In any hospital at home or abroad there is a large amount of routine
work, which must be carried on in an orderly and systematic manner,
and upon the thoroughness with which this is done will largely depend
the effectiveness of the hospital. Patients must be fed and washed,
beds must be made and the wards swept and tidied, wounds must be
dressed and splints adjusted. In an English hospital everything is
arranged to facilitate this routine work. Close to every ward is a sink-
room with an adequate supply of hot and cold water, dinner arrives in
hot tins from the kitchens as if by magic, whilst each ward has its own
arrangements for preparing the smaller meals. The beds are of a
convenient height, and there is an ample supply of sheets and pillow-
cases, and of dressing materials of all kinds arranged on tables which
run noiselessly up and down the wards. At home all these things are
a matter of course; abroad they simply did not exist. Four or five gas-
rings represented our hot-water supply and our ward-kitchens for our
150 patients, and the dinners had to be carried up from the large
kitchens in the basement. The beds were so low as to break one's
back, and had iron sides which were always in the way; and when we
came to the end of our sheets--well, we came to the end of them,
and that was all. In every way the work was heavier and more difficult
than at home, for all our patients were heavy men, and every wound
was septic, and had, in many cases, to be dressed several times a
day. Everyone had to work hard, sometimes very hard; but as a rule
we got through the drudgery in the morning, and in the afternoon
everything was in order, and we should, I think, have compared very
favourably in appearance with most hospitals at home.
But we had to meet one set of conditions which would, I think, baffle
many hospitals at home. Every now and then, without any warning,
from 50 to 100, even in one case 150, wounded would be brought to
our door. There was no use in putting up a notice "House Full"; the
men were wounded and they must be attended to. In such a case our
arrangement was a simple one: all who could walk went straight
upstairs, the gravest cases went straight to the theatre or waited their
turn in the great hall, the others were accommodated on the ground
floor. We had a number of folding beds for emergency, and we had
no rules as to overcrowding. In the morning the authorities would
clear out as many patients as we wished. Sometimes we were hard
put to it to find room for them all, but we always managed somehow,
and we never refused admission to a single patient on the score of
want of room. The authorities soon discovered the capacity of the
hospital for dealing with really serious cases, and as a result our beds
were crowded with injuries of the gravest kind. What appealed to us
far more was the appreciation of the men themselves. We felt that we
had not worked in vain when we heard that the soldiers in the
trenches begged to be taken "a l'Hopital Anglais."
The condition of the men when they reached us was often pitiable in
the extreme. Most of them had been living in the trenches for weeks
exposed to all kinds of weather, their clothes were often sodden and
caked with dirt, and the men themselves showed clear traces of
exposure and insecure sleep. In most cases they had lain in the
trenches for hours after being wounded, for as a rule it is impossible
to remove the wounded at once with any degree of safety. Indeed,
when the fighting is at all severe they must lie till dark before it is
safe for the stretcher-bearers to go for them. This was so at Furnes,
but at Antwerp we were usually able to get them in within a few hours.
Even a few hours' delay with a bad wound may be a serious matter,
and in every serious case our attention was first directed to the
condition of the patient himself and not to his wound. Probably
he had lost blood, his injury had produced more or less shock,
he had certainly been lying for hours in pain. He had to be got
warm, his circulation had to be restored, he had to be saved
from pain and protected from further shock. Hot bottles, blankets,
brandy, and morphia worked wonders in a very short time, and
one could then proceed to deal with wounds. Our patients
were young and vigorous, and their rate of recovery was extraordinary.
When a rush came we all had to work our hardest, and the scenes in
any part of the hospital required steady nerves; but perhaps the
centre of interest was the theatre. Here all the worst cases were
brought--men with ghastly injuries from which the most hardened
might well turn away in horror; men almost dead from loss of blood,
or, worst of all, with a tiny puncture in the wall of the abdomen which
looks so innocent, but which, in this war at least, means, apart from a
difficult and dangerous operation, a terrible death. With all these we
had to deal as rapidly and completely as possible, reducing each
case to a form which it would be practicable to nurse, where the
patient would be free from unnecessary pain, and where he would
have the greatest possible chance of ultimate recovery. Of course, all
this was done under anaesthesia. What a field hospital must have
been before the days of anaesthesia is too horrible to contemplate.
