SOURCE: - STORY OF THE GREAT WAR - BASED ON OFFICIAL DOCUMENTS - MEDICAL SERVICES - SURGERY OF THE WAR - VOL. I

Major-General Sir W. G. Macpherson, k.c.m.g., c.b., ll.d.,

SURGICAL WORK IN FIELD AMBULANCES.

AT one time or another under the widely varying conditions of the war, sections of field ambulances carried out the duties of every organized medical unit. A complete historical survey of the surgical work which they performed would, therefore, involve reference to practically all the operations which can be performed on war injuries. In general, however, when an ambulance worked in its normal relationship to fighting units and to other medical organizations, the amount of surgical work, using this term in its ordinary sense, which they executed was very limited.

The operative work in field ambulances in all theatres of war was invariably beset by certain difficulties. The nearness to the line of battle imposed unfavourable conditions in regard to space and shelter. The necessity for the rapid evacuation of cases rendered the performance of any serious operation inadvisable, and in any case made observations of the results impossible. Further, definite

limitations were set by the amount of equipment and personnel available in these units.

Again, the hazards of war, the nature of the terrain and the different conditions of fighting produced the most remarkably varied demands in the way of surgical work, and imposed on them at the same time special difficulties. For instance, the tent division of a field ambulance often carried out on a small scale the work of a casualty clearing station. In the first month or two of the war, during the

pressure of the retreat from Mons, the whole weight of the treatment of the wounded between the front line and the base hospital fell on the field ambulances. Work of this character was also carried out by them in Gallipoli. Such a condition of affairs was exceptional, and was only necessary in the first instance on account of a rapid retreat involving a complete change of base on the coast, and in the second instance on account of the very short communications between the front line and the sea. However needful and efficient the work was on the occasions mentioned, it may be accepted that when the body of troops served by a field ambulance was fully engaged the normally established unit was not of sufficient size, nor did it possess the adequate equipment to perform such duties properly.

As the war progressed, the medical experience gained led to a crystallization of ideas as to the surgical functions of each type of medical unit. The exact nature of the treatment desirable for the wounded man at the various stages became better defined and the internal organization of various medical units was adapted accordingly.

The experience in the early years of the war emphasized the fact that certain infections were mainly responsible for a high mortality or a slow convalescence in the cases surviving the primary injury. The outstanding and definite advance in the treatment of wounds was concerned with the prevention

of these various infections and it was clearly demonstrated at the casualty clearing stations that healing by first intention of the majority of wounds could be brought about by the early and efficient excision of the missile track. The general recognition of this possibility established all the principles

which controlled the handling of the wounded man from the time he was hit till he could be transported into surroundings which admitted of the necessary operation being carried out under proper surgical conditions. In general, such conditions were established at the casualty clearing

station. The small group of cases in which it was found possible and advisable to carry out operations of a radical character in the field ambulance will be defined below.

The appreciation of the necessity of operations of wound excision exerted an important influence on the treatment of the wounded man during the period he was in the hands of the field ambulance. In order to give such operations their best chance of success it was found that they must be carried

out within 24 hours of injury. A corollary to this was that the wounded man should arrive at the operating centre in as good condition as possible. This meant that the development of shock in any form was to be prevented, or limited as far as circumstances permitted. Thus, two important requirements in the handling of the wounded man in the forward area became clearly established, namely, rapid evacuation and the prevention of shock. In relation to the first of these requirements, it had always been recognized that the prompt removal of the wounded from the field of action assisted materially in maintaining the moral of the combatants, also that as a matter of expediency, the rapid evacuation of forward dressing stations was most desirable in the interests of efficient

action on account of their almost invariably limited accommodation.

It thus became generally accepted that the surgical work in ambulance units was of the greatest value when it concerned itself with the handling of the wounded man on the lines indicated above, rather than when elaborate attempts were made to carry out any specialized surgical treatment of

individuals. It is true that speedy evacuation, desirable though it was in general, was found to be contra-indicated in certain specific cases. For instance, operation was sometimes undertaken at advanced dressing stations on those cases in which, without it, the journey to the casualty clearing station would have been productive of great shock. Under this heading come proceedings undertaken to check haemorrhage and the amputation of badly crushed extremities. It was also found that penetrating wounds of the chest were benefited by a rest in the advanced area, and in any such cases in which an open pneumothorax existed suture of the wound at the earliest opportunity was found to be of the greatest importance in improving the general condition of the patient.

In regard to the prevention of shock in general, apart from the question of haemorrhage, it was found that the avoidance of the loss of body heat and the complete rest of the injured part were the most important factors. The details of the methods employed in the treatment of these various conditions

will be considered below under their various headings. They were usually carried out either at an advanced or at a main dressing station.

