- Email: [email protected]
SOME NOTES ON THE CAMPAIGN IN AUGUST.
THE WAR IN SOUTH AFRICA.
894 SOME NOTES
ON
THE
BY ALFRED D.
CAMPAIGN
IN
AUGUST.
FRIPP, M.S., F.R.C.S.,
SENIOR SURGEON TO THE IMPERIAL YEOMANRY HOSPITAL.
(Continued from p. 826.) One of the essential differences between a civilian and a is that in the latter many of the patients are convalescent and not only need no nursing but are well enough to resent rather the restrictions upon their freedom which are entailed by the presence of a nurse. We got over this
military hospital
difficulty at the Imperial Yeomanry Hospital by arranging the huts and tents roughly in three classes-A, B, and C. Class A includes all the acute and serious cases and the bedridden patients. These are housed in huts. Both a day nurse and a night nurse are provided for every 22 to 34 beds (according to the size of the hut), with an "extra" sister lent for a longer or a shorter time when necessary. Thus every bad case gets a really adequate share of the nurse’s attention, which cannot be ensured when one has to divide her attention among many huts or tents containing ’, 100, or perhaps 200, cases of all sorts and degrees of severity. Class C is the "convalescent camp," and only those patients are sent into it who are on ordinary diet and taking and who require no nursing or even no medicine, temperature-taking but only the daily visit of a medical officer and the disciplinary oversight of an orderly. The patients are housed in a group of belltents separate from the rest of the hospital. Each tent accommodates three beds luxuriously and four with ease, while at times of stress a fifth or a sixth patient can be made comfortable. The occupants of each tent are responsible for its good order and cleanliness and for their own " service." Class B includes the patients who have recently come out of the "serious"huts in Class A, or any that are not sufficiently ill when admitted to hospital to be sent into these huts. A few of the patients are still bedridden, but none are acutely ill, for directly such a case occurs he is moved back into Class A. On the other hand, as soon as they are well enough the patients are moved on into Class C. The patients in Class B are housed in the tortoise and hospital marquees, each of which holds eight to 10, or in times of stress even 13, beds. They are looked after by the less experienced amongst the sisters (the best qualified being promoted to fill any vacancy that may occur among the staff specially selected for service in Class A), each sister on day duty having 50 beds and on night duty 100 beds (about) to look after. This plan has worked out very well. We are never hard up for vacant beds in Class C, because we can always put extra beds into the bell-tents or telegraph to De Aar for carriages and send 100 patients down the line to Victoria West where there is a convalescent camp for 1000 men. There are similar camps for 1000 convalescents each at Bloemfontein, Norval’s Pont, and Cape Town and smaller These convalescent ones elsewhere along the railway line. camps were not instituted till comparatively recently-about two and a half months ago, I believe. They have been of great service, for by enabling the hospitals to avoid blocking up their own beds with convalescents who are not yet quite fit to return to duty they probably prevented a breakdown during the height of the enteric fever epidemic. Only patients who are fully convalescent and fit to eat ordinary rations and who need no "extrasor nursing or medicine must be sent to these camps, for they are in no sense staffed or equipped as hospitals. There is a medical officer at each camp and a handful of orderlies, but the nature of the establishment is indicated by the fact that the commandant is a combatant officer. We have never had any difficulty in providing beds in Class B. There are always a good many patients lingering there who are fit to go into Class C. Class A is where congestion is apt to occur, for the sister and the medical officer who have seen a patient through his operation or through the acute stage of his illness are naturally reluctant to " lose him," and typhoid fever is a disease which pins its victim to the same bed for a long time; but there are two very human emotions which are found in practice to compensate for this tendency and to make for the evacuation of the beds sufficiently early to ensure that there are always enough vacancies, even in Class A, to satisfy any sudden call. The first is that a sister hates to " upset her ward " by crowding in extra beds, which is her only alternative, and the second is that the
is looking forward to his move from Class A to Class B, because it is well known to carry with it an increase of freedom (there is not the slightest doubt that the vast majority of Tommies prefer the tents to the huts) and also an alluring variation of diet. This plan has worked very well with us, and if a new army medical service had to be schemed I cannot but think that it would be a good thing to have a "convalescent camp," or Class C, attached to each non-mobile military hospital; or to put it in another way, I should like to see each non-mobile military hospital divided into two equal-sized parts. In practice it is very easy for either half to enlarge temporarily at the expense of the other when necessary. Of the two halves )( (the hospital proper) would be accommodated in huts or tortoise-tents or hospital marquees, or buildings when available, and would be provided with nurses in the proportion of one to every 10 beds, while Y (the convalescent camp) would be provided with bell-tents. Since it would be a very convenient thing if a large military hospital was an exact multiple of a small one and a very good thing if large and small alike could be arranged on a plan which would permit of easy and rapid expansion from a peace to a war footing by means of the preconcerted assimilation of civilian reinforcements, I would suggest that four classes of nonmobile hospitals should be instituted. The equipment of each class of hospital should always be kept up to war strength, but only half of it should be in use while stationed at home, when it should be served by that half of the personnel which is detailed to it by the Royal Army Medical Corps. The other half of the equipment would only be brought into use and the other half of the personnel would only be appointed when the hospital was sent on foreign service, and such personnel would be chosen from civilians who would be temporarily attached. Convenient sizes for these four classes of non-mobile hospitals wonld be the
patient
following:-
The numbers, especially nf the roughly suggested. The idea is
medical officers, are only that a hospital of any size should be able to divide rapidly on emergency into two equal smaller hospitals and to despatch one of these smaller hospitals with a full staff and yet retain enough officers and non-commissioned officers to work its own beds until a reinforcing draft arrives. The equipment of one class should differ from that of another class in hardly anything but quantity. The rank of the senior officer, and indeed of the officers and non-commissioned officers under him, should of course be higher the larger the hospital. In this way steps up the ladder of promotion would be provided for on a steady scale. There should be one "sister" to every four " nurses," and promotion should be open from the latter to the former rank. I am strongly in favour of the employment of unqualified but highly-trained medical students for
895
THE WAR IN SOUTH AFRICA.
