Original Communications.

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SURGERY IN THE ARMY.

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By

LIEUTENANT-COLONEL D. C. MONRO.

Royal Army Medical .Corps .

In the multitude of middle-aged men who go about their vacations in a daily course determined for them in much the same way as the tie of their cravats, there. is always a good number who once meant to shape their own deeds and alter the world a little . The story of their coming to be shaped after the average and fit to be packed by the gross, is hardly ever told in their consciousness, for perhaps their ardour in generous unpaid toil cooled as imperceptibly as the ardour of other youthful loves, till one day their earlier self-walked like a ghost in its old home and made the new furniture ghastly. Nothing in the world more subtle than the progress of their gradual change! In the beginning they inhaled it unknowingly; you and I may have sent some of our breaths toward infecting them, when we uttered our comforting falsities and drew our silly conclusions: or perhaps it came from the vibration from a woman's glance. "-(Middlemarch.)

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As each January comes round the surgical specialist in the Army must prepare his annual report on the work of his department during the year that has just ended. Ultimately his report reaches the Consulting Surgeon to the Army, who has the unenviable task of reading it, together with others like it, and extracting therefrom such information as he requires to enable him to compile the surgical section of the Annual Report of the Health of the Army. Should he feel annoyed when a surgeon's report fails to bring out succinctly and in a uniform manner the facts and figures he requires, who

shall blame him? In fact, all such formal reports make dull and boring reading. To the surgeon who compiled it, on the other hand, this simple return of numbers of operations performed, with brief notes on fatalities, cases of interest, etc., is a human document. To him, it is the story of his surgical trials, triumphs, and disappointments during the year. It reminds him of moments, even hours, of brow-moistening strain, of emergency calls in the dead of night, of past perplexities and, even more, of numerous exhibitions of pluck and endurance on the part of patients under the stress of

pain and suffering. He remembers with justifiable pride and gratitude occasions when his" team" was instrumental in assisting Nature to coax back a life from the very· brink. How many surgeons, having completed such a report, have not sat a while and pondered, conscious of a tendency to inquire within or even to indulge in self-recrimination?

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It so happens, that after over twenty-five years of active participation in surgical work in the Army I find myself, for the first time, with no Annual report to render.

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Prompted, doubtless, by the realization of this fact, I took down an old file which contained copies of most of the reports I had submitted yearly, and as I committed the contents one by one to the waste paper basket, such relief as I felt was tinged with regret as I reviewed in memory the past years when I, too, had been one of a "number who once meant to shape their deeds and alter the world a little." But there is no profit in regret. Time marches on! Nevertheless, I dare say that few senior

.officers do not wish occasionally that they were again serving during their jollier junior years and struggling with some of the problems which then faced them. .

Those old documents represented considerable experience, and I was reminded of the way in which experience as it accumulated had assisted me to tackle many difficulties which I had encountered in later years. Then I began to wonder whether it would not be possible to turn such experience to some further account. Could I write an article dealing with personal experiences and private views on some aspects of surgery in the· Army, without laying myself open to criticism. Might not the uncharitable reader fail to perceive an altruistic motive and regard such action as unwarrantable presumption? Because I believe that such an article could assist junior surgeons and might be of interest to other officers in the Corps, I intend to risk criticism and attempt it. Much of my own experiences as well as the views I shall express are shared by· surgical colleagues in the Corps, and I trust that the reader will not regard this article as an autobiography, but rather as an attempt to touch superficially on the later history of surgery in the Army, with the improvements in connexion with it that have taken place during the last quarter of a century. Dean Inge in " Social Aphorisms" says: "Individual experience is always one-eyed.

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It takes more than one man to see anything in focus." This is true; so that in presenting somewhat monocular ideas on the subject, I must leave it to those who may care to read them to provide the other eye, and determine for themselves whether there is anything useful in the stereoscopic view.

