THE DEVELOPMENT OF CASUALTY CLEARING STATIONS

AND FRONT-LINE SURGERY IN FRANCE.

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THE Casualty Clearing Station was the development of a unit which was created in 1907 under the name of Clearing Hospital," and retained the latter name until January 1915. This unit had not existed in any previous war in which Great Britain was engaged. It was formed as a link between the field ambulance, which was organized after the South African War by combining the old bearer companies and field hospitals into one medical unit, and the lines of communication. It was intended for the temporary reception and care of sick and wounded pending and during evacuation from the front, and its functions were similar to those of the tent division of a field ambulance but on a larger scale.

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The staff of a casualty clearing station consisted of a commanding officer, a quartermaster, six medical officers, and 77 N.C.O.'s and other ranks. No scale of transport was laid down for the units in the 1914 mobilization tables, but a footnote explained that if transport was required it would be furnished under orders of the Inspector-General of Communications. It was calculated that 17 general service wagons or eight 3-ton motor lorries were necessary for transport when the unit was ordered to move by road. Each unit carried 210 stretchers, 200 paillasse cases, 200 bolster cases,

480 sheets, 50 feather pillows, 400 blankets, and sufficient cooking and feeding utensils, medical stores and comforts, and tents for 200 patients, but no bedsteads or mattresses. The surgical equipment was small and included one small operating tent and one operating table. Each unit was provided with a few wooden splints, all of which were too slender to be of much service, and also with some yards of metal splinting material from which it was intended that other splints should be

improvised as occasion required. This material was called " aluminium splinting." But the reason of clearing hospitals being supplied on mobilization with this comparatively small equipment was because, being at or in the vicinity of railhead, additional equipment and stores could be more readily obtained from the base than in the case of divisional medical units, and it was also intended that use should be made of local resources.

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Before the war, it was an essential part of the scheme for the treatment of the seriously sick and wounded that men should not be retained for treatment in the front-line units, where their presence might create difficulties and might interfere with the movements of the army. The prime duty of the

casualty clearing stations was therefore to arrange for the satisfactory evacuation of the wounded and sick rather than for their active treatment.

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In the earliest days of the war in France the casualty clearing stations Were not in a position to take any great part in either treating or evacuating sick or wounded. At the time of the fighting at Mons and Le Cateau most of them were still packed up and on the railway, and it was not until the battle of the Aisne, in September, that they got to work. After this battle, when the army moved northward, the casualty clearing stations were able to unpack their stores and to make the best use of their equipment, so that they may be considered to have really embarked on their career during the

fighting which extended from Bethune to Ypres. It is interesting to note their positions with relation to the fighting line and the railways. No. 1 was at St. Omer, No. 2 at Bailleul, No. 3 at Ypres, No. 4 at Poperinghe, No. 5 at Hazebrouck, and No. 6 at Bethune. Both Bethune and Ypres were close to the

fighting line. Bailleul was about seven miles behind it ; Poperinghe about seven miles behind Ypres; while Hazebrouck was over fifteen miles from the front, and St. Omer about twenty-five miles.

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All these casualty clearing stations were in buildings, and did not at that time use their tents to any extent, but already they had begun to expand and to take in far more than the 200 for which they were equipped. Thus, at Bethune, the casualty clearing station occupied a very large school for girls, and accommodated more than 600 wounded men while at St. Omer, the big Jesuit College of St. Joseph housed a similar number, and subsequently many more. All the other units also were forced to expand into neighbouring buildings, so that at Poperinghe No. 4 Casualty Clearing Station spread over three separate buildings, and No. 2 Casualty Clearing Station at Bailleul over two. This expansion meant a great strain on the staffs of only seven medical officers, and, combined with the

large numbers of the wounded, quite prevented any surgery being done except in an infinitely small percentage of the total number admitted ; but, small though it was, it was sufficient to show that a front-line hospital might be of very great value in supplementing the work of the field ambulances, and the experience of all the earlier months of the war convinced the surgeons that much more surgery was badly needed at the front.

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The First Battle of Ypres cost in wounded alone about 13,000 men, and almost all of these depended on the general hospitals on the lines of communication for adequate surgical treatment,

whilst very many of them had to be sent at once to England, because of insufficient accommodation on the lines of communication in France. The reason for this was that the sudden move from the Aisne to the Ypres region had made it very difficult to send patients quickly to the hospitals in Paris or Rouen, and want of time had prevented the creation of large enough hospitals at Boulogne or Calais.

