J R Army Med Corps: first published as 10.1136/jramc-43-01-13 on 1 July 1924. Downloaded from

71

\ . .' ~. HISTORY OF' THE GREAT WAR. 'MEDICAL SERVICES. GENERAL HISTORY.

Vol. Ill." THE. MEDICAL SERVICESI DURING THE. OPERATIONS 'ON THE WESTERN FRONT IN 1916, 1917 AND ] 918; IN ITALY, EGYPT AND PALESTINE. By Major-General Sir W. G. Macpherson, KC.M;.G., C.B., . F.R.S., L:L.D. Obtainaole through any bookseller or directly from His Majesty's Stationery Office, Imperial House, Kingsway, London, W.C.2. 1924. Price,£lls. ' The Medical on the Western Front is com- o pleted jn this voluine, and the campaigns in Italy, Egypt and Palestine are described. '. The(preface states that limitations of time and space have been imposed upon the historian,.but we hope that a'description of the medical 'services in Gallipoli, 'Salonika and German East' Africa may yet be publislied. The corps is deeply indebted to' Gerieral Sir W. G. Macpherson for th,ese works

of which tl1e educational value is exceptionally great. . Protected by copyright. The sketch m~ps, charts and diagrams are excellent, and the carefully comp'iled appendices will repay close study. . Chapters I' to XVIII cover the Western Front operations from February, '1916, to the_end of December, 1918, and. account for three-quarters of the book. . The~Somme battles are fully described~ 'but the advance to victory has had to be somewhat compressed. This is unfortunate as much could have been learned of the tactical handling of medical units in a rapid advance, from a more detailed account . . Chapters XVIII to XXII deal with the medical servjces 9f our forces in Italy, Egypt and Palestine. http://militaryhealth.bmj.com/ ;' The actions of the Bluff; St. Eloi Craters; the German attack on the Vimy· Ridge; the ba.ttle of Mount Sorrel and the engagement at Fromelle .: are described in Chapter i. The succeeding fotty-three 'pages forming 'Chapter II describe the medical'arrangemen~s for the battle' of the Samme. ' Fifty-six infantry and six cavalry divisions Itook, part at different periods in this stupendous struggle which 'lasted nearly five ,months .. The main part of the :fighting fell 'to the 4th Army whicp ha.~ five corps on a front' of about twelve miles. A study of App~ndix "B" together with 'page' 50 'enables the arduous' wQrk of the medical services to. be appreciated; on October 1, 2021 by guest. 310,073 wounded wer~ admitted to field ambulances, 6f whom 304,285 were subsequently evacuated to the, base from casualty clearing stations. In: addition some thousands of sick cases had to be prov:ided for.'. . That 26,675 wounded .could be collected by field aQ1bulances in tlie first twenty-four hours ,of a battle would have1;>e'en considered imposflble in' 1914.. Th~ price paid ·in casualties. among the medical ~ervices ,is· shown on p. 53.' .t

. \ /' J R Army Med Corps: first published as 10.1136/jramc-43-01-13 on 1 July 1924. Downloaded from

72 Reviews

The lessons contai~ed in these pages are chIefly:- (1) The rapidity with which casualties reach the clearing stations in the first twenty-four hours of a m'odern-battle necessitates an ,accurate and timely, appreciation of ambulance train requirements in order to avoid congestion of the wounded. . This point is well brought out in a memorandum of the -Director General, -Medical Sel'vices, on p. 47. (2) The constant changes of divisions justify the temporary detachment of samtary sections for area work in order that a continuity of sanitar.y efficiency of a high' standard may be maintained. . (3) The .need for the allotment of clearing stat-ions for treatment of special cases, sick, etc. , . (4) The' general scheme of the medical arrangements evolved as the result of previous experience in the tactical handling of field ambulances and the strategical, grouping of casualty clearing stations proved adequate . even when subjected to such a severe test.

