CHAPTER IX

MEDICAL AND SURGICAL TREATMENT OF THE INTERNED —INSPECTION BY LIEUT.-COLONEL SIR R. JONES, R.A.M.C.

Our men had not long been settled at Château d'Oex when they were inspected by Colonel Hauser, who mentioned to me his surprise at finding an unusually high percentage in need of surgical treatment, the percentage being much higher than in the case of the French, Belgian, or German Interned. He appeared to be satisfied at the time with the adequacy of the medical and surgical arrangements at our disposal, but expressed some concern at a feeling, common to both officers and men, that their surgical treatment was being unduly delayed. He said that the same feeling had prevailed amongst the French and Belgians at an earlier date of the Internment, but that this was based upon a totally erroneous impression. Patients, in their anxiety for an early restoration to health and activity, often failed to realize the danger of premature operative work, and he had been forced to direct his surgeons to exercise due caution. Recrudescent purulent outbreaks had already occurred amongst the French, with fatal consequences, as the result of premature work, and he was determined that his surgeons should not in the future be led away by any signs of impatience on the part of the Interned. He begged me to believe that his officers were acting in the interests of each individual officer and man, and that if operations were deferred, there was good reason for the decision taken. He had evidently warned Major Mercanton, the "Chef de Région," of the necessity for caution in certain classes of surgical work, for, whilst accompanying the first train conveying the men from Montreux to Château d'Oex, I was present when a conversation on this subject took place between the latter and Captain de la Chaux, the D.M.O. of the camp. Major Mercanton warned his subordinates of the advisability of proceeding slowly in the first instance. Apart from the necessity of dealing with urgent cases as they might arise, he recommended a rest of at least a month, in order that the effect of good food and change of climate might be watched before any operative work was undertaken. He also dwelt at length on the danger of blood-poisoning due to the foci of bacteria. I felt at the time that whatever minor evils might result from excessive caution, the greater evil of premature surgery would, within the limits of human judgment, be avoided.

It was a matter of interest to me to learn from Colonel Hauser that, as in the case of the French and Belgian Interned, his officers were already being criticized as a result of this cautious attitude, and that the criticism amounted to a suspicion of neglect. This suspicion may have been aggravated to some extent by a feeling amongst certain of the officers that reasonable facilities were not being granted them for treatment by private Specialists. The regulations affecting this question gave the officer the right of consultation with, and treatment by, a Specialist, but with the proviso that the charges incurred should be debited to the Sanitary Department only, when the necessity for calling in the Specialist had been allowed by the responsible camp doctor. In the case of his non-approval, the charge had to be met from the private purse of the officer. The D.M.Os. took the point of view that, in the majority of cases, treatment could be as well conducted in the camp by the regular Medical Staff as by the Specialist, and as trustees for the proper expenditure of the funds placed at their disposal by our Government, they did not feel themselves justified in employing the Specialist in other than exceptional cases. The charges involved by this latter procedure would, of course, have proved heavier than in the former, and though they did not attach undue importance to the financial side of the question, they did not feel inclined to ignore it altogether. On the one hand, the medical officers complained of the capricious nature of the demands made by our officers for specialized treatment, when the ordinary camp treatment would have amply sufficed, and held the opinion that the latter had no regard whatever for the financial interests of our Government. On the other hand, our officers cast doubts on the quality of the professional skill available in the camp, and criticized the cheese-paring policy of the medical officers.

The one view was directly opposed to the other, and it looked as though it would be difficult to arrive at an understanding on the question. The conclusion which, after conversations with both sides, I personally came to was, that the camp doctors (I am only speaking of Château d'Oex, for the same difficulty was not experienced elsewhere) were disposed to adhere too closely to the letter of their instructions, and were not sufficiently flexible in their dealings with either officers or men. They were too inclined to treat our soldiers as they would their own Swiss compatriots; a great mistake, as, in doing so, they made no allowance for the weaknesses and suspicions of men who had been subjected to hardships of a trying nature during a period of long confinement, and whose nerves were vibrating and sensitive to a degree. Moreover, the mentalities of the Swiss and British soldier were very different, and to judge of one soldier by the other could only lead to error and misunderstanding.