Three months before the Armistice in 1918 I found myself posted to India, and not long after arrival was appointed surgical specialist to a district m the Deccan. As yet unqualified according to regulations for such an appointment at home, this post abroad carried with it extra pay at the rate of 2s. 6d. per diem. I had just left one of the pivotal surgical field units, a casualty clearing station in France, where for the previous eighteen months I had been in charge of a "surgical team." About thirty of us, newly' joined regulars, were required in India to relieve those who had been there for five years or more. I remember being frankly disappointed with the comparative paucity of equipment and the conditions under which one was expected to work. There had been no lack of surgical equipment in France, in fact it would not be an exaggeration to say that team surgeons had been

rather spoilt in this respect. Such a state of surgical affluence was due to concerted action by civilian surgeons from all over the Empire, who were working in the operating centres in the field. .Many of these young men were brilliant and survived to fill important positions in later years. The enormous numbers of casualties meant that surgeons 'were in general demand:

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" The doctors must have what they want" was almost a slogan. It took me some time to realize that I was now to work under a different system of finance and that improvements in equipment and supplies were likely to come about only slowly in a country which had been affected to a less extent by the war.

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The operation room at the hospital where I was to work was in a semidetached hut connected to the two main surgical wards by a roofed-over footpath; an arrangement satisfactory' enough in that warm climate in calm weather, but those who have served in India know that the worst of the monsoon rains and dust storms come upon one with remarkable rapidity.

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A boiler at the back of the hut provided hot water at forty minutes' notice, and the H.P. sterilizer was heated by a prim us stove. Lamps with incandescent mantles provided artificial light. I remember one senior officer parrying my criticism of this arrangement by stating that he had assisted at several operations at one station in India, a few years previously, performed on an outside veranda screened off from the gaze of interested onlookers by carbolized sheets, and that the cases had done well in spite of the fact that the sheets failed to keep out dust and flies. I heard stories concerning C.O.s of the" old school" who regarded the removal of belt or tunic while working in surgical wards as a relaxation of discipline calling for reprimand.

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Spurs and leggings were worn in the operating theatre. I wore a clean white coat in the wards, but such action was regarded at first· as ostentatious.

While checking the surgical instruments I came across several horn-handled " tools.»

Demobilization followed soon afterwards, and there was keen competition on the part of those due to be released to proffer claims for priority. It was difficult to persuade many that an army cannot be demobilized in a month, and grievances were' voiced publicly. Although there had been a reduction in the strength of the local garrison, the hospital staff had to work very shorthanded, until the demand on shipping lessened and the necessary reinforcements of medical personnel could arrive. I shall never forget an .incident about this time. Late one afternoon I was informed that the General

Officer Commanding-in-Chief was being admitted, and that he' had been accidentally struck in the back of the hand by shot from a scatter gun, .while out after snipe. Radiograms showed thirty-six pellets of No. 8 shot among the small muscles and tendons of the back of the hand. My concern 'and forebodings may well be imagined. However, fortune favoured our efforts, and we were able to remove all but two deeply placed pellets, and the General, being of the good old tough school, and a most delightful and obedient patient, healed well, the injury leaving trivial disability. I sometimes think that had it been otherwise my readers might have been spared this article! This operation required a minimum of instruments, but it reminds us that given a healthy optimistic patient, and luck, it is possible to obtain useful results with the barest surgical necessities.

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A year later I was transferred as surgical specialist to another command, where two-thirds of the effective forces of the Army in India are situated: one nearer the Frontier. There had been trouble with Afghanistan and the Frontier tribes, and some fighting, so we had an occasional battle casualty.

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The equipment of the hospital was more up to date. Nevertheless, there were problems and difficulties to overcome, and not the least of these was the influence of precedent and established custom in the changeless East. I hope it will be realized that these particulars are mentioned not only as part Of the history of those months in 1919-20, but also in order to emphasize that great and beneficial changes began in 1921, the year after the submission of the annual report from which these verbatim extracts are taken, and that they have since continued.

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Anaesthetics .

The only alternative to a rapidly dwindling stock of ether, which I am told was supplied' specially for the war,' is chloroform. I fail to appreciate why it should be considered necessary to supply ether only during war time.

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The excuse I have heard put forward, that ether is wasteful because it evaporates too fast in this hot Climate, is ridiculous, in my opinion. Apart from the fact that long administration of chloroform may well be dangerous in certain cases, such as those with hepatitis, or suffering from chronic sepsis, ether is a much safer anaesthetic. The climate here in the cold months or in the Hills is just like that of the U.K."

At this time there were no specialists in anaesthetics, and as often as not one had to depend on the occasional volunteer amateur to administer chloroform

by means of an antique "safety first" apparatus designed by Vernon Harcourt for just such amateurs and stated to be fool proof.

