CHAPTER VIII

MEDICAL ARRANGEMENTS FOR THE TREATMENT OF THE SICK AND WOUNDED —THE PROVISION OF HOSPITALS AND CLINICS

As already stated in a previous chapter, in the first stages of the negotiations of 1915 for the internment of Ps. of W. attention had been directed solely to the hospitalization in Switzerland of one category of prisoners, viz., that of the tuberculous; but very shortly, under the pressure of public opinion, further attention had been drawn to the advisability of extending the principle to other categories, with a view to the inclusion of disabilities of a very varying nature. The discussions were continued during 1915, with a view to the realization of an enlarged programme, and in January, 1916, a first list, comprising twelve categories of disabilities or wounds, had been prepared and agreed upon, including that of tuberculosis, and the first essays of internment were made on the 26th of January, 1916, commencing with 200 tuberculous cases. By the 14th of February 1,247 French and German Ps. of W. had been interned in the regions of Montana, Montreux, Leysin, the Bernese Oberland, the Quatre Cantons, and Davos, comprised of men of the aforesaid categories.

By the 16th of February the list had been increased to twenty categories, to be afterwards reduced in June and July, 1916, to eighteen. These lists formed the basis of the work done by the so-called "Itinerant Commissions of Swiss Medical officers," who were authorized to proceed to Germany, France, and England for the examination and selection for internment in Switzerland of all those prisoners found to be suffering from the diseases or wounds mentioned in the aforesaid eighteen categories.

The "Médecin d'Armée" was thus suddenly faced with the problem of the internment and treatment of a number of Ps. of W. largely in excess of those originally in view, and the whole of his programme had to be re-cast to meet the needs of a body of Interned, not less than the strength of an Army Corps. The serious nature of the demands made on the medical organization of the country may be realized from the fact that every one of the 30,000 men about to reach Switzerland was suffering from one or other form of disability, requiring medical attention at the hands of a Sanitary Service manned and equipped for the ordinary requirements of the small Swiss Army.

To meet the additional requirements of the medical personnel, medical officers in civil employ, liable for further service, were mobilized, and many civilian doctors, not so liable, were called upon for a term of duty.

As regards the housing of those prisoners whose treatment was not of a pressing nature, and who formed the majority of the Interned, accommodation was found in the hotels and châlets with which Switzerland is so richly endowed. In this respect no difficulty was experienced; but for those requiring that care and treatment which could only be given in a hospital, the solution was not so easy, as the necessary accommodation for the large numbers of sick, with which the country was being flooded, was lacking.

It is true that many of the private clinics which form so marked a feature of the modern life of Switzerland had been vacated by their foreign clients on the outbreak of war; but, as an off-set to this relief, the mobilization of the Swiss Army threw a strain on the Sanitary Service and the available accommodation which, perhaps, more than counter-balanced the relief afforded by the withdrawal of the foreign element. The "Médecin d'Armée" did not, at the outset, therefore, find much relief from the release of the private clinics, and a good deal of improvization had to take place before the difficulty was satisfactorily overcome.

Military and civil hospitals, already in being in the different regions, were set apart or partially utilized for the Interned, whilst other suitable buildings were commandeered, and were installed as hospitals or convalescent homes.

As to the treatment in the camps, the methods adopted were of a varying nature. At Château d'Oex, the men were, in the first instance, distributed amongst the hotels and châlets, without much regard to the nature of their physical condition, but as soon as the doctors could get to work, the worst cases were weeded out and sent to the local hospital, the "Soldanelle." Less serious cases, and those awaiting their time and turn for surgical treatment, were dealt with in their own establishments. The "Soldanelle" contained about eighty beds, and had in pre-war days been equipped solely for the use of visitors requiring rest cures, or electric or light treatments. The equipment included electric and X-ray installations, but was deficient on the surgical side. This defect was made good by the "B.L.R.C.O." at Berne, who presented the hospital with the complete equipment for an operating theatre.

