CHAPTER XII_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

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

25_a_. SECTIONS OF MAUSER ENTRY AND EXIT WOUNDS 74

25_b_. 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

53_a._ DIAGRAM OF 'BUTTERFLY' TYPE 180

54. WIRE GAUZE SPLINT 187

55. GUTTER FRACTURE OF PELVIS 191

55_a_. 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

SURGICAL EXPERIENCES

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 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.

[Illustration: 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.

[Illustration: 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 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.

[Illustration: FIG. 3.--Tin Water-bottle for the march (Military

Equipment Company)]

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.

[Illustration: 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 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 diarrhoea 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 diarrhoea,

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 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

+---------------------+--------+------+-------+-------+-----+-------------+

| | of | | | | | killed and |

+---------------------+--------+------+-------+-------+-----+-------------+

| Officers | 297 | 3 | 23 | 0 | 26 | 8.75 |

| and men | 8,396 | 55 | 206 | 4 | 265 | 3.15 |

| +--------+------+-------+-------+-----+-------------+

| Total | 8,693 | 58 | 229 | 4 | 291 | 3.34 |

| | | | | | | |

| Officers | 326 | 3 | 7 | 0 | 10 | 3.06 |

| and men | 8,213 | 18 | 163 | 7 | 188 | 2.29 |

| +--------+------+-------+-------+-----+-------------+

| Total | 8,539 | 21 | 170 | 7 | 198 | 2.31 |

| | | | | | | |

| Officers | 335 | 3 | 19 | 0 | 22 | 6.56 |

| and men | 9,856 | 67 | 377 | 18 | 462 | 4.68 |

| +--------+------+-------+-------+-----+-------------+

| Total | 10,191 | 70 | 396 | 18 | 484 | 4.74 |

| | | | | | | |

| Officers | 379 | 18 | 48 | 2 | 68 | 17.94 |

| 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 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

---------------------+-------+------+------+------+-------+----------------

---------------------+-------+------+------+------+-------+-------+--------

Officers | 297 | 26 | 3 | 3 | 6 | 23 | 2.02

and men | 8,396 | 265 | 55 | 8 | 63 | 23.77 | 0.75

+-------+------+------+------+-------+-------+--------

Total | 8,693 | 291 | 58 | 11 | 69 | 23.71 | 0.79

| | | | | | |

Officers | 326 | 10 | 3 | 1 | 4 | 40[2] | 1.22

and men | 8,213 | 188 | 18 | 3 | 21 | 11.17 | 0.25

+-------+------+------+------+-------+-------+--------

Total | 8,539 | 198 | 21 | 4 | 25 | 12.62 | 0.29

| | | | | | |

Officers | 335 | 22 | 3 | 1 | 4 | 18.18 | 1.19

and men | 9,856 | 462 | 67 | 9 | 76 | 16.45 | 0.77

+-------+------+------+------+-------+-------+--------

Total |10,191 | 484 | 70 | 10 | 80 | 16.53 | 0.78

| | | | | | |

Officers | 379 | 68 | 18 | 4 | 22 | 32.35 | 5.80

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 that in the four battles 1,827 men were hit, of whom 315, or 17.24

per cent., were killed. Among the wounded carried off the field,

however, 49 received mortal injuries, and if these are added to the 315,

we find that the proportion of mortal injuries reaches 19.92 per cent.

TABLE III[4]

+-----------------------+---------+---------+--------+---------+----------+

| | | | 1871. | 1877. | 1899. |

| | (English| War | War | War | Force |

+-----------------------+---------+---------+--------+---------+----------+

| engaged | 36,240 | 97,864 | 887,876| 300,000 | 15,748 |

| | | | | | |

| Number of killed | 1,759 | 2,775 | 17,570| 32,780 | 315 |

| Percentage | 4.85 | 2.81 | 1.97| 10.92 | 2 |

| | | | | | |

| Number of wounded | 5,892 | 12,094 | 96,189| 71,268 | 1,512 |

| Percentage | 16.25 | 12.35 | 10.83| 23.75 | 9.60 |

| | | | | | |

| Number of missing | 807 | -- | 4,009| -- | 132 |

| Percentage | 2.19 | -- | 0.45| -- | .83 |

+-----------------------+---------+---------+--------+---------+----------+

| wounded, and missing | 8,458 | 14,849 | 117,768| 104,050 | 1,959 |

| Percentage | 23.31 | 15.17 | 13.26| 34.68 | 12.43 |

+-----------------------+---------+---------+--------+---------+----------+

The proportion of men killed to those wounded was as follows: killed

315, wounded 1,512, or 1 to 4.8. If we add to the men killed on the

field of battle the 49 dying in the next 48 hours, the proportion of

fatalities is increased to 1 to 4.15. The higher of these proportions is

certainly the surgically correct one.

With regard to the general accuracy of the numbers given above, a

comparison of those published for the campaign up to September 15, 1900,

is of value, as the two series substantially tally. Thus, up to that

date, 17,072 men were hit, and of these 2,998 were killed. The

proportion killed to wounded was therefore 1 to 4.69.

If it be borne in mind that of the wounded men included in Table I., 1.5

per cent. died later in the Base hospitals, the percentages are almost

identical.

Table III. is inserted with a view to instituting a comparison between

the number of casualties in the present and earlier campaigns.

For the purposes of this table it is necessary to take the approximate

number of men at Lord Methuen's disposal, irrespective of their active

participation in the fighting.

The result of this addition to the total is to show that the percentage

of men killed and wounded was slightly lower than in the Crimean war,

and nearly corresponded with that observed in the Franco-German

campaign.

As it has been shown that our numbers correspond in general with those

of the whole war up to September 15, 1900, there can be little doubt

that the same ratios will be maintained to the close of the campaign.

