Читать книгу Surgical Experiences in South Africa, 1899-1900 - George Henry Makins - Страница 17

Fig. 9.—Interior of one of the Wagons of No. 2 Hospital Train

Hospital Ships.—These were numerous and some especially well arranged. Fig. 10 is of the 'Simla,' a P. & O. vessel which was admirably adapted to the requirements of a hospital ship. On her main deck some 250 patients were accommodated in a series of wards all on the same level, which much lightened the difficulties of service usually experienced. During the present campaign the abundance of transport vessels rendered the transhipment of patients to England a matter of comparative ease, and good vessels were always available. Considering the constant transhipment of invalids from India and our other colonial possessions, it would seem advisable that, in place of having to hurriedly improvise hospital ships, the Government should possess two or three hospital ships of the 'Simla' type. It is true this would deprive our naval transport officers of a duty which in this war was performed with extraordinary celerity and success; thus the 'Simla' was fitted in seven days, and sailed with a cargo of invalids ten days after her arrival at Durban; but on the other hand it would ensure that really suitable vessels were always provided.

Fig. 10.—P. & O. Hospital Ship 'Simla' in Durban Harbour

To give some idea of the amount of work contingent on the transport of wounded men from an army of some 15,000, fighting its way against continued opposition, I will quote the approximate number of men moved during Lord Methuen's advance from Orange River to Magersfontein. (The number of men actually present at each battle is shown in Table I., p. 12.)

Belmont, the first battle, was fought on November 23.

November 24.—No. 2 hospital train removed 152 cases to the Stationary Field hospitals at Orange River, then returned and loaded up with 130 more. Some of the most severe cases in the latter were detrained at Orange River, and the remainder were taken direct to Wynberg (591½ miles).

The division marched, and the battle of Graspan was fought during the day.

November 26.—A train of specially constructed trucks brought 90 of the less severe cases, including 20 Boers, to Orange River.

November 27.—The division marched, and in the morning No. 3 hospital train removed 80 severe cases from the Field hospitals direct to Wynberg.

November 28.—Battle of Modder River.

November 29.—339 patients, including a few sick, and some wounded Boers, were sent down to Orange River in open trucks with impromptu shelters made with rifles and blankets.

Later, 97 severe cases were sent down in ordinary carriages, of which some had doors sawn out to admit lying-down patients.

December 10.—The division marched, and on the next day the battle of Magersfontein was fought.

December 11.—Nos. 2 and 3 trains were loaded up during the night and early morning of the 12th, in part from the Field hospitals, in part directly from the Ambulance wagons. During the day of the 12th, No. 3 train made three journeys to Orange River, and No. 2 was sent direct to Wynberg.

In all some 800 patients needed transport; they were picked up by 10 ambulance wagons and 5 buck wagons for slighter cases and the two bearer companies sent out from Modder River. On the 12th Lord Methuen sent out a number of bearers with stretchers, and at 12 noon all the wounded were collected, but many had lain out through the night. The bearers had to retire under a shell fire kept up by the Boers as long as our army was within range of their position.

Four Field hospitals were present, but only that of the IX. Brigade at Modder River was so situated as to be of general use. This hospital, under the command of Major Harris, R.A.M.C., did an immense amount of work most expeditiously and with great success.

The nature of the advance on Kimberley necessitated the evacuation of the Field hospitals with extreme promptitude, as the troops were in constant action, and the arrangements for this were carried out with great success by Colonel Townsend, the P.M.O. of the First Division.

The amount of fighting far exceeded anything that had been expected, and the Stationary hospitals on the lines of communication at Orange River and De Aar were unable to cope with the number of severe cases thrown on their hands, with the constant possibility of new arrivals. Hence a number of severe cases had to be sent direct to Wynberg.

This experience strongly illustrated the necessity of possessing Stationary hospitals of greater mobility and a higher degree of equipment than the service at present possesses. In these a large number of severe cases could have been retained, and only the slighter ones exposed to the fatigue and general disadvantage of transport. In South Africa very special difficulties existed in the length of the line of communication, the single line of rails, and the absence of any source of supply within 500 to 600 miles; but in any other country mobile Stationary hospitals, although more easily equipped, would be equally valuable.