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It must next be noted that efficient evacuation and treatment by casualty clearing stations were necessarily dependent upon the transport of wounded from the battle-field. When the fighting was transferred to the Aisne, and the line became stabilized, evacuation by train was less difficult, although extremely slow.

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Motor ambulance cars were employed for the first time in bringing back wounded to railhead on the 20th September 1914, and the first organized motor ambulance convoy was formed on the Aisne at the end of September from ambulance cars sent out by the War Office early in the month.

Subsequently other convoys were organized and were at work on the Flanders front after the Expeditionary Force moved there from the Aisne. Thus, on 13th October, wounded, to the number of about 400, from the fighting around Meteren and the Mont des Cats were taken by motor ambulance cars to No. 1 Casualty Clearing Station at St. Omer. At about the same time other motor ambulance cars were bringing the wounded into No. 6 Casualty Clearing Station at Bethune from the area of Festubert, Aubers and Estaires. The numbers passing through the casualty clearing stations during the last week of October were very great, and without the motor ambulance convoys they could not have been brought in so rapidly from the field ambulances. On some days more than a thousand were admitted to a single casualty clearing station, so that all that the small staff could do was to dress the wounds and put the patients into trains as quickly as possible, while matters

were made still more difficult by the shelling of Ypres and the consequent removal of No. 3 Casualty Clearing Station from the town. A few days later No. 6 Casualty Clearing Station was shelled in Bethune and had also to retire.

It was during November 1914, when the German attack had been held up and defeated, that the opportunity came for improving the buildings occupied by the various casualty clearing stations. At the same time two very important changes took place, namely, the appointment of a few nursing

sisters and the supply of a small number of bedsteads and bedding. These were not only valuable additions in themselves, but they showed clearly the alteration of the original policy that wounded men were not to be retained for treatment at the front. This period, indeed, marked the first important development of a new arrangement by which, ultimately, the wounded were no longer retained in the field ambulances for operative treatment, but were sent on as quickly as possible

to the casualty clearing stations.

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Early in January 1915, a most important development took place, in that a new and additional surgical equipment was supplied at this time to all casualty clearing stations, and this coincided with the formal approval of the Director-General of more operating work being systematically undertaken by the casualty clearing stations. The consequence was that during January and February large numbers of operations were performed at the front, and in quiet times when no heavy fighting was in progress a large proportion of the wounded were submitted to operation in the casualty clearing stations and were retained for some time before being entrained. Many of the worst cases were head wounds, the result of sniping, for the trenches afforded insufficient protection to both officers

and men. But while in quiet times the surgical work could be satisfactorily done to a great extent, as soon as the heavy fighting of Neuve Chapelle, Hill 60, the Second Battle of Ypres, and Festubert developed, the wounded had all to be evacuated to the lines of communication or even to England,

and the surgery of the front became again limited to the performance of only the most urgent operations and the application of dressings.

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In June 1915, a further increase of equipment for casualty clearing stations was authorized and was quickly supplied,* so that during the rest of that summer the opportunities for good surgical work were greatly improved. At the Battle of Loos, however, on 25th September, the conditions again resulted in so large a number of wounded in proportion to the supply of casualty clearing stations and surgeons, that only a very small proportion of the wounded could be treated adequately at the front. In the Battle of Neuve Chapelle, in March, there were about 9,256 wounded, and during the months of April and May they amounted to approximately 67,041. The Loos fighting cost 38,161

wounded between 9 a.m. 25th September and 9 a.m. 15th October, and during the whole year 1915 the wounded totalled 206,113.

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* "Bowlby Outfit No. 2."

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It must be noted, however, that before the Battle of Loos was fought there had been two other important developments, namely, the erection of the first hutted and tented casualty clearing stations, and the creation of the first " Advanced Operating Centre." Nos. 10 and 17 Casualty Clearing Stations were erected in June and July 1915 at Remy Siding, near Poperinghe, and an advanced operating centre was established in preparation for the Battle of Loos in the 1st Army at Bac St. Maur, in the area of the 3rd Corps, and at Noeux les Mines in proximity to the battle front.

From this time onwards it was the policy of the Army Medical Service to erect casualty clearing stations on open ground, so situated as to be supplied with a railway siding for their own use, and with good road communication towards the front . Advanced operating centres were only erected when it was not possible to place casualty clearing stations sufficiently near the trench line, or when it seemed advisable to supplement the casualty clearing stations in anticipation of heavy fighting.