On the face of the numbers, therefore, there is little ground for

assuming that the change in the nature of the weapons has materially

influenced the deadliness of warfare at all. This is capable of

explanation on the ground that in the Crimea the battles were fought at

much closer quarters, and hence the weapons of the time were as

effective, or more so, than the present ones. That this increased

distance between the combatants will always counterbalance the increased

deadliness of the weapons in the future is more than probable, since the

range of effectiveness has been increased both in rifle and in artillery

fire. In the present campaign the effect of the latter was very

noticeable, since the Boers were, as a rule, quickly displaced by shell

fire, unless they were in especially favourable positions, and this

although no great number of men was hit by the projectiles. Under these

circumstances, except on some occasions, neither side derived all the

advantage from the increased shooting powers of their rifles which might

have been expected. To a lesser degree this will probably always be the

case in the future.

In connection with these remarks, however, I would point to column 4 of

Table III., as showing how difficult it is to draw definite deductions

from any particular set of numbers alone. This column shows that in the

Russo-Turkish War of 1877 all the percentages were practically doubled

or more, and in the case of the number of men killed on the field of

battle, the number was nearly five times as great as either in the

Crimea or the present campaign. The explanation here depends on the race

of men and their tenacity in resistance alone. In the case of either

nation death in battle is little feared, and slight inclination to avoid

it exists. When the theory of war held by the Boer--_i.e._ going out to

shoot an enemy without incurring risk of being yourself shot--is borne

in mind, the special circumstances attending the present campaign are

sufficiently obvious to need little further remark. A future campaign in

which the combatants are as equally well armed, but each side stands to

the last, will probably give very different results.

It is unfortunate that no details can be given as to the influence of

range in altering the relative numbers of killed to wounded. It may be

stated, however, that in no instance did the percentage of killed to

wounded reach 25 per cent. At the battle of Magersfontein it amounted to

19.26 per cent., at Colenso to 17.97 per cent., and at both these

engagements there is little doubt that a considerable number of the men

were hit within a distance of 1,000 yards. When the distances were very

short the injuries were frequently multiple; and this character was a

more common source of danger than increase of severity in the individual

wounds received at a short range.

A short consideration of the circumstances especially influencing the

ultimate mortality amongst the wounded subsequent to the reception of

the injury is here necessary, although I shall be obliged to make my

remarks as short as possible. The subject is best treated of under the

two headings of Transport and Hospital Accommodation.

_Transport._--The importance of transport is felt from the moment of the

injury till the time of arrival of the patient in the mother country. To

the surgeon it is of the same vital importance as the carrying of food

for the troops is to the combatant general.

(_a_) Removal of the wounded from the field of battle. My experience was

opposed to hurried action in this matter, although it is necessary to

gather up the wounded before nightfall if possible. As a rule wounded

men should not be removed from the field of battle under fire, at any

rate when the troops are in open order at a range of 1,000 yards or

more. I saw several instances in which mortal wounds were incurred by

previously wounded men or their bearers during the process of removal,

while it was astonishing how many scattered wounded men could lie out

under a heavy fire and escape by the doctrine of chances. The erect

position and small group necessary to bear off a wounded man at once

draws a concentrated fire, if fighting is still proceeding.

As to the best and quickest method of removing the patients to the first

dressing station, there were few occasions when this was not more

satisfactorily done by bearers with stretchers than by wagons. The

movement was more easy to the wounded men, and, as a rule, time was

saved. Over rough ground the wagons travel slowly, and patients with

only provisional splints were shaken undesirably. A stretcher party in

my experience easily outstripped the wagon unless a road or very smooth

veldt existed. A larger number of men is of course required, but I take

it that on the occasion of a great war men are both more easily obtained

and fed than are transport animals. From what I have been able to learn,

both the Indian dhoolie-bearers and the hastily recruited Colonial

bearer companies were most successful in the removal of the large number

of wounded men from the field of Colenso. I had several opportunities of

comparing the two methods on a smaller scale during the fighting in

Orange River Colony, and felt very strongly in favour of the stretcher

parties.

For removal of patients from one part of a hospital to another, or

sometimes in loading trains, &c., great economy of men, and increased

comfort to the patients, may be attained by the use of some form of

ambulance trolly.

I append an illustration of what seemed to me the simplest and best I

came across among several in use in South Africa. The description

beneath is by Major McCormack, R.A.M.C., its inventor (fig. 5).

When wagons were necessary or preferable, the Indian Tongas (fig. 6),

presented by Mr. Dhanjibhoy, were most useful; they carried two men

lying down, the same number as the big service wagon, and were drawn by

two ponies only. Although somewhat highly springed, the vehicle is so

well arranged and padded, that the occupants are seldom hurt by striking

against the sides with rough jolting, unless quite helpless. I

occasionally made long journeys in this vehicle with much comfort.

[Illustration: FIG. 5.--The McCormack-Brook Wheeled Stretcher Carriage.

It consists of an under-carriage built up of two light wheels with steel

spokes and rims with rubber tyres and ball bearings; on the axle are two

light elliptic springs, to which is attached a transverse seat for the

stretcher-carrier proper. This is securely bolted on to the seat, and

consists of two pieces of hard wood, suitably worked, and forming an

angle frame. On the bottom side the stretcher poles rest, and the sides

of the L formed by the carrier proper prevent most effectually any

jerking or turning of the stretcher when once it has been laid in the

carrier. The carrier is about thirty inches long, but can be increased

to any length desired. It has been found that this length is admirably

suited for all purposes. To prevent the stretcher from any lateral or

upward movement, two buttons with tightening screws are attached to the

top of the carrier on each side. When the stretcher is laid on the

carrier the screws are tightened and the stretcher is held rigid.