A question in connection with this operating theatre was raised at the time by the "Médecin d'Armée," which is of some interest as illustrating the point of view of the Swiss Medical Staff in respect to the surgical treatment of serious cases. When I first suggested to Colonel Hauser the desirability of bringing this hospital up to date by the addition of an operating theatre, he threw cold water on the scheme, on the ground that Château d'Oex had never been intended as an operating centre, and its equipment as such might and would, probably, lead to the performance of operations by local surgeons, when such operations had best be left to the specialist. There was no gainsaying this argument, and for a time the matter was left in abeyance; but when an immediate operation had to be conducted at Château d'Oex, in a hastily improvised room, as the only means of saving the life of an officer suffering from acute appendicitis, the need for a suitable operating theatre again came prominently to notice, and Colonel Hauser gave his consent for its installation.

In the course of the first twelve months some 400 minor operations were carried out in this theatre by Dr. Brüstlein, who fully justified his reputation as a rising young surgeon. Occasionally operations of a serious character were also performed there, with the assistance of specialists who were called in for the occasion, Dr. Arndt, of Berne, amongst others. The hospital thus served an excellent purpose in relieving the specialized institutions of minor cases, for which the accommodation would have proved insufficient.

The nursing personnel consisted of orderlies, both Swiss and British. The latter were untrained, but acquired in the course of time a certain skill and readiness in their duties. As regards women nurses, the doctors at Château d'Oex were firmly opposed to their employment, as being contrary to the usual custom of Swiss military hospitals, and it was only at my repeated instance, after considerable opposition, that an offer to supply Swiss nursing sisters at the expense of the "B.L.R.C.O." was accepted.

Another difficulty, and one for which no immediate remedy could be found, was experienced in the lack of properly qualified masseurs. In this respect the Sanitary Service was faced with a very real difficulty. Most of the trained masseurs of the Swedish type had left the country on the outbreak of war, and the number available from all sources for the use of the Interned was totally inadequate. Training schools were at once opened, but it was not until the end of 1916 that the deficiency was made good.

Meanwhile the Sanitary Service was subjected to much severe and exaggerated criticism, owing to the refusal of the authorities to accept assistance from outside. The attitude of the "Médecin d'Armée" _vis-à-vis_ of the aid offered by the Red Cross organizations of the Allies with regard to the supply of nurses, masseurs, etc., was influenced in no small measure by the decisive stand taken by Swiss Trade Unions, who were jealously opposed to the employment of foreign labour to the detriment of the Swiss worker. He was obliged to give due consideration to popular opinion on the subject, and to follow the lead of his Government, so that in many cases the acceptance or non-acceptance of the assistance offered was determined _for_ him, and not _by_ him. I may safely assert that his decisions were never inspired by personal prejudice, or based on a narrow or jealous view.

As regards Mürren, no local hospital being available, cases requiring any special treatment were sent to the District Hospital at Interlaken, or to the hospitals at Berne, Lucerne, and Fribourg. Two small wards were set aside in one of the hotels for patients suffering from ordinary ailments, and a good deal of medical work was carried out in the hotels, sun cures being much in favour for the treatment of open wounds, etc. For massage and orthopædic exercises a gymnasium was installed, with apparatus of a useful kind. We were indebted to the generosity of a Swiss friend for certain of the more delicate and costly pieces for vibratory exercises. The equipment consisted of twenty-five apparatuses for "mécanothérapie," two for "faradization," and one for "galvanization." During 1916 above 253 cases were treated, of which 96 were by massage, 45 by "électrothérapie," and 112 by "mécanothérapie"; 180 men were subjected to sun cures.

A description of the District Hospital of Interlaken, where so much work was done for us, will serve to illustrate the general type of civil hospitals placed at the disposal of the general public all over Switzerland. This hospital is divided into wards of five to ten beds, affording accommodation for some 150 patients. The personnel consists of a resident surgeon with a staff of doctors capable of dealing with all the ordinary work of the district. The surgeon in charge had served his novitiate under Professor Kocher, of Berne, and was well known throughout the length and breadth of the Bernese Oberland as a very skilful operator.

I may here call attention to a marked feature of the civil work in Switzerland, in that many of the most promising young surgeons and practitioners of the country, after their early years of study and association with such masters of their art as Professors Kocher and Roux, take up their life-work in the smaller towns, where they build up a reputation in their turn, second only to that of their erstwhile masters. The peasants and the general public have, therefore, at their very doors, up and down the country side, specialists of a high order of professional skill. Perhaps in no country in the world are there specialists so widely distributed as in Switzerland, much to the advantage and well-being of the people. These doctors live hard and frugal lives, and give their services for fees which in our country would be considered derisory; but they lend lustre to a Sanitary Service which is held in high esteem by their countrymen, and which is the admiration of the foreigner within their gates.