Chapter III 'describes the advance to the in 1917. Protected by copyright. The chief anxiety at this time, from the medical point of view, was to 'ensure an adequate number of vacant hospital beds for reception of the estimated battle casualties. . Lack of available medical personnel rendered the formation of ne'Y hospitals impossible, but 36,000 beds were provided by increased evacuation of 'patients to Engiand. In thesE') operations collection and removal of casualties from the forward area was rendered more difficult owing to the destruction 'Of roads and bridges by the retreating .enemy. The medical arrangements for the ] 917 are contained in Chapter IV. The pooling of the divisional ambulance cars with the

motor ambulance convoys is ,described on pp. 77 'aud 78, and th€l special http://militaryhealth.bmj.com/ orders for the clerical-work at casualty clearing stations on p. 79. These innovations did not fulfil expectations as the later. stages of the battle clearly proved. ' . The cavalry advance to Monchy-Ie-Preux is of great interest as it records' the medical arrangen;lents for amounted force in an advance. The Assistant Director of MedIcal Services of the Cavalry Division had taken over . immediate control of his field ambulances except the pack mounted sections which were commanded by the field ambulance commanders in person.' These sections /failed in their function and it would appear that their value is doubtful. There was loss of close touch between regimental ,medical on October 1, 2021 by guest. officers and field ambulances which cau~ed confusiQn and regrettable delay in the evacuation of casualties. , . . The nex;t c,hapter gives the medical arrangements for the·battle-of Vimy Ridge which worked-smoothly and well. , Chapter VI outlines the.Fland~rs_ offensives in 1917 in which was first use~ by the enemy.' Special arrangements to deal with this were introduced in forward areas and at casualty clearing stations. The ..... J R Army Med Corps: first published as 10.1136/jramc-43-01-13 on 1 July 1924. Downloaded from

Reviews 73

surgical cleansing of wounds before evacuation became the rule, and tbe 5th Army adopted tbeprinciple of retaining for treatment so' called sbel1- shock cases in a specially organized casualty clearing station sited in an advanced position as possible. _ The next chapter describes tbe medical arrangements for tbj battle of Messines wbich worked well. The spberes, of responsibility were clearly defined, and trencb tramways Were fully utilized from regimental aid posts to advanced dressing stations. A good specimen of corps i:nedical orders is given on pp. 125-6-7. Tbe first instance of tbe formation of an advanced convalescent' depot for 1,000 patients likely to be fit for duty in four to five days, QCcurs in tbe preparations for this battle. The diagram facing page 134 is worthy of close attention as it outlines the evacuation from the line to casualty clearing station. Chapter VIII is tbe story of the battle of Ypres, 1917, wbicb lasted nearly four montbs and resembled the Somme ba~tles, in that various divisions were engaged at difierent'times. The attack on November 6 was made by tbe 3rd and 4tb Canadian Divisions with the 1st British Division. The Somme Redoubt Advanced Dressing Station was shared by a Canadian and British division. Protected by copyright. The hand-carry of 5,000 yards to this advance 1 dressing station was a severe strai!l on the field ambulance bearers. The tracks were Qver sbell­ pitted ground which the rains had turned into a quagmire. Enemy s'belling a~d'bombing of medical units during tbese battles were specially noticeable. The siting of casualty clearing stations too far forward was brougbt to notice by the pirector General, Medical Services. The medical arrangements of tbe 5th Army were voluminous and contained much detail. Many returns . were demanded from divisional assistant directors of medical services, wbo were often only a few days in the same corps. High-explosive shell

wounds predominated amdl1g tbe 10,789 wounded evacuated. Sick cases http://militaryhealth.bmj.com/ were in the proportion of 1 to 2'3 wounded among officers, and 1 to 2'46_. wounded among otber ranks'. Chapter IX gives a brief account of the , while in . Chapter X the Dunkirk Nieuport area if;! described. The sketcb opposite 'page 177' was apparently drawn after July 10, ~s previously two regimental aid posts in the support trenc? across t,he Yser of the L'eft Sector provided medical aid for the two battalions holaing tbe line. dost Dunk"erke Bains w\tS the headquarters of a field ambulan~e and had considerable accom­ mQdation for casualties. The advanced dressing station of this sector in