foreign service. The largest or first-class hospitals wouldI make very little difference to the healing of a wound probably seldom be mobilised, but under this scheme eacl1 whether it be really clean or only slightly infected, I such equipment would easily be available for forming smallerr brought the surfaces together by superficial and deep units. stitches. Sure enough nature was equal to the ocoasion There is a good deal of difficulty in securing the services off and immediate union occurred, not of quite the whole the right class of woman to act as wardmaid,"but I think: length of the wound but throughout enough of it to curtail that if an endeavour was made to form such a class it wouldI very materially the time which it would have taken if the be found very useful, especially on active service. Not only, whole area had been left open to granulate up. do the nurses require waiting upon but there is a good deal ofE 3. Of typhoid abscesses we have seen very little, work of one kind and another about a hospital besides actual1 only a few subcutaneous and parotid ones. We have nursing which is better done by women than by men, only opened three abdomens in typhoid fever patients. Mr. Raymond Johnson did one, but there was advanced notably the laundry and the dairy work. There is a horrible custom which is apparently universalt general peritonitis and the patient died. I have done throughout South Africa (the land of empty meat-tins and ofE two, the first with an exactly similar result to the last people who are too lazy to build proper drains or to bore forr case. The second was in a vigorous, well-nourished patient water) of bringing the milk to market in old glass and beer- who had come to us a few days before as convalescent from bottles and of selling it at so much a bottle. TheJ simple continued fever. Dr. Black, his medical officer, had vendor takes no steps to clean the bottles and heJ taken the precaution to keep him in bed on milk diet for a few considers that six of them, whether large or small, full or: days and while still under this treatment he was seized with partly empty, are equal to a gallon. Now here was ani sudden colic. Dr. Washbourn and Dr. Black asked me to instance in point. Until we took the collection, sterilisa- come and see him with them. The pain was localised to the tion, and distribution of the milk out of the hands of thei right iliac fossa which was also tender and very hard and "
,
-
.
army man and put it into the hands of one of the sisters; the milk was continually going sour and the farmers were being regularly overpaid. But the sister very soon taught; them to measure it properly and already she has saved the committee her year’s salary, though she delegates the overseeing of the actual work of the dairy to whichever sister isi temporarily incapacitated from work in the wards. Again, we most fortunately brought out from England Miss Cheesman to act as housekeeper and business manager to our nursing sisters. She has proved simply invaluable, for, in addition to her other work in which she has been assisted by 10 wardmaids, she has taken entire charge of the work of the laundry which, in a camp of 600 to 1200 inhabitants, is a big job by itself. It is to be hoped that the time has come when it will be considered criminal ever again to dispatch a non-mobile sanitary hospital from England without a steam steriliser and a complete laundry and large filter plant all capable of being worked by one boiler. The expense cannot matter to a country like England, and if by any bad chance it should really prove impossible to work in any particular case we should at least feel that we had done our best to put modern ideas of cleanliness at the service of Tommy when sick. To put it on the lowest possible ground it is an expensive thing to the country unnecessarily to lose men over whose training and transport and feeding much money has been spent, and it is not much good to go to the expense of keeping up hospitals and a Royal Army Medical Corps if we do not give them the best possible tools for staving off disease. 11 All right, try it if you like, but when you are as old as I am you’ll know the uselessness of it," is a mode of damping the endeavour to bring modern methods and appliances to the service of the State which has become considerably and deservedly discredited of late. The pity is it was ever permitted to curb effort, but it is to be hoped that it is now dead, along with several other methods of doing things which this war has proved to be obsolete. Small as has been the amount of operative surgery done here in the last few weeks I have had a few cases both of ordinary or civil surgery and of bullet-wounds which it may be of interest to record briefly. Among the former are the .
.
.
.
.
.
following :1. A successful nephrolithotomy urgently called for in an officer who was invalided from Pretoria with about the most continuously agonising pain that I have ever seen caused by a stone. It proved to be a small oxalate one, lying loose in pelvis of the kidney, and its removal was attended by the immediate and complete relief and was followed by perfect
healing.