Two iron supports are provided, one at each end and on opposite sides of

the carrier. These are lowered when it is desired either to place the

stretcher on the carriage or remove it therefrom, which can be effected

in a second. The carriage meanwhile remains perfectly still. When the

carriage is in motion the iron supports are turned up, and lie along the

respective sides of the carrier, where each rests in a small clip. The

great object of this stretcher carriage has been to obtain mobility,

strength, and lightness combined with efficiency and a ready and easy

means of transport for sick and wounded, no matter where a patient has

to be transported from. The loaded stretcher and wheeled carriage can be

readily handled by one man on good roads, and by two men in rough

country. The springs prevent any jar being felt by the patient on the

stretcher.]

(_b_) For the longer journeys to the Field or Stationary hospitals, the

service wagon and other transport vehicles came into use, particularly

the South African ox-wagon.

[Illustration: FIG. 6--Indian Tonga on the march. (Photo by Mr. Bowlby)]

The service wagon (fig. 7) is a heavy four-wheeled vehicle, drawn by ten

mules. The good construction of the wagon was amply proved by the manner

in which it stood the hard wear and tear of the present campaign. It is,

however, very heavy, and in comparison with its size affords very small

accommodation. Two lying-down patients and six sitting is its entire

capacity. Some modified patterns were in use, notably those with the

Irish and Imperial Yeomanry Field Hospitals, capable of carrying four

lying-down cases, the men being arranged in two tiers. Major Hale,

R.A.M.C., made a very successful trek from Rhenoster to Kroonstadt with

some of these, carrying twice the regulation number of lying-down cases

in his wagons. Some modification in the mode of fixation is, however,

necessary to increase the security of the stretchers of the upper

series.

A really satisfactory wagon, combining both strength and comfort, still

remains to be devised.

[Illustration: FIG. 7.--Service Ambulance Wagon, the six front mules

removed.

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

During the later stages of the campaign, a very large number of patients

were transported by the South African ox- or mule- (buck) wagons.

Although not of prepossessing appearance, and unprovided with any sort

of springs, these vehicles were far from unsatisfactory. The ox-wagon

consists of a long simple platform, 19 ft. 2 in. in length, 4 ft. 6 in.

in width, from the sides of which a slanting board rises over the wheels

for the posterior two-thirds. These bulwarks increase the actual width

to 6 ft. 6 in., which corresponds with the gross width occupied by the

wheels. One third is covered by a small hood 5 ft. 6 in. in height

erected on wooden stave hoops. The latter was often absent in transport

wagons. The two hind wheels are large, the fore somewhat smaller. They

are attached to very heavy wooden cross-beams bearing the axles, and the

two beams are connected by a longitudinal bar, continuous with the

düssel boom or pole. This latter bar is in two sections, the connection

of which allows considerable play in the long axis and serves to break

the jolts occurring when either pair of wheels passes over uneven spots

on the ground. When some sacks of oats or hay were spread over the

floor the wounded men travelled comparatively comfortably in these

wagons, the great distance between the fore and hind wheels tending to

minimise the jolting. The principal objection to them was the slow pace

of the oxen, and the fact that to obtain the greatest amount of work

from these animals a major part of the journey must be performed during

the night. The ox-wagon carries, with comfort, four lying-down cases on

stretchers, or six without stretchers; or twenty sitting-up cases.

[Illustration: FIG. 8.--South African Wagon, loaded with patients, and

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

The mule- or buck-wagon, which is of the same class but smaller, can

only accommodate two stretchers, four lying-down men without stretchers,

or 12-14 sitting-up cases. As a rule, the wagons were loaded with

recumbent cases in the centre, while more slightly wounded men sat

around, and were able to give help to those lying down when needed. The

wagons can be covered with canvas throughout.

The steady even pace of the oxen is a great advantage, and I was often

surprised to see how well men bore transport in these wagons, who seemed

utterly unfit to be moved had it not been an absolute necessity. A very

large number of the wounded from Paardeberg Drift were transported to

Modder River in them.

One other advantage of these wagons, the possibility of converting them

into an excellent laager, is not to be underrated. Any one who saw the

comfortable encampment which a naval contingent on the march made by

massing the wagons with intervals covered by macintosh sheets, could at

once appreciate their capabilities for a long trek.

Traction engines were, as far as I know, never employed as a means of

transporting the sick. The tendency of these heavy machines to stick in

the mud and to break down bridges is so well known that it hardly needs

mention. Putting these disadvantages on one side, with a supply of fuel

ensured, and such roads as are afforded by a civilised country, a great

future is probably before this means of transport for the wounded. A

large number of patients might be carried at an even pace, and the camps

would be saved all the trouble and worry of the transport animals.

_Trains._--In many cases in Natal, and in a few instances on the western

side, the wounded men were able to be transferred from the first

dressing station directly into the trains. Space will not allow me to

describe any of those in use, but the accompanying illustration shows

the general arrangement of the beds in Nos. 2 and 3 trains (fig. 9). The

carriages were converted from ordinary bogie wagons of the Cape

Government Railway stock under the supervision of Colonel Supple,

R.A.M.C., P.M.O. of the Base at Cape Town. Each train was provided with

accommodation for two medical officers, two nursing Sisters, orderlies,

a kitchen, and a dispensary, and each carried some 120 patients. The

trains were under the charge of Major Russell, R.A.M.C., and Dr. Boswell

(and later other civilian medical officers) and of Captain Fleming,

R.A.M.C., D.S.O., and Mr. Waters, and carried many thousand patients

from all parts of the country to the Base and Station hospitals. They

were most admirably worked, and seemed to offer little scope for

improvement except in minor details. To them much of the success in the

treatment of the wounded who had to traverse the immense distances

incident to South Africa must be attributed. I made many pleasant

journeys in each of them. Later, two additional trains, Nos. 4 and 5, of

a similar nature, were added. Two trains, No. 1, and the Princess

Christian train, which I was not fortunate enough to see, performed

similar duties for Natal.

