ALDER HEY

 

Until the South African War the British soldier was not embarrassed by national sentiment, or even accepted as an honourable burden by the state. Whatever complacency may have been enjoyed by our victories in Flanders, Spain, or India, the public preferred that the military spirit should be within the pages of a history book.

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One must repeatedly remind oneself that, until the European War, the very idea of hostilities affecting the English home Had remained outside serious consideration. The difference Between the wars of yesterday and to-day was signally described by Robert Jones when he asked an audience during the war To remember that “ near the Liverpool Military Orthopaedic Hospital stands the workhouse into which Charles Dickens turned to see Havelock’s men on their return from India.

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He wrote—‘ before going to their wards to visit, I enquired how they had made their triumphant entry there. They had been brought through the rain on carts and had been carried upstairs on the backs of paupers. The groans and pains during the performance of this glorious pageant had been so

distressing as to bring tears to the eyes of the spectators, but too well accustomed to scenes of suffering. The men were so dreadfully cold that those who could get near the fires were hard to be restrained from thrusting their feet in among the blazing coal. They were so horribly reduced

that they were awful to look upon. Racked with dysentery and black with scurvy, one hundred and forty soldiers had been revived with brandy and laid in bed, and the cultivation of laurels on a sandy soil had brought the soldiers in question to that abode of glory.’ ”

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As a natural consequence of the gulf which more and more separated the soldier from the civilian, the attitude towards his disability and declining years was increasingly remote and unsympathetic. A notable change in the public attitude towards the British soldier certainly came with the South

African war, when the volunteer first took his place with the regular army. But the national emotion aroused by Mr. Kipling’s popular verses did not cure the hereditary neglect of the disabled. The c.i.v. might march home again, but the realities of mutilation were obscured by thousands of miles, or banished to the wards of general hospitals. The great majority of British people still remained outside personal contact with the soldier as an individual. For all its dismal humiliations the South African war taught nothing except a renewed gratitude to the almighty for the British navy and the English channel.

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In 1914 delusions good and bad were discredited with equal impartiality. The unparalleled efficiency of the expeditionary force was the first introduction to our place in modern warfare. The British soldier and the British officer ceased to be a subject of indifference, or derision, or sentimentality,

and became one for unqualified admiration and pride. The second shock to national complacency was the comparative Isolation of the navy. It became a mystery force, and reluctantly the householder was forced to swallow the fact that stalemate may happen on sea as well as on land.

 

There followed in Kitchener’s prophetic poster the crowning blow to the legendary security of England in the moral obligation upon every fit man to fight overseas. To the medical services the prospect of a long and critical European conflict meant enormous casualties and the urgency of hospital accommodation. The retreat from Mons began on Monday, 24th august, 1914, and in three days we had lost in killed, wounded, and missing, nearly 8,000 men. Early in September, the allies turned and fought the battle of the Marne, followed by the drawn-out battle of the Aisne, which, in less than a month, cost the country in killed, wounded, And missing, 13,500 men. Still more appalling were the losses at the heroic first battle of Ypres in October and November, when under the reckless onslaughts of the German masses our casualties were numbered by tens of thousands.

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During that heartrending autumn, Robert Jones no more than another anticipated the magnitude and prolongation of the conflict which was to come, nor foresaw the overwhelming call for that branch of surgery which was his own specialty.

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But to a mind which had been thinking in terms of orthopaedics for the better part of forty years realisation must have come very quickly. Within a few months he must have realised the great place that the treatment of bone injuries would take in the restoration of the wounded. Here was a war in which all previous experience was practically useless. It meant gigantic organisation and highly skilled surgery if a huge army of the disabled were to be averted. Having spent his life in an atmosphere of the deformed and crippled, he must very soon have foreseen, more accurately perhaps than anyone else, what a terrible cumulative incubus was in store if this growing mass of war-crippled men were to be cast adrift. He knew from experience how handicapped such people are in body and mind, he understood their peculiar Psychology, he could picture the time, labour, skill, and expense required if the disastrous results of all previous wars were not to be exaggerated a thousandfold. He knew that in so grave a national crisis no provision could be made for such a predicament. He also quickly realised that while wartime conditions were in general propitious to expenditure, the country’s thought was bent first and last on beating the enemy. “ lose the war and we lose all ” was the natural view.