The difficulties of transport experienced in the advance of the Kimberley Relief Force were many times multiplied in that upon Bloemfontein, since the whole of the severely wounded men had to be sent back thirty to forty miles to the railway. The ambulance accommodation on the occasion of this march, although, if untouched, proportionately smaller than that possessed by Lord Methuen, was reduced to one-fifth to meet the exigencies of warfare. Beyond this the equipment transport of the Field hospitals was reduced from four ox-wagons to two, and the Scotch cart was cut off, only two ox-wagons and the two water-carts being allowed. This greatly hampered the Field hospitals on the march, and when they arrived at Bloemfontein and had to undertake the work of Stationary hospitals, their efficiency was seriously impaired. Again, on the advance from Bloemfontein to Kroonstadt many of the Field hospitals were unable to accompany their respective divisions, not alone on account of the number of patients remaining in them, but also because the mule transport had been otherwise employed for military purposes.

The transport of the ambulances and hospitals stands in a very special position. As far as my experience went, neither ambulances nor hospitals were ever taken or retained by the Boers, and consequently the transport animals originally devoted to this purpose should have been held sacred to it.

Hospitals.—Accommodation for the wounded was provided under canvas in the Field hospitals, also in the large General hospitals. Beyond this iron huts were erected in many of the Base and Station hospitals. At Capetown, Maritzburg, and Ladysmith barrack huts were modified and equipped as hospitals, and in towns such as Bloemfontein, Kimberley, and Johannesburg large civil hospitals were at our disposal. Beyond these sources of accommodation, churches, schools, public institutions, and private houses were made use of in the smaller towns.

As to the broad question of canvas v. buildings, experience amply showed that in a climate such as is possessed by South Africa, canvas affords the greater advantages. The hospitals are more mobile, more readily extended, and the more healthy. Except under unusual conditions of rain and dust, the patients did excellently in the tents.

Rain and dust were occasionally most troublesome, especially when combined with wind. I once saw a whole hospital, fortunately unoccupied, levelled to the ground in the course of some twenty minutes. Under such circumstances iron huts present advantages, and were on many occasions utilised with much success. They are readily erected, and it would have been a considerable improvement if a number of them had been ready for use at the earliest part of the campaign. Except in the matter of weight, they possess in a considerable degree the advantage of mobility possessed by canvas, and in addition they offer much more protection from the weather. On the other hand, they are more liable to become unhealthy from prolonged use.

Churches and public institutions were mainly troublesome from the necessity of having to improvise sanitary arrangements, and sometimes the disadvantage of the collection of a large number of men in one chamber could not be avoided. None the less I cannot look back without admiration on the temporary hospitals established in the Raadzaal at Bloemfontein, and the Irish hospital in the Palace of Justice in Pretoria.

The State schools in the smaller towns of the Orange River Colony also afforded excellent accommodation as small temporary hospitals.

Private houses, possessing the disadvantages of ill-adapted construction and the necessity of a considerably increased staff to work them, were on the whole little used as hospitals. The scattered farmhouses occasionally afforded shelter to very severely wounded men. In most of the country I traversed, however, the farms were so wide apart as to be of little use in this respect; and again, under the special circumstances, patients left in them might have to be abandoned to the enemy.

The chief interest during the campaign centred in the working of the Field and General hospitals.

Two types of Field hospital were employed, one the Home, the other the Indian. The latter differs from the Home in that in it the bearer company is attached and consists of Indian natives, and that the hospital is separable into four sections in place of two only.

The amalgamation of the Field hospital and bearer company into one unit is much to be desired in the Home service, both for economy of working and the more equal distribution of duties to the medical officers engaged. Again the divisibility of the hospital into four sections is also an advantage. It allows of the advance or the leaving of sections, in the case of either small expeditions or the presence of a number of severely wounded men unfit to travel. As far as I could judge, it necessitates very small addition to the present equipment, and is in every way desirable.

As to the working of the Field hospitals in the present campaign, it was universally acknowledged to possess a very high degree of excellence. The equipment, with small exceptions, proved equal to the demands made upon it. The mobility of the camps was proved again and again, and the rules governing their administration evidenced by their effectiveness the care and experience which have been bestowed on the organisation of the hospitals.

