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In: Boer War·History - Modern (1750+)·History - Warfare
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The work is a detailed clinical study of injuries caused by small‑calibre bullets during the South African War, written by the surgeon George Henry Makins. It opens with a series of case reports that trace the course of wounds, from the initial haemorrhage and formation of axillary haematomas to the later development of abscesses, traumatic aneurysms and secondary haemorrhages. Makins records the precise anatomical paths of bullets, the temperature changes observed during healing, and the surgical interventions employed, such as ligature of major vessels, incision of haematomas and the use of tourniquets. The narrative is anchored in the medical realities of 1899‑1900 field hospitals, offering a systematic account of how small‑calibre projectiles behaved in the body and how military surgeons adapted ordinary surgical principles to the exigencies of war.
The prose reflects the formal, didactic style of late‑Victorian medical literature, with a focus on observation, measurement and procedural instruction. Makins writes as a practitioner addressing fellow surgeons, using the technical terminology of his day while occasionally citing contemporary authorities such as Pirogoff. Readers with an interest in the history of military medicine, the evolution of trauma surgery, or the South African War’s medical dimensions will find the book rewarding. It also appeals to scholars of nineteenth‑century pathology who appreciate the meticulous case documentation and the early attempts to systematise the treatment of gunshot wounds.
The opening · free to read
In a patient wounded at Kamelfontein the bullet entered four inches below the acromion, pierced the deltoid, splintered the humerus, and crossed the axilla. A large blood extravasation developed in the axilla, accompanied by cutaneous ecchymosis extending halfway down the arm. There was no perceptible pulsation in either the brachial or radial artery, but the limb was warm. There was partial paralysis of the parts supplied by the ulnar and musculo-spiral nerves and complete loss of power and sensation in the area of distribution of the median nerve. Six months later the radial pulse was still absent in this patient, but there was no sign of the development of an aneurism.
The accompanying temperature chart is characteristic. The blood effusion gradually gained in consistency and underwent steady diminution in size. No suppuration occurred.
The median paralysis was found to be accompanied by the inclusion of the nerve in a sort of foramen of callus, when the patient was explored at a later date by Mr. Ballance.
In a patient wounded at Paardeberg, a Mauser bullet entered by the left buttock, pierced the venter ilii, traversed the pelvis, and emerging at the brim of the latter, crossed the back, fractured the spine of the fourth lumbar vertebra, and escaped below the twelfth right rib. The track suppurated where it crossed the back, but the man did well until the twentieth day, when a swelling developed in the left iliac fossa and the general temperature rose to 102 deg.. An abscess was at once suspected and the swelling incised by Major Lougheed, R.A.M.C. A large subperitoneal haematoma only was discovered, and evacuated. The temperature at once fell and the after progress was uneventful, the wound healing by primary union.
_Primary._--No deviation from the ordinary rules of surgery should be necessary in the majority of cases, but in a certain number the conditions are so unusual that the special considerations must be taken into account. The natural tendency to spontaneous cessation of primary haemorrhage in small-calibre wounds is the first of these. Experience has shown that often mere dressing, or at any rate slight pressure, suffices to efficiently stanch immediate bleeding. Although, however, immediate control is to be obtained by such means, the cases of traumatic aneurism of every variety related in the next section show that the ultimate result is in many such cases by no means satisfactory.
Under these circumstances it may be said that the classical rule of ligation at the point of injury should never be disregarded. Against this, however, certain objections may be at once raised; thus in many cases both artery and vein need ligature, a consideration of much importance in the case of such vessels as the carotid and femoral arteries. Again in many of the injuries to the popliteal artery the wound directly communicated with the knee joint, a complication which, while it may be disregarded in civil practice, must take a much more important place in the circumstances under which many operations in military surgery are performed.
On the whole, it seems clear that the military surgeon must be guided by circumstances, since it may be far better to risk the chances of recurrent haemorrhage, or the development of an aneurism or varix, all of which are amenable to successful treatment later, than those of gangrene of a limb or softening of the brain. As a general rule, therefore, on the field or in a Field hospital, primary ligature of the great vessels is best reserved for those cases only in which haemorrhage persists, while in those in which spontaneous cessation has occurred, or in which bleeding is readily controlled by pressure, rest and an expectant attitude are to be preferred.
A word must be added as to the objections to distant proximal ligature for primary or recurrent haemorrhage. In some situations this may be unavoidable, and it is sometimes successful, but none the less it is opposed to all rules of good surgery and a most uncertain procedure. It leaves the patient exposed to all the risks attendant on the employment of simple pressure. In one case which I saw, the third part of the subclavian artery had been ligatured for axillary bleeding; secondary haemorrhage, as might have been expected, occurred, and that as late as five weeks after the operation. In another case ligature of the femoral artery for popliteal haemorrhage was followed by the development of a traumatic aneurism in the ham.
_Secondary._--In secondary haemorrhage the treatment to be adopted depends upon the nature of the case. When the wound is aseptic, and bleeding the result of the separation of sloughs, local ligature is the proper treatment, and this was often successfully adopted, especially in the case of such arteries as the tibials. In septic cases, on the other hand, it is usually far better if possible to amputate, unless the general state of the patient and the local conditions are especially favourable.