I discussed this question with Colonel Hauser, who spoke to me on the subject with the utmost frankness. It was apparently all the more easy for him to do so, as he had already been through the same phase of doubt and dissatisfaction with the Interned of our Allies, and had succeeded in proving to their satisfaction that all was well with their medical treatment. He pointed out that the conditions under which our men were being treated were, when compared with those of the Swiss soldier, exceptionally favourable, and this I believe to have been the case. It was true, he said, that in respect of food, nursing, etc., no comparison could be drawn, as either the circumstances differed, or the system adopted varied in our respective countries in a greater or less degree, but we could not expect the Swiss Government to adapt itself to the idiosyncracies of the soldiers of any one nationality; we must be prepared to judge by results. He could only deplore the lack of confidence displayed towards his Staff at Château d'Oex, and thought that our officers were over critical.

I, in reply, stated that I was at a disadvantage in having no qualified British doctor to assist me, and suggested that a visit of inspection by a distinguished British surgeon would, in all probability, serve to allay suspicion on the part of the Interned, and bring about a better feeling between his Staff and our men. He met the suggestion with enthusiasm, and said that both he and his Staff would welcome such a visit. Any officer nominated by the War Office for the purpose would be warmly received, and be given every facility to make himself acquainted with the conditions which determine the care and treatment of our Interned, and the attitude of the Swiss Sanitary Service towards them. He would be more especially pleased to see a medical expert of international reputation, as his doctors would have much to gain from an expert of wide experience.

Thereupon, I lost no time in making the situation clear to the Authorities at home, and asked that a surgeon of standing should be sent to inspect and report on the medical treatment, and to advise me as to the sufficiency or otherwise of the care bestowed upon our officers and men. Some delay took place before the right man could be found, but at last Lieut.-Colonel Robert Jones, R.A.M.C. (now Sir Robert Jones), the distinguished inspector of Military Orthopædics in Great Britain, was nominated for the purpose by Sir Alfred Keogh, K.C.B., Director-General A.M.S., and arrived in Berne on December 22, 1916.

He commenced his inspection at once, and in due course visited the camps at Mürren, Château d'Oex, Leysin, and the hospitals affiliated to these camps at Interlaken, Berne, and Lucerne. Shortly before his arrival, a contingent of Ps. of W. had reached Switzerland from Germany, and he therefore had an opportunity in each of the camps of comparing the conditions of these newly-arrived men with those who had been in residence in Switzerland for some time, a matter, to my mind, of great importance, as Colonel Hauser had contended that the true test of the efficiency of his Sanitary Service could best be demonstrated by results, the methods by which those results were achieved being of secondary importance. In principle, I agreed with this view, and looked upon it as a very happy circumstance that the arrival of this contingent had coincided with that of Colonel Jones, who would be able to apply this test when making his examinations.

As regards the medicine and surgery practised in the camps, Colonel Jones found the doctors to be well-informed young practitioners, who had undergone a sound modern training. Assisting at an emergency operation, conducted by Captain Dr. Brüstlein, at Château d'Oex, he writes:

The technique was good, and the theatre staff compared quite favourably with many more ambitious theatres at home. This experience gave me confidence with regard to the conduct of emergency operations in this camp. Neither at Mürren nor at Leysin is there an operating theatre in the camp. This is as it should be, as at neither place is there a surgeon qualified for serious surgical emergencies. Should such emergencies arise, an operating surgeon would be telephoned for from Interlaken or from Montreux. The character of the cases is very similar to those which we find in the ordinary British Military Hospital….

I was much pleased to find that the Swiss doctors were conservative, and did not show an undue haste to operate. They were beginning to learn of the dangers of recrudescent purulent outbreaks in those instances where operations were performed too early. This delay, in one of the camps, has given rise to suspicion of neglect, a suspicion which I took pains to dissipate….

The treatment of the Swiss doctors was quite equal to that which we find in a well-conducted auxiliary hospital at home, and the facilities offered the men to consult specialists were even greater than we often find to be the case at home.