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But, while the developments described above had been taking place, the personnel of the casualty clearing stations had remained unchanged and important reinforcements of medical officers and orderlies had not as yet been supplied until after the commencement of a battle. It must also be

remembered that it was only at the end of 1915 that the policy was finally adopted of not doing more operations than could be helped at field ambulances, and of consequently using the casualty clearing stations as front-line hospitals and transmitting wounded to them as quickly as possible.

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The definite adoption of such a policy was necessarily followed by further changes in the casualty clearing stations. It had been found by experience that better results were obtained by getting wounded into the casualty clearing stations before any operations were undertaken, and for several reasons. In the first place, it was very advisable that serious cases should be in beds and well nursed ; and secondly, it was often much better to move a man before an operation than after it, for in many cases of bad abdominal, chest or head wounds movement directly after operation was very dangerous to life. Arrangements for sterilizing instruments, gowns, etc., were also much more difficult at field ambulances, and it was more difficult to obtain the necessary quietude and freedom

from disturbance. It may, therefore, be concluded that after the end of 1915 the bulk of the surgical work at the front was finally transferred from the field ambulances to the casualty clearing stations, and continued to be so during the rest of the war.

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The necessary result of this transference of surgery was the appointment and training of suitable surgeons, and, whereas at first a single "surgical specialist" was allotted to each casualty clearing station, a "second surgeon" was now appointed as well. It was also very necessary that when any

surgeon showed great surgical ability and aptitude he should not be moved from his unit without sufficient cause, for the right sort of man would not only improve his own work by experience but would also help to train other members of the staff, and would organize and develop, in conjunction with his commanding officer, the whole surgical routine of his unit.

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It thus happened that there grew up a body of young surgeons who, guided by the advice of the consulting surgeons of their respective armies, gradually developed a "surgery of the front,"based upon the principles of good civilian surgery ; and, as time went on, one heard less and less that the difficulties of the war conditions were sufficient to excuse poor technique or inadequate asepsis.

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During the earlier part of 1916 many of the new casualty clearing stations were greatly enlarged, some of them being entirely hutted, but others partly in tents. As early as October 1915, it had been agreed that the small operating tent should be given up, and its place taken by a hut of 60 feet in length and 20 feet in width. This was subsequently the regulation supply on the entire front. It gave good room for four operating tables and their equipment. At the beginning of 1916 a " Memorandum on Wounds "was published by the War Office, and issued to all medical officers. It had been written by some of the consulting surgeons and physicians in France, on the instructions of the Director-

General of the British Expeditionary Force, and it formulated the conclusions as to some general principles of treatment agreed to in 1915.* The distribution of the memorandum was of * An enlarged edition was issued in 1917 under the title of "Injuries and Diseases of War." great assistance in establishing definite methods, and it enabled general instructions to be easily circulated at the front.

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It was in accordance with this that the following memorandum, drawn up by the advising consulting surgeon for the front areas, was issued on the 27th April 1916, by the D.M.S. Fourth Army. It gives a good general idea of the methods which were then being adopted everywhere, and shows what

progress had been made at that time in the arrangements for treating wounded men.

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'• TREATMENT OF WOUNDS."

"The attention of all R.A.M.C. of&cers is called to the memorandum—* Treatment of Injuries in War.'

All D.Ds.M.S., A.Ds.M.S. and Commanders of Medical Units should ensure that all medical officers serving under them (more especially those who have come from hoine) are in possession of the book, and that, as far as possible, the treatment advocated therein is carried out.

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Special stress should be laid upon the following points :—

(1) Only operations of emergency should be performed in field ambulances,

but the' following exceptions should be noted :—

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(a) Completely smashed limbs should be removed, and the patients

retained for at least a day before being sent to a casualty

clearing station.

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[b) Haemorrhage should be arrested by ligature of bleeding vessels

whenever possible. If this is not possible, then plugging and

direct pressure on the wound itself should be resorted to ;

and patients should never be sent down with elastic tourniquets

on their limbs. Tourniquets have often caused gangrene,

and always cause very severe pain.

(2) Abdominal wounds require treatment at a casualty clearing station

as early as possible, and even if penetration is doubtful, should

be at once sent on by special motor ambulance. All wounds

of the loins and buttocks which are associated with abdominal

pains are probably penetrating wounds of the abdominal cavity,

and should be treated as such. Operations on the abdomen

are to be done at the casualty clearing stations, or at special

emergency hospitals.

