A surgeon in khaki

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.