2. A large chronic burrowing abscess of the sacral region which rendered another officer quite unable to keep upon his horse. He had had an abscess there for four years, during which it had twice been " opened." A small caudal dimple attracted my attention and under the anaesthetic it admitted the blunt end of an ordinary small probe for an inch-passing upwards in the subcutaneous tissue of the middle line. I slit up this epithelial tube and found that it contained a wisp of hairs varying from an inch to an inch and a half in length. Their attached ends were at the skin orifice of the tube and their free ends were lying loose in the cavity of the abscess. I excised the whole suppurating area, leaving a wound from two to three inches wide and four inches long, but, as in this wonderful land it seems to
the whole of the abdomen moved very little with respiration. He had nausea, but not vomiting. There was not much evidence of shock, the pulse being normal in rate and volume. We thought it was very doubtful whether there was any perforation, but we considered that it would be safer to explore at once than to wait. I made an incision in the right linea semilunaris half way between the anterior superior spine and the umbilicus and explored the whole of the ileum and the ascending and transverse colon. All we found was (a) some huge mesenteric glands and (b) several swollen areas within the ileum on its unattached surface (the ulcers seen in our mortuary here in cases of enteric fever have often been of the hypertrophic variety). We found (c) one such mass making the ileo-csecal valve feel as if there was the apex of an intussusception projecting through it, (d) that the appendix was some three and a half inches long and of the size of an ordinary lead-pencil and so congested that it felt like a tightly injected brachial artery in which the injection had not yet quite "set," and (e) that the peritoneum about the ileo-cascal junction was acutely congested but quite smooth. I immediately sewed up the wound and primary union occurred, while the patient went through a relapse of his enteric fever. He got well and went home. Before leaving the subject of civil surgery I would add that morphia seems, when called for, to be needed in larger doses out here than at home and that we are constantly seeing fresh cases in which head symptoms that look at first sight as if they were due to bullet wounds or to concussion rapidly cleared up under a course of iodide of
potassium. Among the
cases
of
gunshot
wound at
present under
my
care are :-
1. An officer from whose calf Mr. Hall-Edwards’s most accurate x-ray localisation enabled me to remove with great ea-se and rapidity no fewer than 10 pieces of a leaden bullet which were lying at depths varying from half an inch to two inches and keeping up suppuration. 2. A most interesting and severe case of bullet wound of the base of the skull. The bullet passed inwards and slightly backwards and downwards through the zygoma on the right side. There was complete facial and auditory paralysis and considerable involvement of the fifth cranial nerve all on that side. No exit wound could be found. There was such violent bleeding from the right external auditory meatus that after repeated trials of other means of arresting it I was driven to ligature the common carotid. As there was also commencing optic neuritis with rigors and some swelling just below the mastoid process I thought it wiser to put a ligature round the internal jugular vein at the same time. The haemorrhage ceased, the wound in the neck healed perfectly, and for a time all went well, but later an abscess developed in the pterygoid, mastoid, and parotid regions and hsemorrhage from the meatus recurred. So I made an incision widely curved from the entrance wound of the bullet backwards above the pinna and downwards behind it to the tip of the mastoid and turned the flap downwards with the pinna attached. The condyle of the mandible and several fragments of bone derived from the ramus and from the pterygoid plates were found lying loose in a large abscess The among the pterygoid muscles and were removed. abscess cavity was drained and the haemorrhage arrested by plugging and by leaving a pair of Spencer Wells’s forceps
THE WAR IN SOUTH AFRICA.
896
vessel in the periosteum of the mandible. The patient IHandson, with Mr. E. N. Thornton as dresser, have gone made an uninterrupted recovery and despite the loss of one tGO the Mackenzie Farm Branch at Cape Town, where Mr. of the condyles of his mandible he can now masticate7Turner is acting as principal medical officer. The medical ordinary diet, including chicken and beef. The optic neuritis sside consists of Dr. J. W. Washbourn, senior consulting did not progress, but on the contrary Mr. Cargill thinks thatIphysician, and Dr. A. Elliot, Dr. G. E. Richmond, Dr. C. W. it may be clearing up. In fact, the subject of these extensive 1Breeks, and Dr. Barclay Black. Mr. Hamilton A. Ballance injuries has now no signs remaining except the facial 1has become the senior consulting surgeon, the other surgeons 1being Dr. J. B. Christopherson, Mr. W. C. G. Ashdowne, paralysis, the unilateral deafness, and the scars. IDr. A. P. Parker, and Dr. H. W. Bruce. The writer still There is a group of three interesting cases of paraplegia. 1. In this case Mr. Hall-Edwards localised the bullet lying tremains in charge of the ophthalmic department and Mr. two inches deep, parallel with and almost accurately in the IHall-Edwards in charge of the x-ray department. The middle line with its nose downwards at the disc between the (dressers are Mr. J. Atkins, Mr. A. de V. Blathwayt, Mr. A. first and second lumbar vertebrae. The entrance wound was IPearson, Mr. A. C. Ransford, Mr. 0. Richards, Mr. Hawkins, Dr. Elliot and Dr. Parker, who have been three inches to the left of the twelfth dorsal spine. Its lowzand Mr. Sells position in the canal gave room for hope that the cord atkaway on sick leave, have returned to duty. Mr. D. J. least was not irretrievably damaged, and as there was severe (Greenfield; one of the dressers, who has had enteric fever, 1 been away on sick leave to Lady Gifford’s convalescent pain shooting down the left leg which, with the sphincters has 1 at Norval’s Pont, and is returning to England. Of the of the bladder and rectum, remained absolutely paralysed home 1 after 10 weeks, while the right leg had recovered almost nursing staff Sisters Brereton and Leggatt have gone to the 7 branch, and Sisters Stephenson, Cable, and Cooper to completely within a few days of the infliction of the wound, Pretoria I removed the laminse of the first and second lumbar1the Mackenzie Farm Branch, Cape Town. vertebras and extracted from the spinal canal the bullet and Under the supervision of Mr. Hall-Edwards electric light 1 now been