Even in civil hospitals the surgeons must have reached a degree of
"Kultur" beside which its present exponents are mere children. It is
not so many years since a famous surgeon, who was fond of walking
back from his work at the London Hospital along the Whitechapel
Road, used to be pointed to with horror by the Aldgate butchers,
whose opinion on such a subject was probably worth consideration.
But now all that is changed. The surgeon can be a human being
again, and indeed, except when he goes round his wards, his patients
may never know, of his existence. They go to sleep in a quiet
anteroom, and they waken up in the ward. Of the operation and all its
difficulties they know no more than their friends at home. Perhaps
even more wonderful is the newer method of spinal anaesthesia,
which we used largely for the difficult abdominal cases. With the
injection of a minute quantity of fluid into the spine all sensation
disappears up to the level of the arms, and, provided he cannot see
what is going on, any operation below that level can be carried out
without the patient knowing anything about it at all. It is rather
uncanny at first to see a patient lying smoking a cigarette and reading
the paper whilst on the other side of a screen a big operation is in
progress. But for many cases this method is unsuitable, and without
chloroform we should indeed have been at a loss. The Belgians are
an abstemious race, and they took it beautifully. I am afraid they were
a striking contrast to their brothers on this side of the water.
Chloroform does not mix well with alcohol in the human body, and the
British working man is rather fond of demonstrating the fact.
With surgery on rather bold lines it was extraordinary how much could
be done, especially in the way of saving limbs. During the whole of
our stay in Antwerp we never once had to resort to an amputation.
We were dealing with healthy and vigorous men, and once they had
got over the shock of injury they had wonderful powers of recovery.
We very soon found that we were dealing with cases to which the
ordinary rules of surgery did not apply. The fundamental principles of
the art must always be the same, but here the conditions of their
application were essentially different from those of civil practice. Two
of these conditions were of general interest: the great destruction of
the tissues in most wounds, and the infection of the wounds, which
was almost universal.
Where a wound has been produced by a large fragment of shell, one
expects to see considerable damage; in fact, a whole limb may be
torn off, or death may be instant from some terrible injury to the body.
But where the object of the enemy is the injury of individuals, and not
the destruction of buildings, they often use shrapnel, and the resulting
wounds resemble those from the old smooth-bore guns of our
ancestors. Shrapnel consists of a large number of bullets about half
an inch in diameter packed together in a case, which carries also a
charge of explosive timed to burst at the moment when it reaches its
object. The balls are small and round, and if they go straight through
soft tissues they do not do much damage. If, however, they strike a
bone, they are so soft that their shape becomes irregular, and the
injury they can produce in their further course is almost without limit.
On the whole, they do not as a rule produce great damage, for in
many cases they are nearly spent when they reach their mark. Pieces
of the case will, of course, have much the same effect as an ordinary
shell.
The effects of rifle-fire, particularly at short ranges, have led to a
great deal of discussion, and each side has accused the other of
using dum-dum bullets. The ordinary bullet consists of a lead core
with a casing of nickel, since the soft lead would soon choke rifling.
Such a bullet under ordinary circumstances makes a clean
perforation, piercing the soft tissues, and sometimes the bones, with
very little damage. In a dum-dum bullet the casing at the tip is cut or
removed, with the result that, on striking, the casing spreads out and
forms a rough, irregular missile, which does terrific damage. Such
bullets were forbidden by the Geneva Convention. But the German
bullet is much more subtle than this. It is short and pointed, and when
it strikes it turns completely over and goes through backwards. The
base of the bullet has no cover, and consequently spreads in a
manner precisely similar to that in a dum-dum, with equally deadly
results. There could be no greater contrast than that between the
wounds with which we had to deal in South Africa, produced by
ordinary bullets, and those which our soldiers are now receiving from
German rifles. The former were often so slight that it was quite a
common occurrence for a soldier to discover accidentally that he had
been wounded some time previously. In the present war rifle wounds
have been amongst the most deadly with which we have had to deal.
It will thus be seen that in most cases the wounds were anything but
clean-cut; with very few exceptions, they were never surgically clean.
