A surgeon in khaki

FUNCTIONAL BLINDNESS.

At Bethune some of us met for the first time in this war cases of functional temporary blindness, and many other cases were met with at various points of the front.

The following example will give an idea of the condition. A young officer, nineteen years of age, was standing by a haystack in the north of France when a large Black Maria burst near him, rolled him over, and plastered him with clay, but did not kill him. The concussion had thrown him down. He remained unconscious for half an hour, and when he woke to consciousness he discovered he was “blind.” His mental state then was terrible. He cried out, “Oh, why wasn’t I killed?” “Won’t some one carry me out and put me on the parapet of a trench so that I may be killed?” His grief was pathetic, and one can easily understand it. A careful examination was made of the interior of the eyes with the ophthalmoscope and nothing was found wrong. He was assured by the medical officers that he would certainly recover after perhaps a week or two of blindness. He was quiet and composed after this, but was a little bit suspicious that we were only trying to cheer him up. One medical officer then explained to him what sort of blindness it was: that it was due to concussion of the nerve of sight, and the delicate structures at the ball of the eye; that nothing was destroyed, and that a complete rest would bring back his vision. Next day he was transferred by hospital train to the Base en route for England. This note, unknown to him, was pinned on his coat: “Functional blindness. Any medical officer handling this officer on Hospital Train, Base Hospital, or Hospital Ship, please tell him that he will fully recover his sight.” Knowing the kind-hearted nature of the medical profession, one can be sure that he was cheered up all the way to England. I received a letter from this officer’s mother some weeks after, saying that her son had completely recovered his vision, and was as well as ever.

NERVE CONCUSSION

Nerve concussion is a pathological condition that has received more attention in this war than at any previous time. A young Fusilier at La Bassée was hit by a bullet through the fleshy part of the forearm. The wound was a purely flesh one and no important nerve could have been struck. He had paralysis of the wrist and hand, due to concussion of the important nerves of the forearm. The bullet in its course did not strike these nerves. He got completely better in eight weeks.

A Gordon Highlander was struck by a bullet in the right buttock. No important nerve was struck, yet he had paralysis of the limb owing to concussion of the sciatic nerve. He got better by rest in bed and massage of the muscles. A soldier of the Wiltshire Regiment was rolled over by the concussion of a bursting shell. He retained consciousness, but could not get up or move his right arm. The right side of his body was paralysed. He got better by rest. A Bedfordshire sergeant got a bullet wound through the upper arm, and paralysis of certain muscles supplied by nerves in the vicinity of the track of the bullet. It was thought that the nerves were divided, and after the wound had healed the nerves were exposed at an operation intending to join the severed ends. The nerves were found to be uninjured, and the incision in the skin was closed up. He made a complete recovery.

There is also the story of the soldier who suddenly recovered his voice in the presence of King George. The story is going the rounds of the hospitals, and it is said that His Majesty was extraordinarily interested in the phenomenon. This soldier was taken prisoner by the Germans during our retreat from Belgium. He was picked off the field in a dazed condition and unable to speak. He was interned later in a prison camp in Germany and was all this time quite unable to speak. When the exchange of permanently disabled prisoners of war was recently made between England and Germany, this man was sent back as permanently incapacitated on account of being dumb. He was admitted to a hospital near London. One day the King visited the hospital, and this man on getting up from his chair as the King entered the ward, inadvertently touched a heating pipe which was then very hot. He at once exclaimed “Damn,” and was able to speak perfectly afterwards. The King was very much interested. Was this an hysterical loss of voice or a concussion? It was a mental shock of some kind, and the recovery was due to the other shock of touching a hot pipe.

I attended one young officer and three men who had been buried in the earth when their trench was blown up. The officer and one man were unconscious, and when the man recovered consciousness he was nervy and excitable. He had a startled, terrified expression, and when in bed he would peer round in a wild, anxious way, and then suddenly pull the blankets well over his head and curl up underneath as if anxious to shut out his surroundings, or what he thought were his surroundings. He seemed really to be living through some terrifying experiences of the past few days antecedent and up to the time when his trench was blown up and he was engulfed in the mud and débris.

The officer recovered consciousness more slowly, and spoke in a curious staccato speech; his nerves were completely gone, and he had fine tremors of the lips and tongue and fingers. He told me that his memory had gone, that he had only a hazy recollection of recent things, which seemed far away and dim.

DEAF MUTISM.