Nieuport Bains communicated :with a covered boyau running along tbe sea on October 1, 2021 by guest. wall. It was sited in the cellars of two houses and was specially notable for the artistic talent displayed on tbe walls by its previous French, occupants, " Th,e medical arrl,Lngements for ,combined naval and military operations are outlined, on p. 181. 'Jt, was in tbis camp that tpe 1st Division in­ augurated its 'own d~ntal service wbi,ch functioned Eluccessfully up to the and saved mqch ~voidable sick w,astage. J R Army Med Corps: first published as 10.1136/jramc-43-01-13 on 1 July 1924. Downloaded from

74 Reviews· , Chapter XI is of exceptional interest owing to the necessity for extreme secrecy in the preparations 0'£ .casualty 'clearing stations for the Cambrai b!tttle' of 1917. 1 , That t,he medical arrangements worked. so efficiently is a tribute to the distinguished. originator' at general headquarters. The German ~ounter attack proved the folly of having large dumps of medical stores too far in front,! as had often been pointed out. , The next fi~e chapters deal with the \German offensives in 19is. In Chapter XII the general situation and the transition from the offensive to the defensive of the British Armies in is described. , 'ol'he' strategical disposition' of casualty ci'earing stations in' defensive operations was not fully appreciated in all cases, although emphasized by the, Director General Medical Services at a conference on March 2. Apparently' too, the careful preparation, of schemes for a withdrawal by corps and - divi,sions was not adequately carried out,. This resulted in the loss ',of much valuable material and the capture of medical personnel and wounded by the enemy. . ' ,

Much valuable knowledge may' be, acquired by careful reading of Protected by copyright. these chapters' which' are well illustrated. Chapter 'XIII discusses the offensive againet the 5th Army, Chapter XIV that against the 3rd Army, while' Chapter XV is an account of the offensive on the Lys against the, 1st and 2nd Armies. The 1st C.orps account is somewl;lat "coI~pressed and much' of 'interest omitted. During the Festubert 'action, 251 casualties of the 55th Division (of which fifty,one were French c'ivilians), were evacuated by the 1st Division. For' this assistanc'e, the only gained by a motor ambulance driver during the war was awarded, together wit4 the Croix de Guerre avec Palmes. . After these somewhat 'dishearteqing pages, Chapter XVII, which is the

advance to' victol'Y, is pleasant .reading. Undue compression causes the "­ http://militaryhealth.bmj.com/

I- omission of much that would have been ·of value, such as more ·detail of the medical arrangements in oEen warfare, and the inarc4 to the Rhine. In the 9th Corps, the corps main dressing .station was so orgaIJized by. . its commanding officer (Acting-Lieutenant-ColoIiel'L. T. Poole,' D,S.O. M.C.) that ,the two parts could' advarice alternately l;>y 'a system· of leap­ frogging, and in 'this -way .the dressing station always functioned arid kept touch with divisions. The' bearer division and one tent subdivision of.a 'fi~ld,ambulance per brigade,' cleare.d to the brigade advanced dressing station. ..." on October 1, 2021 by guest. This corps' aiso sent a motor ambulance party formed by one heavy car from each field ambulance and one ~orryintoGermany, to bring in our sick and wounded prisoners.' Armed guards were c'arried on each car, and the. little' convoy passed through the GerIban rearguard, and collected case~ throughout Germany . Captain Hart in ,,!1, car of No. 2 Field Am btilance reached Posen'; this is not mentioned on p. 325. ,It is understood that other, corps formed similar convoys. '

, , J R Army Med Corps: first published as 10.1136/jramc-43-01-13 on 1 July 1924. Downloaded from