Nitrous Oxide.

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It would be difficult to overestimate the value of even a limited supply of N20, with an apparatus for administering it. Apart from its safety, pleasantness to take, and absence of after-effects, it is easy to administer, and its use would save much time and labour. Used in combination with oxygen, it was in constant use in France, and is also extensively used in all the leading civil hospitals of the world." .

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Nitrous oxide was supplied . shortly afterwards, and it can be imagined what a popular addition it made.

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Local Anaesthesia (Regional and Infiltration).

Stovain (spinal) and various other proprietary drugs or preparations have to be obtained by local purchase' in small amounts, at exorbitant prices, when it would appear that they could be purchased wholesale by the Indian Government at contract rates and retailed by stores at half the price.

[Note.-It is noted that both Ether and Kerocain (Tabs. gr. t) appear in a list of surplus medical stores, published by Controller of Sales, at dated August 1921."

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Treatment of Fractures.

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One is at times faced with the treatment of fractures with incomplete union in bad position, transferred to this hospital, when, to quote my letter of 2 months ago, every available means' has failed to retain the fragments in an extended and reduced position, and the case is sent here, for further treatment. ? Operation.' In many cases the utmost ingenuity has been exhibited by M.O.s who have been previously treating the case in their efforts to splint the limb and extend the fragments. Nevertheless, the patient often arrives here with his fracture semi- and malunited, the skin broken with pressure sores and blisters where various retentive apparatus, strappings, or glues have been applied. The underlying, cause of failure in this class of case is that, in the heat of this climate, not only will various extension strappings or glues fail to hold, but the skin, being in poor condition from sweat gland infection, easily blisters and sloughs, and each successive means of extension attempted, is effective only long enough to do harm in the end by permitting recurring and intermittent movements. The remedy suggested is the immediate transfer of fracture cases to a hospital, where the fragments can be reduced by open operation or by extension applied direct to the bone. The latter method is preferable.

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N.B.-Sir Arbuthnot Lane's open methods were in vogue at the time.

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Somewhere in one of my boxes there is an old riding stirrup which the local ordnance officer kindly converted into a tolerable imitation of an extension calliper, with which I treated several fractures of the femur with average results.

Thomas pattern leg splint.

The Officer Commanding the Station Hospital at  (a subsidiary Out· Station in the District, some 130 miles distant) stated the other day, that he has no Thomas splint on charge and is not entitled to one on the equipment scale.' It is hard to believe that this could be so when the Station is the headquarters of a cavalry brigade and a horse battery."

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So much for my first tour of India. On completion of my five years' tour abroad I returned to home service, and soon after attended the senior promotion course at the Royal Army Medical College, and was fortunate enough to be able to satisfy the College Council that I was fit to specialize in surgery . During the latter six months I did an excellent Fellowship Course at St. Thomas's Hospital and duly qualified as a surgical specialist, and was then entitled to draw, at home also, the special rate of pay (still only 2s. 6d. per diem) when employed in that capacity.

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Since then I have completed another tour in India, and I shall always regard those two tours as embracing. some of the most interesting, most strenuous, and happiest years of my service.

SURGERY AS A CAREER IN THE CORPS.

Very naturally, one is often asked by junior officers for advice on the question of taking up surgery as a career in the Corps. My reply has usually been that I, personally, have never regretted it, though at times I have felt that the work was rather more strenuous than I liked and that there have been numerous occasions when I felt that one was terribly tied by it in comparison with officers specializing in some other branches of our work.

It is necessary that aspirants should appreciate the advantages and disadvantages of taking up surgical work as a special subject in the Army.

As to the former: In the first place we deal mostly with fit young men in the prime of life, so that we get little of the surgery of senility. Of our patients, officers retire at the age of 55 or 57, and other ranks go to the Army Reserve while still in early middle age. Compared with civil hospital work, we get less of the surgery of malignancy, though there would appear to have been a definite tendency in the last ten years or so for this fell disease to affect younger soldiers. Female surgery is limited by the comparatively small numbers of married men and the officers' families, but when the officer in charge of the military families' hospital is not a practising- surgeon, a proportionate increase in the numbers of this class of case will fall to the surgeon. Much of our work deals with the effects of trauma or pyrogenic infection.