Several cases of deaf mutism have occurred during the hard fighting near Ypres and La Bassée, and these are certainly very curious. The men so afflicted have written down that shells burst near them, that they were thrown down, and remembered nothing more for a time. On coming to again, they were deaf and dumb. These men also show other signs of nerve shock; they are restless, troubled with sleeplessness, and have anxious expressions. Generally all get completely well in a few weeks, but some of the cases remain mute for a much longer time.

LICE.

The medical officer at the front to-day has other duties besides those of attending to the sick and wounded. He is concerned with the prevention of disease, with water supplies, sanitation of billeting areas and camps, means to prevent frostbite, and so on. He has also to advise on methods of treating and avoiding vermin. Lice are, without a doubt, one of the terrors of war. These little beasts are not harmless. They take a high place in the sphere of destructive agents. I would group them in the class with shrapnel bombs and high explosives. Wherever many men are gathered closely together, and hygienic laws, owing to military needs, are in temporary abeyance, there will lice be found, constituting themselves one of the terrors of war. Officers and men get them, and once these pests gain entry to one’s wardrobe they entrench themselves in their battalions and divisions, and require very drastic efforts to dislodge. In the early fighting in Flanders and in Northern France, on the Marne and Aisne, these beasts gave us great trouble. They are most active at night when one gets warm in bed. It is not the bite that counts, but, as the old French Countess once expressed it to a Minister of State, it is “toujours le promenade.” The promenading causes irritation and insomnia. Scratching produces excoriations of the skin, and then a whole lot of sequent complications. Lice are factors in the spread of typhus fever, and when typhus visits an army in the field it carries death and desolation to thousands. To illustrate the point read this extract from a letter written from an English hospital in Serbia: “The great scourge of this country is typhus fever. It was introduced by the Austrian prisoners at Christmas. Out of 2500 Austrian prisoners at Uskub, 1000 had died of fever and 1200 were down with it. It is a terrible disease, and is carried not by infection but by lice. One has to take tremendous precautions to avoid these creatures.”

The majority of our wounded taken from the fighting line at La Bassée to the hospital at Bethune were infested with lice. Lice invaded the clothing of all who handled these poor fellows, and very drastic measures had to be taken to combat the scourge.

The following story will illustrate the vitality of these nasty little beasts. Our Field Ambulance once stopped at a small town in Northern France and was billeted in a French convent. The good sisters allowed us the use of the schoolrooms, the kitchen, and some of the bedrooms. All the officers were anxious to get their shirts and linen washed. The laundrywoman duly appeared and boiled all these articles, and the sisters ironed them for us. On the afternoon of the ironing the Mother Superior and two sisters came to us in a state of excitement, talking rapidly, and evidently overcome with amazement. They explained that our shirts had been boiled and then dried in the open air. When they began to iron the necks of our shirts the lice sprang to life and were exceedingly active. They assured us solemnly that scores sprang to active life under the comfortable warmth of the hot iron. I do not doubt the story. The heat had matured the chitinous envelope in which the young lice lay, and out they came, joyous, active, and sportive on the nice warm surface. Hence the amazement, the uplifted hands, and the consternation of the good sisters. The riddle of their extermination has not yet been completely solved, but measures are in active progress. It is an unsavoury subject, but it is a very important one for troops in camp and in the field.

SHELL FUMES.

A great deal has been written on the effect of shell fumes in this war. So much is hearsay and so little really authentic, that one cannot dogmatise.

One naval surgeon said that men exposed to fumes of bursting shells develop acute pneumonia, which proves fatal as a rule. This is supposed to be due to the nitric peroxide produced by the explosion.

Artillery officers have told me that stories were going the round of the batteries that the Germans fired certain shells at our aeroplanes which, on bursting, set free certain gases which intoxicated the aviators.

A French gunner-major circumstantially related that a German trench which had been heavily shelled with turpinite shells was found full of dead Germans, standing or sitting in life-like attitudes and with faces quite black. He said that the look-out man was lying in his natural attitude holding field-glasses to his eyes. He was apparently alive, but was really dead, stiff, and with black face and hands. These statements have not been confirmed, but the stories of similar incidents are many. There is no doubt that lyddite and melinite fumes can, when inhaled, produce sudden poisonous changes. I have myself seen British soldiers and German prisoners, after having been exposed to these fumes, come in with deeply yellow jaundiced skin. One man, in fact, looked exactly like a man suffering from acute jaundice.