In general, it may be said that towards the end of the war the advanced dressing station was the centre of surgical work in the forward area and it may, therefore, be worth while to outline the type of structure which best met the requirements of such an establishment in France.

An advanced dressing station was bound to be situated in the medium battery zone and could never be placed far from a main route of approach to the sector of the one which it served. It was, therefore, subject from time to time to heavy shellfire. Adequate cover could as a rule only be hoped for under conditions of trench warfare. In open warfare, the advanced dressing station had to be placed under such shelter as could be found in a spot consistent with accessibility from the line and the means for rapid evacuation. The accommodation was organized as follows :—^A receiving-room with an adjacent compartment for gassed cases, a dressing-room in direct communication with the receiving-room, and an evacuating waiting-room leading from the dressing-room. A storeroom,

cookhouse and latrines were conveniently placed and the personnel was accommodated close at hand in dugouts. In Fig. 1, the plan of a satisfactory station of this type organised in a church cellar is shown. The church had been completely demolished above ground by shellfire, so that the area was not unnecessarily conspicuous to hostile observation.

The importance of good road communication right up to the dressing-station cannot be over-estimated. In Flanders, corduroy roads were usually available or were constructed for the purpose. Where metalled roads were in fair order, they were much more satisfactory as they were less liable to be rendered temporarily impassable to motors by the results of shellfire.

It must be understood that the elaborately protected advanced dressing station was a development of the later years of stationary warfare. In the earlier years, the convenience of the accommodation was considered rather than defence against high explosives, but, with the great increase in the shelling to which the back area was subjected as the war continued, protection became the point to which most thought was given. In the last phase of the war, the rapid advance reduced hostile gunfire to a minimum and dressing stations were seldom shell-proof and suffered but few casualties.

In not a few instances during this period the operation tents carried by the field ambulances were used for overflow work in advanced dressing stations and in some cases even large marquees were pitched. When canvas shelter was used, some protection from bomb or shell fragments was secured by sinking the floor of the tent two or three feet and banking up the sides. Such an arrangement called for very careful trenching to avoid flooding in wet weather.

The general principles of the organization of walking wounded posts and main dressing stations did not differ essentially from those of an advanced dressing station.

Treatment of Shock.

The systematic treatment of shock was not completely developed in the forward areas till 1917. Its occurrence and severity were in all cases influenced by psychical factors. Severe injuries involving the long bones and joints produced the most severe form of primary shock, but appearances which resembled this condition were often produced by a serious or sudden loss of blood. Secondary shock was observed to follow exposure and anxiety, and was seen in its most intense form in starved, fatigued, or nervous men, even though the primary wound was slight. The treatment of shock in field ambulances was directed to combat the factors generally recognized as responsible for its induction.

The checking of all bleeding was found to be of the first importance. In cases in the field where there was a sudden loss of much blood the degree of collapse which ensued was extreme. Obviously, such primary bleeding under the conditions of warfare could seldom be directly controlled. In any

such cases which were not at once fatal and had been temporarily controlled in the field by tourniquet, steps were taken at the dressing station to prevent reactionary haemorrhage. The

general treatment of bleeding from large vessels is referred to further on. Cases in which there was oozing from the wound were found to require careful packing ; otherwise the recurrent loss of small quantities of blood might produce profound exhaustion before the man reached the casualty

clearing station.

The most radical method of dealing with pain, as a factor in shock, was found to be the removal of the damaged tissue, but this procedure was only occasionally practicable in a dressing station.

Support and protection of the part from further injury were desirable. Morphia was usually given

hypodermically in a dosage of quarter to half a grain, although some authorities were of the opinion that the administration of this drug in any quantity, shortly after the man was wounded, tended to favour the production of acidosis. The conditions in the forward area prevented, in general, the provision of the rest and quiet desirable for these cases.

Loss of body heat was one of the conditions associated with shock, and various attempts were made to keep the wounded man warm in the forward area, although in practice it was often found impossible to prevent a severely wounded man arriving at the dressing station more or less chilled. When possible, his wet clothes were removed and he was treated as described in Chapter III.

It was always recognized that fluid nourishment was an early and pressing need of a wounded man.

The administration of hot tea well sweetened with the addition of milk was found to be the most valuable and practical form in which to give fluid by the mouth. The only cases in which it was

customarily withheld were those with perforating abdominal injuries. In such cases, some medical officers forbade administration of any fluid by the mouth, and others allowed an ounce or so only, at half-hour intervals. It was generally recognized that if a man could and would take fluid by the mouth, in the forward area, there was seldom reason for administering it by any other route. Administration of fluids by the rectum was not found to be a useful procedure in dressing stations.