[Illustration: FIG. 9.--Interior of one of the Wagons of No. 2 Hospital

Train]

_Hospital Ships._--These were numerous and some especially well

arranged. Fig. 10 is of the 'Simla,' a P. & O. vessel which was

admirably adapted to the requirements of a hospital ship. On her main

deck some 250 patients were accommodated in a series of wards all on the

same level, which much lightened the difficulties of service usually

experienced. During the present campaign the abundance of transport

vessels rendered the transhipment of patients to England a matter of

comparative ease, and good vessels were always available. Considering

the constant transhipment of invalids from India and our other colonial

possessions, it would seem advisable that, in place of having to

hurriedly improvise hospital ships, the Government should possess two or

three hospital ships of the 'Simla' type. It is true this would deprive

our naval transport officers of a duty which in this war was performed

with extraordinary celerity and success; thus the 'Simla' was fitted in

seven days, and sailed with a cargo of invalids ten days after her

arrival at Durban; but on the other hand it would ensure that really

suitable vessels were always provided.

[Illustration: FIG. 10.--P. & O. Hospital Ship 'Simla' in Durban

Harbour]

To give some idea of the amount of work contingent on the transport of

wounded men from an army of some 15,000, fighting its way against

continued opposition, I will quote the approximate number of men moved

during Lord Methuen's advance from Orange River to Magersfontein. (The

number of men actually present at each battle is shown in Table I., p.

12.)

Belmont, the first battle, was fought on November 23.

_November 24._--No. 2 hospital train removed 152 cases to the Stationary

Field hospitals at Orange River, then returned and loaded up with 130

more. Some of the most severe cases in the latter were detrained at

Orange River, and the remainder were taken direct to Wynberg (591-1/2

miles).

The division marched, and the battle of Graspan was fought during the

day.

_November 26._--A train of specially constructed trucks brought 90 of

the less severe cases, including 20 Boers, to Orange River.

_November 27._--The division marched, and in the morning No. 3 hospital

train removed 80 severe cases from the Field hospitals direct to

Wynberg.

_November 28._--Battle of Modder River.

_November 29._--339 patients, including a few sick, and some wounded

Boers, were sent down to Orange River in open trucks with impromptu

shelters made with rifles and blankets.

Later, 97 severe cases were sent down in ordinary carriages, of which

some had doors sawn out to admit lying-down patients.

_December 10._--The division marched, and on the next day the battle of

Magersfontein was fought.

_December 11._--Nos. 2 and 3 trains were loaded up during the night and

early morning of the 12th, in part from the Field hospitals, in part

directly from the Ambulance wagons. During the day of the 12th, No. 3

train made three journeys to Orange River, and No. 2 was sent direct to

Wynberg.

In all some 800 patients needed transport; they were picked up by 10

ambulance wagons and 5 buck wagons for slighter cases and the two bearer

companies sent out from Modder River. On the 12th Lord Methuen sent out

a number of bearers with stretchers, and at 12 noon all the wounded were

collected, but many had lain out through the night. The bearers had to

retire under a shell fire kept up by the Boers as long as our army was

within range of their position.

Four Field hospitals were present, but only that of the IX. Brigade at

Modder River was so situated as to be of general use. This hospital,

under the command of Major Harris, R.A.M.C., did an immense amount of

work most expeditiously and with great success.

The nature of the advance on Kimberley necessitated the evacuation of

the Field hospitals with extreme promptitude, as the troops were in

constant action, and the arrangements for this were carried out with

great success by Colonel Townsend, the P.M.O. of the First Division.

The amount of fighting far exceeded anything that had been expected, and

the Stationary hospitals on the lines of communication at Orange River

and De Aar were unable to cope with the number of severe cases thrown on

their hands, with the constant possibility of new arrivals. Hence a

number of severe cases had to be sent direct to Wynberg.

This experience strongly illustrated the necessity of possessing

Stationary hospitals of greater mobility and a higher degree of

equipment than the service at present possesses. In these a large number

of severe cases could have been retained, and only the slighter ones

exposed to the fatigue and general disadvantage of transport. In South

Africa very special difficulties existed in the length of the line of

communication, the single line of rails, and the absence of any source

of supply within 500 to 600 miles; but in any other country mobile

Stationary hospitals, although more easily equipped, would be equally

valuable.

The difficulties of transport experienced in the advance of the

Kimberley Relief Force were many times multiplied in that upon

Bloemfontein, since the whole of the severely wounded men had to be sent

back thirty to forty miles to the railway. The ambulance accommodation

on the occasion of this march, although, if untouched, proportionately

smaller than that possessed by Lord Methuen, was reduced to one-fifth to

meet the exigencies of warfare. Beyond this the equipment transport of

the Field hospitals was reduced from four ox-wagons to two, and the

Scotch cart was cut off, only two ox-wagons and the two water-carts

being allowed. This greatly hampered the Field hospitals on the march,

and when they arrived at Bloemfontein and had to undertake the work of

Stationary hospitals, their efficiency was seriously impaired. Again, on

the advance from Bloemfontein to Kroonstadt many of the Field hospitals

were unable to accompany their respective divisions, not alone on

account of the number of patients remaining in them, but also because

the mule transport had been otherwise employed for military purposes.

The transport of the ambulances and hospitals stands in a very special

position. As far as my experience went, neither ambulances nor hospitals

were ever taken or retained by the Boers, and consequently the transport

animals originally devoted to this purpose should have been held sacred

to it.

_Hospitals._--Accommodation for the wounded was provided under canvas in

the Field hospitals, also in the large General hospitals. Beyond this

iron huts were erected in many of the Base and Station hospitals. At

Capetown, Maritzburg, and Ladysmith barrack huts were modified and

equipped as hospitals, and in towns such as Bloemfontein, Kimberley, and

Johannesburg large civil hospitals were at our disposal. Beyond these

sources of accommodation, churches, schools, public institutions, and

private houses were made use of in the smaller towns.