It is difficult for any one who has not had an opportunity of observing the actual amount of work performed in the Field hospitals either to appreciate the storm and stress following an important engagement when the wounded men are first brought in, or the demands that are made on the powers of the medical officers in charge. To a civilian the first feeling is one of impotence, followed by an attempt to see no further than the case under immediate observation, and to nurture the conviction that the work is to be got through if it is only stuck to. I gathered that this first impression was absent in the minds of the officers in charge of the Field hospitals, as work commenced at once, and was carried on without intermission during the persistence of daylight, in the winter often by the aid of lanterns, and eventually the huge task was accomplished. In early days at Orange River work commenced at 4 a.m., and was steadily continued until 6 p.m. or later, and this state of things persisted sometimes for many days together.

The officers of the Field hospitals, the bearer companies, and those doing regimental duty carried out their duties with a calmness and efficiency which not only impressed observers like myself, but also excited the admiration of our German colleagues sent by their government to observe the working of the British system.

I saw on several occasions the German and Dutch ambulances, and was much struck by the excellence of their equipment. In some details there was much to be learned from them, especially in the matter of appliances, dressings, and instruments. The Dutch ambulance I saw at Brandfort had a complete installation of acetylene gas, which was carried, gasometer and all, in one Scotch cart. They were, however, really designed to fill the combined position of our Field, Stationary, and General hospitals, and when it became necessary for them to move about frequently, the inferior mobility they possessed in comparison with our own Field hospitals was at once demonstrated.

The large General hospitals of 500 beds were a great feature in the campaign. Although designed and organised some time since, the present was the first occasion on which they have come into general use, and they may be said to have actually been on trial. The organisation of these hospitals proved itself excellent, and in the case of the best of them left little to be desired.

In some cases the accommodation was temporarily strained enormously, and the number of patients was extended beyond more than three times the regulation limit. The additional patients were then accommodated in marquees and bell tents, according to the nature of their diseases. Under these circumstances the working of the hospitals was difficult, and the officers both of the R.A.M.C. and the civilian surgeons were placed at a great disadvantage.

My space does not allow me to give any description of the general arrangement of these hospitals, but I would suggest that a certain number of them should be so modified as to increase their mobility and allow of their being more readily utilised as Stationary hospitals.

During the whole campaign it seemed to me that the Stationary hospitals (that is to say, the hospitals necessary to receive patients when the Field hospitals were rapidly evacuated), were those in which some increased uniformity of organisation was most needed.

It scarcely needs to be pointed out that this is the most difficult link of the whole hospital chain to be uniformly well organised and equipped. It is needed at short notice, and often for a short period, and it is difficult to maintain a regular staff of officers ready for any emergency without keeping a certain number of men idle.

The conversion of Field hospitals to Stationary purposes is undesirable, as the troops move with only a regulation number of the former, which under ordinary circumstances is the minimum that may be necessary.

Stationary hospitals as individual units are undesirable for the reasons above given.

Fig. 11.—Type of a General Hospital (No. VIII. Bloemfontein) extended by use of bell tents in the distance. (Photo by Mr. C. S. Wallace)

The difficulty might be met by increasing the mobility of a certain number of the General hospitals, by making them divisible into five sections, each of which should be able to move independently, and to the last of which should be attached the heavy part of the equipment, such as the iron huts for operating and X-ray rooms, kitchens, store sheds, &c. The tents might also be lightened by the substitution of the tortoise tent for the service marquee. The tortoise tent is lighter (360 as against 500 lbs.), easily pitched and moved, and holds at least two more patients with ease. The capabilities of this tent were amply proven during its use by the Portland, Irish, and other civil hospitals attached to the army. It withstood wind and weather, the former better than the service marquee. Figs. 11 and 12 show the appearance of camps composed of the two varieties. I must admit a warm preference for the appearance of the service pattern, but I think it is indubitable that the other is the more useful.

Given the possibility of division of a General hospital in this manner, single sections could readily be sent up the lines of communication to serve as Stationary hospitals at various points behind the advance of the troops, and on the cessation of active need, the sections could be reunited at any point to form an advanced Base hospital. The sections could be kept in touch throughout by visits from the officer of the lines of communication. This would appear a ready means of providing well-organised Stationary hospitals at short notice, and would save the disadvantage of a definitely separate series.

Fig. 12.—Type of Tortoise Tent Hospital. Portland Hospital, Bloemfontein. (Photo by Mr. C. S. Wallace)

Such hospitals might have been used on many occasions when the transport of an entire General hospital was an impossibility. The service, moreover, has some experience in this direction, since at one time No. 3 General Hospital was divided into two definite sections.