The administration to be effective necessitated the lower bowel being empty ; in any case, the rate of

absorption was slow and uncertain.

The subcutaneous infusion of saline solution was at one time employed in some units. This method did not give rapid results and, in general, was found to be useful only when the patient was likely to be left at rest for some hours. Moreover, unless the infusion was effected with care sloughing of the

suprajacent skin might result later.

Intravenous infusion of fluid was recognized as being the best method when prompt and vigorous measures were urgently required. It was admitted that infusion of any kind by this route should, if possible, be reserved for administration at the casualty clearing station, as it was there that the essential operation was to be performed. Such operation could be carried out in cases suffering from shock with the best chance of success shortly after the first transfusion of fluid had been effected.

For this reason, this restorative procedure was latterly employed at dressing stations only when

it was considered that the patient would be otherwise unable to bear the strain of the journey to the casualty clearing station. The storage and transport of sterile fluid presented some difficulties in the forward area and the provision of blood for infusion even greater ones. On a few occasions, the transfusion of citrated blood was carried out, but on account of the technical difficulties referred to, its use did not become generalized. The infusion of gum solution was employed more frequently, and, on the whole, proved the most satisfactory method.

In the early days of the war, it was the common practice to administer subcutaneously stimulant drugs such as strychnine and camphor. Further experience showed that, though such drugs apparently improved a man's condition shortly after administration, their effect was invariably transient and was commonly followed by a relapse. In the latter years of the war, the use of hypodermic stimulants in dressing stations was practically given up. Of stimulants given by the mouth, caffeine contained in tea always held first place.

Treatment of Haemorrhage.

The surgical treatment of haemorrhage in the forward area was not so commonly called for as might be expected. The tourniquet was used both by the stretcher-bearers and by the regimental medical officer. At the advanced dressing station it became the rule to remove any tourniquet, and if bleeding

persisted to check it by direct surgical treatment. The importance of doing this was made evident by the unfortunate results in those cases in which a tourniquet was left in-situ more than a few hours ; in such instances severe local infection or even massive gangrene of the extremity so treated almost inevitably followed.

The type of haemorrhage which had to be dealt with was either primary or reactionary, and could be divided into the two main clinical divisions according to whether it came from a main vessel or from the capillaries ; the treatment of arterial haematomata resulting from arterial injury had also to

be considered.

In any case in which there was evidence of damage or laceration of a main vessel in a patient under treatment at the advanced dressing station an operative attempt was made to tie the vessel or, at any rate, to clamp it. The use of a general anaesthetic for the purpose of this procedure was not advised as it was considered that it prejudiced the further and more radical treatment of the patient's wound when he arrived at the casualty clearing station.

In cases of general oozing it was customary to open up the wound to secure any minor vessels which could be seen and to pack the cavity with dry gauze and apply a firm bandage.

Such a procedure was clearly only temporary in nature, and a note on the subject was made on the field medical card for the information of the surgeons at the casualty clearing station.

Arterial haematomas, unless rapidly extending, were not treated at the advanced dressing station. A firm dressing was applied, rest for the parts secured by suitable splintage if necessary, and a small dose of morphia given subcutaneously.

Fig. 2.—Samways’s tourniquet with modified anchor catch.

As stated above, the practice of evacuating patients from the forward area with a tourniquet applied was definitely condemned; at the same time there were cases in which as a precautionary measure the tourniquet was loosely put in place to be tightened by the ambulance orderly in case of need.

On some occasions the pressure or conditions of work made radical treatment of bleeding at the advanced dressing station impossible, and then the man was evacuated with the tourniquet applied; a special note being put on his label.

The most practical tourniquet for general service in the forward area was found to be the type made from rubber pressure tube and fitted with a Samways’s anchor catch (Fig. 2) .

The screw and webbing type of instrument issued to the stretcher-bearers was found to be unsatisfactory both as regards efficiency and comfort.

Treatment of Wounds in general.

In the early days of the war many efforts were made in the forward area to carry out a prophylactic disinfection of wounds. The procedures adopted varied from the application of tincture of iodine to the exposed wound surface and the surrounding skin to attempts at bringing an antiseptic into contact with the whole wound track, either by squeezing in an antiseptic paste through the aperture

of entry, or by syringing the wound with bactericidal fluid. None of these methods was found to be effective in preventing the onset of grave infection in shell wounds otherwise left untreated. Finally, it became clearly recognized that all operations for the removal of damaged tissue could be most

effectively carried out at the casualty clearing station. It will thus be seen that with the progress of the war the actual direct treatment applied to wounds in field ambulances became limited to the application of a simple protective dressing and adequate splintage ; partial attempts at disinfection and repeated changes of dressing had been found to be productive of more harm than good. In fact, in the latter part of the war, the first field dressing applied by the regimental bearers was often deliberately left in place until the patient arrived at the casualty clearing station.