As to the broad question of canvas _v._ buildings, experience amply

showed that in a climate such as is possessed by South Africa, canvas

affords the greater advantages. The hospitals are more mobile, more

readily extended, and the more healthy. Except under unusual conditions

of rain and dust, the patients did excellently in the tents.

Rain and dust were occasionally most troublesome, especially when

combined with wind. I once saw a whole hospital, fortunately unoccupied,

levelled to the ground in the course of some twenty minutes. Under such

circumstances iron huts present advantages, and were on many occasions

utilised with much success. They are readily erected, and it would have

been a considerable improvement if a number of them had been ready for

use at the earliest part of the campaign. Except in the matter of

weight, they possess in a considerable degree the advantage of mobility

possessed by canvas, and in addition they offer much more protection

from the weather. On the other hand, they are more liable to become

unhealthy from prolonged use.

Churches and public institutions were mainly troublesome from the

necessity of having to improvise sanitary arrangements, and sometimes

the disadvantage of the collection of a large number of men in one

chamber could not be avoided. None the less I cannot look back without

admiration on the temporary hospitals established in the Raadzaal at

Bloemfontein, and the Irish hospital in the Palace of Justice in

Pretoria.

The State schools in the smaller towns of the Orange River Colony also

afforded excellent accommodation as small temporary hospitals.

Private houses, possessing the disadvantages of ill-adapted construction

and the necessity of a considerably increased staff to work them, were

on the whole little used as hospitals. The scattered farmhouses

occasionally afforded shelter to very severely wounded men. In most of

the country I traversed, however, the farms were so wide apart as to be

of little use in this respect; and again, under the special

circumstances, patients left in them might have to be abandoned to the

enemy.

The chief interest during the campaign centred in the working of the

Field and General hospitals.

Two types of Field hospital were employed, one the Home, the other the

Indian. The latter differs from the Home in that in it the bearer

company is attached and consists of Indian natives, and that the

hospital is separable into four sections in place of two only.

The amalgamation of the Field hospital and bearer company into one unit

is much to be desired in the Home service, both for economy of working

and the more equal distribution of duties to the medical officers

engaged. Again the divisibility of the hospital into four sections is

also an advantage. It allows of the advance or the leaving of sections,

in the case of either small expeditions or the presence of a number of

severely wounded men unfit to travel. As far as I could judge, it

necessitates very small addition to the present equipment, and is in

every way desirable.

As to the working of the Field hospitals in the present campaign, it

was universally acknowledged to possess a very high degree of

excellence. The equipment, with small exceptions, proved equal to the

demands made upon it. The mobility of the camps was proved again and

again, and the rules governing their administration evidenced by their

effectiveness the care and experience which have been bestowed on the

organisation of the hospitals.

It is difficult for any one who has not had an opportunity of observing

the actual amount of work performed in the Field hospitals either to

appreciate the storm and stress following an important engagement when

the wounded men are first brought in, or the demands that are made on

the powers of the medical officers in charge. To a civilian the first

feeling is one of impotence, followed by an attempt to see no further

than the case under immediate observation, and to nurture the conviction

that the work is to be got through if it is only stuck to. I gathered

that this first impression was absent in the minds of the officers in

charge of the Field hospitals, as work commenced at once, and was

carried on without intermission during the persistence of daylight, in

the winter often by the aid of lanterns, and eventually the huge task

was accomplished. In early days at Orange River work commenced at 4

A.M., and was steadily continued until 6 P.M. or later, and this state

of things persisted sometimes for many days together.

The officers of the Field hospitals, the bearer companies, and those

doing regimental duty carried out their duties with a calmness and

efficiency which not only impressed observers like myself, but also

excited the admiration of our German colleagues sent by their government

to observe the working of the British system.

I saw on several occasions the German and Dutch ambulances, and was much

struck by the excellence of their equipment. In some details there was

much to be learned from them, especially in the matter of appliances,

dressings, and instruments. The Dutch ambulance I saw at Brandfort had a

complete installation of acetylene gas, which was carried, gasometer and

all, in one Scotch cart. They were, however, really designed to fill the

combined position of our Field, Stationary, and General hospitals, and

when it became necessary for them to move about frequently, the inferior

mobility they possessed in comparison with our own Field hospitals was

at once demonstrated.

The large General hospitals of 500 beds were a great feature in the

campaign. Although designed and organised some time since, the present

was the first occasion on which they have come into general use, and

they may be said to have actually been on trial. The organisation of

these hospitals proved itself excellent, and in the case of the best of

them left little to be desired.

In some cases the accommodation was temporarily strained enormously, and

the number of patients was extended beyond more than three times the

regulation limit. The additional patients were then accommodated in

marquees and bell tents, according to the nature of their diseases.

Under these circumstances the working of the hospitals was difficult,

and the officers both of the R.A.M.C. and the civilian surgeons were

placed at a great disadvantage.

My space does not allow me to give any description of the general

arrangement of these hospitals, but I would suggest that a certain

number of them should be so modified as to increase their mobility and

allow of their being more readily utilised as Stationary hospitals.

During the whole campaign it seemed to me that the Stationary hospitals

(that is to say, the hospitals necessary to receive patients when the

Field hospitals were rapidly evacuated), were those in which some

increased uniformity of organisation was most needed.

It scarcely needs to be pointed out that this is the most difficult link

of the whole hospital chain to be uniformly well organised and equipped.

It is needed at short notice, and often for a short period, and it is

difficult to maintain a regular staff of officers ready for any

emergency without keeping a certain number of men idle.

The conversion of Field hospitals to Stationary purposes is undesirable,

as the troops move with only a regulation number of the former, which

under ordinary circumstances is the minimum that may be necessary.

Stationary hospitals as individual units are undesirable for the reasons

above given.