Before concluding this account of the sanitary organization of Mürren, I must add a word regarding an important branch of that work inaugurated at the "Manor Farm." This châlet, the property of an English lady, Miss Simpkin, served in pre-war days as a pension for British and American visitors. It was beautifully situated, two kilometres from Interlaken, on the shore of the Lake of Thoune, and Miss Simpkin conceived the happy thought of offering it to the medical authorities as a convalescent home for soldiers suffering from neurasthenia, shell shock, heart, etc. The offer was gladly accepted. Twenty officers and men were in constant residence there, and it would be difficult to exaggerate the care and kindness lavished on them by this devoted lady.

Apart from the treatment afforded by the ordinary camp organizations, with their associated hospitals as already described, the principle was adopted of utilizing, so far as practicable, the services of specialists in such centres as Berne, Fribourg, Lausanne, Montreux, Geneva, etc. We thus find many of the best-known professors and doctors of Switzerland, some of whom have a world-wide reputation, actively engaged in their own hospitals in the service of the Interned.

At Berne: Professors Kocher, Capt. Dr. Matti, Dr. Arndt, Dr. Kocher.

At Lausanne: Professor Roux, Dr. Dufour.

At Montreux: Dr. Chessex.

At Geneva: Dr. Julliard, Dr. Machard.

At Fribourg: Dr. Clement.

A special Sanitary Establishment was also created by the "Médecin d'Armée" at Lucerne, in June, 1916, with 190 beds and a staff of eleven doctors, known as the "Armée-Sanitäts-Anstalt," destined for the common use of the Interned of all nations for operative work in connection with bone-grafting, tendon-transplantation, brain and nerve surgery, and complicated plastic movements. The beds were distributed as follows: 6 to officers, and 78 to French, 22 to British, and 84 to German N.C.Os. and men, the different nationalities being accommodated in different wards. This hospital was well equipped from a scientific point of view, and was supplemented by annexes to which the convalescents were transferred. The annexe set aside for the British was the congeries of châlets at Seebourg, four kilometres from Lucerne, owned by the London Polytechnic Society. This was kindly placed at my disposal by the Society, and was further utilized for the accommodation of men attending the classes for technical instruction established under the auspices of the B.R.C.S., London. The "A.S.A.," however, proving unequal to the ever-increasing strain, had to be supplemented on September 8, 1916, by the addition at the "Clinique Générale," Geneva, under the direction of Dr. Julliard, of a _service_ for the treatment of lesions of the jaw and face. Another _service_ was also opened by Dr. Machard, at Geneva, and a third by Dr. Matti, at the Salem Hospital, at Berne, also for lesions of the face and jaw.

The specialization demanded was in this way gradually placed at the service of the Interned, but its creation was not the outcome of a day. The year 1916 was a transition period of trial and evolution, during which many mistakes were made, but which ended in the development of an efficient organization capable of meeting all demands. That the Swiss Sanitary Service, both in its military and civil branches, should have met so readily demands of so unprecedented a nature, shows a remarkable spirit of originality and adaptability, which is deserving of record and acknowledgment.

One other special establishment, set apart in 1917 for the use of the Allies, was that of the Fribourg Hospital. Early in that year I received a visit from the Comtesse de Zürich de Reynolds, informing me of a scheme initiated by herself and the Baronne de Montenach, both residents of Fribourg, for the equipment of a large hospital on the outskirts of the town, built originally by the municipality as a Maternity Hospital, but which for financial reasons had never been opened as such. The municipal authorities had expressed their willingness to hand over the building as a Military Hospital dedicated to the use of the Allies for the period of the war, and funds were being collected with the intention of transferring it, after equipment, to the "Médecin d'Armée." The hospital was calculated to provide beds for about 120 officers and men, at a cost originally estimated at frs. 100,000. Of this sum, frs. 75,000 had already been promised, by French Red Cross sources, to Mme. de Montenach, who was devoting herself more especially to the Franco-Belgian side of the question.