At field ambulances the first injections of anti-tetanic serum were given. Every man who was wounded or who was suffering from severe trench foot received a minimum dose of 500 units. If the wound was extensively lacerated or accompanied by injury to the bone, a primary dose of 1,500 units was given.

First in 1916, and again later, an attempt was made to produce an anti-gas-gangrene serum, on some occasions in combination with anti-tetanic serum ; this anti-serum was experimentally given at a few field ambulances, but, so far as evidence was available, did not prove effective in reducing

the incidence of the infections.

It can thus categorically be stated that the responsibility of field ambulance units in the direct treatment of wounds was limited to their protection, using the term in its widest sense. The few exceptional cases in which more active treatment was found desirable in the forward area are described below. The protection of a wound was recognized as not limited to the application of a dressing, but as involving all those procedures which procure repose of the injured part. These included the application of splint, even apart from the presence of fracture, and the gentle handling of the wounded man during transport and dressing.

Treatment of Fractures.

It has always been recognized that the fixation of a broken bone at the earliest possible moment after the injury is important, but it was not until 1915 that it became clearly realized how much the subsequent satisfactory progress of any case of gunshot fracture depended on efficient splinting

prior to transport. The appreciation of this fact was chiefly due to the demonstration afforded by the use of the Thomas' knee-splint in the treatment of fractures of the femur. Fractures of this class were, in the early days of the war, fixed in the forward area by some splint of the long outside type. The

mortality among patients so treated was extraordinarily high, and those cases which recovered were almost all subject to severe infections and a prolonged convalescence. After the general introduction in the forward area of the Thomas' splint for the treatment of this fracture, the improvement in results was too great not to attract attention. Apart from any advance which had been effected in wound treatment in general, it was clearly shown that an apparatus which fixed a fracture was able largely to prevent shock and to reduce the incidence of infection in the wound.

The actual splint employed in the forward area to fix the various fractures, excluding the more experimental kinds which had temporary or local vogues, were few in number. On mobilization, the supply of splints to a field ambulance was limited to the contents of the standardized field fracture box. this contained a supply of stapled aluminium bars and ribbon, a small quantity of plaster of Paris, and some malleable sheeting.

No ready-made splints were issued. It was soon found that, in view of the large number of fractures to be treated, this arrangement was not satisfactory, and the following supply of prepared wooden splints was obtained, for the arm, rectangular splints: for the thigh, Liston long outsides and bracketed modifications ; and for the leg, back splints with and without side and foot-pieces.

The type of splint used for the upper extremity was not materially changed until the later stages of the war, when the Thomas' splint adapted to the arm was tried in many units. On the whole, these later introductions were not found to be very satisfactory for transport. They required very careful adjustment if injurious or, at any rate, uncomfortable pressure in the axilliary area was to be avoided.

moreover, they were also liable to displacement when the patient was moved about. The Bowlby-Clark hinged internal angular splint proved to be a practicable and safe method of fixation for most injuries of the humerus and elbow at the stage under consideration. (Fig. 3.)

Fig. 3.—Showing the Bowlby-Clark splint applied for fracture of right humerus and Thomas' splint (bent near ring) applied for low fracture of left humerus.

With regard to splintage of the thigh, it soon became clear that the long outside splint left much to be desired ; by its application, extension was seldom efficiently maintained and access to the wound was only possible at the price of displacing the whole splint. Moreover, the control of rotation was poor.

The first modification of this splint to be adopted was the splint which had a rectangular foot-piece and a bracketed interruption to leave the wounded area clear of contact with the splint. It was an advance as regards the treatment of compound fractures of the thigh under stationary conditions, and was better for transport purposes than the original Liston. In 1915 a modified Thomas' splint made from the aluminium strips contained in the field fracture box was introduced. This splint was of the skeleton type and allowed proper extension of the limb and free access to the wounded part. Its employment remained limited because the making of each splint took time and some little experience.

A splint of this type, the Page, was standardized and made in quantity in malleable iron, and for a time had a certain vogue.

By the end of 1915, the use of Thomas' splint in the treatment of fractures of the femur had become generalized at the base hospitals and at most of the casualty clearing stations. It was not until the end of 1916, however, that it came into common use in field ambulances. Applied as detailed below it was found to be of the greatest value in fixing fractured thighs from the earliest time after injury, and the regular supply of standardized splints of this type became general for all units. Fractures of the leg below the knee were in the early days fixed at the field ambulance by somewhat casual methods.

