FIELD AMBULANCES AND MILITARY HOSPITALS.
The military medical unit known as a Field Ambulance deserves some
description.
The Field Ambulances are officially designated as Divisional Troops
under the command of the Assistant Director of Medical Services. A Field
Ambulance consists of three sections, known as A, B, and C sections,
and each of these sections is divided into a “bearer” and a “tent”
subdivision.
The _personnel_ consists of a commanding officer, generally a major or
a lieutenant-colonel of the Royal Army Medical Corps, who is always in
one of the tent subdivisions, and of nine other medical officers and
a quartermaster, generally an honorary lieutenant or captain, of the
R.A.M.C. In addition there are 242 of other ranks, bearers, orderlies,
cooks, Army Service Corps drivers, officers’ servants, dispensers,
clerks, washermen, etc. The _personnel_ is fairly evenly divided amongst
the three sections, so that on occasion a section of a Field Ambulance
can carry on a limited but complete service. As will be seen later on at
Bethune, one section of our ambulance did this, and for a time acted as
a Clearing Hospital and passed thousands of wounded through its hands.
B and C sections have three four-horsed ambulance waggons, and A section
has four, making a total of ten waggons for the transport of wounded.
The other transport of a Field Ambulance consists of six general service
waggons, three medical store carts, three water carts, a cooks’ cart, and
an extra cart for odd jobs. The drivers and grooms have about one hundred
horses to look after.
The Field Ambulance carries a complete hospital emergency equipment.
Theoretically, if necessary a serious abdominal operation, a trephining
operation, or an amputation could be carried out at an ambulance station
by skilled surgeons surrounded by the latest and best of surgical
instruments and in antiseptic surroundings. I said theoretically, but as
a matter of fact such a state of affairs is not achieved, and the surgery
performed at Field Ambulance stations is crude and temporary.
A Field Ambulance station is a first-aid station, and surgery is avoided
as much as possible. The equipment of our Field Ambulance to-day
leaves very much to be desired, and I earnestly hope that during this
war the whole organisation will be thoroughly reviewed, reorganised,
and remodelled, and that there will be evolved a medical unit more in
consonance with the modern conceptions of good clean surgery. The Field
Ambulance should receive the wounded from the Brigade which it serves,
and as long as it holds these wounded it should be able to give them
the very best surgical and medical help. It must send the wounded as
speedily as possible to the hospitals and stations in the rear, and keep
the fighting line, of which it is really a part, as clear of wounded as
possible. It must conform to the demands of the military situation; for
after all war is war, and the purpose of a war is to beat the enemy with
sound troops and get the wounded out of the way. A Field Ambulance can
do all this and must do all this, and yet it need not be too obsessed
with the idea that immediately a badly wounded man is brought in he must
necessarily be bundled off to the base, irrespective of the nature or
magnitude of his wounds. The future of very many battlefield injuries
depends on the first treatment received, and a skilled surgeon surrounded
with familiar tools and appliances to ensure absolute cleanliness can
be a god of mercy and confer health and power on many a stricken man. A
blundering, incompetent amateur, lacking the divine essence of knowing
his own imperfections and courageously taking responsibilities which are
sky-high above him, can inflict a lifelong wrong and deprive a man of his
power to earn his livelihood in the future. The cautious and conservative
surgeon is ever the boldest when boldness means success. In every Field
Ambulance in this war and in future wars, let us see to it that we have a
cautious and conservative surgeon.
The medical officer is not as a rule a good horse master. From my
experience (and I am speaking both from what I saw in the South African
War and in this war), the medical officer is a very indifferent horse
master. He will do his best, as he always does in all circumstances; but
it is clearly unfair to ask a doctor, who knows as much about horses as
a monk does about antelopes, to take charge of a unit comprising about
one hundred horses, sixteen four-horsed waggons, and seven or eight
two-horsed carts, Army Service Corps drivers, and a miscellaneous lot
of grooms. I have seen an amiable and competent Army Medical officer
dismayed when he was compelled, owing to some duty, to get on a horse’s
back, and the horse seemed to know and enjoy it, for, usually a docile,
mild-eyed beast, he at these times became exceedingly sportive. Yet this
officer may have, owing to his rank, to assume charge later of a hundred
horses and a lot of waggons. A shoemaker should stick to his last, and a
doctor is only at home with his own professional work.