It is also said that the fumes induce drowsiness. Turpinite shells were employed at one stage of the war and are to be employed again. M. Turpin has recently been at the front with a French battery. Certainly turpinite does emit dangerous fumes. Many believe that it is some form of cyanogen gas—allied to prussic acid.

The force of these high explosives is well illustrated by an occurrence of 25th January. Previous to making an assault the Germans fired a mine under our front trench near the railway east of Cuinchy. The explosion hurled a piece of rail weighing 25 lbs. a distance of over a mile, into a field close to where some of our men were working.

It is reported that on 1st February the detonation of one of our lyddite shells in the enemy trenches on the embankment south of the canal, threw a German soldier right across the railway and the canal amongst our men on the north side of the latter.

At Fort Condé, on the Aisne, the air concussion of a bursting shell from a French 75 mm. lifted a large four-wheeled country waggon bodily out of a yard and planted it on the roof of a barn. The waggon was not injured. A bursting shell is the very incarnation of violence. Lord Fisher said that “The Essence of War is Violence. Moderation in War is Imbecility. Hit first. Hit hard. Hit everywhere.” The big shells to-day do all this.

The fumes emitted by bursting charges of lyddite, melinite, or turpinite must not be confused with the poison gases sent out over our men by the Germans. The lyddite and melinite are put in the shells for a definite object which is permitted by the Hague Convention, and by the opinion of mankind generally. Their object is to burst the shell at the desired time and distance, and plaster the enemy with the iron or shrapnel. They are not intended to kill, and do not kill by poisonous fumes. The German poison gas is intended to kill, and does produce intolerable agony and lingering deaths, and for this the German stands accused before High Heaven.

NEURASTHENIA OR “NERVES.”

Many officers and some men have been sent back from the front in France and Flanders suffering from Nerves. These men are not “nervous” as the public generally understand that term. They are brave and courageous men who are anxious to do their duty. They are, moreover, men who have done their duty in the face of a determined foe, have endured great hardships and discomforts in the trenches and batteries, and have faced death in all the many hellish shapes that it assumes to-day. I said “many officers and some men” have been so afflicted, and it is true that the officer is much more prone to get “nerves” than is the simple soldier. The life of the officer is one of responsibility and worry, but the soldier’s mental lot is simpler—he just does what he is told and has “not to reason why.” The education and upbringing of the officer are different, as a rule, from that of the soldier, and heredity has an influence on a man’s nervous organisation. In civil life anyone can call to mind certain boys and girls who are more “nervous” than others. I do not mean more afraid of danger or more effeminate, but more likely to be exalted or depressed by certain circumstances than their more stolid neighbours. What is true of homes and of schools is equally true of nations. Unreal though it sounds, there is no doubt that the Germans are more emotional than the French, and German leaders know full well the emotional side of their people. The German is easily exalted and can be easily depressed. The Frenchman can be made furiously angry when he is affronted or insulted, but he is not easily depressed, and he is too cautious to be easily exalted. The German soldier and people must be strengthened and mentally sustained by stories of German victories and prowess, but the Frenchman, like the Englishman, is most formidable when he knows the worst there is to know and is “up against things.”

It may be that our officers who develop neurasthenia at the front are more emotional and imaginative than those who do not, but they are no less courageous. An officer was sent to England for neurasthenia, and felt ashamed to tell his friends that he was sent back as his “nerve was gone.” He was not in the list of wounded, yet his brain and nervous system had received a wound as much as the man with a bullet-hole through his shoulder, and the treatment for these “mental wounds” is like that for most other wounds, “time and rest,” but the mental wound also requires quietness. The officer with the mental wound, the nerve shock, the neurasthenia, cannot be treated successfully in the general wards of a noisy hospital. He must be put in quiet and peaceful surroundings and live in an atmosphere free from noise, bustle, and commotion. His treatment must also be directed by physicians who are authorities on this subject. A successful general practitioner or a renowned obstetrician are not likely to achieve brilliant results in treating neurasthenia.

Fortunately the medical profession has already arranged special provision for these nerve cases, and the results, I am sure, will be eminently good.