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Our organization is such that we get our acute and urgent cases early. Then again, it is a definite advantage, when appointed to a station or command, to be assured of comparative fixity of tenure. The appointment is usually for three years, and it is the exception for military exigencies to

intervene and necessitate an unforeseen move. We work in a good climate as a rule, avoiding most of the hot weather in stations abroad by accompanying our patients to the more salubrious climate of a hill station.

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Consideration for the comfort of the patients, rather more than for that of the surgeon, demands such an arrangement. Finally, the main surgical centres are situated in the more populated and important stations, where there is plenty of life going on around one, and no dearth of opportunity for recreation and sport if one has time to participate. Private practice is permitted, but only on the strict understanding that it involves no expenditure of Government time or material.

Now for the disadvantages.

Too often one is the only surgeon in the station, and this means ploughing rather a lonely furrow.

There is a natural tendency to regard an only surgeon as indispensable, and although he is usually excused from doing his share as orderly medical officer, in reality he is constantly on duty and is apt to be ,overworked. At times, too, one experiences a tendency to compare one's lot with that of a few more fortunate brethren in civil life, who get fat fees for performing many operations for which the Army surgeon's only extra remuneration is (now) 5s. a day. On the other hand, a fixed income is assured and there is a pension to look forward to. When consideration is given to the opportunities for work, recreation, and social intercourse with those of the same station in life, to the fact that it is often possible to obtain two months' leave per annum (and one period of six months during a foreign tour) or sick leave on full pay, and without the necessity to employ a locum tenens, who would wish

to change places with the average surgical colleague in civil life .

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THE TRAINING OF A SURGEON.

In a recent address from the chair of the Medical Society of London (delivered on October 9, 1939) and published by the British Medical Journal on October 21, 1939, Mr. Zachary Cope made many essentially sound statements under the heading" The Profession of Surgery."

Of the surgeon he said :-

" To no man was the destiny of human life so often delivered. As judge he had not only to give the verdict but himself to carry out the sentence. " It must be admitted that the surgeon could not be standardized any more than the general practitioner, but it should be possible to ensure a greater minimum knowledge and experience in everyone wishing to become a surgeon. The responsibility of the profession to the public was such that adequate guarantees as to sufficient training of anyone wishing to practice major surgery should be furnished. . .. It was probably true that in none of the higher British surgical qualifications was supervised practical experience sufficiently insisted on as an essential preliminary for a candidate. Some qualifications indeed were open to the criticism that they seemed more in the nature of competitive examinations than tests designed to demonstrate a candidate's skill and experience in surgery."

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The possession of a special surgical degree is not essential for junior officers who wish to specialize, but a surgical Fellowship of one of the colleges will not only entitle him to prior consideration but also ensure that he ·is employed in surgical work as soon as it is established that he can put his theoretical knowledge into practice. To have had practical surgical experience would be a factor of value, but one of the most important assets that a prospective candidate can possess is that he shall have served an apprenticeship for at least six months as house surgeon to a recognized master of the art. On joining, an officer may be seconded for a period to enable him to obtain such training. For the rest, his anatomy book should be his medical bible, he should have confidence in his nerve, " good hands," sufficient conscience, and a sense of responsibility. With experience he will gain in assurance and inspire confidence. A surgeon is more often born than made. The best surgeon has a natural flare for the work. Haye we not all seen men with the highest surgical qualifications who have none of these natural aptitudes? Some who are wise enough to appreciate their limitations will not handle a scalpel; others, alas, with less perception, muddle, and burrow through an operation, using many of their instruments after the manner of shovels or tyre levers !

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Under the recent Short Service Commission regulations, a junior officer who has given proof of sufficient experience may be graded "surgeon”  after  recommendation by competent authority and approval by the R.A.M. College Council. If thereafter employed on specialist duties in a station which is entitled to a surgeon on peace establishments, he may draw the extra allowance which the appointment carries. Under normal circumstances the special qualification is not granted until the candidate has obtained qualifying marks in the various subjects at the senior promotion

course at the College and has passed the special examination in surgery which will follow. In preparation for-this he has what is tantamount to a fellowship coach course lasting six months, and for which the Army pays all fees. The newly qualified surgeon should be posted to a station to work for his first six months under a senior surgeon, whenever such an arrangement is possible. In my experience, this plan has not only been popular with the junior officers, but of considerable value to them. Those of us who have worked in London, freely acknowledge the added feeling of confidence which the presence not only of the Consulting Surgeon to the Army, but, also of the several Honorary Consultants to Queen Alexandra Hospital, gives "them I have long felt that our appreciation of the unsparing and entirely voluntary assistance which our honorary consultants in London have always rendered, might be recorded in some more tangible manner.