installed in the cruciform building containing also a spicule of bone of about the same size and shape has which had been driven in and which, with the bullet, was 1the operating theatre and surgical store, the x-ray and photo. rooms, and the surgery. It is proving a great boon. compressing the theca severely. I did not open the theca,graphic I which expanded to its natural size directly the compressingThe dynamo is worked by a four horse-power oil-engine. The agents were removed. The wound healed well. The painRussian bath which has been opened in the laundry building down the leg ceased at once and within a fortnight of the is i a great success and is largely patronised. It is managed the his urine for two was able to hold by Hale-Smith, the chief masseur. operation patient hours (which he had never been able to do since the injury) There are 770 patients in hospital, 38 of whom are officers and there was a most encouraging return of function in someand nearly one-half of the total number belong to the of the motor and sensory nerves of the left leg. Imperial Yeomanry. Patients are being received and dis2. This patient presents complete motor and sensory charged daily, and a week ago No. 4 ambulance train brought paralysis of both lower extremities without any wasting of 17 officers and 95 men from Wynberg, most of whom came muscles and without any visceral symptoms following on an from General Clements’s force. They were nearly all surgical injury which must have been a slight one. The history he cases. Judging from the few cases which we now have of gives is that a shell knocked a basket out of his hand and enteric fever and dysentery, the epidemic has completely subburied itself, without exploding, in the ground close by. sided. The majority of the medical cases now admitted He lost consciousness and fell to the ground and has been in consist of various forms of rheumatism. As a rule, the his present condition ever since he was picked up. We have rheumatism takes a subacute form which is not readily been watching him for some weeks and I have formed a amenable to treatment. Presumably, its prevalence is due to the weather which, contrary to the general rule, has been strong suspicion that he is malingering. 3. This patient has apparently had his cord completely and not only cold but exceptionally damp, in spite of this being cleanly divided by a Mauser bullet which crossed it the dry season for up-country. In addition to rheumatism transversely at the junction of the cervical and dorsal a not inconsiderable number of cases of malaria have spine. The wound of entrance is two inches above the been admitted, the patients either being old sufferers left clavicle at the anterior border of the trapezius. Mr. from malaria or having contracted the disease north of Hall-Edwards got an excellent skiagram which shows no Bloemfontein and Kimberley. One of the wardmaids has abnormality except a bullet lying loose in the right axilla. developed measles, but from what source has not at present There is complete anaesthesia below the region supplied by been determined. There have been no further cases of scarlet the cervical plexus. There is no zone of hyperaesthesia. The fever. Among the enteric cases there have been several breathing is entirely diaphragmatic. There is no weakness cases of typhlitis, usually recrudescences of a former attack. in the arms but absolute paralysis of the intercostals and of A case recently operated on by Mr. Ballance is now doing all the muscles below them. The sphincters are completely well. Dr. Washbourn reports that musk has been of great value in paralysed and there are very large bedsores. The reflexes He has no pain except a little in the the treatment of certain cases of enteric fever. In a case in are completely absent. which the patient was comatose and almost pulseless rapid abdomen when he is rolled over. Though I am glad to say we have not yet had to break the improvement ensued upon the administration of musk in fivegood record that I told you of in the matter of amputations, grain doses every four hours. The improvement was mainyet we have had many patients sent to us who have lost a tained and the patient is now convalescent. In another case limb in the field hospitals, where of course most of such of enteric fever with persistent pyrexia continuing after the operations are chiefly called for. I wonder what arrange- other symptoms had subsided the administration of salol ments have been made for seeing that each stump is fitted caused the temperature to return to normal in a couple of with that particular appliance which is most suited to the days. It would appear that the pyrexia was due to putrefacneeds of the owner. The maimed of our heterogeneous army tivechanges occurring in the intestinal canal which were belong to very varied classes and walks in life, and the prevented by the salol. In addition to the operations performed on wounded men appliance which is the most suitable for a farm or factory labourer is sometimes the most unsuitable for a clerk or there has been a fair amount of ordinary civil surgery policeman. Even in times of peace one frequently sees a lately. During the last week Mr. Ballance has operated on bad selection made, and as the future ability of each patient two cases of mastoid disease following recent otitis media. to help himself and others depends so much upon the In one case the patient was suffering from enteric fever and adaptability of the appliance provided for the particular end in the other from scurvy. There are in hospital a considerwhich is in view there ought to be a really good selection able number of cases of compound fracture of the lower limb based, not upon the question of expense-that ought with extensive and troublesome necrosis needing repeated not to arise and I believe does not-but upon the operations. The weather here has been very variable. A few days have question of the particular requirements of the particular been genial, but other days have been bitterly cold, windy, case. and gloomy, and we have had snow and hail as well as rain. Deelfontein. Fortunately last Wednesday was a fine day for the athletic THE IMPERIAL YEOMANRY BASE HOSPITAL. sports which had been chiefly organised by Captain Mosley BY L. V. CARGILL, F.R.C.S., Leigh of the Cheshire Yeomanry. They proved a great OPHTHALMIC SURGEON TO THE HOSPITAL. relief to the monotony of camp life and were immensely There have been the toltowing changes in the staff. Mr. appreciated by all. We are expecting the Hospital Commission here next A. D. Fripp, Mr. Raymond Johnson, and Dr. H. W. Saunders have left for England. Mr. W. Turner and Dr. L. E. C. Thursday, and our chaplain, the Rev. J. Blackbourne, has on a
I
-
have left forEngland.Johnson, andandH. W. Saunders I
894 SOME NOTES
ON
THE
BY ALFRED D.