Later it was generally accepted that the most satisfactory results were obtained by using Barbour's back splint with foot piece, in conjunction with two long side splints. For fractures near or into the knee-joint the use of the Thomas' splint was subsequently introduced. In general, towards the

end of the war, it was recognized that all splints should as far as possible be standardized and simple in nature.

In applying splints in the forward area no determined attempt was made to procure complete reduction of the bone fragments to the normal position. Angulation was corrected, but restoration of the normal length of the bone and the control of axial rotation was found to be more suitably left to a later period of the treatment. Some extension was found most desirable, however, from the earliest period, for the action of extension afforded one of the most efficient methods of securing fixation.

The dangerous results which may arise from the pressure of splints applied soon after injury were in evidence from time to time till the end of the war. In the period immediately after a man was hit and a bone broken there was little reactionary effusion in the limb, but very considerable swelling might

develop during the next few hours, either from haemorrhage or inflammation. Such swelling occurring under a firmly applied splint was liable to produce pressure effects varying in extent from a local pressure sore to complete gangrene of an extremity. On this account it became the rule to

cut down and examine at the dressing station all fractures which were causing much pain, or in which the blood circulation in the hand or foot appeared to be impeded.

Fractures of the Humerus.—The splints employed for fixation of the upper arm could be divided into two main types. First, there were those which possessed a crutch or ring taking its purchase on the axillary folds. Splints of this kind permitted the application of extension to the upper arm and were

usually of a skeleton form. Jones' modification of the Thomas and Leclercq's were the best-known examples of this kind.

Secondly, there were those which had no point of fixation in the axilla and merely supported the arm by being directly bandaged to it. The various forms of angle elbow splints came into this category.

For transport in the period immediately following injury, splints of the first, or crutch type, did not prove satisfactory.

It was found that they tended to produce pressure in the axilla, which was usually the source of discomfort and sometimes was sufficiently severe to interfere with the nutrition of the limb.

For fractures of the upper-third of the humerus it was generally agreed that the most satisfactory and comfortable method of fixation was effected by securely bandaging the arm to the body with the elbow semi-flexed and with a wool pad placed in the axilla. As an additional protection and support

a gutter of Gooch splinting was applied to the outer side of the limb, extending from the point of the shoulder to just below the elbow. No extension beyond the weight of the limb was required in order to effect satisfactory and safe alignment of these fractures. For the fractures of the middle- and lower third of the humerus an angular splint was commonly applied internally with a gutter of Gooch splinting as detailed above.

Clark's hinged internal angular splint acted in a similar way and was often used for these cases.

These simple methods showed little change from those adopted at the commencement of the war, and were found to be the most satisfactory. Their advantage lay in the simplicity and ease with which they could be applied, the comfort they afforded the patient, and the infrequency with which they

caused pressure sores.

It will be noted that these methods of immobilization of the upper arm were not likely to procure good alignment of the fragments and that injurious pressure on the Musculo-spiral or other nerves might be produced by the jagged ends of the fragments. However, in practice, no method of fixation

calculated to give really accurate reposition of the fragments was found to be suited to the conditions of work in the forward area.

Fractures of the Fore-arm.—^Whether one or both bones were involved, the elbow was usually fixed by means of an internal angular splint, the lower limb of which reached the level of the wrist, the hand tending to fall into the position midway between pronation and supination. An additional gutter splint was usually applied to the back of the fore arm, being of sufficient length to support the hand.

The final results of fractures of this nature were often very poor, both as regards the function of the hand and the union of the bone. It does not, however, appear that these failures should be attributed to inefficient early splintage. Important nerves and tendons are packed into so small a space in the fore arm that the primary injury alone was almost bound to produce interference with function.

Fractures of the Pelvis.—Special treatment for this type of case was seldom called for in the field ambulance. When the iliac bones were alone involved a firm bandage applied round the pelvis gave sufficient fixation. If the acetabulum was damaged the thigh of the same side was fixed by means of a long outside splint. Cases of injury to the bladder were often not diagnosed at the advanced dressing station, and in any case the treatment of this injury was left to be carried out at the

casualty clearing station.

Fractures of the Femur.—The severe and dangerous nature of this injury in war was early impressed upon all medical officers in the army. An historical outline of the appliances put forward for the improvement of the fixation of these fractures for the purposes of transport has already been given. It is sufficient to repeat that splints of the long outside type were gradually given up in the treatment of these cases, except when the bone was damaged at, or very near, the hip joint.

For the treatment of all other injuries of the femur the Thomas' knee splint established itself as by far the most satisfactory apparatus. On account of its importance and value some points in relation to its use in the forward area may be gone into in detail.

In the later years of the war a systematic method for the application of Thomas' splint for fractures of the femur was laid down by the medical administration of most armies.