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India is a fertile training ground for our young surgeons. If a junior officer in one of the more isolated stations can acquire a passing knowledge of the local language and customs, and gain the confidence of those in the locality, he will find a wealth of opportunity and material and gain in experience and self-reliance.

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Most surgeons working in India have felt the need on occasion for an Army surgical consultant. By simply touring to inspect the surgical divisions in hospitals, and getting to know the surgeons working under him, he could do useful and valuable work. But the vast distances he would have to travel. in case of emergency, even should the local government emulate the "flying doctors" in Australia by providing aerial transport (a most unlikely supposition), would not only tend· to render his help in person ineffectual, but would certainly reduce the number of applicants for such a post to an insignificant and rather heroic few. In many districts where Royal Army Medical Corps surgeons are employed there is an experienced officer on the civil side of our sister Service, the Indian Medical

Service, who is both capable and willing to help if required. A courtesy call and a "bak" about "shop" is always appreciated, and a profitable alliance results.

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Once a year each officer' is r()ported on through the medium of his confidential report. This raises a difficult question. How is a commanding officer, who makes no pretence to special surgical knowledge, to appraise the work of his surgeon? At all events, the reporting officer will be a man of experience, who is unlikely to be influenced by a mere account of numbers of operations performed. He will be uninfluenced by fatalities without full consideration of the facts concerning them. He will know how much weight to give to local reputation and will not be misled by station gossip. He will weigh industry and conscientiousness against the state of the waiting list for operation and the" turn-over" of the wards.

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He will be particularly influenced by the organization of the surgical work, the morale and confidence in the surgical wards, and the causes which led to invaliding. Surgical semi-invalids with little chance of ever  returning to full duty should not be kept hanging about in the station to swell the numbers of those "constantly sick" when there is little prospect of their recovery in under six months. The junior surgeon should study the war organization of the medical services, and by reading official medical history should attempt to visualize the conditions under which he may have to work in wartime. The value of advances in surgical knowledge should be assessed in terms of their applicability to conditions in the field. As regulars, our principal function in war is to assist in the organization.

POSTED.

When posted to a station to fill a surgical vacancy the newly qualified specialist's troubles have really begun. Arriving at his destination he will be instructed to report to the senior executive medical officer, who will take an early opportunity of presenting him to the officer in command of the garrison.

In due course he will proceed to the military hospital to report to the officer  commanding and will be conducted round the premises and given useful general information concerning his duties and life in the station.

Whenever possible, and this is almost invariably so, he should take over from his predecessor in person, seeing the cases during a personally conducted tour of the wards. Should the station be small or second class he will be expected ‘to take his share in the general medical duties. In a larger station, however, he will be a very busy man, constantly on call, and should be excused, as he generally is, from taking his turn on the roster of orderly medical officers (O.M.O.s). It not infrequently happens that the "new man" has to take over from a surgeon of repute, who is not only popular but enjoys the confidence of the station, and whose departure is obviously regretted. People are wont to be thoughtless or tactless enough to say so, openly, in the new man's presence. Little wonder that at such a time he is apt to feel aware that his own reputation and that of the Corps, will probably depend on a " lucky break," and that the successful handling of his first few important cases will make or mar him. Strange how often over-anxiety or ill-luck will tip the scales against a villain under the circumstances!

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He should then check over his equipment and get to know his theatre' staff. It is a mistake to rush a strange staff with a host of instructions concerning personal preference in theatre routine and the preparation of cases for operation. This only fusses everyone, 'and such changes as are deemed necessary can be brought about gradually. Any special instructions concerning routine after-treatment are best communicated in 'writing and issued to the sisters in charge. of the wards, as routine orders. A courtesy call should always be made on the matron or senior sister. Her cooperation can be assured, but an informal talk will reveal many ways in which the general conduct of the work can be furthered, such as restricting operations to certain days to enable the staff to have their off-duty periods.