Bearing in mind the extreme readiness and promptitude with which the officers during the present campaign extended the accommodation of either Field or General hospitals, one of such sections as are proposed might readily be made far more capacious than its regulation number would suggest.

My duties being entirely in connection with the service hospitals, I did not become intimately acquainted with any of the volunteer hospitals which did such excellent service, except the Portland, to the staff of which I was indebted for much hospitality and kindness. This hospital was practically of about the capacity proposed for the above-mentioned sections, and the report of its work will no doubt furnish many points of detail as to equipment, &c., which may be useful.

The general results of the surgical work done during the campaign were excellent, and taken as a whole the occurrence of any severe form of septic disease was unusual.

Pure septicæmia, especially in connection with abdominal injuries, severe head injuries and secondary to acute traumatic osteo-myelitis, was the form most commonly seen. Pyæmia with secondary deposits was uncommon, and often of a somewhat subacute form; thus I saw several patients recover after secondary abscesses had been opened, or the primary focus of infection removed. The only really acute case of joint pyæmia I heard of, developed in connection with a blistered toe followed by cellulitis of the foot.

Cutaneous erysipelas I never happened to see, and really acute phlegmonous inflammation was rare.

I may mention the occurrence of acute traumatic gangrene in two cases. This developed in each instance with gunshot fracture of the femur; in one amputation was performed, and the process extended upwards on to the abdomen. The cases occurred with the army in the field in the neighbourhood of Thaba-nchu and not in a stationary hospital.

Acute traumatic tetanus occurred only in one instance to my knowledge. In this case the primary injury was a shell wound of the thigh, and the patient developed the disease and died within ten days.

To the civil surgeon the performance of operations, and the dressing of severe wounds at the front, proved on occasions a somewhat trying ordeal.

When operations were necessary in the field, during the daytime, it was often possible to perform them in the open air, provided tolerable protection could be obtained from the sun. A number of cases were so operated upon during the march of the Highland Brigade from Wynberg to Heilbron, and gave excellent results, the patients deriving considerable benefit from the early cleansing and closure of the wounds.

Fig. 13.—Tortoise Hospital Tent. Portland Hospital. (Photo by Mr. C. S. Wallace)

In camp, in the Field, or Stationary hospitals, the difficulties were often much greater. The operations were necessarily performed under shelter for reasons of privacy. In the tents the draught carrying the dust from the camp was one of the commonest troubles. The exclusion of dust was impossible, and it not only found its way into open wounds, but permeated bandages with ease. Often when a bandage was removed, an even layer of dust moistened by perspiration covered the whole area included with a coating of mud. Again, in dust storms a similar layer of mud sometimes covered the whole of the exposed parts of the bodies of patients lying on the ground in the tents.

It is of some interest to remark with regard to this dust, that Dr. L. L. Jenner lately kindly examined a specimen collected at Modder River after the camp had been more than two months established, and discovered no pathogenic organisms in it. As a period of seven months had elapsed since this dust was collected, the fact is of no practical import, beyond showing that, if such organisms had existed, at any rate they were not of a resistent nature.

Insects, particularly common house-flies, were an intolerable pest at times. In a fresh camp they were sometimes not abundant, but after two or three days they multiplied enormously. Not only hospital tents, but living and mess tents, swarmed with them, the canvas appearing positively black at night. Even when dressing a wound, without unceasing passage of the hand across the part, it was impossible to keep them from settling, and during operations the nuisance was much greater.

Storms of rain were occasionally as troublesome as, though perhaps less harmful than, those of dust. On one occasion a whole Field hospital was flooded only a few hours after a number of important operations had been performed, and the patients were practically washed out of the tents. It was somewhat remarkable that none of the men suffered any serious ill as a result.

At times the temperature was sufficiently high to make either dressing or operating a most exhausting process to the surgeon. The heat of the day was not on the whole so disadvantageous from the point of view of the operator, as the cold of the nights during the winter in Orange River Colony. On one or two occasions serious operations had to be left undone, as it was only possible to consider them in camp, where, as we arrived at night only, the temperature was too low to justify the necessary exposure.

Water for use at operations was often a great difficulty. Even at Orange River, where, though muddy, the water was wholesome, it was impossible to get water suitable for operations unless it had previously gone through the complicated processes of precipitation by alum, boiling, and filtration. At Orange River a small room in the house of one of the railway servants was obtained and fitted as a rough operating room by the Royal Engineers. The necessary utensils were provided by Colonel Young, Commissioner of the Red Cross Societies. Here a stock of prepared water was kept for emergencies.