[Illustration: FIG. 11.--Type of a General Hospital (No. VIII.

Bloemfontein) extended by use of bell tents in the distance. (Photo by

Mr. C. S. Wallace)]

The difficulty might be met by increasing the mobility of a certain

number of the General hospitals, by making them divisible into five

sections, each of which should be able to move independently, and to the

last of which should be attached the heavy part of the equipment, such

as the iron huts for operating and X-ray rooms, kitchens, store sheds,

&c. The tents might also be lightened by the substitution of the

tortoise tent for the service marquee. The tortoise tent is lighter (360

as against 500 lbs.), easily pitched and moved, and holds at least two

more patients with ease. The capabilities of this tent were amply proven

during its use by the Portland, Irish, and other civil hospitals

attached to the army. It withstood wind and weather, the former better

than the service marquee. Figs. 11 and 12 show the appearance of camps

composed of the two varieties. I must admit a warm preference for the

appearance of the service pattern, but I think it is indubitable that

the other is the more useful.

Given the possibility of division of a General hospital in this manner,

single sections could readily be sent up the lines of communication to

serve as Stationary hospitals at various points behind the advance of

the troops, and on the cessation of active need, the sections could be

reunited at any point to form an advanced Base hospital. The sections

could be kept in touch throughout by visits from the officer of the

lines of communication. This would appear a ready means of providing

well-organised Stationary hospitals at short notice, and would save the

disadvantage of a definitely separate series.

[Illustration: FIG. 12.--Type of Tortoise Tent Hospital. Portland

Hospital, Bloemfontein. (Photo by Mr. C. S. Wallace)]

Such hospitals might have been used on many occasions when the transport

of an entire General hospital was an impossibility. The service,

moreover, has some experience in this direction, since at one time No. 3

General Hospital was divided into two definite sections.

Bearing in mind the extreme readiness and promptitude with which the

officers during the present campaign extended the accommodation of

either Field or General hospitals, one of such sections as are proposed

might readily be made far more capacious than its regulation number

would suggest.

My duties being entirely in connection with the service hospitals, I did

not become intimately acquainted with any of the volunteer hospitals

which did such excellent service, except the Portland, to the staff of

which I was indebted for much hospitality and kindness. This hospital

was practically of about the capacity proposed for the above-mentioned

sections, and the report of its work will no doubt furnish many points

of detail as to equipment, &c., which may be useful.

The general results of the surgical work done during the campaign were

excellent, and taken as a whole the occurrence of any severe form of

septic disease was unusual.

Pure septicæmia, especially in connection with abdominal injuries,

severe head injuries and secondary to acute traumatic osteo-myelitis,

was the form most commonly seen. Pyæmia 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

pyæmia 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 tetanus occurred only in one instance to my knowledge.

In this case the primary injury was a shell 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.

[Illustration: 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

passage 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 assistance 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 circumstances the limitation of the transport facilities of a

department so closely concerned with the well-being of all, and which

has been organised on a most moderate scale, must soon become a

tradition of the past in civilised armies.

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 institutions are worked by committees and

staffs of permanent constitution.

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 aptitude 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 class 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 gratitude to those inhabitants who spared no effort

to render their position as happy as possible under the circumstances;

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 circumstances.

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 massed, 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 assumption 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 assumed, since the remaining velocity of flight of such

projectiles falls more rapidly than that of those of slightly greater

mass. 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 circumstances 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.

The actual degree of velocity, as judged by the range of fire at which

an injury is received and the resulting injury, is very hard to estimate

on account of the many and varying factors which enter into its

determination. The mere recital of some of these will suffice to make

this evident.

1. Quality of the individual cartridge employed, as to loading, the

materials employed, and their condition.

2. The condition of the rifle as to cleanliness, heating, and the state

of the grooves of the barrel.

3. The angle of impact of the bullet with the part injured.

4. Resistance dependent on the weight of the whole body of the man

struck, or of an isolated limb.

5. Special peculiarities of build in the individual struck, such as

thickness and density of the integument and fasciæ, strength and

thickness of the bones, &c.

6. State of tension of the muscles, fasciæ, and ligaments at the moment

of impact, and fixity or otherwise of the part of the body struck.

7. The degree of wind, temperature, and hygroscopic conditions of the

atmosphere.

These form some of the more important points which have to be taken into

consideration, in addition to a mere calculation of the actual distance

from which a wound has been received from a particular rifle, and taken

with the unsatisfactory nature of the evidence as to the latter, which

is usually alone obtainable, it is clear that definite assumptions are

scarcely possible. In a great number of cases I came to the conclusion

that the only indisputable evidence of low velocity was the lodgment of

an undeformed bullet. There is little doubt, moreover, that the general

tendency of wounded men was to minimise the range of fire at which they

were struck, and again that in the majority of cases in this campaign it

was quite impossible to determine whence any particular bullet had come,

since the enemy was seldom arranged in one line, but rather in several.

Again, smokeless powder was generally employed. Beyond this, in some

cases where there was no doubt of the short distance from which the

bullet was fired, the wounds were due to 'ricochet' of portions of

broken-up bullets. The following instance well illustrates this. A

sentry fired five times at two men within a distance of six paces,

knocking both down. One man received a severe direct fracture of the

ilium, the bullet entering between the anterior superior and inferior

iliac spines and emerging at the upper part of the buttock. The entry

and exit apertures were large but hardly 'explosive,' as a subcutaneous

track four to five inches long separated them. Besides this both men had

other lesser injuries; thus in the second two perforating wounds of the

arm existed. The latter were not unlike type Lee-Metford wounds, and

were regarded as such until a few days afterwards when a hard body was

felt in the distal portion of one track and removed. This proved to be a

part of the leaden core only, and the similar wound had no doubt been

produced by a like fragment, the bullet having broken up on striking the

stony ground.