The remedy is to put Field Ambulances under trained officers of the
Army Service Corps. They are experts in the management of convoys and
transports, and could manage the field work of an ambulance to the
infinite satisfaction of everybody. Leave the doctors to the purely
professional work. There is enough of that to be done. Doctors are too
valuable as doctors to spare them for work which A.S.C. subalterns and
young captains can perform. The arranging of advanced dressing stations,
the choosing of buildings as hospital sites, can be done by the A.D.M.S.
of the division, and the purely workman’s part of the job can be done by
the A.S.C. officer and his men.
The transportation of wounded from the fighting line has been
extraordinarily well carried out by the Royal Army Medical Corps and the
Red Cross since our army took up its present fighting line in France and
Flanders. During the great retreat the transportation was ineffective,
and there is no doubt at all that many of our wounded who had to be left
behind could have been rescued if we had had motor ambulance convoys as
we have to-day.
On the Marne, and for the first week on the Aisne, the transport of the
wounded to the base was most imperfect. Who is to blame for this is a
matter that will have to be thrashed out when the piping days of peace
arrive, and we have time once again to put our house in order and profit
by the lessons of the war. The only means of transport previous to the
arrival of the motor ambulances was by transport lorries belonging to
the Army Service Corps. These waggons brought provisions and supplies to
the front, and on returning empty had to call at the various ambulance
stations. Straw was laid on the floors of these lorries, and the wounded
were packed tightly on the straw. This method of transportation for a man
suffering from pneumonia or compound fracture, a chest wound or a wound
in the abdomen, was a terrible ordeal, and undoubtedly added intense
suffering, misery, and discomfort to our badly stricken soldiers. Things
improved directly on the advent of the comfortable, well-sprung motor
ambulance. From the firing line to the horsed or motor ambulance the man
is carried on a stretcher by hand, but all future transportation is by
motor ambulance, train, river-barge, and steamer.
When a man is wounded at the front he is brought in by regimental bearers
to the dressing station of the medical officer of the battalion. This is
generally either a “dug-out” or is situated in a cottage a little way
back or sometimes behind a stone wall or near a clump of trees. Here
the regimental doctor simply dresses the wound, as cleanly as possible
under the circumstances, stops all bleeding and applies rough splints to
fractured limbs, and administers morphia if there is much pain. These
regimental aid posts are dangerous places well within shell fire, and
the wounded are got out of them as quickly as possible, and generally
at night. They are carried on stretchers to the ambulance waggons—horse
or motor—which are drawn up on some point of a road, or sometimes in
a village farther back. From here the wounded man is conveyed to the
headquarters of the ambulance in a village or château or church, and
his wounds are again dressed, if necessary, but as little handling as
possible is done, although the soldier thinks that his wounds should be
frequently dressed. At the ambulance headquarters urgent operations,
often of a serious character, have sometimes to be carried out, but no
operation is done if the case will permit of safe transportation farther
back. The next rest-house for the wounded man is the Clearing Hospital
or Casualty Clearing Station, and through this pass the wounded of
many ambulances. Many wounded are brought direct from the trenches to
a Casualty Clearing Hospital without calling at all at the ambulance
headquarters. All urgent operations are performed at the Casualty
Clearing Station, and this station should be thoroughly well equipped in
staff and _personnel_ as well as with all the modern appurtenances so
necessary for the safe performance of intricate and dangerous surgical
operations.