CAMPAIGN
IN
AUGUST.
FRIPP, M.S., F.R.C.S.,
SENIOR SURGEON TO THE IMPERIAL YEOMANRY HOSPITAL.
(Continued from p. 826.) One of the essential differences between a civilian and a is that in the latter many of the patients are convalescent and not only need no nursing but are well enough to resent rather the restrictions upon their freedom which are entailed by the presence of a nurse. We got over this
military hospital
difficulty at the Imperial Yeomanry Hospital by arranging the huts and tents roughly in three classes-A, B, and C. Class A includes all the acute and serious cases and the bedridden patients. These are housed in huts. Both a day nurse and a night nurse are provided for every 22 to 34 beds (according to the size of the hut), with an "extra" sister lent for a longer or a shorter time when necessary. Thus every bad case gets a really adequate share of the nurse’s attention, which cannot be ensured when one has to divide her attention among many huts or tents containing ’, 100, or perhaps 200, cases of all sorts and degrees of severity. Class C is the "convalescent camp," and only those patients are sent into it who are on ordinary diet and taking and who require no nursing or even no medicine, temperature-taking but only the daily visit of a medical officer and the disciplinary oversight of an orderly. The patients are housed in a group of belltents separate from the rest of the hospital. Each tent accommodates three beds luxuriously and four with ease, while at times of stress a fifth or a sixth patient can be made comfortable. The occupants of each tent are responsible for its good order and cleanliness and for their own " service." Class B includes the patients who have recently come out of the "serious"huts in Class A, or any that are not sufficiently ill when admitted to hospital to be sent into these huts. A few of the patients are still bedridden, but none are acutely ill, for directly such a case occurs he is moved back into Class A. On the other hand, as soon as they are well enough the patients are moved on into Class C. The patients in Class B are housed in the tortoise and hospital marquees, each of which holds eight to 10, or in times of stress even 13, beds. They are looked after by the less experienced amongst the sisters (the best qualified being promoted to fill any vacancy that may occur among the staff specially selected for service in Class A), each sister on day duty having 50 beds and on night duty 100 beds (about) to look after. This plan has worked out very well. We are never hard up for vacant beds in Class C, because we can always put extra beds into the bell-tents or telegraph to De Aar for carriages and send 100 patients down the line to Victoria West where there is a convalescent camp for 1000 men. There are similar camps for 1000 convalescents each at Bloemfontein, Norval’s Pont, and Cape Town and smaller These convalescent ones elsewhere along the railway line. camps were not instituted till comparatively recently-about two and a half months ago, I believe. They have been of great service, for by enabling the hospitals to avoid blocking up their own beds with convalescents who are not yet quite fit to return to duty they probably prevented a breakdown during the height of the enteric fever epidemic. Only patients who are fully convalescent and fit to eat ordinary rations and who need no "extrasor nursing or medicine must be sent to these camps, for they are in no sense staffed or equipped as hospitals. There is a medical officer at each camp and a handful of orderlies, but the nature of the establishment is indicated by the fact that the commandant is a combatant officer. We have never had any difficulty in providing beds in Class B. There are always a good many patients lingering there who are fit to go into Class C. Class A is where congestion is apt to occur, for the sister and the medical officer who have seen a patient through his operation or through the acute stage of his illness are naturally reluctant to " lose him," and typhoid fever is a disease which pins its victim to the same bed for a long time; but there are two very human emotions which are found in practice to compensate for this tendency and to make for the evacuation of the beds sufficiently early to ensure that there are always enough vacancies, even in Class A, to satisfy any sudden call. The first is that a sister hates to " upset her ward " by crowding in extra beds, which is her only alternative, and the second is that the
is looking forward to his move from Class A to Class B, because it is well known to carry with it an increase of freedom (there is not the slightest doubt that the vast majority of Tommies prefer the tents to the huts) and also an alluring variation of diet. This plan has worked very well with us, and if a new army medical service had to be schemed I cannot but think that it would be a good thing to have a "convalescent camp," or Class C, attached to each non-mobile military hospital; or to put it in another way, I should like to see each non-mobile military hospital divided into two equal-sized parts. In practice it is very easy for either half to enlarge temporarily at the expense of the other when necessary. Of the two halves )( (the hospital proper) would be accommodated in huts or tortoise-tents or hospital marquees, or buildings when available, and would be provided with nurses in the proportion of one to every 10 beds, while Y (the convalescent camp) would be provided with bell-tents. Since it would be a very convenient thing if a large military hospital was an exact multiple of a small one and a very good thing if large and small alike could be arranged on a plan which would permit of easy and rapid expansion from a peace to a war footing by means of the preconcerted assimilation of civilian reinforcements, I would suggest that four classes of nonmobile hospitals should be instituted. The equipment of each class of hospital should always be kept up to war strength, but only half of it should be in use while stationed at home, when it should be served by that half of the personnel which is detailed to it by the Royal Army Medical Corps. The other half of the equipment would only be brought into use and the other half of the personnel would only be appointed when the hospital was sent on foreign service, and such personnel would be chosen from civilians who would be temporarily attached. Convenient sizes for these four classes of non-mobile hospitals wonld be the
patient
following:-
The numbers, especially nf the roughly suggested. The idea is
medical officers, are only that a hospital of any size should be able to divide rapidly on emergency into two equal smaller hospitals and to despatch one of these smaller hospitals with a full staff and yet retain enough officers and non-commissioned officers to work its own beds until a reinforcing draft arrives. The equipment of one class should differ from that of another class in hardly anything but quantity. The rank of the senior officer, and indeed of the officers and non-commissioned officers under him, should of course be higher the larger the hospital. In this way steps up the ladder of promotion would be provided for on a steady scale. There should be one "sister" to every four " nurses," and promotion should be open from the latter to the former rank. I am strongly in favour of the employment of unqualified but highly-trained medical students for
895
THE WAR IN SOUTH AFRICA.