The remaining difficulties mainly consisted in those we are familiar with in civil practice, such as the securing of suitable assistance in the handling of instruments and dressing, when the rush of work was very great.

At the Base hospitals accommodation for operating in properly equipped rooms obviated many of the difficulties above referred to.

In concluding this introduction I should sum up in a few words my experience of the general working of the hospital system during my stay in South Africa.

The excellence of the Field hospitals for their purpose has been already alluded to, and, as far as I could ascertain, won the confidence and approval of patients, military commanders, and civilians such as myself.

The Stationary hospitals (by which I intend to indicate those receiving the patients directly from the Field hospitals before the establishment of advanced Base hospitals), as already indicated, were not in my opinion so perfectly conceived or organised. The requirements of these are, however, far greater than those of the Field hospitals, and they of all others are dependent on the possession of facilities for rapid transport. In South Africa the difficulties of supplying them were enormous, and no doubt the conditions of the campaign in this, as so many other particulars, were novel and unusual. None the less the experience gained will no doubt be utilised in the future. With regard to the extravagant criticisms levelled at the Field hospitals serving as Stationary hospitals at the time of the early period of the occupation of Bloemfontein, it may be pointed out that the only proper ground for comparison was not between the patients at Bloemfontein and those in hospital at the base, but between the men in hospital and those in the field at that time, since the conditions were equally adverse to both. Besides, it must not be forgotten that a large proportion of the patients, at that time, were really comfortably housed in the Raadzaal and other buildings, the preparation of which entailed a very great amount of both labour and resource.

The difficulties experienced at that time will, it is hoped, go far towards securing greater facilities and rights of transport to the Royal Army Medical Corps in the future. As a civilian, one cannot but recognise that the conditions of modern warfare are much altered from those of the past. Prisoners are well cared for and kindly treated, the sick and wounded are respected by both sides, and except in the actual horrors of fighting the condition of the soldier is a happier one. Under these circumstances the limitation of the transport facilities of a department so closely concerned with the well-being of all, and which has been organised on a most moderate scale, must soon become a tradition of the past in civilised armies.

As to the efficiency of the organisation of the General hospitals, either at the advanced or actual base, I have already testified. Naturally the working of these hospitals varied with the personal equation of the officer in charge of them, but as a whole the service has every reason to be proud of their success. As far as surgical results are concerned, and with these I had special acquaintance, the success of the hospitals was amply demonstrated.

Adverse criticism was not however wanting, and often expressed in the strongest terms by persons totally unacquainted with hospital methods, and apparently unconscious that such excellence as is exhibited in a London hospital is the result of continuous work and development for some centuries, and that such institutions are worked by committees and staffs of permanent constitution.

The proportion of female nurses employed in these hospitals underwent steady increase from the commencement of the campaign, and the immense value of the nursing reserve was fully proved. There is no doubt that in Base hospitals the actual nursing should always be entrusted to women.

The demands of the campaign necessitated the employment of a large number of civil surgeons in the various hospitals. These gentlemen accommodated themselves with true British aptitude to the conditions under which they were placed, and in all positions their sterling work contributed in no small degree to the success that was attained.

One class of hospital still remains for mention. I refer to the improvised hospitals prepared in the Boer towns prior to the British occupation. They were met with in all the smaller towns, and also in the larger ones such as Johannesburg and Pretoria.

The Burke hospital in Pretoria, started by a private citizen and his daughter, and the Victoria hospital in Johannesburg, presided over by Dr. and Mrs. Murray, were two of the largest, but each and all deserve due recognition.

I am sure that many of our wounded officers and men who were cared for in these hospitals while prisoners in the hands of the Boers, will never lose their sense of gratitude to those inhabitants who spared no effort to render their position as happy as possible under the circumstances; and the existence of these hospitals was no small boon to the service when called upon to take charge of the sick and wounded therein contained.

I cannot close this chapter without recognition of the immensity of the task which has fallen on the Royal Army Medical Corps in the treatment of the sick and wounded during the course of the campaign and full appreciation of the manner in which that task has been met. The strain thrown upon this department of the service, originally organised for the needs of an army less than half the magnitude of that eventually taking the field, was incalculably great, and the medical profession may well be proud of the efforts made by its military representatives to do the best possible work under the circumstances.