For obvious reasons the Clearing Hospital or Casualty Clearing Station
could not fulfil its destiny during the retreat of our army from Belgium
to the east of Paris. If the army is retreating, the Clearing Hospital
must go. It is part of the line of communications and would impede and
cumber the fighting divisions as they fall back. If full of wounded at
this time, it would of course be captured by the advancing enemy, as
the Clearing Hospital has no transport of its own, and depends on the
regular transport department of the army. There ought to be a transport
attached to a Clearing Hospital and solely under the control of the
commanding officer, and it would be of great advantage to have the whole
Clearing Hospital under the command of an Army Service Corps officer of
experience, a man accustomed to the transportation of supplies and to
commanding drivers of vehicles and mechanics. To put a Clearing Hospital
under the command of a doctor as is now done is as absurd as it would be
to place a large civil hospital under the control of a doctor.
Our civil hospitals are governed by Boards and a Secretary who has the
whole administration at his finger-ends. The medical staff do not
control or govern a civil hospital. They are busy enough in their own
sphere, which is a purely professional one—the treatment and cure of the
sick inmates. So with the Clearing Hospitals, the Army Service Corps
officer should be in charge of the hospital, and the purely professional
part of the hospital, the treatment of the wounded, should be entirely
and absolutely under the control of the medical staff, and completely
outside the range of action of the administrative chief. The evacuation
of the wounded from the Clearing Hospital to the hospital train and Base
could be controlled also by the administrative lay head of the hospital,
and all that the medical officers would be concerned with would be the
cases suitable to evacuate and when they should be evacuated. There would
at first be considerable opposition to this course by the regular Army
Medical Corps, but they could not advance any cogent arguments against
the devolution of administrative authority from them to the Army Service
Corps.
The Royal Army Medical Corps is, or should be, a professional body of
men. Anything that impairs their professional efficiency is bad. The
control of Field Ambulances and Clearing Hospitals is not a professional
man’s _métier_, and he does not shine in this position. Too much military
control or command changes the army medical officer from a doctor to a
military officer, and this change is not to be desired.
In civil life the more experienced a doctor is, the bigger becomes his
practice and the wider becomes his sphere of professional usefulness. In
military life, experience means promotion to higher rank, and the higher
the rank the less the professional work and the more the administrative
work.
In war time, as witness South Africa and this present war, civil surgeons
have to be called in large numbers to undertake important surgical work.
The experience of medical officers of the army in peace is professionally
a poor one. They are rarely called upon to perform serious surgical
operations, for a man requiring an important surgical operation is no
longer of use as a soldier, and is invalided out of the army. This man
then necessarily comes under the civilian surgeon, who sets about to
cure him, if possible, of his affliction. An urgent appendix operation,
a rupture, the removal of a loose cartilage in a knee joint and varicose
veins in their various manifestations—these, roughly speaking, compose
the experience in surgery of the army doctor in times of peace.
In advanced and intricate surgery in the abdomen he gets no practice, and
yet it is just the experience gained in this branch of surgery that is so
vitally important to surgeons at the front to-day.
A surgeon at the front should be a man of ripe judgment and a good
operator. He should know when to operate, and what is equally important,
when not to operate. He should know whether a wounded man should be
operated upon at once without exposing him to the risk of further
transportation, or whether he could be transported to a Base Hospital
without endangering his safety. And if the case demands immediate
surgery at the front, this surgeon should be able to undertake the
operation himself. Surgeons of approved judgment and skill are not hard
to find, and every Base Hospital, every stationary Hospital, every
Casualty Clearing Hospital, every Field Ambulance should have one officer
on its staff possessing the qualities and attributes mentioned. And such
a distribution is the easiest thing in the world to effect.
These men can be drawn from the civil side of the profession, as the
military side, the Royal Army Medical Corps proper, cannot provide them.
There are of course able surgeons in the Royal Army Medical Corps, men
who, were they in civil life, would have large consulting practices and
great reputations, but these men are few and are of that surgical bent
which will rise superior to its military environment, and keeping touch
with modern work, will absorb all that is good and new in the methods and
technique of surgery.
This lack of appreciation of the requirements of modern surgery has been
evidenced in so many instances at the front with our Field Ambulance and
Clearing Hospital equipment.
