A Surgeon in Belgium

by Henry Sessions Souttar

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.