{3) Chest wounds penetrating the lungs, and having large openings

admitting the free passage of blood and air, should be treated

by cleansing the wound, and plugging it with sterile gauze, and

applying rubber plaster so as to close it hermetically. If not so

treated, the patients often die of haemorrhage.

(4) In cases of fractures of the extremities, splints should always be

applied before the limb is bandaged. All wounds of joints should

also be splinted.

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(5) The application of iodine to the skin, followed bj^ the use of cyanide

gauze, results in severe blistering, and this combination should be

avoided.

(6) Neither amputation wounds nor any other wounds should be

closed by sutures. They should be left completely open.

(7) All severe cases reciuiring early treatment at a casualty clearing

station should be at once sent there by a special motor ambulance

direct from field ambulances. They should not be kept waiting

for the regular convoys."

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The preparations for the offensive on the Somme in July 1916 gave the first opportunity of arranging for surgery on a large scale in heavy fighting, and fourteen casualty clearing stations and one advanced operating centre with forty beds were supplied to the Fourth Army, which was the chief seat of attack, apart from the casualty clearing stations in the adjacent Third Army. Many of these casualty clearing stations were large enough to accommodate 1,000 patients, and on the night

of 1st July several of them accommodated twelve or thirteen hundred. In order to deal with the great numbers of wounded expected, the staff of medical officers of the casualty clearing stations had all been more than doubled before the battle began, and additional nursing sisters had also been supplied beforehand. All of these were further increased as soon as the numbers of wounded were realized. They were more numerous than in any previous battle, for on the first day about 14,400 men were admitted into 13 clearing stations of the Fourth Army, on the second day 13,806, and on the third day 8,793. The difficulties of adequately treating such large numbers were increased by

the fact that during the first twenty-four hours of the battle a sufficient number of ambulance trains had not come up to relieve the congestion in the casualty clearing stations. Yet many hundred operations were performed even when the stress was greatest, and in the four and a half months during which the battle lasted more than 30,000 operations were performed in the casualty clearing stations and the advanced operating centre of the Fourth and Fifth Armies alone. It should further

be noted that, in anticipation of much operating, very large numbers of additional surgical instruments and equipment of all sorts had been supplied, for without these the additional surgeons would have been of comparatively little help. The total number of wounded during the Battle of the Somme from 1st July to 17th November was approximately 318,408, of whom over 124,796 were treated in the month of July alone. 

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In the whole year 1916 the number of wounded was over 450,887. It has already been mentioned that the casualty clearing stations had been greatly enlarged for the Somme offensive, and it was at this time that certain general principles began to be evolved which ultimately resulted in the standardization of a definite system for the distribution and treatment of the wounded. In accordance with this, a casualty clearing station comprised :—

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(1) A general admission tent or hut in which the necessary particulars were entered as each patient arrived.

(2) A tent for the dressing of walking patients.

(3) A tent for the dressing of lying-down patients.

(4) A pre-operation tent.

(5) A resuscitation tent.

(6) Tents where patients might be kept for treatment.

(7) Tents where patients for evacuation were placed.

In any casualty clearing station so planned, the patient was given hot drink of some kind on arrival, generally tea, and, if a walking case with a slight wound, he would be passed through the dressing tent straight to the evacuation area, and thence to the train. If an operation was advised his dirty clothes were removed in the pre-operation ward, and he was if possible dressed in clean pyjamas before being taken to the operating theatre. If he was suffering from shock or exposure he was

taken first to the resuscitation ward, and after operation he was either put in bed to be retained, or on a stretcher for evacuation.

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X-ray Work in Casualty Clearing Stations.

As it had not been foreseen that much, if any, operation work would be done in casualty clearing stations, no X-ray outfits were originally supplied, but early in January 1915, mobile X-ray vehicles were allotted, one to the First and one to the Second Army. Later on, as the surgery of the front increased, additional mobile and fixed sets were supplied, and in 1917 many of the casualty clearing stations had their own apparatus. The value of the mobile X-ray vehicles varied greatly, and while

some of them were really mobile, others moved with difficulty or sometimes only moved at the expense of many breakages. As time went on, it became evident that the ideal was for each

casualty clearing station to be supplied with a lorry which carried all the X-ray apparatus arranged so that the power could be supplied from the lorry. Experience also showed that it was necessary to provide suitable "X-ray" huts instead of tents, as without huts the results obtained were never satisfactory. It was soon evident that X-rays were of the very greatest value at the front, and were if anything even more important there than at the base hospitals. In many cases their use obviated an exploratory operation, while in others they supplied the information without which no operation could

be performed. They undoubtedly constituted a very essential part of the equipment of all casualty clearing stations.