By surgically clean we mean that no bacteria are present which can
interfere with the healing of the tissues, and only those who are
familiar with surgical work can realize the importance of this condition.
Its maintenance is implied in the term "aseptic surgery," and upon this
depends the whole distinction between the surgery of the present and
the surgery of the past. Without it the great advances of modern
surgery would be entirely impossible. When we say, then, that every
wound with which we had to deal was infected with bacteria, it will be
realized how different were the problems which we had to face
compared with those of work at home. But the difference was even
more striking, for the bacteria which had infected the wounds were
not those commonly met with in England. These wounds were for the
most part received in the open country, and they were soiled by earth,
manure, fragments of cloth covered with mud. They were therefore
infected by the organisms which flourish on such soil, and not by the
far more deadly denizens of our great cities. It is true that in soil one
may meet with tetanus and other virulent bacteria, but in our
experience these were rare. Now, there is one way in which all such
infections may be defeated--by plenty of fresh air, or, better still, by
oxygen. We had some very striking proofs of this, for in several cases
the wounds were so horribly foul that it was impossible to tolerate
their presence in the wards; and in these cases we made it a practice
to put the patient in the open air, of course suitably protected, and to
leave the wound exposed to the winds of heaven, with only a thin
piece of gauze to protect it. The results were almost magical, for in
two or three days the wounds lost their odour and began to look
clean, whilst the patients lost all signs of the poisoning which had
been so marked before. It may be partly to this that we owe the fact
that we never had a case of tetanus. In all cases we treated our
wounds with solutions of oxygen, and we avoided covering them up
with heavy dressings; and we found that this plan was successful as
well as economical.
Though any detailed description of surgical treatment would be out of
place, there was one which in these surroundings was novel, and
which was perhaps of general interest. Amongst all the cases which
came to us, certainly the most awkward were the fractured thighs. It
was not a question of a broken leg in the ordinary sense of the term.
In every case there was a large infected wound to deal with, and as a
rule several inches of the bone had been blown clean away. At first
we regarded these cases with horror, for anything more hopeless
than a thigh with 6 inches missing it is difficult to imagine. Splints
presented almost insuperable difficulties, for the wounds had to be
dressed two or three times, and however skilfully the splint was
arranged, the least movement meant for the patient unendurable
agony. After some hesitation we attempted the method of fixation by
means of steel plates, which was introduced with such success by Sir
Arbuthnot Lane in the case of simple fractures. The missing portion of
the bone is replaced by a long steel plate, screwed by means of small
steel screws to the portions which remain, "demonstrating," as a
colleague put it, "the triumph of mind over the absence of matter."
The result was a brilliant success, for not only could the limb now be
handled as if there were no fracture at all, to the infinite comfort of
the patient, but the wounds themselves cleared up with great rapidity.
We were told that the plates would break loose, that the screws would
come out, that the patient would come to a bad end through the
violent sepsis induced by the presence of a "foreign body" in the
shape of the steel plate. But none of these disasters happened, the
cases did extremely well, and one of our most indignant critics
returned to his own hospital after seeing them with his pockets full of
plates. The only difficulty with some of them was to induce them to
stop in bed, and it is a fact that on the night of our bombardment I met
one of them walking downstairs, leaning on a dresser's arm, ten days
after the operation.
And this brings me to a subject on which I feel very strongly, the folly
of removing bullets. If a bullet is doing any harm, pressing on some
nerve, interfering with a joint, or in any way causing pain or
inconvenience, by all means let it be removed, though even then it
should in most cases never be touched until the wound is completely
healed. But the mere presence of a bullet inside the body will of itself
do no harm at all. The old idea that it will cause infection died long
ago. It may have brought infection with it; but the removal of the bullet
will not remove the infection, but rather in most cases make it fire up.
We now know that, provided they are clean, we can introduce steel
plates, silver wires, silver nets, into the body without causing any
trouble at all, and a bullet is no worse than any of these. It is a matter
in which the public are very largely to blame, for they consider that
unless the bullet has been removed the surgeon has not done his job.
Unless he has some specific reason for it, I know that the surgeon
who removes a bullet does not know his work. It may be the mark of a
Scotch ancestry, but if I ever get a bullet in my own anatomy, I shall
keep it.