At Bethune one able artillery officer was brought into the Clearing Hospital suffering from neurasthenia. He had been through the retreat, the fighting on the Marne and Aisne, and at La Bassée, and had done splendid service with his battery, and had been promoted. When I saw him he was walking up and down a room like a caged animal. I wished him good morning, and he pulled up suddenly in his stride, gazed at me with widely open eyes, and replied in a hesitating staccato voice, “G-g-good m-m-morning, doctor.” He had never stuttered before. Then away he went up and down again. I got him to sit down on a box and told him to light his pipe and talk about himself. He filled his pipe with difficulty, stuffing the tobacco into the bowl with trembling and agitated fingers. He broke several wooden matches in trying to light them. He had lost the fine, practised discrimination necessary to rub a match on the side of the box, and he “jabbed” his match hard on it. I lit a match and gave it to him, as I was interested to see how he would light the pipe. He let that match fall. I lit another, and with this he burned his finger. I then held a lighted match over his pipe, and in a jerky way he managed to light the tobacco; but he could not smoke properly, and the pipe soon went out. In the same jerky way he told me that he was forty-four years of age and had never been ill before. He was a good rifle shot, and had killed big game in India. He was a fair billiard player, and had been a temperate man all his life in all things. Talking in his spasmodic fashion, he had to stop for a word, and he then waved his hand about and frowned, as if angry with himself for having forgotten it. Up till a week ago he had been in perfect health, although the “strain” of the war had been tremendous; then one of his brother officers and a sergeant had been killed close beside him, and his guns had to be moved to another position under a heavy fire. He could not sleep that night, and the firing of the guns, which previously had not troubled him in the least, now worried him. Next day he could not eat. In a few days he was a physical and mental wreck. He was sent to England, and I heard that he had made a complete recovery.

One officer developed neurasthenia on the Aisne. His regiment had done brilliantly, but had suffered severe losses. The officer said that he was going to blow his brains out, so he was invalided into the hands of the doctors and later made a good recovery. He was suffering from the effects of strain and mental shock.

Another officer on the staff was standing close by his chief when a shell fell near, killing his chief outright. The staff officer had to be sent home for neurasthenia.

Our wounded often show signs of neurasthenia. I well remember at the hospital at Bethune one man who had had to have his arm off at the shoulder joint for a bad shrapnel wound. He was dangerously ill and semi-conscious for several days. When he had fully roused to his surroundings and the knowledge of his weakness he was like a little child, crying and begging me to get him away from the sound of the firing. He said that he would be happy if only he could get away to some place where he would not hear the sound of the guns. On the day the German aeroplane dropped a bomb near the hospital the windows of the building shook and rattled with the concussion, and this poor devil screamed aloud with terror and tried to get out of bed and crawl away—anywhere from the sound of the firing.

The French nursing sisters told me that the wounded Frenchmen work themselves into a terrible state of excitement in hospital when the firing is very brisk. They beg and beg to be taken away to the south of France, as far away as possible from the sound of conflict.

These were all brave men with injured nervous systems.

SMALL ARM AMMUNITION.

The Germans have charged the British, French, Russians, and Belgians with using Dum-Dum bullets. The Austrians have made the same charge against the Serbians and Montenegrins. The Triple Entente and its Allies have accused the Germans and Austrians of firing Dum-Dum bullets—so there you are.

The Dum-Dum bullet was first made at Dum-Dum, near Calcutta. It was a Lee-Enfield bullet with an imperfect nickel sheath. This nickel or cupro-nickel sheath in the Dum-Dum stops at the “shoulder” of the bullet, and the point is therefore bare lead, a continuation of the core of the bullet. Some modifications of the Dum-Dum exist. By rubbing the point of a nickel-coated Lee-Enfield bullet on a rough stone the cover is rubbed off, exposing the core of lead. A saw or file can make incisions in the long axis of the bullet exposing the lead this way, but leaving the tip covered with nickel. The destiny of a Dum-Dum is to break up when it strikes a bone. If it strikes a bone at a high rate of velocity it fragments and rips and tears the bone and surrounding soft structures. It is supposed to have greater “stopping power” against an infantry charge than an undeformed bullet. This supposition is incorrect. Certainly a Dum-Dum in traversing a limb or the chest can cause terrible and widespread destruction. In wounds inflicted by a Dum-Dum bits of the lead core and casing are scattered in various directions. But,—and this is important,—the same thing can be found in a wound inflicted by an undeformed Lee-Metford, Lebel, or Mauser bullet. The only certain proof of the employment of the Dum-Dums is to find them in the trenches captured from the enemy, or in the cartridge belts of wounded or prisoners. Again, a man may have a bullet wound with a small entrance hole and a large, gaping, jagged exit. One unaccustomed to bullet wounds would immediately say that such a wound was caused by an explosive bullet. But it can be caused by the ordinary Lee-Metford, Lebel, and Mauser bullets. I have seen these wounds frequently amongst Germans, French, and British. The explanation is that the bullet on striking a bone often carries along with it a fragment, large or small, and it is this fragment of bone that tears out a passage to the exit wound. The German bullet is easily extracted from the cartridge. It is almost impossible to extract the Lee-Metford bullet without strong instruments. The Germans have made use of this fact to extract the bullet from the cartridge and put it back “upside down,” that is, with the nickel point inside the metal cartridge case, and the base with its exposed lead core outwards. Such a bullet on striking a bone expands and fragments, and causes great damage. I am not repeating a rumour when I make this statement. I have seen these cartridges with the inverted bullets in the belts of German prisoners captured in the trenches. Other surgeons have seen them also. The French say that it is a common practice amongst the Germans, and so did our men at Ypres. One German prisoner on the Yser when confronted with these bullets taken from his own belt, admitted having used them. He said that his company officer told him that they were useful to break down barbed-wire entanglements!