Many modifications and accessory appliances had been suggested for its use, but the final results were found to depend on a proper appreciation of the main principles of its action in its original form. Splints with very large rings were generally used. The point of counter-fixation was often the

perineum and ischio-sacral angle, instead of the tuber ischii.

The splint was put on without the patient's clothing or boots being removed. Such a practice was convenient and helped to prevent chilling of the patient during transport moreover, the foot with the boot on was easily and comfortably fixed in the foot-piece of the splint. As the extension required was destined to remain in action only for the few hours necessary for the transport of the patient to the casualty clearing station adhesive applications were seldom employed. Commonly, the attachment was effected by means of a triangular bandage hitched round the ankle over the boot, a wool pad being interposed. A spring clip to hold the heel of the boot was another convenient method of applying the extension. The pressure produced about the ankle by such appliances, if circumstances led to their remaining in place more than a few hours, was sometimes the source of discomfort and, not infrequently, caused serious pressure sores.

In cases in which there was a suspicion of trench foot it was found to be safer to remove the boot and apply an adhesive extension.

It was found to be most satisfactory to hang the splint from an iron suspension bar clipped across the whole width of the stretcher (Fig. 4). When this was not available the end of the splint was propped up on a block of wood or roll of blanket in order to keep the leg free of the stretcher.

Fractures of the Tibia and Fibula.—For those cases of fracture of one or both bones in which the degree or position of the injury did not justify immediate amputation, fixation was usually effected by means of a back splint with a foot-piece coupled with two side splints long enough to fix the knee joint.

For fractures into or near the knee-joint a Thomas' knee splint was found to be more effective.

The experience at the base hospitals showed that a large proportion of the cases in which both bones of the leg were broken sooner or later came to amputation. The subsequent history of injuries of this class emphasized the relatively poor results which were to be expected when the fracture was in the lower half of the bone. In these injuries the main nerves and vessels, on account of their anatomical position, were particularly liable to injury by the fragments. Severe infection, muscle gangrene and secondary haemorrhage were correspondingly common.

In view of these considerations it became recognized that a certain percentage of the worst injuries of this nature were best treated by early amputation before any infection had gained a footing. Such an operation could be conveniently carried out at the field ambulance in quiet periods, though during

active operations it was more often left to the casualty clearing station. If the limb was badly smashed, this delay was certainly not in the best interests of the patient, for the shock which such cases developed in course of transport was severe, whereas if early amputation was carried out the

incidence of this complication was much reduced.

Injuries of the Joints.

The dangerous effects of infected injuries to a large joint have always been prominent in the mind of the surgeon.

The treatment demanded in the field ambulance consisted in the efficient fixation of the joint, and the prompt transfer of the case with a particular note on the field medical card to the casualty clearing station. The large joints were fixed in accordance with the method detailed above for fractures of the long bones entering into the formation of the respective articulations.

Amputations.

In many cases, as just noted, severe fractures of the tibia and fibula are best treated by early amputation. In general, it was not customary to carry out such amputations in the field ambulance or the advanced dressing station unless it was a question of dividing a few remaining structures with one sweep of the knife. Towards the end of the war the view was taken that a formal, and one

which might be expected to be a final, amputation could be undertaken at the advanced dressing station under favourable circumstances. The conditions for which such a course might be considered advisable were, besides fractures of the leg, gross injuries to the knee-joint, and those wounds in

which the main vessels and nerves of the limb had been severed. With regard to injuries in the upper extremity, greater conservatism ruled.

Head Injuries.

In the early days of the war it was somewhat generally held that early operation was of benefit to most perforating wounds of the cranium. It soon became clear, however, that the apparent signs of pressure on the brain commonly to be observed after such injuries were in no way relieved by immediate operation. Progressive sub-dural or subcranial arterial haemorrhage of the classical type leading to compression was very rare in cases of penetrating wounds of the cranium. On these grounds, operation on such cases in the forward area was given up.

It was found that head injuries in the advanced dressing station could be roughly classified into two types : first, those severe injuries associated with a thin, rapid pulse, in which there was extensive damage to the brain, and where an early fatal result was to be expected ; and secondly, those with a slow, steady pulse, who bore transport well, and could be considered to have a fair chance of

recovery. The same principles of wound treatment were applied in dealing with injuries of the head as in the case of the other parts of the body, so far as the nature of the brain substance allowed.

Wounds of the Spine.

The diagnosis of these cases rested, apart from the condition of wounds, on the presence of paraplegia or the interference with control of the bladder function. These signs might be produced by mechanical damage to the cord, by intramedullary haemorrhage, or as the result of concussion.