Reviews' 75

The history of'the medical service's with our troops in Italy is contained in Chapter XVIII. The outstanding points are:- (1). The excl;lptionally long line of communications ending, in France, which necessitated special railway aid posts along the line,. (2) The siting of advanced opera.ting centres close to the front line. These centres were staffed by surgeons, nursing sisters; and ,had a much· more complete outfit than those in France. Immediate operations were possible much earlier, and patients could be retained for post-operative treatment. The natural facilities, 6f the mountainous country were fully utilized in siting the centres .. (3) The' adoption of high-powered Fin.t ambulance cars, capable of carrying six lying-down cases. These cars were necessary owing to the severe gradients. , (4) ,The high sickness admission rate from influenza during the months of October and November; , ' . (5) The length oUhe hand-carry of stretcher cases after the crossing of the Piave, which exceeded anything in France.· The remaining chapters (XIX, XX, XXI and XXII) deal with operations Protected by copyright. in Egyyt; against the Senussi; in the Sinai-Peninsula, and in Palestine. The administrative confusion o'Ying to constant changes and overlapping was very marked, and undoubtedly affected efficiency adversely. _ Taken as a.wholethe'medical services were most hampered during-these operations ~y difficulties in water supply, transport, and reorganiz~tion of medical units when. the/force became largely Indian, than by battle casualties. , The final battle on September 19, 1918, was one of thl1greatest victories of the war, and terminated after a cavalry break through an:d an advance of 300 miles .. Medical units were severely strained by the length of this advance and http://militaryhealth.bmj.com/ the hordes of slightly wounded and sick Turkish' prisoners. Malaria became rife at the. end of this s~riesof engagements. Camel litters, sand ' carts and sledges were used fo~ medIcal transport. Roads had frequently to be mad~ by" pegging wire netting on the sand. In conclusion, we think this volume will prove most valuable to the Services gen,erally and to the Royal Army Medical Corps' in particular.

To VENICE AND BACK IN- A TWO-SEATER. 'By E.Halford Ross. With'­

nineteen illustrations from sketches by the author. London: Cas sell on October 1, 2021 by guest. and Company, Limited. Pp. 235. Price 6s. '. To, be as~ed to review a book wpen the auph?r is personally kno~n to _ you is not always either-a congenial or easy task,~especially if one has some faults to.find. In. this case, the conting~ncy does not arise as we can say at once that this book, pleases. It not only pleases but it also educates, because it presents inforrpation not eas}ly picke~ up.. The title explains aptly what th'e 'book is. It is the simple story of. a man 'and his wife who own a small , \ • ". " I J R Army Med Corps: first published as 10.1136/jramc-43-01-13 on 1 July 1924. Downloaded from

76 Reviews car In which, they decide to take a month's holiday by motoring from Piccadilly in London to Venice and back. They cross the, Channel from Southampton to Le Havre, ,and thence journey leisurely across the valleys of the Seine, the Eure, the Loir, the Loire and the Oher"through the heart.­ of France' to Languedoc and Provence, whence by easy stages they reach the Riviera. Next, having .croBsed the Ligurian Apennines, the travellers crossed the plains of Lombardy, passing through Milan and Verona, to ,Maestre where necessarily the car had to be left while a'visit was paid to the 11 queen of the seas." The journey back appears to have been n_o less intriguing, for it was made through the Italian lake district as far as 1se11e, where the car was put on a goods truck and the travellers passed with it through the Simplon tunnel into Switzerland. Thence, over the ;rura. range, they reached the plains of Burgundy, travelled down the valley of the Yonne until they reached Fontainebleau and Versailles and on home. The whole trip appears to have been done for only £120. ' \ From this summary of the tour, it must not be assumed that this volume is either a motor-tour record or a guide-book. It is neither, nor is it in the ordinary sense a travel-book. It is more than all these, for it is a. Protected by copyright. pleasantly written account of an irresponsible motor trip undertaken abroaQi by two beginners in motor touring, and a very good time they seem to have haa. The al,1thor has the saving sense of humour and makes such good use. of it that the whole narrative is pervaded with a light-hear:tedness which removes entirely the seriousness and monotony so characteristic of many 'books of travel. Some of his digressions into history are not happy, but. these lapses are few and far between.. Whether many of th~ places which he depicts in his' drawings would be recognized at once by their inhabitants is problematical, v but that is of no importance as he claims only to show

them as he saw them and as perhaps they may be 'seen by others. To those http://militaryhealth.bmj.com/ who are'motorists, this book should appeal because it strikes a new note in travel stories, while, to those who love adventure and the unconventional, it. gives a hint to the means whereby a relatively- small sum of money may be made to provide a most enjoyable hofiday. 'Vie congratulate both the a.uthor and his fellow-wanderer upon the good use which they seem to have made of their holiday and the very readable book which is the outcome of - their peregrination. Perhaps, one or other of them may give us another. ' R. H. FIRTH. , , I "