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In some cases where there was a group of casualty clearing stations close to each other, a single power station was erected for the supply of them all. Thus at Tincourt in 1917 the X-rays of three casualty clearing stations were run from a single installation. But, as more and more demands were made for the use of X-rays at the front, it became evident that the officer in charge could not do the work unaided, and a skilled N.C.O. was added to the original staff. It also appeared that, just as it was necessary to supply surgical reinforcements for heavy fighting, it was necessary in addition to obtain the services of additional X-ray specialists. The supply of X-ray equipment and of special officers was never equal to the demand, for while the apparatus itself could be readily obtained, difficulties in supplying suitable engines remained to the very end of the war. The Grouping of Casualty Clearing Stations. As soon as the first grouped casualty clearing stations were established at Remy Siding in 1915, it became possible to arrange that they should be on duty "turn and turn about," and this meant that in so-called "quiet times" each was taking in during alternate periods of twenty-four hours. In this way each unit was able to get through the necessary work of treating the patients already admitted without being disturbed by the arrival of fresh wounded, and the whole staff had a period of rest from fresh admissions. From that time onwards the system of grouping two or more casualty clearing stations was adopted as a general principle, and by this arrangement it was easy to provide for a single railway siding or a single water supply for all the casualty clearing stations of any one group.

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This was a saving of great importance. During heavy fighting the group system was also of great

practical value in another way, for it was then arranged that each casualty clearing station of a group should take in wounded, not for a certain fixed period but up to a certain number, and when this number was reached the motor ambulances arriving with wounded were "switched off" to the next casualty clearing station, until it also had received the allotted number. This arrangement was first put into practice for groups in the Somme fighting in 1916,* but afterwards became universal. The number that should be taken in before "switching off" necessarily varied in proportion to the pressure and to the number of surgeons at work, but whereas at first as many as 400 were admitted before another casualty clearing station took on the work, the longer the war lasted the more the

numbers tended to be reduced, so that 150 or 200 became a standard, and one severe case was often by arrangement counted as the equivalent of two patients able to walk. It was also found that when large numbers of wounded were arriving at the beginning of heavy fighting it was best to take in only 100 at first, or even less, for in this way the staffs of two or more casualty clearing stations got quickly to work instead of being kept waiting in idleness while the first casualty clearing station

on duty took in a large number.

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*The system had actually been in practice in the First Army during the Battle of Loos in 1915, but before the grouping of casualty clearing stations.

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The Work of Consulting Surgeons in Casualty Clearing Stations.

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The development of the surgery of the casualty clearing stations was largely the work of the consulting surgeons at the front. In September 1914, two consulting surgeons were sent to France, and after the middle of October one of them. Sir George Makins, remained at Boulogne and the other. Sir Anthony Bowlby, began to visit the casualty clearing stations. It was not until May 1915, when the British Expeditionary Force had been divided into two armies, that a second consultant

was appointed to the front, but from that time onwards a consulting surgeon was appointed to each of the armies, and each of these held the rank of Colonel A.M.S. or, later on, of Surgeon-General.

Early in 1916 the Director-General in France decided that in order to co-ordinate the surgical work of the four armies now in the field, it had become advisable to have an additional consulting surgeon, and Sir Anthony Bowlby was appointed with the title of "Advising Consulting Surgeon, British Armies in France," and was thenceforth on the staff of the Director-General, with the rank of Surgeon-General.*

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The work of the consulting surgeon at the front underwent very great changes as the war progressed. At first he was entirely utilized for the purpose of giving advice on certain wounded men or of doing an operation, and he visited the casualty clearing stations in order to see patients for whom his opinion was sought. Subsequently he also made suggestions on the equipment of the casualty clearing stations, and his advice was invited on various methods of wound treatment. At this period, however, it was no part of his duties to make arrangements for the surgical treatment of large numbers of wounded, nor was he consulted on the surgical arrangements for proposed offensives

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* Sir George Makins was at the same time appointed "Advising Consulting Surgeon for the Lines of Communications " also with the rank of Surgeon-General.