One day early in the war I had a number of wounded men to treat, all
with dirty septic wounds. The method of sterilising our hands was
inefficient and I asked for rubber gloves. Rubber gloves for the hands
of the surgeon are absolutely essential when dealing with a number of
septic cases. After handling septic cases he may be called upon at
any moment to operate on a case requiring the strictest antisepsis or
asepsis to give the wounded man a fighting chance of life. I asked a
senior medical officer of the ambulance for these rubber gloves. Judge
of my consternation and amazement when he said that “There were no
rubber gloves in the ambulance equipment, and _he did not believe in the
necessity for rubber gloves_.” When the ambulance was being equipped
previous to leaving this country at the outbreak of war he could have
obtained as many pairs of rubber gloves as he wished, but because he did
not think them necessary, they were not obtained. He did not realise what
war surgery would be like and had not been accustomed to operate on a
large scale. This blunder on his part was inexcusable and serious, and
the one who suffered from such a blunder was not himself but a wounded
officer or man.
In a Clearing Hospital in a small town in France to which I was
temporarily attached for some days, again I could not obtain rubber
gloves, although I had there to operate on profoundly septic cases, on
the cases of appalling gas gangrene and also on recent wounds of knee
joints, of brain, and abdomen. I asked for rubber gloves and was promised
them. None came. On my own initiative I wrote to a London surgical supply
establishment and obtained three dozen pairs of rubber gloves by return
mail.
Was this fair to our wounded?
At another time I had a difficult bowel operation to do, and the only
fine needles in stock could not be used as the finest silk available
there would not go through the eyes of the needles. The examination of
the silk and the needles had not been carried out when the equipment
was being put together in England. At this same place I had nothing
strong enough to ligature blood-vessels at the bottom of deep septic
wounds, except silk. The catgut was too fine and brittle to hold a big
blood-vessel, yet any surgeon will tell you that to put a silk ligature
on a vessel in a foul wound is very bad surgical technique. Yet it had to
be done. Again, in a dangerous operation on the knee joint I could not
get any sterilised towels nor an aneurism needle nor a pair of scissors.
The only scissors had been lost, and only one aneurism needle, which
had also been lost, was supplied in the instrument case. The patient
was an officer who had been struck by shrapnel at the back of the knee,
on the shoulder, and on one foot and one hand. He bled smartly and was
admitted to this Clearing Hospital with a tourniquet round his thigh to
control the bleeding temporarily. I opened up the wound behind the knee
and secured the large bleeding artery and veins there, and all I had
to ligature these vessels with was silk. There was no stout catgut, as
there ought to have been. Also I could only get two sterilised towels,
and these I had to boil myself. This was in a Clearing Hospital at the
front in November last year. There were no gloves. There were none of the
things round one to treat shock from which the officer suffered after
the operation. It made one despair. Yet all of these things should have
been at hand, and could have been easily obtained by the exercise of
some forethought. No wonder the wounds in so many cases were at this time
sent back to England in such a foul and septic condition. It was not
the military authorities who were to blame. The military chiefs did all
they could to help the medical department and always have done so. The
fault lay at the door of the Royal Army Medical Corps chiefs, and after
the war these things will again be reviewed in order to prevent a future
repetition.
My criticism is meant entirely for the good of our wounded officers
and men. They deserve the best, and it is the duty of the Army Medical
Department to give them of the best. It is only by pointing out defects
that improvement can follow, and the only man who can point out these
medical defects is a surgeon who has actually had to operate on wounded
men in a Field Ambulance or in a Clearing Hospital under adverse
surroundings.
It is an easy matter to arrange for a modern surgical equipment for a
Field Ambulance or a Clearing Hospital. Sterilisers for instruments
and towels and dressings are not cumbrous appliances and do not take
up much space. The surgical instrument case at present in use by the
Royal Army Medical Corps is out of date and requires a complete revision
and overhaul by a surgeon who is accustomed to operate, and not by a
committee of senior or retired officers of the Army Medical Staff. The
younger officers of the Royal Army Medical Corps and the “professional”
men amongst the seniors recognise the defects of the present system,
but naturally they cannot say much. This lack of medical equipment and
the “unreasonableness” of the medical department is a common subject of
conversation at the front amongst civilian medical officers, and I have
seen some of these men indignant beyond measure at what they have seen
and met with.