_Trajectory._--The comparative flatness of this depends on the

construction of the rifle and the propulsive force employed, and varies

as does velocity with the nature, excellence, and amount of the

explosive, the correctness of the principles upon which the bullet is

devised, and the mechanical perfection of its manufacture. Its

importance naturally consists in the manner in which it affects the

possibility of covering objects on a wide area of ground and thus

creating a broad 'dangerous zone.' A bullet fired on level ground from

any one of three of the rifles referred to later (Lee-Metford, Mauser,

Krag-Jörgensen), sighted to 500 yards and fired from the shoulder in

the standing position, will cover some part of an erect man of average

height during the whole extent of its flight. A body of men within that

distance is therefore in a position of extreme peril in the face of a

good shooting enemy.

The importance of a flat trajectory is progressively lost, however, with

any rifle, as the weapon is gradually sighted to greater distances. Thus

when sighted to 2,000 yards the bullet from the Lee-Metford rifle rises

174 feet, and a whole army might comfortably be situated over a

considerable area within that distance. The importance of flatness of

trajectory is also influenced by the nature of the ground occupied by

the combatants. Thus when the area to be covered consists in ground

first rising then falling from the rifleman, the trajectory will become

more or less parallel to the surface crossed, and the 'dangerous zone'

will be correspondingly increased in extent. On the other hand, when the

ground slopes away from the rifleman the rise of the projectile is

exaggerated, and reaches its most limited capacity of covering an

intervening space when the flight crosses a hollow.

_Revolution of the bullet._--It only remains in this place to say a few

words concerning the revolution imparted to the bullet by the rifling of

the barrel. This ensures the flight of the projectile on a line parallel

to its long axis, and notably increases its power of penetration.

Both these properties of the flight are to the advantage of the wounded,

since, as already mentioned, the more exactly the impact corresponds to

a right angle with the skin, the more limited will be the area of

contusion, even if it be of the most severe character, while to the

twist of the bullet must be ascribed a not inconsiderable part in the

explanation of the ready and neat perforations of narrow structures

which are frequently produced.

It has been pointed out that the Lee-Metford bullet turns on its own

axis once in a distance of ten inches, while the Mauser revolves once in

a distance of eight and eleven-sixteenths inches; hence not more than at

most two revolutions are made in tracks crossing the trunk, and not more

than half a full revolution in the perforation of a limb. None the

less, no one can deny the influence of the one half turn of supination

in entering a perforating tool of any description, both as preventing

splintering, and in preserving the surrounding parts from damage.

Beyond this, the spiral turn of the bullet, by diverting a part of the

transmitted vibrations into a second direction, must, in the case of

wounds of the body, help to throw off contiguous structures, and while

those that are in actual contact are more severely contused, the

surrounding ones suffer somewhat less direct injury. It must be borne in

mind, also, that rapidity of revolution does not fall _pari passu_ with

that of velocity of flight, but that the former undergoes a

comparatively slighter diminution until the bullet is actually spent.

Hence, the influence of revolution is felt, however low the velocity may

be, provided sufficient striking force is retained to enter the body. A

word must be added here as to the surface of a discharged bullet; this,

in taking the rifling of the barrel, becomes permanently grooved. The

depth of the groove differs with the variety of rifle. In the

Lee-Metford the grooves are deep (.009), in the Mauser slightly less so

(.007), but the surface of both bullets is comparatively roughened when

revolving in the body, and this circumstance, since the projectile

exactly fits its track, may influence the degree of the surface

destruction of tissue, and somewhat aid in the clean perforation of

bone, since a little bone dust is always found at the entrance aperture

of a canal in cancellous bone.

During the campaign many varieties of rifle projecting bullets of widely

differing calibre were employed by the Boers, many of whom as sportsmen

preferred the rifle to which they were accustomed to a regulation

weapon, and an illustration of a large variety of bullets from

cartridges which I collected from arsenals and camps is given below (p.

96). The great majority of the men, however, were armed with

small-calibre weapons of some sort, and as the wounds produced by these

are of chief interest at the present day, I shall say little of any

others, beyond an occasional reference to Martini-Henry rifle wounds

which may be considered to represent approximately those made by large

leaden sporting bullets.

[Illustration: FIG. 14.--Type Cartridges in common use during the war.

From left to right: Martini-Henry, Guedes, Lee-Metford, (Spanish)

Mauser, Krag-Jörgensen]

The most important, as the most frequently employed, rifles projecting

small-calibre bullets were the Krag-Jörgensen, Mauser, Lee-Metford, and

Guedes, given in the order of increase of calibre (from 6.5 to 8

millimetres, or .254-.314 in.) in the bullets. As to the seriousness of

wounds produced by these there is little to choose, differences in

character being only those of degree. Such differences depended on the

area of tissue implicated, corresponding with the calibre of the

particular bullet, the comparative weight of the bullet, and the degree

of velocity of flight maintained at the moment of impact. When, however,

any of these bullets have been exposed in their flight to influences

capable of causing deformity of their outline and symmetry,

peculiarities of construction and in the composition of the metals

employed in their manufacture may materially alter the character of the

wounds produced and revolutionise a classification founded purely on the

relative weight, calibre, and degree of velocity with which each is

endowed.

TABLE I

[Transcriber's note: table split to fit on page.]