An examination of the building showed me that it was eminently suited for the purpose, and a visit to Fribourg made it clear that the medical faculty of the town, as well as the authorities, were deeply interested in the scheme. The "Médecin d'Armée" also adopted it with warm approval, but told me that the funds allocated to him by the Allies would not admit of the capital expenditure involved. As we were at that time awaiting the arrival of a fresh British contingent from Germany, for whom further hospital accommodation was most desirable, the scheme made a strong appeal to me, and I felt no hesitation in placing it before the British Red Cross Society in London, with a request for a donation of frs. 30,000. This sum was immediately placed at my disposal, and in a very short time the ladies at Fribourg had the satisfaction of transferring to the "Médecin d'Armée" a hospital equipped from top to bottom, the total expenditure being about frs. 150,000 in all.

Here some forty of our soldiers lay side by side with the French and Belgians, and benefited greatly by the highly skilled work of Captain Dr. Clement and his able assistants. Mme. de Zürich de Reynolds was untiring in her interest in and kindness to our men, as well as their Allied comrades. I am happy to be able to cite this as one amongst the many instances of kindness and practical sympathy of our Swiss friends.

It gives me pleasure to record the fact that the Swiss surgeons often spoke to me of the cheeriness of our men whilst under treatment, their quiet acceptance of operative work, and their powers of endurance. One surgeon, when commenting on these temperamental qualities, accounted for them by the love of the British for the open air life, their addiction to sport, and the quality of their diet.

In preparing a comparative return of mortality in Switzerland during the years 1916 and 1917, I found, to my surprise, that the percentage of loss by death of Interned French and Belgians more than doubled that of the British. I understood from my French colleague, Comte de Manneville, that his figures by no means represented the total losses of his countrymen, as so many of them had, on arrival in Switzerland, been repatriated as "grands blessés." How many of them had died in France he could not tell, but doubtless a considerable number, as the majority were in the last stages of tuberculosis. That fell disease appears to have been more common to the French than to the British whilst in captivity in Germany.

The mortality amongst the British in Switzerland from all causes during the years 1916 and 1917, out of an average of about 2,000 men, amounted to fourteen only, most of whom died of tuberculosis, pneumonia, or accident—a gratifying record as far as Swiss surgeons are concerned, when the sum total of their surgical work is taken into account.

Many of the Leysin patients had been sent out of Germany by the Itinerant Commissions on the mere suspicion of tuberculosis, and these men failed to understand that their condition could be in any way dangerous. The restrictions imposed as regards smoking, drinking, and exercise, the lying out in the open in a recumbent attitude, exposed to sun and air for six to eight hours per diem, and the general want of freedom thereby involved, proved extremely trying to them, and they were, I am afraid, often a thorn in the side of the medical officers. On one occasion they persuaded the doctors to give them permission to play a friendly game of football with other enthusiasts of the camp, with results disastrous to certain of their number, who realized, perhaps for the first time, that unusual strain could only lead to hemorrhage or other evils of a cognate nature.

A large proportion of the sick were drafted to Château d'Oex, or Mürren, as completely cured, after a residence at Leysin from six months to a year. The percentage of incurables was small, and there is no doubt in my mind that the treatment, as practised in the Swiss Sanatoria, is of immense advantage to those not far advanced in the disease.

As regards an important branch of treatment, viz., that of dentistry, provision was made by the "Médecin d'Armée" as part of the ordinary medical work. This, however, owing to the strain imposed by the mobilization of the Swiss Army, proved totally inadequate, and it was a great relief to me when, in June, 1916, I received a letter from Mr. Joseph A. Woods, M.D.S., L.D.S., offering me his personal service in Switzerland. He wrote to me as follows:—

"My proposition would be to go to some suitable centre for, say, one month. I would take all necessary instruments and supplies and would attend to any Interned who would care and need to have such treatment. The whole service would be entirely gratuitous, whether to officers or men, and, as far as possible, I would, in addition to operative treatment, fit artificial dentures or make splints or other appliances in any cases of jaw injuries. I would be personally responsible for the expenses. I should, of course, accept any regulations or conditions which may be in force and would loyally fall in with them."

