Chapter 2

But if we give them credit for their courage and cheerfulness, we must not forget how largely they owed it to the devoted attention--yes, and to the courage and cheerfulness--of the nurses. I wonder how many of us realize what Britain owes to her nurses. We take them as a matter of course, we regard nursing as a very suitable profession for a woman to take up--if she can find nothing better to do; perhaps we may have been ill, and we were grateful for a nurse's kindness. But how many of us realize all the long years of drudgery that have given the skill we appreciated, the devotion to her work that has made the British nurse what she is? And how many of us realize that we English-speaking nations alone in the world have such nurses? Except in small groups, they are unknown in France, Belgium, Germany, Russia, or any other country in the world. In no other land will women leave homes of ease and often of luxury to do work that no servant would touch, for wages that no servant would take--work for which there will be very little reward but the unmeasured gratitude of the very few. They stand to-day as an unanswerable proof that as nations we have risen higher in the level of civilization than any of our neighbours. To their influence on medicine and surgery I shall refer again. Here I only wish to acknowledge our debt. As a mere patient I would rather have a good nurse than a good physician, if I were so unfortunate as to have to make the choice. A surgeon is a dangerous fellow, and must be treated with respect. But as a rule the physician gives his blessing, the surgeon does his operation, but it is the nurse who does the work.

III. The Day's Work

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.

IV. Antwerp

There is no port in Europe which holds such a dominant position as Antwerp, and there is none whose history has involved such amazing changes of fortune. In the middle of the sixteenth century she was the foremost city in Europe, at its close she was ruined. For two hundred years she lay prostrate under the blighting influence of Spain and Austria, and throttled by the commercial jealousy of England and Holland. A few weeks ago she was the foremost port on the Continent, the third in the world; now her wharves stand idle, and she herself is a prisoner in the hands of the enemy. Who can tell what the next turn of the wheel will bring?

Placed centrally between north and south, on a deep and wide river, Antwerp is the natural outlet of Central Europe towards the West, and it is no wonder that four hundred years ago she gathered to herself the commerce of the Netherlands, in which Ypres, Bruges, and Ghent had been her forerunners. For fifty years she was the Queen of the North, and the centre of a vast ocean trade with England, France, Spain, Portugal, and Italy, till the religious bigotry of Philip II of Spain and the awful scenes of the Spanish Fury reduced her to ruin. For two hundred years the Scheldt was blocked by Holland, and the ocean trade of Antwerp obliterated. Her population disappeared, her wharves rotted, and her canals were choked with mud. It is hard to apportion the share of wickedness between a monarch who destroys men and women to satisfy his own religious lust, and a nation which drains the life-blood of another to satisfy its lust for gold. One wonders in what category the instigator of the present war should appear.

At the very beginning of last century Napoleon visited Antwerp, and asserted that it was "little better than a heap of ruins." He recognized its incomparable position as a port and as a fortress, and he determined to raise it to its former prosperity, and to make it the strongest fortress in Europe. He spent large sums of money upon it, and his refusal to part with Antwerp is said to have broken off the negotiations of Chatillon, and to have been the chief cause of his exile to St. Helena. Alas his enemies did not profit by his genius. We are the allies of his armies now, but we have lost Antwerp. Germany will be utterly and completely crushed before she parts with that incomparable prize. A mere glance at the map of Europe is sufficient to convince anyone that in a war between England and Germany it is a point of the first strategical importance. That our access to it should be hampered by the control of Holland over the Scheldt is one of the eccentricities of diplomacy which are unintelligible to the plain man. The blame for its loss must rest equally between Britain and Belgium, for Belgium, the richest country in Europe for her size, attempted to defend her greatest stronghold with obsolete guns; whilst we, who claim the mastery of the seas, sacrificed the greatest seaport in Europe to the arrangements of an obsolete diplomacy. If we are to retain our great position on the seas, Antwerp must be regained. She is the European outpost of Britain, and, as has so often been pointed out, the mouth of the Scheldt is opposite to the mouth of the Thames.

In Antwerp, as we saw her, it was almost impossible to realize the vicissitudes through which she had passed, or to remember that her present prosperity was of little more than fifty years' growth. On all sides we were surrounded by wide boulevards, lined by magnificent houses and public buildings. There are few streets in Europe to eclipse the great Avenue des Arts, which, with its continuations, extends the whole length of the city from north to south. The theatres, the Central Station, the banks, would adorn any city, and the shops everywhere spoke of a wealth not restricted to the few. The wide streets, the trees, the roomy white houses, many of them great palaces, made a deep impression upon us after the darkness and dirt of London. Even in the poorer quarters there was plenty of light and air, and on no occasion did we find the slums which surround the wealthiest streets all over London. In the older parts of the city the streets were, of course, narrower; but even here one had the compensation of wonderful bits of architecture at unexpected corners, splendid relics of an illustrious past. They are only remnants, but they speak of a time when men worked for love rather than for wages, and when an artisan took a pride in the labour of his hands. If it had not been for the hand of the destroyer, what a marvellous city Antwerp would have been! One likes to think that the great creations of the past are not all lost, and that in the land to which the souls of the Masters have passed we may find still living the mighty thoughts to which their love gave birth. Are our cathedrals only stones and mortar, and are our paintings only dust and oil?

The inhabitants of Antwerp were as delightful as their city. On all sides we were welcomed with a kindness and a consideration not always accorded to those who are so bold as to wish to help their fellow-men. Everywhere we met with a courtesy and a generosity by which, in the tragedy of their country, we were deeply touched. They all seemed genuinely delighted to see us, from the Queen herself to the children in the streets. Our medical confreres treated us royally, and the mere thought of professional jealousy with such men is simply ludicrous. They constantly visited our hospital, and they always showed the keenest interest in our work and in any novelties in treatment we were able to show them; and when we went to see them, we were shown all the best that they had, and we brought away many an ingenious idea which it was worth while going far to obtain. Wherever we moved amongst the Belgians, we always found the same simplicity of purpose, the same generosity of impulse. Everywhere we met the same gratitude for what England was doing for Belgium; no one ever referred to the sacrifices which Belgium has made for England.