the more important if it be allowed, as I believe to be the case, that velocity _per se_ is of no practical import in the case of wounds of the soft parts of the body, which after all form the preponderating number of all gunshot injuries. The effect of the higher degrees of velocity differs, however, with the amount of resistance met with on the part of the body; hence its serious import is well exemplified when parts of the osseous skeleton are implicated, although even here considerable variations exist, dependent upon the structure of that part of the bone actually involved. The most obvious ill effect of injuries from bullets travelling at high rates is seen in the case of the various parts of the nervous system, and here it is undeniable. High velocity and striking force are also responsible for the prolonged course sometimes taken by bullets through the body.