The Clearing Hospital, in addition to being a “rest-house” on the _via
dolorosa_ of the wounded, is also a sieve. It has to sift the lightly
wounded from the seriously wounded and the serious cases from the
desperate cases. In this process of sifting a large collection of wounded
men, it discriminates between those who are fit to be sent to the Base
and those who must remain for a longer or a shorter period. Many claim
that the Clearing Hospital is not a hospital _per se_ but holds a purely
administrative position. I feel sure that it will become more and more
a hospital as time goes on, and that its present surgical and medical
equipment will necessarily undergo a complete reorganisation. To-day
its equipment is little more than that of a Field Ambulance. It is not
equipped to deal with extensive and serious operations, and yet serious
operations have been performed and will necessarily continue to be
performed at the Clearing Hospital.
There is no shadow of doubt that many of the men operated upon at Bethune
in the Hôpital Civil et Militaire later on in the war owe their recovery
in a very large measure to the excellence of the complete sterilising
equipment and cleanly surroundings. No trouble can be too great and no
expense should be spared to make the surgical stations at the front up to
date in all that makes for surgical cleanliness.
It is even more necessary to have the skilled surgeon at the front
than at the Base, but we have any amount of skilled surgeons for both
places. A skilled operating man of experience should not be attached to a
regiment as regimental surgeon while a recently qualified man is deputed
to blood his ’prentice hand at a major operation in a Clearing Hospital.
Yet this has been done, and I know of an instance where a recently
qualified man performed his first trephining operation on a soldier
with a bad head injury whilst a few miles away there was an experienced
operator engaged solely in first-aid work as regimental surgeon.
I was told by a senior officer of the R.A.M.C. that in the city of X——
before the war he had as assistant in his military operating room a
very clever young R.A.M.C. orderly. This man was well trained in the
sterilisation of instruments and dressings and in the preparation of a
room for operations. When the ambulance was mobilised in this city on
the outbreak of war the medical officer applied for this man, who would
have been invaluable, to be appointed to the tent section of the Field
Ambulance. Here the training and knowledge of this orderly would have
been of great service. Instead of that, the man was appointed to look
after the water waggon of an infantry regiment and was killed early in
the war. Any untrained man would have done for the water cart, but a lot
of training is necessary to make a good hospital room assistant.
At the Clearing Hospital the wounded man meets for the first time the
Army Nurse. This is the nearest point to the firing line that our nurses
are allowed to go, but I know lots of them who are extremely anxious to
go into the trenches. The nurse is a welcome sight to both officers and
men, and no man nurse can adequately take the place of a trained woman.
The presence of nursing sisters in a hospital is good and wholesome, and
where they are the hospital work is carried on infinitely better and
the patient is well looked after. R.A.M.C. orderlies do not like our
nursing sisters. The sister makes the orderly work, will not allow him
to smoke in the wards, makes him wash his hands and keep tidy. To the
slacker, of course, these things are highly unpalatable, and there are
many slackers about. Our British nursing sisters are splendid women,
and work ungrudgingly and sympathetically always. It is good to see
a bright-faced, white-aproned nurse amongst the wounded, and she is
extraordinarily popular with her patients.
The hospital train in France is a well-run unit. The accommodation for
the sick and wounded is excellent, trained nurses accompany each train,
and the medical arrangements are controlled by three doctors, generally a
regular army medical officer in charge and with two temporary lieutenants
or civil surgeons to assist him to do the actual professional work. No
surgical or medical work worth mentioning is done on hospital trains;
they are simply means to an end—the end is the Base Hospital.
The Base Hospitals in France are well-run units also. There are here big
medical and nursing staffs, a large number of orderlies, and any amount
of equipment. I was for some time Surgical Specialist at No. 6 General
Hospital at Rouen, and this hospital was splendidly administered by the
commanding officer, Lieutenant-Colonel ——. In the Base Hospitals there
are good operating rooms, and in fact every modern appliance that one
could desire. It is a pity that the same care in administration and
equipment had not been carried farther up and nearer our soldiers at the
front.