This generous proposition naturally commended itself to me, and with the approval of the "Médecin d'Armée," and the sanction of the War Office, Mr. Woods was appointed Head Dental Surgeon to the British Interned. He immediately closed down his private practice at Liverpool, and exactly three weeks later reached Berne, bringing with him a large stock of instruments and general dental supplies. It was a good thing he did so, for all such stocks had run very low in Switzerland, and the problem of supply has since then become increasingly difficult. Mr. Woods, at my request, made Mürren his centre, and within a few days most of the officers and 200 men were on his register as prospective patients. His original offer to remain one month was extended to three, and then as the work increased, owing to fresh arrivals from Germany, he decided, on my representations, to remain for a much longer period, and in fact only left the country when the camps were closed down on the repatriation of all Ps. of W. in the autumn of 1918, having thus completed two years and four months voluntary service with British troops in Switzerland. The camps at Interlaken (where he fitted up an additional surgery), Gunten, Meiringen, Seebourg, Leysin and Château d'Oex, also came within his purview at one time or another. Leysin and Château d'Oex were subsequently, in August, 1917, placed in dental charge of Mr. W. I. Law, L.D.S., where the work was almost as heavy as at Mürren. Mr. Law's expenses were defrayed by the North-Midland Branch of the British Dental Association, supplemented by a donation from the B.R.C.S., London. The services of Mr. Woods were entirely honorary: all expenses, both professional and personal, were met by him, and no fees or charges of any sort were accepted under any circumstances.

The following summary will give some idea of the magnitude of his work:—

Total number of patients treated 1,229 Visits 6,033 Operations 9,725 Restorations (dentures), etc. 673

Mr. Woods laid himself out to give as full dental treatment as though he were in his own private consulting-room at home, and to avoid the suggestion or appearance of merely giving the bare essentials of dental treatment. The fact that 99 per cent. of the officers, and about 80 per cent. of the men, consulted him, shows how entirely he obtained the confidence of all ranks, and how necessary a dental service was. He was able, by a series of lectures and demonstrations, to impress upon all his patients the extreme importance of dental hygiene.

Writing on the subject of his work, he mentions that, like all other members of his profession, he had been anxious since the outbreak of the war to be of service to his fellow-countrymen, and when he saw that Ps. of W. were being transferred to Switzerland, he felt an overpowering desire to offer a dental service to them. That this loving desire has received a wonderful fulfilment, the foregoing record amply shows, a fulfilment towards which he was so well assisted by Mrs. Woods, who gave up all her time and strength in the furtherance of her husband's task. It is a pleasure to add that Mr. Woods received the heartiest support of Captain Dr. Llopart, the Directing Medical Officer at Mürren, and of the Swiss Dental Service.

As regards the provision of artificial limbs, it is casting no slur on the Swiss medical authorities and Swiss artisans to say that they were unable to meet the demands of the Interned. In Switzerland, as in other countries, trained artisans skilled in this class of work were lacking, and the type of limb in use was in no wise suitable for the demands of modern life; in short, good artificial limbs were unprocurable in the country, and though some of the men were fitted out locally, the majority preferred to wait in the hope that a more suitably-designed limb would have been evolved before their return to England. A few officers were supplied with artificial legs by a Lyons firm, with which they were satisfied at the time, but whether these compared favourably with the home product I have not heard. Lady Dorothy Dalrymple did useful service at Château d'Oex in supplying peg-legs, which proved most useful.

A few words here as to the expenses caused by the administration and the medical care of the Interned will not be out of place. The foreign Governments concerned engaged to pay to the Swiss Government, in liquidation of these expenses, 50 centimes per diem for every officer and man interned, with an additional sum of 50 centimes for those under treatment for tuberculosis. This payment covered charges for the pay and allowances of all Swiss officers and men engaged in the service of the Interned; hospital expenses of every kind and nature except food; hire of offices and expenses of installation; allowances to Interned men working in the administrative offices of the Interned, or employed as masseurs, etc.; also the laundry of officers and men.

It was only by the exercise of a careful economy that the expenditure was maintained within the limits agreed upon, but I understand that, as the Internment developed, the funds placed at the disposal of the Swiss Government were found sufficient for the purpose.