His responsibilities were limited to giving professional advice. It was not until the Somme offensive was in preparation in 1916 that authority was given to the advising consulting surgeon to arrange with the D.M.S. of the Fourth Army for the necessary preparations to be made for surgical operations to be done in the casualty clearing stations on a large scale, and for the consequent increase of equipment and personnel. From that time onward the role of the consulting surgeon

was changed, and. he took his place on the staff of his Army D.M.S. and became responsible as an adviser in all arrangements for the surgical preparations in proposed offensives, for the surgical equipment and work in casualty clearing stations, and for the appointment of surgical specialists. As experience of front-line surgery grew, it became evident that good work required the co-operation of a responsible surgeon with the D.M.S. of each Army, and this in turn led to the Director-General appointing a committee composed of consultants and administrative officers, and also calling from time to time meetings of all the consulting physicians and surgeons. The consulting surgeon in each army also gave surgical instruction to the field ambulance personnel on such matters as the use of new splints, on new proposals for the treatment of shock, and on the various methods of intravenous

infusion.

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It was the duty of the advising consulting surgeon to visit all casualty clearing stations and to co-ordinate the surgical work of all the different armies, to supply information of new methods of treatment, and to bring to the notice of the Director-General any surgical matter of which he ought to

be informed. He also advised on the appointments of surgical specialists to the casualty clearing stations, and as to the composition of the "surgical teams" which as occasion arose were sent as reinforcements, either from one army to another, or from the lines of communication units to the front.

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The Battle of the Somme, in 1916, may be said to have fully justified all that had been agreed upon with regard to the necessity of good front-line surgery and the early operative treatment of the wounded man. It was, however, very evident that as yet only a beginning had been made, and that much more was required. Consequently, on 28th February 1917, an important consultation took place between the Director-General and the consulting surgeons of the front, to consider a memorandum by the advising consulting surgeon on the " Treatment of Wounds at the Casualty Clearing Stations," and it was decided—

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(1) That early operation on wounds requiring it should be done at the casualty clearing stations whenever possible.

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(2) That for heavy fighting the staffs of casualty clearing stations should be reinforced to a minimum of fourteen medical officers and fifteen nurses.

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(3) That when surgeons were sent from one casualty clearing station to another for reinforcement they should take with them, so as to constitute a "surgical team," an assistant, an anaesthetist, and a nursing sister of experience in operative work.

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(4) That beds should be provided for at least 10 per cent. of the total accommodation in each casualty clearing station.

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(5) That when only one group of casualty clearing stations in any army was heavily worked reinforcements of medical officers should be sent by the D.M.S., in motor ambulances from his other casualty clearing stations, even if for only a few hours,

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(6) That gas and oxygen and suitable apparatus for its administration should be supplied in large quantities for anaesthetic purposes.

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The above conclusions arrived at by this conference were of the greatest importance to the surgery of the front, and may be said to. mark an era in the development of military surgery in France, for they definitely approved in principle of the arrangements recently evolved during the Somme offensive, while they also permitted a further expansion of the casualty clearing stations by officially providing a percentage of beds and an increase in the staffs of medical officers and nursing sisters.

In addition to this, the initiation of the system of reinforcement by definite "surgical teams "

proved to be of the utmost importance to the further development of military surgery in the ensuing years of the war, and from this time onward the custom of reinforcements by surgical teams within each of the five armies, apart from those sent by General Headquarters, was carried out at the discretion of the D.M.S. concerned. Consequently, whenever only a small proportion of the casualty

clearing stations of any army was heavily worked, it was very easy to send surgical teams from neighbouring casualty clearing stations by motor ambulance car within an hour or two.

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The year 1917 opened with British attacks in the Somme region on a limited scale, but on 9th April the Battle of Vimy and Arras resulted in heavy casualties in the First and Third Armies. The rush of wounded had been fully anticipated and, in accordance with the arrangements already authorized, all the casualty clearing stations concerned were prepared with increased staffs and equipment of all kinds. The result was that a larger proportion of the wounded were passed through the operating theatres than ever before, and that an average of about 20 per cent, were operated upon in the casualty clearing stations, although between 9th April and 31st May the total wounded in the First, Third and Fifth Armies amounted to over 90,000, of whom over 17,000 were treated in the first three days of the battle. The results of this early surgery were shown at the general hospitals by a great diminution in the occurrence of gas gangrene, sepsis and secondary haemorrhage, and a general improvement in the well-being of the patients.