foreign service. The largest or first-class hospitals wouldI make very little difference to the healing of a wound probably seldom be mobilised, but under this scheme eacl1 whether it be really clean or only slightly infected, I such equipment would easily be available for forming smallerr brought the surfaces together by superficial and deep units. stitches. Sure enough nature was equal to the ocoasion There is a good deal of difficulty in securing the services off and immediate union occurred, not of quite the whole the right class of woman to act as wardmaid,"but I think: length of the wound but throughout enough of it to curtail that if an endeavour was made to form such a class it wouldI very materially the time which it would have taken if the be found very useful, especially on active service. Not only, whole area had been left open to granulate up. do the nurses require waiting upon but there is a good deal ofE 3. Of typhoid abscesses we have seen very little, work of one kind and another about a hospital besides actual1 only a few subcutaneous and parotid ones. We have nursing which is better done by women than by men, only opened three abdomens in typhoid fever patients. Mr. Raymond Johnson did one, but there was advanced notably the laundry and the dairy work. There is a horrible custom which is apparently universalt general peritonitis and the patient died. I have done throughout South Africa (the land of empty meat-tins and ofE two, the first with an exactly similar result to the last people who are too lazy to build proper drains or to bore forr case. The second was in a vigorous, well-nourished patient water) of bringing the milk to market in old glass and beer- who had come to us a few days before as convalescent from bottles and of selling it at so much a bottle. TheJ simple continued fever. Dr. Black, his medical officer, had vendor takes no steps to clean the bottles and heJ taken the precaution to keep him in bed on milk diet for a few considers that six of them, whether large or small, full or: days and while still under this treatment he was seized with partly empty, are equal to a gallon. Now here was ani sudden colic. Dr. Washbourn and Dr. Black asked me to instance in point. Until we took the collection, sterilisa- come and see him with them. The pain was localised to the tion, and distribution of the milk out of the hands of thei right iliac fossa which was also tender and very hard and "
,
-
.
army man and put it into the hands of one of the sisters; the milk was continually going sour and the farmers were being regularly overpaid. But the sister very soon taught; them to measure it properly and already she has saved the committee her year’s salary, though she delegates the overseeing of the actual work of the dairy to whichever sister isi temporarily incapacitated from work in the wards. Again, we most fortunately brought out from England Miss Cheesman to act as housekeeper and business manager to our nursing sisters. She has proved simply invaluable, for, in addition to her other work in which she has been assisted by 10 wardmaids, she has taken entire charge of the work of the laundry which, in a camp of 600 to 1200 inhabitants, is a big job by itself. It is to be hoped that the time has come when it will be considered criminal ever again to dispatch a non-mobile sanitary hospital from England without a steam steriliser and a complete laundry and large filter plant all capable of being worked by one boiler. The expense cannot matter to a country like England, and if by any bad chance it should really prove impossible to work in any particular case we should at least feel that we had done our best to put modern ideas of cleanliness at the service of Tommy when sick. To put it on the lowest possible ground it is an expensive thing to the country unnecessarily to lose men over whose training and transport and feeding much money has been spent, and it is not much good to go to the expense of keeping up hospitals and a Royal Army Medical Corps if we do not give them the best possible tools for staving off disease. 11 All right, try it if you like, but when you are as old as I am you’ll know the uselessness of it," is a mode of damping the endeavour to bring modern methods and appliances to the service of the State which has become considerably and deservedly discredited of late. The pity is it was ever permitted to curb effort, but it is to be hoped that it is now dead, along with several other methods of doing things which this war has proved to be obsolete. Small as has been the amount of operative surgery done here in the last few weeks I have had a few cases both of ordinary or civil surgery and of bullet-wounds which it may be of interest to record briefly. Among the former are the .
.
.
.
.
.
following :1. A successful nephrolithotomy urgently called for in an officer who was invalided from Pretoria with about the most continuously agonising pain that I have ever seen caused by a stone. It proved to be a small oxalate one, lying loose in pelvis of the kidney, and its removal was attended by the immediate and complete relief and was followed by perfect
healing.