+-------------------+----------------+------------------+----------------+

+-------------------+----------------+------------------+----------------+

|Calibre of rifle | .45 in. | .314 in. | .303 in. |

|Number of grooves | 7 | 4 | 7 |

|Muzzle velocity | 1,300 f.s. | 1,988 f.s. | 2,000 f.s. |

|Sighted to | 1,450 yds. | 2,600 paces | 2,800 yds. |

|Length of bullet | 1.250 in. | 1.250 in. | 1.250 in. |

|Calibre of bullet | .450 in. | .315 in. | .309 in. |

|Thickness of | -- | -- | Mark II. bullet|

|Tip | -- | .031 | .036 |

|Sides .984 from tip| -- | .011 | .015 |

+-------------------+----------------+------------------+----------------+

+-------------------+---------------+--------------------+---------------+

+-------------------+---------------+--------------------+---------------+

|Calibre of rifle | .303 in. | .276 in. | .254 in. |

|Number of grooves | 5 | 4 | 4 |

|Muzzle velocity | 2,000 f.s. | 2,262 f.s. | 2,309 f.s. |

|Sighted to | 2,800 yds. | 2,187 yds. | 2,406 yds. |

|Length of bullet | 1.250 in. | 1 in. | 1.250 in. |

|Calibre of bullet | .309 in. | .280 in. | .260 in. |

|Thickness of |Mark II. bullet| -- | -- |

|Tip | .036 | .031 | .022 |

|Sides .984 from tip| .015 | .015 | .015 |

+-------------------+---------------+--------------------+---------------+

Some particulars of the four rifles and their projectiles are collated

in Table I., to which is added the corresponding information regarding

the Martini-Henry for the purposes of comparison.

TABLE II.--PENETRATION

The penetration of the Martini-Henry and the Lee-Metford or Lee-Enfield

rifle with Mark II. bullet is as follows:

Martini-Henry 15-1/2 in. of 1 in. deal boards 19 in. of sand

1 in. apart containing 15 per

cent. of moisture

Lee-Metford {Mark II.} 42 in. of 1 in. deal boards 60 in. of sand

Lee-Enfield {bullet } 1 in. apart containing 15 per

cent. of moisture

The penetration of bullets of .314 calibre differs little from that

possessed by the Lee-Metford or Lee-Enfield, of which the muzzle

velocities are very little lower, with Mark II. bullet. The Belgian

Mauser perforates 55 inches of fir-wood at 12 metres distance. With

regard to the penetration of bullets of smaller calibre that of the

Roumanian Mannlicher (.256) may be taken as typical. When fired into a

sand butt at 25 yards the bullet enters 9 inches and then breaks up.

The comparative size of the different cartridges is shown in fig. 14.

The general remarks already made as to the effect of weight, calibre,

and velocity sufficiently explain the importance of the particulars

given in this table, but it will be noted that the Lee-Metford rifle is

inferior to both the Krag-Jörgensen and Mauser rifles in the initial

velocity transmitted to its bullet. The tendency to equalisation, in

this particular, when the remaining velocity is considered, has been

mentioned; but it may be of interest if I quote from Nimier and Laval[7]

the scale on which the decrease in velocity takes place in the case of

the three weapons.

METRES PER SECOND

+---------------------+-------------+--------+----------------+

+---------------------+-------------+--------+----------------+

| | | | |

| Initial velocity | 630 | 718 | 720 |

| At 100 metres | 574 | 699 | 718 |

| At 1,000 metres | 249 | 264 | 269 |

| At 2,000 metres | 159 | 165 | 165.9 |

| | | | |

+---------------------+-------------+--------+----------------+

Giving full importance to the effects of velocity as a factor in the

severity of the injuries produced, when the large proportion of wounds

received at distances above 1,000 yards is borne in mind, we see how

rapidly the superiority of the smaller projectiles is lost. This loss,

even in the early stages, is probably more than made up for in the case

of the Lee-Metford, when the superiority in weight, calibre, and

bluntness of extremity as contributing to striking force is taken into

consideration.

The striking force (kinetic energy) of a bullet is indicated by the

following formula: F = 1/2 mv.^{2}; that is to say, the striking force

is equal to half the weight of the bullet multiplied by the square of

the velocity.

In point of fact, with unaltered regulation bullets I was never able to

determine any very material difference between the wounds produced,

further than that the wounds of entry and exit in the soft parts tended

to correspond with the calibre of the particular bullet concerned.

Although the immense majority of the wounds which came under my notice

were caused by the Mauser bullet, yet I saw some hundreds of wounded

Boers and a good many of our own men wounded by Lee-Metford bullets, in

the latter case no doubt by some of the sporting varieties. The only

cases that I can call to mind or have noted as exhibiting a superior

wounding power in the Lee-Metford bullet are some injuries to bone. Thus

I saw a considerable number of clean perforations of the patella

produced by Mauser bullets, while the only two Boers whom I saw with

injured patellæ had suffered transverse fractures. Again, I have a

lively recollection of an old Boer who had suffered a fracture of the

middle third of the femur, in the thigh of whom, with small apertures of

entry and exit, a cavity of destroyed tissue, five inches across, was

found beneath the fascia lata at the distal side of the fracture. I

cannot however say that I did not observe many equally severe injuries

to the femur produced by Mauser bullets in our own men, and as far as

fractures of the skull went, a somewhat crucial test, among the men

brought off the battlefield alive, I never saw any difference in

severity whatever.

[Illustration: FIG. 15.--Sections of four Bullets to show relative shape

and thickness of mantles.

From left to right: 1. Guedes; regular dome-shaped tip; mild steel

mantle; thickness at tip 0.8 mm.; at sides of body 0.3 mm. 2.

Lee-Metford; ogival tip; cupro-nickel mantle; thickness at tip 0.8 mm.;

gradual decrease at sides to 0.4 mm. 3. Mauser; pointed dome tip, steel

mantle plated with copper alloy; thickness at tip 0.8 mm.; gradual

decrease at sides to 0.4 mm. 4. Krag-Jörgensen; ogival tip as in

Lee-Metford; steel mantle plated with cupro-nickel; thickness at tip 0.6

mm.; gradual decrease at sides to 0.4 mm. The measurements of the sides

are taken 2.5 cm. from the tip. Note the more gradual thinning in the

Lee-Metford mantle.]

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 · 第 12 / 20 章