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On 7th June the Battle of Messines was fought by the Second Army, and here, owing to the more limited objective, a larger proportion of casualty clearing stations was available and also larger staffs. On the first day 10,434 wounded were treated in eleven casualty clearing stations and one small advanced operating centre, and in three days a total of 16,238 wounded passed through the same units.* Over 2,400 of these were operated upon at once, with the result that the general hospitals reported only one-half per cent, of gas gangrene, very few amputations, and a very low death-rate. At the end of July Hill 70 at Loos was captured by the Canadians, and the consulting surgeon of the First Army reported that of the 4,000 wounded 20 per cent, were operated upon by thirty surgical teams utilizing twenty-three operating tables, and he compared this with 13,910 wounded on the first day of the Battle of Loos in September 1915, when there were only sixteen teams and sixteen tables. Preparations were begun early in anticipation of the fighting in the Ypres Salient, and in view of the experience gained at Arras and Messines, and of the unanimous reports of the greatly improved conditions of the wounded in units on the lines of communication, the advising consulting surgeon at General Headquarters proposed that—

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* The actual number of wounded in all divisions of the Second Army was considerably higher, namely, 17,404, with 1,386 of the enemy in addition.

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(1) Each casualty clearing station should provide arrangements for eight operating tables, instead of four as previously.

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(2) Six surgical teams should be supplied to each casualty clearing station, and should each include an orderly used to operating theatre work.

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(3) Extra medical officers should be supplied to bring the total medical officers of each casualty  clearing station up to a minimum of twenty-four.

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(4) Twenty additional orderlies should be allotted to each casualty clearing station, as well as additional stretcher bearers.

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(5) The number of nursing sisters should be increased to twenty-five.

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(6) Each casualty clearing station should be supplied with additional equipment of surgical instruments, operating tables, gowns, towels and other articles in proportion to the increase of the staff and according to schedules supplied for the purpose.

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All this was agreed to, but as it was not possible to supply enough surgical teams from the casualty clearing stations of other armies alone, thirty-two teams were drawn from the general and stationary hospitals. It must also be noted that for the first time a number of surgeons from the United States and from the British Dominions were included in these teams. The supply of all these surgeons by the lines of communication was only made possible by the fact that the more operating work was done at the front the less there was to do at the base. The pendulum had now swung so far over that not only were operations not confined to the general hospitals as in early days, but far more were performed in the casualty clearing stations than on the lines of communication. At the beginning of the battle most of the fighting was done by the Fifth Army, but in the later stages the Second Army took the chief part. The attack began on 31st July, and from that date to 13th November 1917, the total wounded in the Third Battle of Ypres were :—

                                   Second Army.               Fifth Army.
August ..                            5,631 ..                       47,704
September                       26,658 ..                      22,504
October                            48,212 ..                      29,592
November                        13,216 ..                        3,600
Total .. ..                           93,717 ..                    103.400
Grand Total                                        197,117.

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In the Fifth Army the casualty clearing stations dealt with 16,088 wounded in the first two days of the fight, and in the first three days 3,091 wounded were operated upon out of a total of 15,430 men. The percentage of operations to total  wounded was 10-5 per cent, on the first day, 20-5 per cent, on

the second day, and 30-0 per cent, on the third day. The reports from the Second Army were much the same, and for the two armies together, during the whole period of three and a half months ending on 16th November, in all 61,225 operations were performed on 199,664 patients, t.g., more  than 30 per cent, of the wounded passed through the operating theatres, with the result that comparatively few operations required to be performed at the general hospitals. The latter also reported that there was a welcome absence of surgical complications and a very low death-rate. The condition of the wounded from a battle of the same magnitude had never been so good.

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The heavy fighting of 1917 terminated with the attack and counter-attack of Cambrai in the Third Army area in the last ten days of November, but, owing to rapid reinforcements from casualty clearing stations in the neighbourhood, the casualty clearing stations of the Third Army were well able to deal thoroughly with 25,000 casualties in ten days, notwithstanding the surprise of the German attack on 30th November. During 1917, the casualty clearing station work had