2. A large chronic burrowing abscess of the sacral region which rendered another officer quite unable to keep upon his horse. He had had an abscess there for four years, during which it had twice been " opened." A small caudal dimple attracted my attention and under the anaesthetic it admitted the blunt end of an ordinary small probe for an inch-passing upwards in the subcutaneous tissue of the middle line. I slit up this epithelial tube and found that it contained a wisp of hairs varying from an inch to an inch and a half in length. Their attached ends were at the skin orifice of the tube and their free ends were lying loose in the cavity of the abscess. I excised the whole suppurating area, leaving a wound from two to three inches wide and four inches long, but, as in this wonderful land it seems to
the whole of the abdomen moved very little with respiration. He had nausea, but not vomiting. There was not much evidence of shock, the pulse being normal in rate and volume. We thought it was very doubtful whether there was any perforation, but we considered that it would be safer to explore at once than to wait. I made an incision in the right linea semilunaris half way between the anterior superior spine and the umbilicus and explored the whole of the ileum and the ascending and transverse colon. All we found was (a) some huge mesenteric glands and (b) several swollen areas within the ileum on its unattached surface (the ulcers seen in our mortuary here in cases of enteric fever have often been of the hypertrophic variety). We found (c) one such mass making the ileo-csecal valve feel as if there was the apex of an intussusception projecting through it, (d) that the appendix was some three and a half inches long and of the size of an ordinary lead-pencil and so congested that it felt like a tightly injected brachial artery in which the injection had not yet quite "set," and (e) that the peritoneum about the ileo-cascal junction was acutely congested but quite smooth. I immediately sewed up the wound and primary union occurred, while the patient went through a relapse of his enteric fever. He got well and went home. Before leaving the subject of civil surgery I would add that morphia seems, when called for, to be needed in larger doses out here than at home and that we are constantly seeing fresh cases in which head symptoms that look at first sight as if they were due to bullet wounds or to concussion rapidly cleared up under a course of iodide of
potassium. Among the
cases
of
gunshot
wound at
present under
my
care are :-
1. An officer from whose calf Mr. Hall-Edwards’s most accurate x-ray localisation enabled me to remove with great ea-se and rapidity no fewer than 10 pieces of a leaden bullet which were lying at depths varying from half an inch to two inches and keeping up suppuration. 2. A most interesting and severe case of bullet wound of the base of the skull. The bullet passed inwards and slightly backwards and downwards through the zygoma on the right side. There was complete facial and auditory paralysis and considerable involvement of the fifth cranial nerve all on that side. No exit wound could be found. There was such violent bleeding from the right external auditory meatus that after repeated trials of other means of arresting it I was driven to ligature the common carotid. As there was also commencing optic neuritis with rigors and some swelling just below the mastoid process I thought it wiser to put a ligature round the internal jugular vein at the same time. The haemorrhage ceased, the wound in the neck healed perfectly, and for a time all went well, but later an abscess developed in the pterygoid, mastoid, and parotid regions and hsemorrhage from the meatus recurred. So I made an incision widely curved from the entrance wound of the bullet backwards above the pinna and downwards behind it to the tip of the mastoid and turned the flap downwards with the pinna attached. The condyle of the mandible and several fragments of bone derived from the ramus and from the pterygoid plates were found lying loose in a large abscess The among the pterygoid muscles and were removed. abscess cavity was drained and the haemorrhage arrested by plugging and by leaving a pair of Spencer Wells’s forceps
THE WAR IN SOUTH AFRICA.
896
vessel in the periosteum of the mandible. The patient IHandson, with Mr. E. N. Thornton as dresser, have gone made an uninterrupted recovery and despite the loss of one tGO the Mackenzie Farm Branch at Cape Town, where Mr. of the condyles of his mandible he can now masticate7Turner is acting as principal medical officer. The medical ordinary diet, including chicken and beef. The optic neuritis sside consists of Dr. J. W. Washbourn, senior consulting did not progress, but on the contrary Mr. Cargill thinks thatIphysician, and Dr. A. Elliot, Dr. G. E. Richmond, Dr. C. W. it may be clearing up. In fact, the subject of these extensive 1Breeks, and Dr. Barclay Black. Mr. Hamilton A. Ballance injuries has now no signs remaining except the facial 1has become the senior consulting surgeon, the other surgeons 1being Dr. J. B. Christopherson, Mr. W. C. G. Ashdowne, paralysis, the unilateral deafness, and the scars. IDr. A. P. Parker, and Dr. H. W. Bruce. The writer still There is a group of three interesting cases of paraplegia. 1. In this case Mr. Hall-Edwards localised the bullet lying tremains in charge of the ophthalmic department and Mr. two inches deep, parallel with and almost accurately in the IHall-Edwards in charge of the x-ray department. The middle line with its nose downwards at the disc between the (dressers are Mr. J. Atkins, Mr. A. de V. Blathwayt, Mr. A. first and second lumbar vertebrae. The entrance wound was IPearson, Mr. A. C. Ransford, Mr. 0. Richards, Mr. Hawkins, Dr. Elliot and Dr. Parker, who have been three inches to the left of the twelfth dorsal spine. Its lowzand Mr. Sells position in the canal gave room for hope that the cord atkaway on sick leave, have returned to duty. Mr. D. J. least was not irretrievably damaged, and as there was severe (Greenfield; one of the dressers, who has had enteric fever, 1 been away on sick leave to Lady Gifford’s convalescent pain shooting down the left leg which, with the sphincters has 1 at Norval’s Pont, and is returning to England. Of the of the bladder and rectum, remained absolutely paralysed home 1 after 10 weeks, while the right leg had recovered almost nursing staff Sisters Brereton and Leggatt have gone to the 7 branch, and Sisters Stephenson, Cable, and Cooper to completely within a few days of the infliction of the wound, Pretoria I removed the laminse of the first and second lumbar1the Mackenzie Farm Branch, Cape Town. vertebras and extracted from the spinal canal the bullet and Under the supervision of Mr. Hall-Edwards electric light 