There is one interesting point about the German bullet, and that is its property of spinning on its short axis when it strikes an object. The centre of gravity of the German bullet is low down on its base, owing to its long and tapering shoulder. It therefore turns over on reaching its object. I had on the Aisne one man of the Norfolk Regiment admitted with a tiny entrance wound between the great and second toes of the foot. The bullet was found lodged in the large heel bone, and its base was facing towards the entrance wound. It could not have entered the foot in that position, because the entrance wound was too small. A bullet spinning round when traversing a limb can cause considerably more damage than one that pursues a direct course, and this fact is important in brain injuries. The bullet penetrates the skull by a small punctured opening, and then whirls round and round inside the brain. It may then again strike the bone on the other side with its long axis and cause considerable shattering and bleeding. This spinning action of the Mauser was a thing that every surgeon had to remember when treating his wounded.

The Hague Convention of 1907 prohibits “the use of projectiles calculated to cause unnecessary suffering.” The Hague Declarations of 1899 decide to “abstain from the use of bullets which expand or flatten easily in the human body,” such as bullets with a hard envelope which does not entirely cover the core or is pierced with incisions. The St. Petersburg Declaration of 1868 agrees to abolish the use of “any projectile of a weight below 400 grams which is either explosive or charged with fulminating or inflammable substances.”

The British Medical Journal of 21st November 1914 reports as follows on the subject of small arm ammunition:

The British service ammunition is known technically as Mark VII. ·303 S.A. Ammunition. The length of the bullet is 1·28 inches; weight, 174 grains; muzzle velocity, 2440 feet per second. The bullet is a pointed one with an envelope of cupro-nickel which completely covers the core except at the base. The ordinary German service ammunition is very similar. Length of bullet, 1·105 inches; weight, 154 grains; muzzle velocity, 2970 feet per second. This bullet is pointed, with a steel envelope coated with cupro-nickel covering the cone except at the base. Both bullets carry out the provisions of the Hague Convention.

There is clear evidence that Germany has not confined herself solely to this unobjectionable ammunition. Her troops, both in Togoland and in France, have been proved to have used bullets with a soft core and hard, thin envelope not entirely covering the core, which type of bullet is expanding and therefore expressly prohibited by the Hague Convention.

Such bullets, of no less than three types, were found on the bodies of dead native soldiers serving with the German armed forces against British troops in Togoland in August, and on the persons of German, European, and native armed troops captured by us in that colony. All the British wounded treated in the British hospitals during the operations in Togoland were wounded by soft-nosed bullets of large calibre, and the injuries which these projectiles inflicted, in marked contrast to those treated by the British medical staff amongst the German wounded, were extremely severe, bones being shattered and the tissue so extensively damaged that amputation had to be performed. The use of these bullets was the subject of a written protest by the general officer commanding the British troops in Nigeria to the German acting governor of Togoland.

Again at Gundelu, in France, on 19th September 1914, soft-nosed bullets were found on the dead bodies of German soldiers of the Landwehr, and on the persons of soldiers of the Landwehr made prisoners of war by the British troops. One of these bullets has reached the War Office. It is undoubtedly expanding and directly prohibited by the Hague Convention. I am sure that Germany will be terribly upset at this, for Germany, we know, pays great respect to the articles of the Hague Convention!