SELECTIONS FROM THE WORKS OF AM~ROISE PARE, WITH'SHORT BIOGRAPHY on October 1, 2021 by guest. AND BIBLIOGRAPHICAL NOTES. By Dorothea Waley Singer. London: John Bale, Sons and Daniels'son, Ltd. Pp. iv and 246. Price 12s. 6d. Those of us who were at Netley in the time of ~ir Thomas Longmore can recall his eloquent references to Amhroise Pare. It is probable that few of us appreciated then ,the old, man's enthusiasm for the subject. 1f this be so ,then a perusal of this book will do much to correct our ideas, forit is a most interesting volume 'about a very remarkable man. Born.in J R Army Med Corps: first published as 10.1136/jramc-43-01-13 on 1 July 1924. Downloaded from

- Reviews

1510, Ambroise Pare is a figure very typical of his co'untry and period. In those days army surgeons were not. appointed tQ regiments, but formed part of the personal and domestic suite of the generals whose troops they were to tend, and in this capacity Pare saw much service during the stormy times in which he lived. Born of humble parentage, Pare did not, belong originally to the Faculty but was apparently a medical free-lance picking up his knowledge as best he could and essentially by his own . personal observations and experiences. This involved him for many years in a series ,of controversies with the orthodox surgeons of the Paris Faculty and· the Oollege of St. Cosmas. His abilities and the soundness of his views were so marked that ultimately he was accorded professional pro- . motion from the status of "Master Barber Surgeon" to that of 'I Sworn Master Surgeon of the Brgtherhood of St. Cosmas,". and in 1554 he. was admitted "bachelor" and 'successively' I>romoted to .. licentiate" and "~aster." Pare's chief crime was that he maintained the superiority of surgery to medicine and pharmacy, thus coming into collision with the 'Hippocratic Oath which then dominated the practice of the French schools of medicine. It is, however, not without significance that in the campaigns Protected by copyright. of 1562, after Pare had become first surgeon to the King, we first hear of the ·services of other master surgeons -with the troops, this class of work having been performed hitherto by the h.umbler barber-surgeons. So long as:surgical work was considered derogatory there could of course be little . progr:ess in the art. . . No one can read this book without coming to the conclusion that Pare was a great man, an original thinker and within the limits' of the period in which he lived, also a good surgeon. He made three great definite con~ tributions to tbe surgical art. He discovered that gunshot wounds were not poisonous alId therefore did not require the applicatio~ of l::!oiling oil http://militaryhealth.bmj.com/ but were best treated by soothing applications; secondly, he established the cogQ.ate doctdne that hremorrhage .after amputations should be arrested not by the terrible method of the cautery, but by simple ligature; and.' .­ thirdly, he advocated tbe metbod of podalic .. version of tbe child before delivery in cases of abnormal presentation. In addition to these matters, P~re wrote voluminously on the whole range of surgery. The French e'ditions of his works followed one another in quick succession. 'The fifth edition, prepared by himself, was published posthumously in11598, Pare having died in 1590. Tbe first Englisb edition appeared in 1634, being' a. translation

by Thomas Johnson, an eminent botanist and royalist surgeon. The present on October 1, 2021 by guest. volume con'sists of extracts from Johnson's translation, in which bis quaint sp~lling is retained. The extracts are chiefly from Pare's Book XI which / embodies his historic first work and also others from his final book sum- • mlng up the surgical 'experience of his long life. The~e are all delightful reading, more particularly those which Pare calls his .. voyages," as they . convey a 91ear idea of the personality of the kindly, humorous, shrewd, old surgeon. ..:. J R Army Med Corps: first published as 10.1136/jramc-43-01-13 on 1 July 1924. Downloaded from