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A country in this state of mind—and more especially the responsible government of the country, and particularly and specifically the war office—was not competent to grapple promptly and radically with a problem which Robert Jones, with the perspective of the experienced orthopaedist, visualised in all its urgency.

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Thus, all through the war, he must be studied in the position of a man ahead of his time. But, if he had vision, he was no visionary but an exceedingly practical man. Good humour was his birthright and tact a point of natural genius. The habit of a lifetime stood him in good stead in his patient campaign for the wounded soldier ; without it he would never have succeeded.

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Patience is the supreme virtue of the orthopaedist. He does Not expect immediate results ; on the other hand he knows That if he lays his foundations well, time will work for him.

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Robert Jones realised at once that a subordinate officer like himself, however much in the right, could not coerce the war machine. Had he attempted any such thing he would not have lasted a day, and his immense and valuable knowledge would have been lost to the country.

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Looking back upon his work in the war years, it is instructive, and sometimes amusing, to see how deftly he adapted himself to the rigidities of the system. It will be observed how watchful and active he prepared his ground with great pains and discretion and then, at the proper moment,

Submitted his proposals in such succinct and convincing shape that they could usually be granted with acclamation and with credit to the authorities. However much he wanted, he rarely asked for more than he was likely to get at any particular moment. Thus, he never embarrassed the authorities, and kept the path open for further demands as current opinion advanced.

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It will be observed that not the least part of his achievement was that by patience and tact, singleness of purpose and unswerving devotion to an ideal which neither delay nor obstruction could impair, he succeeded in building up an organisation which proved of incalculable assistance to soldiers during the war, and when peace came of permanent service to Great Britain. It is the arduous accomplishment of these things that the following pages attempt to illustrate. It will be seen how infinitely beyond anything that had gone before was the ideal which Robert Jones conceived, strove for, and in great measure achieved, in the treatment of the Disabled Soldier.

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II

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When war broke out he was fifty-seven years of age. He had been working continuously at his profession since he was eighteen, his reputation was international, and he might, without any reflection upon his patriotism, have continued his normal occupation. But war is indifferent to age or

distinction—was not Archimedes himself slain at a blow in his laboratory by a nameless raw barbarian ? For all his longing for international friendship, Robert Jones joined up at once as a captain in the reserve and was attached to the 1st Western General Hospital. He was soon promoted Major, and in the normal course of duty made an inspection tour of the various hospitals in the Western Command.

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Accustomed for years to the highest perfection of treatment, he was horrified by what he saw and about the end of 1914 he sent a damaging report which quickly reached the War Office. This is the first indication that the wounded, like crippled children, would require, in a large percentage of cases, prolonged treatment under orthopaedic specialists.

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It was the old story of the general hospital and quick evacuations to provide beds for fresh cases. The first step was to direct or transfer such cases into some institution which he could staff and control, as an example for future developments.

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In a letter to the late Sir George Makins (May, 1918) Robert Jones wrote :—“ during the first twelve months of the war no provision of any sort was made for cases crippled and deformed, and early evacuation was both the instruction and the routine. The result was that many men were discharged from the army in a very large number of cases totally unfitted either for military or civilian life. These men promised to become foci of seething discontent and at that time a menace to successful recruiting. Letters poured in and representations were made which rendered it imperative that some effort should be made to stem the tide of premature discharges. It was then that Sir Alfred Keogh asked me if I could help him, and it was decided (in early 1915) that an experiment should be made in Liverpool. Two hundred and fifty beds were allocated for this work at Alder Hey, which soon expanded to five hundred and sixty. I then went over the country to see the type of case which required reconstruction. . .

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The A.D.M.S. Western Command, Colonel William Coates, A Manchester surgeon, wrote to him on January 18th, 1915, That the war office authorised as many beds as necessary, Up to four hundred, to be set apart at alder hey for the accommodation of cases in military hospitals likely to benefit

By orthopaedic treatment. The various hospitals were to be circularized on the subject. Robert Jones was put in charge of the surgical division, with Major Armour and Captain McMurray to assist him. “ I am quite sure,” concluded Colonel Coates, “ there will be a great field opened out, and that the authorities will be very grateful to you for placing your special knowledge at their service in this way.”

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Alder Hey was—like shepherd’s bush in 1916—a landmark in the history of medical services in the war. Upon its success or failure depended the restoration of thousands of wounded soldiers in the coming years. From the experiment at Alder Hey, with its four hundred beds, developed the whole

scheme with 30,000 beds for the wounded in this country.

