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 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 extremity[154]
CHAPTER VI
INJURIES TO THE JOINTS
General character—Vibration synovitis—Wounds of joints—Classification—Course and symptoms—General treatment—Special joints[225]
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—Treatment[314]
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 hæmothorax[374]
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 wounds[474]
Index of Contents[487]
ILLUSTRATIONS
PLATES
Varieties of Ammunition collected at Ladysmith[Frontispiece]
1. Section of Mauser Aperture of Entry To face p. [73]
2. Section of Mauser Aperture of Exit [76]
3. Punctured Fracture of Clavicle[162]
4. Comminuted Fracture of Shaft of Humerus[180]
5. Comminuted Fracture of Humerus accompanied by an Explosive Exit[182]
6. Comminuted Fracture of Humerus due to Oblique Impact[184]
7. Same Fracture healed[186]
8. Low Velocity Fracture of Humerus With Retained Bullet[188]
9. Localised Fracture of Humerus Showing Fragmentation of the Bullet[190]
10. Wedge-shaped Fracture of the Radius[192]
11. Fracture of the Metacarpus, showing Fragmentation of the Bullet[194]
12. Finely Comminuted Fracture of the Femur[196]
13. The same Fracture Healed[198]
14. Stellate 'Butterfly' Fracture of the Femur[200]
15. Lateral Impact of Bullet, with Comminution of the Femur[202]
16. Rectangular Impact of Bullet, with highly Oblique Line of Fracture of the Femur[204]
17. Punctured Fracture of the Femur with Exit Bone-flap[206]
18. Fractured Patella[208]
19. Oblique Comminuted Fracture of the Tibia[210]
20. Transverse Fracture of the Tibia[212]
21. Puncture of the Tibia, with an Oblique Fissure[214]
22. Notched Fracture of the Tibia[216]
23. Punctured Fracture of the Fibula[218]
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 Instruments[4]
2. Instrument Hold-all Rolled for Packing[5]
3. Tin Water-bottle for Emergency Operations[6]
4. Buggy on the Veldt[7]
5. McCormack-Brook Wheeled Stretcher Carriage[19]
6. Indian Tonga[20]
7. Service Ambulance Wagon[21]
8. Buck-wagon Loaded with Wounded Men[22]
9. Interior of a Wagon of No. 2 Hospital Train[24]
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 War[47]
15. Sections of Four Bullets To Show Relative Thickness of Mantles[51]
16. Entry and Exit Mauser Wounds[56]
17. Gutter Wound of Shoulder[56]
18. Oblique Gutter Exit Wound [57]
19. Oval Entry, Starred Exit Wounds[58]
20. Circular Entry, Slit Exit Wounds[59]
21. Circular Entry, Starred Exit Wounds[59]
22. Entry and Exit Wounds in Six Successive Spots made by same Bullet[61]
23. Four Successive Entry and Exit Wounds of same Bullet[62]
24. Superficial Abdomino-thoracic Track[64]
25. Superficial Linear Ecchymosis of Thigh[65]
25a. Sections of Mauser Entry and Exit Wounds[74]
25b. Prolapsed Omentum[77]
26. Sections of Four Bullets[82]
27. Normal Mauser Bullet[83]
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 Ricochet[88]
34. Normal Lee-Metford Bullet[89]
35. Apical Lee-Metford Ricochets[90]
36. " " " [91]
37. Four Types of Soft-nosed Bullets[92]
38. 'Set-up' Soft-nosed Lee-Metford Bullets[92]
39. Flattened, Solid-based Mantle From Ricochet[93]
40. Mauser Bullet, Jeffreys-Tweedie Modification[94]
41. Section of Mark IV. and Soft-nosed Mauser[94]
42. Tampered Bullets[95]
43. Large Leaden Sporting Bullets[98]
44. Explosive Wound of Back[100]
45. Dead Men on Field of Battle[102]
46. Flattened Leaden Cores from Mantled Bullets[105]
47. Explosive Exit Wound over Fractured Ulna[156]
48. Explosive Exit Wound over Fractured Humerus[158]
49. Explosive Exit and Entry Wounds of Legs[159]
50. Types of Gunshot Fracture[161]
51. Lower End of Fractured Femur[164]
52. Oblique Perforation of Femur, Separation of Fragment at Exit Aperture in Bone[169]
53. Gutter Fracture of Head of Humerus[178]
53a. Diagram of 'Butterfly' Type[180]
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 Hæmothorax[392]
84. Subcutaneous Division of Abdominal Muscles[409]
85. Lateral Incomplete Wound of Small Intestine. Slit Form[416]
86. Lateral Perforation of Small Intestine. Gutter Form[417]
87. Entry and Exit Wounds in a Transverse Perforation of Intestine[418]
88. Inner Aspect of Piece of Intestine Shown in Fig. 87[419]
89. Impaction of Omentum in Exit Wound of Abdominal Wall[421]
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 Shell[481]
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]