1 now been installed in the cruciform building containing also a spicule of bone of about the same size and shape has which had been driven in and which, with the bullet, was 1the operating theatre and surgical store, the x-ray and photo. rooms, and the surgery. It is proving a great boon. compressing the theca severely. I did not open the theca,graphic I which expanded to its natural size directly the compressingThe dynamo is worked by a four horse-power oil-engine. The agents were removed. The wound healed well. The painRussian bath which has been opened in the laundry building down the leg ceased at once and within a fortnight of the is i a great success and is largely patronised. It is managed the his urine for two was able to hold by Hale-Smith, the chief masseur. operation patient hours (which he had never been able to do since the injury) There are 770 patients in hospital, 38 of whom are officers and there was a most encouraging return of function in someand nearly one-half of the total number belong to the of the motor and sensory nerves of the left leg. Imperial Yeomanry. Patients are being received and dis2. This patient presents complete motor and sensory charged daily, and a week ago No. 4 ambulance train brought paralysis of both lower extremities without any wasting of 17 officers and 95 men from Wynberg, most of whom came muscles and without any visceral symptoms following on an from General Clements’s force. They were nearly all surgical injury which must have been a slight one. The history he cases. Judging from the few cases which we now have of gives is that a shell knocked a basket out of his hand and enteric fever and dysentery, the epidemic has completely subburied itself, without exploding, in the ground close by. sided. The majority of the medical cases now admitted He lost consciousness and fell to the ground and has been in consist of various forms of rheumatism. As a rule, the his present condition ever since he was picked up. We have rheumatism takes a subacute form which is not readily been watching him for some weeks and I have formed a amenable to treatment. Presumably, its prevalence is due to the weather which, contrary to the general rule, has been strong suspicion that he is malingering. 3. This patient has apparently had his cord completely and not only cold but exceptionally damp, in spite of this being cleanly divided by a Mauser bullet which crossed it the dry season for up-country. In addition to rheumatism transversely at the junction of the cervical and dorsal a not inconsiderable number of cases of malaria have spine. The wound of entrance is two inches above the been admitted, the patients either being old sufferers left clavicle at the anterior border of the trapezius. Mr. from malaria or having contracted the disease north of Hall-Edwards got an excellent skiagram which shows no Bloemfontein and Kimberley. One of the wardmaids has abnormality except a bullet lying loose in the right axilla. developed measles, but from what source has not at present There is complete anaesthesia below the region supplied by been determined. There have been no further cases of scarlet the cervical plexus. There is no zone of hyperaesthesia. The fever. Among the enteric cases there have been several breathing is entirely diaphragmatic. There is no weakness cases of typhlitis, usually recrudescences of a former attack. in the arms but absolute paralysis of the intercostals and of A case recently operated on by Mr. Ballance is now doing all the muscles below them. The sphincters are completely well. Dr. Washbourn reports that musk has been of great value in paralysed and there are very large bedsores. The reflexes He has no pain except a little in the the treatment of certain cases of enteric fever. In a case in are completely absent. which the patient was comatose and almost pulseless rapid abdomen when he is rolled over. Though I am glad to say we have not yet had to break the improvement ensued upon the administration of musk in fivegood record that I told you of in the matter of amputations, grain doses every four hours. The improvement was mainyet we have had many patients sent to us who have lost a tained and the patient is now convalescent. In another case limb in the field hospitals, where of course most of such of enteric fever with persistent pyrexia continuing after the operations are chiefly called for. I wonder what arrange- other symptoms had subsided the administration of salol ments have been made for seeing that each stump is fitted caused the temperature to return to normal in a couple of with that particular appliance which is most suited to the days. It would appear that the pyrexia was due to putrefacneeds of the owner. The maimed of our heterogeneous army tivechanges occurring in the intestinal canal which were belong to very varied classes and walks in life, and the prevented by the salol. In addition to the operations performed on wounded men appliance which is the most suitable for a farm or factory labourer is sometimes the most unsuitable for a clerk or there has been a fair amount of ordinary civil surgery policeman. Even in times of peace one frequently sees a lately. During the last week Mr. Ballance has operated on bad selection made, and as the future ability of each patient two cases of mastoid disease following recent otitis media. to help himself and others depends so much upon the In one case the patient was suffering from enteric fever and adaptability of the appliance provided for the particular end in the other from scurvy. There are in hospital a considerwhich is in view there ought to be a really good selection able number of cases of compound fracture of the lower limb based, not upon the question of expense-that ought with extensive and troublesome necrosis needing repeated not to arise and I believe does not-but upon the operations. The weather here has been very variable. A few days have question of the particular requirements of the particular been genial, but other days have been bitterly cold, windy, case. and gloomy, and we have had snow and hail as well as rain. Deelfontein. Fortunately last Wednesday was a fine day for the athletic THE IMPERIAL YEOMANRY BASE HOSPITAL. sports which had been chiefly organised by Captain Mosley BY L. V. CARGILL, F.R.C.S., Leigh of the Cheshire Yeomanry. They proved a great OPHTHALMIC SURGEON TO THE HOSPITAL. relief to the monotony of camp life and were immensely There have been the toltowing changes in the staff. Mr. appreciated by all. We are expecting the Hospital Commission here next A. D. Fripp, Mr. Raymond Johnson, and Dr. H. W. Saunders have left for England. Mr. W. Turner and Dr. L. E. C. Thursday, and our chaplain, the Rev. J. Blackbourne, has on a
I
-
have left forEngland.Johnson, andandH. W. Saunders I