78 Reviews

It is many years since we have read a book dealing with professional matters w}lich ha:s given greater pleasure, and we congratulate both the editoress and the publishers upon the issue ofa m-edical classic which should be in the library of every doctor. Pare lived in times when religious stri~ was at its bitterest in France. :Few retained a clear head in those days, but Pare was one of them, and the stately progress of his well-ordered. ' usefri~ and mercifril career is outlined in this book, showing bright upon a dark 'stage. . R. J H. FIRTH. " NOTES 'OF THE rrREATMENT OF' MALARIA, WITH THE ALKALOIDS, OF CINCHONA. By W. Fletcher. M.D.Camb.Bale, Sons and Danielsson. Pp. viii + 91.' Pric~ 6s. n,et. This volume is No. 18 of the Studies ,from the Institute for Me,dical , Research, :Jiuala Lumpur. The author gives the results of series of cases· of malaria'treated with various alkaloids of cinchona, and in the main his findings support' those of, other workers. , Unfortunately he was unable to investigate the question of permanent cure of the disease, and Protected by copyright. his experiments, were ccincerned'cbiefly with the treatment of attacks without referen<;e to subsequentcrelapses. Regarding cinchona febrifqge • . he found that a dosage' often grains twice a day is as efficient as quinine and not more toxic. Unfortunately the coruposition of cInchona febrifuge ,is not defined by law, and .the proportion of the yarious ingredients vary and adulteration is easy. . . , The research included investigations on the differentcmethods of admin­ istration of quinine., Rectal injections he unequivocally condemns as ~'ausing severe pain with the 'passage of membranous shreds- and blood- '.

stained mucus.. Mofeover, quinine could not be-detected in the urine http://militaryhealth.bmj.com/ of any of the cases tt;eated, thus. .," . His investigatiQns in the matter, of intramuscular injections lea& to the conclusions, amongst others: "It is unjustifiable to employ quinine injec-.· tions in ordinary cases of malaria when the patient can take tb~drugby the mouth. It is equally unjustifiable to withhold injections in very serious'- cases when the patient's life is in d'anger." He points out that many of the apparent failures of oral quinine are due to the prescribed doses not being taken. In. one hospital 116 patients, nominally receiving twenty grains of quinine daily, were examined, and twenty-seven of

them showe(1 n.o quinine in ,the urine. To these Dr. Fletcher repeated the on October 1, 2021 by guest. 'dose himself, with the result that quinine appeared in the urine of them all. From these. and many similar experiences he considers that at least a q~arter_.of the quinine prescribed in native hospitals is not swalloweu by , \ the patients .. He. emphasizes the importance. of controlling quinine • administration by frequent urinary tests. . T..he book concludes with an interest'ing section on qriinineresistance: Details are given .of the investigation .. of a number of' cases· of supposed J R Army Med Corps: first published as 10.1136/jramc-43-01-13 on 1 July 1924. Downloaded from

Reviews 79

quinine resistance, and in all of these the resis,tance was apparent and not real. Most of .those, called on to investigate similar cases have had the same experie,nce. as Dr. Fletcher. The publication will interest all who are concerned in the treatment of malaria, and is a worthy, successor to the previous' volumes issued by this institute. . " '\. W.P. MAC A

VENEREAL .DISEASE: ITS PREVENTION, SYMPTOMS AND TREATMENT. By Hugh .Wansey BayIy, M.C. Second Edition. J. and A. Churcpill, 1924. ,Pp. xiv and 176. Price 7s. Sd.' This 'book, republished after five years,gives in a concise form the present-day knowledge of venereal diseases both,as regards symptoms and treatment. In the first chapter the author'p~ts forward a plea for efficient prophylaxis, particularly as regards education and iegislation. In Chapter II the, 'symptoms of syphilis in its various forms are described clearly and concisely. A chapter on laboratory work and one OQ

modern treatment follow . Protected by copyright. . The next section', on~gonorrhooa, is also good, although some practitioners '.. might, object to the dogmatic tendency of the author with ,regard to treat­ ment.Ijowever, those who require a definite line to work on, will find/this, section of great a~sistance.,', ,- . The b.ook concludes' with a chapter on non-specific' lesions and one on - , routine in private prs.ctice. ' The description of, technique lis p'articularly .good thoroughdut., The, illustrations, though not very numerous, are sufficient: ' , n" , ,This book. should be especially useful to thQse who have b~en out ,of practice with regard to venereal disease and who, with a limited time at

, their: disposal, wish to refresh their knowledge on the subject. ' http://militaryhealth.bmj.com/ , , ' - .' , . ' , F. J). -A .

• on October 1, 2021 by guest.

'-.