When neither amputation nor direct local ligature is practicable, proximal ligature may be of use. Sometimes this may be obligatory in consequence of the difficulties attendant on direct local treatment. I saw a few cases successfully treated in this manner: in one the common carotid was tied (Mr. Jameson) for haemorrhage from an arterial haematoma in connection with the internal maxillary artery. Although ligature of the external carotid would perhaps have been preferable, the result was excellent. When even this expedient is impracticable, local pressure is the only resort.
Lastly, as to the treatment of secondary interstitial blood effusions, I believe the best initial treatment is the expectant. If interference is needed, it is much more likely to be satisfactory the more chronic the condition has become, since the source of the bleeding may be impossible to discover. I never saw a patient's life endangered by the amount of such haemorrhage, but if this should seem to be likely, local treatment is of course unavoidable. In several cases quoted below, incision and evacuation were followed by excellent results; in any such operation too much care to ensure asepsis is impossible.
The experience of the campaign fully bears out that of the past as to the steady increase of the number of aneurisms from gunshot wounds in direct ratio to diminution in the size of the projectiles employed. Every variety of traumatic aneurism was met with, and most frequently of all, perhaps, aneurismal varices and varicose aneurisms. While so experienced a military surgeon as Pirogoff could say, in 1864, that he had never seen a case of aneurismal varix, every young surgeon lately in South Africa has met with a series. Again, although the condition is a well-known one, it has been rather in connection with civil life; for the great majority of recorded cases were the result of stabs or punctured wounds such as are liable to be received in street brawls, or as a result of accidents with the tools of mechanics. Thus of ninety cases collected by K. Bardeleben in 1871, only 12 or 13.33 per cent. were the result of gunshot wound.
_False traumatic aneurism or arterial haematoma._--This condition was met with comparatively frequently, and bears a very close relation to that already described under the heading of interstitial haemorrhages. The latter might almost have been included here, since the difference between the two conditions depended merely on the size of the vessels implicated. The exact correspondence in the period of development of some of the arterial haematomata, and of the occurrence of the aseptic form of secondary haemorrhage, also explains the pathology of the two conditions as identical; except that in the former the effused blood is retained in the tissues, while in the latter it escapes externally. The history of these cases was uniform and characteristic. A wound of the soft parts, or sometimes a fracture, was accompanied by a certain degree of primary interstitial haemorrhage, which might or might not have been associated with external bleeding. A haematoma resulted in connection with the wounded vessel, the general tendency in the effusion being to coagulation at the margins and subsequent contraction. Meanwhile the opening in the artery became more or less securely closed by the development of thrombus, and possibly by retraction of the inner and middle coats of the vessel. With the return of full circulatory force as shock passed off, or with the resumption of activity and consequent freer movement of the limb, the temporary thrombus became washed away. The newly formed wall of soft clot bounding the effusion proved insufficient to withstand the full force of the blood pressure, and extension of the cavity resulted. In the more rapidly developing haematomata, temporary pressure by the effused blood on the bleeding vessels was also, no doubt, a common explanation of temporary cessation of increase in size.
A diffuse soft fluctuating swelling, sometimes accompanied by pulsation, but oftener without, developed, and not uncommonly diffusion was accompanied by some discoloration of the surface and elevation of the general temperature. Such arterial haematomata commonly developed from ten days to three weeks after the original wound. A few examples will suffice.
(1) A patient wounded at Elandslaagte was sent down to Wynberg. The antero-posterior wound in the upper third of the arm was healed, but a month after the injury a large fluctuating arterial haematoma developed in the axilla and upper third of the arm. This was incised (Colonel Stevenson) and a wound of the axillary artery in its third part discovered, and the vessel ligatured. The patient made an excellent recovery.
(2) A patient received a wound at Doornkop which traversed the calf in an obliquely antero-posterior longitudinal direction. Three weeks later a soft fluctuating swelling developed at the inner margin of the tendo Achillis occupying the lower third of the leg. Neither pulsation nor murmur was detected. There was anaesthesia in the area of distribution of the posterior tibial nerve. No tendency to further increase was observed, and operation was postponed. The temperature was normal.
(3) An Imperial Yeoman was struck at Zwartskopfontein at a range of one hundred yards. The man rode four miles on his horse after being hit, but the horse then fell and rolled over him twice. The man was treated successively in the Van Alen, Boshof, and Kimberley Hospitals, and from the last he was sent to Wynberg which place he reached on the twenty-third day. When admitted into No. 2 General Hospital the wounds of type form and size (entry, in posterior fold of axilla; exit, 1-1/2 inch below junction of anterior fold with arm) were healed. The whole upper arm was swollen and discoloured, while an indurated mass extended along the line of the vessels into the axilla. This was considered a blood effusion; it was not obviously distensile, and pulsation was very slight. The brachial radial and ulnar pulses were absent. A fluctuating swelling was present along the anterior border of the deltoid. There were some signs of nerve contusion, but no paralysis, beyond tactile anaesthesia in the area of distribution of the median nerve.
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