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Nowadays, fortunately, most C.O.s appreciate that it is generally impracticable, particularly in a busy station, for the surgeon to report daily to him at a stated hour. It should be sufficient for the C.O. to know that his surgical adviser will keep him informed and is available for interview concerning such problems as may arise, when not engaged on his primary duty of attending to his cases. Routine work is always arranged to a fixed programme, which is drawn up so as to fit in with that of the other specialists (ear, nose, and throat, medical, etc.).

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The contents of the splint room should also be checked, and it is a good plan to pay a friendly visit to the neighbouring medical stores depot to see the reserves and mobilization equipment. Make a point of never hoarding superfluous stock and see that no items which require repairs or replacement are allowed to accumulate.

In most stations in 'India surgical work is transferred to the associated hill station for the hot weather (May to August). The surgical unit moves up as a team, complete with instruments, etc . , leaving. A reduced emergency set of instruments in the plains in charge of the second theatre. orderly, who' remains there.

On occasion it may be necessary to visit one of the out-stations. The surgeon's services may be required for a consultation with the local M.O . or to operate on a case. Though generally unavoidable, these journeys upset routine or a prearranged programme in an annoying way. On the other hand, they may provide a welcome change of scene, and in later years have been made occasionally by air. Any train journey in the heat in India is tiring and often uncomfortable, and it is not inclined to improve the temper when you are told on arrival that the case you came to see is dead.

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The problem of providing for treatment of cases of haemorrhage is· nowadays simplified. A list of registered local volunteer blood donors is available in the theatre, and it is the duty of the officer in charge of the district laboratory to see that the volunteers are available, and their numbers kept up to requirements.

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The first whole blood transfusion I saw was carried out by members of the Harvard Medical Unit (Drs. Denis Crile, Alton, and Fish) at a casualty clearing station in France in 1916. The old paraffin coated Kimpton tube was. used. Later the citrated method was in common use, and of many cases I have since seen resuscitated in this dramatic manner, the one that sticks out most vividly in my memory occurred later, when the victim was the late Lieutenant Osier, son of his distinguished father. We had no listed donors and I had to go round a convalescent marquee with a hurricane lamp in the dark, asking for a volunteer. The operation enabled the patient to regain consciousness and carry out a longish intimate conversation with his godfather, the late Harvey Cushing, before Professor Darragh and Dr. Brewer (both of D.S.A. M.S.) operated skillfully on a forlorn hope.

An important duty for which the surgeon is responsible is the selection and training of operating room attendants. The first is more often easier said than done. The candidate should be .a first-class nursing orderly if possible. Too often it happens that the man you would like is one of the mainstays in the wards, and the nursing staff is loath to let him go. Considerable collaboration is required between the company officer, the matron, and yourself. Here it is essential to get a man who is smart, conscientious, keen, and trustworthy. He must be fond of the work, and realize that he

holds a position of responsibility and one which is confidential. It should never be allowed to hinder his advancement, no matter how much it upsets the running of the work. Whenever he can be spared from the operating theatre, he should accompany you on ward rounds and with the senior nursing orderlies, there to be instructed or questioned on the cases and problems connected with each. Your senior ward orderly should know the diagnosis of each case in his ward, and the basis of treatment and your operating room attendant should· know about each case. which has been operated on, and about the progress of them. Make all your instruction interesting and practical, and above all, train the powers of observation and anticipation.

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ADVICE ON THE ORGANIZATION.

Out-patients.-Two half-days in the week are usually occupied in seeing out-patients (O.P.s). At this stage let me say that one of the soundest bits of advice I can give any specialist, or for that matter any officer in the Corps, is to purchase and learn to use a portable typewriter. A specialist, in particular, has a good deal of writing to do, and if you happen to be one of a number who use a particular form of calligraphy, which might be styled " all your own," the adoption of a typewriter as a means of conveying your thoughts to paper will be welcomed by all colleagues and most friends.

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At all times in professional work, a typewritten document is more business-like. Another, and perhaps the greatest advantage, is that you can so easily duplicate reports and letters and keep a copy for your personal file, at the same time saving yourself the annoyance, especially at the end of a long day when you are hot, tired, and irritable, of having to scan and correct the efforts of one of the less proficient babus (Indian clerks) who are capable of making the most imperial hash of our technical words.

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