In the treatment of these cases, rapid evacuation from the forward area was always recognized as of the first importance, in order that the nursing facilities essential for their survival could be provided. No form of fixation of the spine was employed beyond that procured by the supine position on the stretcher. The greatest care in padding the sacrum, buttocks and heels was found necessary in order to avoid the formation of pressure sores. The treatment of the retention of urine common in these cases changed during the war. In the earlier days it was customary to advise regular catheterization.

Latterly, experience at the base and at home proved that cases which had been systematically catheterized inevitably developed cystitis, and it became customary not to pass a catheter at the field ambulance, but to allow the bladder to fill and overflow as it became over-distended

Wounds of the Chest.

A considerable proportion of wounds penetrating the chest proved fatal on the field owing to gross injuries of the heart or large vessels. In the surviving cases varying degrees of respiratory distress and cyanosis were the prominent features shortly after injury.

In the advanced dressing station, treatment was directed to providing conditions which might allow the re-establishment of the respiratory and circulatory balance. The two factors necessary to recovery were a reduction in the extent of any pneumothorax and complete physical rest. Suture of the wound margin including the whole thickness down to the fascial layer of the chest wall was found to be the most efficient method of effecting wound closure. Failing this, the wound was packed with gauze which was then fixed with adhesive strapping. After such a procedure had been carried out the air in the pleural cavity was rapidly absorbed, the lung expanded again, and the improvement in oxygen exchange became correspondingly apparent.

Absolute rest in the position giving greatest ease to the patient reduced the demand of the tissues as a whole for oxygen to a minimum, and so gave the hard-worked respiratory and cardiac muscles a chance of reasonable nutrition.

The length of time these cases should be kept at the advanced dressing station before transfer was found to vary considerably. When there was no cyanosis and little dyspnoea, evacuation on the ordinary lines was carried out, other cases put on one side as moribund made good immediate

recoveries after 24 to 48 hours' complete rest. It was generally held that all injuries of the chest were benefited by a quarter or half grain dose of morphia given hypodermically. Direct cardiac stimulants were not found to be of value, though the general procedures detailed in relation to the treatment of

shock were carried out, unless there was reason to expect reactionary haemorrhage.

Wounds of the Abdomen.

The diagnosis of injury to the abdominal contents, though not always possible shortly after injury, was usually suggested by the position of the wounds and confirmed by the condition of the patient. In many instances, including those of gross injury to the solid viscera, the signs of internal haemorrhage were the most outstanding features. In other cases, prolapse of the intestine through the wound in the abdominal wall made the need of early operation clear.

In the first few months of the war it was held that cases of perforating abdominal wounds were more likely to recover if they were not operated on except when there was prolapse of some viscus. This attitude resulted from the relatively satisfactory outcome of conservative handling of abdominal

wounds in the South African War. It gradually became evident that with the extensive lacerations caused by the pointed bullet and shell fragments of modem warfare, the results of treatment on these Hues were disastrous, and series of cases in which early operation was undertaken showed that this method yielded better results.

It was demonstrated that the sooner the operation was carried out after the injury the better the chance of success.

The reduction to the minimum of the exposure and fatigue to which the patient was submitted after being hit was found to have a similar favourable influence, and it was on account of these desiderata that during periods of stationary warfare special operating centres devoted entirely to the treatment of abdominal injuries were set up as near the line as practicable. These units were usually established by a section of a field ambulance with the addition of some personnel from a clearing station. From time to time attempts were also made to carry out operative work on abdominal cases in dressing stations. In Gallipoli, one field ambulance systematically operated on all penetrating

abdominal wounds, but the final results of these cases were not traced.

In general, attempts to carry out radical abdominal operations in the forward area were not successful ; on occasions it was possible to arrange for adequate surgical technique but it was impossible to supply the reasonable quiet and the skilled nursing, both of which were essential in the

after-treatment of the cases. On these grounds it was found better to make a casualty clearing station the operating centre for abdominal cases, as well as for most others.

With the establishment of this routine, the treatment of abdominal injuries in field ambulances became limited to the application of a simple dressing and rapid evacuation to the operating centre. It was found better not to attempt the reduction of herniated viscera, as in most cases of this kind there was extensive internal injury as well, and the mere reduction of prolapse did but partly deal with the case. Especial care was taken to keep the patients warm, and fluid nourishment was only given in small quantity if the position of the wound or the symptoms suggested an injury of the stomach, fluid was sometimes given subcutaneously. The value of the administration of morphia was a matter upon which differences of opinion existed ; it unquestionably rendered the patients more comfortable during the period of transport, but some workers at casualty clearing stations came to the conclusion that cases so dosed were in a less satisfactory state to stand operation than those who had received no morphia. As a matter of practice, most cases of this class received I gr, of morphia at the advanced dressing station, and as long as they did not get a much larger dose, they seemed to do fairly well.

Dressings for Field Ambulances.