developed out of all proportion as compared with previous periods, and it will be seen later that in the last year of the war, 1918, it was not found possible to increase the surgical staffs further, because the whole front was simultaneously so much engaged at that period that such large staffs as those employed during the Third Battle of Ypres could not be supplied. It was, however, during the year 1917 that very many important surgical improvements were so established that in 1918 they had become generally adopted. Wounds which had formerly been merely opened and drained were now submitted to careful operation and excision. Some of them were being treated by the Carrel method of irrigation, but in an increasing number of cases they were closed by  "primary" or "secondary" suture, as described on p. 244. The surgery of various special regions had been very greatly improved, so that operations on the abdomen, which were performed without great success in 1915, and by only a few surgeons, were now performed everywhere with gratifying results. Wounds of the lung were subjected to surgical treatment in many cases, and operations

for injuries of the head gave a much lower death-rate. Wounds of the joints, and especially of the knee, were carefully closed after excision of damaged tissues, and drainage of them was never employed where it could possibly be avoided. The administration of anaesthetics had developed the use of the "Shipway" warm ether apparatus, and gas and oxygen had proved so invaluable in cases of shock that, where it could be obtained, it was always employed in preference to all other anaesthetics.

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At this time also the nursing sisters were trained in the  administration of anaesthetics, because the shortage of medical officers had gravely increased. The experiment was a complete success, and more than a hundred medical officers were freed for other duties. During the fighting in the Ypres salient transfusion of blood was first employed on a large scale, and proved of the greatest value. It was given either direct through a paraffin-coated glass receiver, or else mixed with a "citrate solution," and before the end of 1917 the methods of transfusion and the classification of donors were standardized in every casualty clearing station, with the consequent saving of many

lives. During 1917 also much more attention had been paid to the treatment of shock, and in every casualty clearing station a special hut or tent was provided where arrangements were made for warming such patients, for administering rectal injections, or for transfusing blood. In addition to all these changes, the careful splinting of fractures had been greatly developed. It was at the end of

1915 that the " Thomas' knee splint" began to be used for a few cases of fracture of the femur, but it was not until the Battle of the Somme in 1916 that it came into general use during heavy fighting. In anticipation of this battle it had been supplied in large numbers to all the casualty clearing stations, and during the progress of the battles its use was taught to the field ambulances also by the consulting surgeons of the armies engaged. Its value was immensely increased by the invention in 1915 in the First Army of the "Stretcher Suspension Bar," which enabled the limb to be comfortably slung during the transport of the patient. And in 1917, before the British attacks began in April, the use of the Thomas' splint and the suspension bar had been demonstrated by the consulting

surgeons of all armies throughout the field ambulances, so that as the year progressed this method of splinting was carried as far forward as the regimental aid posts. Greatly improved splints of various kinds for the upper extremity had also been provided in large numbers, and it had become the custom to put up all fractured limbs in suitable splints before the patient was removed from the battle area, with the result that the condition of patients on arrival at the casualty clearing station

was very greatly improved. In the large majority of these cases there was no such shock as had always been the case when smashed limbs had been only imperfectly immobilized during transport by road.

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As the natural result of all these improvements, the beginning of the last year of the war found the casualty clearing stations in every way better able to look after the wounded, and this was not only because there were now so many experienced surgeons but because there had been an advance in

surgical methods and equipment. The experience gained by the commanding officers also was of the greatest value in the invention of ingenious methods of utilizing huts and tents to the greatest advantage. The methods of pitching the latter quickly, and so as to make convenient wards and dressing rooms, had undergone great improvements ; the supplies from ordnance stores and from the Red Cross depots gave an infinitely greater amount of gowns, towels, gloves and so on, for the surgeons and nurses, while the selection of suitable N.C.O.'s and orderlies added to the experience of many battles had resulted in more rapid methods of recording particulars and of dealing with blankets, stretchers and motor ambulances than in former periods. Finally, but most important, it was now recognized that for heavy fighting it was essential that orderlies should be supplemented by from 50 to 100 stretcher bearers, and it had also been reiterated in many reports that stretcher carrying was very heavy work for which men of low category were of little value. It must also be noted that the whole motor ambulance transport had become most efficient. The transport was

really the pivot on which the whole surgery of the front turned, for unless the wounded could be rapidly evacuated from the field ambulances the casualty clearing station surgeons could not get

to work. The original custom of collecting large numbers of wounded in field ambulances and then sending them down en masse had long been given up, and every single man urgently requiring treatment at a casualty clearing station was brought direct to the latter in a special car from the advanced dressing station of the field ambulance. The cars were now often heated by warm air from the exhaust of the engine, and plenty of hot-water bottles and blankets were to be obtained.