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Robert Jones was on trial with one hospital wholly reserved for the orthopedic case. Years afterwards, in 1931, Sir Alfred Keogh (Director General of Medical Services, 1914- 1917) wrote to him recalling “ the early days of orthopaedic work in the war, when its importance had to be vindicated and established. To you and to you alone the successful result has been due.” A generous tribute from the illustrious chief who backed him so staunchly.

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But only patience could hope to gain either official or public attention at such a time. It was training for war, not physical recovery which faced the country. In 1915 there were the terribly costly British attacks on the German entrenched lines in France and Flanders, and the Gallipoli campaign. At 

Neuve Chapelle in March there were over 8,500 wounded ; There followed the Second battle of Ypres with Hill 60 in April, and Festubert in May ; Loos filled the hospitals in September, and autumn came with every assurance of trench warfare until 1916.

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During this year Robert Jones consolidated his position at Alder Hey prior to the inevitable development of specialist treatment for gunshot cases. He travelled and wrote and demonstrated. Already the overcrowded hospitals had no room for men who could never fight again, already the partially recovered were being discharged uncured, and already recruiting was suffering discouragement by the presence of patched and grumbling soldiers in every district and town.

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Alder Hey could now only touch a fraction of the problem, And Robert Jones was at last asked to give his views on the subject. What, in fact, was the position as he had experienced it?

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“ in the early days of the war,” he said, “ when the wounded passed into our country in countless numbers, our hospitals soon became full to overflowing. The same conditions were experienced in France. There was nothing for it but to evacuate the less serious cases to make room for others, with the result that our towns and even villages began to feel the burden of the cripple.

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“ if the men were not discharged they were found segregated in command depots, and these depots from their nature were not equipped with the personnel which could effectively deal with them. A visit through these large camps very early proved to us that it was necessary to have certain hospitals

Governed by less stringent rules, where every accommodation should be provided for the type of case which required a sufficiently protracted stay to prevent deformity and to restore function without segregation and continuity of treatment we were in danger of scrapping thousands of cases who possessed the potentialities of recovery, and these were not merely the serious cases, but also those suffering from lesser injuries, upon the recovery of which we depended in order to replenish our fighting forces.

 

Many of these conditions were recoverable, and most of them might have been prevented. “ the treatment of these cases in the early part of the war,” he wrote to Sir George Makins, Major General A.M.S., “ was deplorable. Everybody operated and everywhere hardly a single surgeon had an opportunity of following his case up.

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This was the testimony I received from surgeons in many parts, who deplored their fate in not being able to learn any lesson which should be gathered from operative results. ‘ we cannot follow up our cases,’ I heard frequently, and the result was that unchecked adventurous enterprises in nerve implantation, nerve grafting, and nerve anastomosis were of frequent occurrence. Continuity of treatment, an essential desideratum, was impossible. A case might enter any of our large hospitals with an ulnar paralysis and stiff fingers. Early evacuation often meant that the surgeon would have to operate without an adequate preparation in the way of mobilising the fingers, and shortly after the wound had healed the case might be found nursing his stiff fingers in an auxiliary hospital or undergoing routine treatment at command depots, or sent back to another hospital for a fresh operation because recovery had not taken place in four or five months.”

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The fatal neglect of orthopaedic training before 1914 was now tragically demonstrated. Surgeons trained to treat occasional accidents in peace time stood helpless before men shattered by shell and bullet. Overwhelmed by the deepening catastrophe, Robert Jones struggled to collect the small band of surgeons whom he had taught. But in order to preach the principles of orthopaedics he gave the fruits of his experience in several papers and later in military manuals. They were largely read at the front, and in March, 1915, sir George Makins wrote to him :

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“ your papers in the journals have proved the one effort of our friends at home that has been followed by useful results. I, and others here, are most appreciative of the practical value of them to the workers here. As you know well, the younger men will never see what importance to their reputation the treatment of a fracture will be, and here they have found themselves in the midst of very troublesome ones. Your papers have exerted a tremendous influence for good.”

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Robert Jones, awaiting direct permission to handle the orthopaedic case in special hospitals similar to Alder Hey, decided in 1915 by the written word and by personal demonstration to advise the better handling of cases of fractures at the front line clearing stations.