Both wool and gauze were supplied in large unsterilized packets in the British Army, but in the allied armies in France they were supplied in packets of various sizes ready sterilized. It was only at the end of the war that similar packets were supplied at the British front.

The chief objections to the large packets were that very unnecessary quantities were often used, that an open packet of gauze or wool was liable to become dirty and that in cutting up gauze or wool the material was often contaminated by the hands of orderlies or officers. Much time was saved if

the dressings were already cut up.

The conclusions arrived at by most of the surgeons were that it was advisable in the future to issue sterilized dressings to field ambulances ready packed in parcels of three different sizes, and it was believed that such dressings would be safer for wounds and would also prove more economical.

SURGICAL WORK IN FIELD AMBULANCES.

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limitations were set by the amount of equipment and personnel available in these units.

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The experience in the early years of the war emphasized the fact that certain infections were mainly responsible for a high mortality or a slow convalescence in the cases surviving the primary injury. The outstanding and definite advance in the treatment of wounds was concerned with the prevention

which controlled the handling of the wounded man from the time he was hit till he could be transported into surroundings which admitted of the necessary operation being carried out under proper surgical conditions. In general, such conditions were established at the casualty clearing

station. The small group of cases in which it was found possible and advisable to carry out operations of a radical character in the field ambulance will be defined below.

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The appreciation of the necessity of operations of wound excision exerted an important influence on the treatment of the wounded man during the period he was in the hands of the field ambulance. In order to give such operations their best chance of success it was found that they must be carried

action on account of their almost invariably limited accommodation.

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It thus became generally accepted that the surgical work in ambulance units was of the greatest value when it concerned itself with the handling of the wounded man on the lines indicated above, rather than when elaborate attempts were made to carry out any specialized surgical treatment of

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will be considered below under their various headings. They were usually carried out either at an advanced or at a main dressing station.

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In general, it may be said that towards the end of the war the advanced dressing station was the centre of surgical work in the forward area and it may, therefore, be worth while to outline the type of structure which best met the requirements of such an establishment in France.

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The general principles of the organization of walking wounded posts and main dressing stations did not differ essentially from those of an advanced dressing station.

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Treatment of Shock.

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The checking of all bleeding was found to be of the first importance. In cases in the field where there was a sudden loss of much blood the degree of collapse which ensued was extreme. Obviously, such primary bleeding under the conditions of warfare could seldom be directly controlled. In any

such cases which were not at once fatal and had been temporarily controlled in the field by tourniquet, steps were taken at the dressing station to prevent reactionary haemorrhage. The

general treatment of bleeding from large vessels is referred to further on. Cases in which there was oozing from the wound were found to require careful packing ; otherwise the recurrent loss of small quantities of blood might produce profound exhaustion before the man reached the casualty

clearing station.

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The most radical method of dealing with pain, as a factor in shock, was found to be the removal of the damaged tissue, but this procedure was only occasionally practicable in a dressing station.

Support and protection of the part from further injury were desirable. Morphia was usually given

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It was always recognized that fluid nourishment was an early and pressing need of a wounded man.

The administration of hot tea well sweetened with the addition of milk was found to be the most valuable and practical form in which to give fluid by the mouth. The only cases in which it was

The administration to be effective necessitated the lower bowel being empty ; in any case, the rate of

absorption was slow and uncertain.

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suprajacent skin might result later.

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For this reason, this restorative procedure was latterly employed at dressing stations only when

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Treatment of Haemorrhage.

The surgical treatment of haemorrhage in the forward area was not so commonly called for as might be expected. The tourniquet was used both by the stretcher-bearers and by the regimental medical officer. At the advanced dressing station it became the rule to remove any tourniquet, and if bleeding

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The type of haemorrhage which had to be dealt with was either primary or reactionary, and could be divided into the two main clinical divisions according to whether it came from a main vessel or from the capillaries ; the treatment of arterial haematomata resulting from arterial injury had also to

be considered.

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In cases of general oozing it was customary to open up the wound to secure any minor vessels which could be seen and to pack the cavity with dry gauze and apply a firm bandage.

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Such a procedure was clearly only temporary in nature, and a note on the subject was made on the field medical card for the information of the surgeons at the casualty clearing station.

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Arterial haematomas, unless rapidly extending, were not treated at the advanced dressing station. A firm dressing was applied, rest for the parts secured by suitable splintage if necessary, and a small dose of morphia given subcutaneously.

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Fig. 2.—Samways’s tourniquet with modified anchor catch.

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As stated above, the practice of evacuating patients from the forward area with a tourniquet applied was definitely condemned; at the same time there were cases in which as a precautionary measure the tourniquet was loosely put in place to be tightened by the ambulance orderly in case of need.