Our soldiers are very well situated in all the camps, from the point of view of access to specialists. Berne, Lucerne, Montreux, and Lausanne contain most distinguished surgeons—many of them of international reputation. Careful inquiry proved to my satisfaction that whenever really necessary a consultation was allowed. These consultations, as long as recommended by the Directing Medical Officer, were never charged to British officers or men. I questioned the medical officers as to the specialists recommended, and was satisfied they were well-known men. If officers desired to consult any special man other than the person recommended by the D.M.O. no objection is taken to it, and so long as the D.M.O. thinks the consultation necessary, no charge is made for it. Occasions sometimes arise when an officer visits a specialist without consulting the D.M.O. and in that case he pays his own expenses. It is always advisable that the officer should consult the D.M.O. before seeking the advice of the specialist, as it sometimes happens that the officer chooses a surgeon with a brilliant abdominal reputation, when he should have consulted a specialist versed in bones. I had a long talk with the officers on this subject, and explained to them that they were as well off in the matter of expert opinion as if they lived in London.

The nursing was mostly of a comparatively unskilled type. Women nurses were not encouraged, and the duties were performed by orderlies who had undergone instruction. The disadvantage of this was largely counteracted by the fact that the surgeons themselves dressed their cases.

There are too few masseurs. I spoke of this, and I learn that the shortage is to be remedied. The Swiss authorities are to start a School of Massage, which several of our men will attend. This may easily prove to be a vocation of advantage to them after the war.

I visited several of the hospitals where the more serious cases had been removed for operation. I found the surgeons keen and very interested in their patients, and the hospital accommodation quite good. The food was excellent, and I could hear no complaints. In these various hospitals every type of operative work is done, such as bone-grafting, tendon-transplantation, brain and nerve surgery, and complicated plastic operations. I had long conversations with the staffs, and am now well aware of their views and methods of procedure. They seemed thoughtful, conscientious and careful men, and I feel our wounded are safe in their hands.

I found the British officers wanted encouragement, and I trust I was able to cheer many of them by truthfully assuring them of their recovery after the war. I endeavoured to instil into them a spirit of confidence in the doctors with whom they had to deal. In certain more complicated cases I suggested that the final operation should be performed upon them on their return. I think I examined every officer.

In respect of the general condition of the men, Colonel Jones writes:—

The newly arrived seemed indifferently nourished, many of them dazed, and some apprehensive of those in authority. After a very short time, so I am informed, these conditions are overcome, and the men become cheerful and trustful. The condition of those who had been in camp in Switzerland for longer periods was very satisfactory. They looked well and felt happy, and I had opportunities of examining their charts, and noted that they soon began to fatten after arriving in camp. Indeed, they represented generally a well-conditioned body of men. Many spoke well of their treatment by the Swiss officials, and seemed to fraternize with the villagers, with whom they were in general accord.

The three camps (Mürren, Château d'Oex, and Leysin) are admirably chosen … and the residential establishments for the men comprise most of the well-known hotels of the district. It would be difficult to conceive of more appropriate or delightful surroundings for men who have returned from German prisons.

Summarizing his experience of the camps, Colonel Jones stated that:—

The sanitation and housing were excellent; the feeding good in quality and plentiful; the Swiss doctors in charge well trained and attentive, and quite competent; the specialists extremely good, and every reasonable facility afforded for consulting them; the General Hospitals for serious cases were staffed by competent and often distinguished surgeons.

This visit of Colonel Jones, and the satisfactory nature of the report, once and for all set my mind at rest as to the general efficiency of the service and the skill of the medical officers, and certainly had a tranquillizing effect on the majority of our own officers and men. The contrast between the condition of the recent arrivals and those who had been in residence for some time was most marked, and furnished a proof of the almost miraculous change effected by the climate, the freedom from anxiety, and the good work of the doctors. In every camp the two classes of men were paraded for inspection side by side, and the difference in their mental outlook and physical condition was of a marked nature.

Further confirmation of the activities of the Swiss doctors reached me about this time from another quarter. Having regard to the great mass of Ps. of W. arriving in Switzerland, the majority of whom had received insufficient treatment in Germany, the "Médecin d'Armée" found it necessary to call for an objective and uniform examination of all wounded men, with a view to obtaining detailed indications for the treatment of their wounds, and in September, 1916, Dr. Matti, a distinguished specialist of Berne, was charged with the duty of visiting the "regions," and of examining every case where surgical and orthopædic treatment was in question. In December this order was modified, the "regions" being divided into four zones, for each of which a Specialist was nominated. The result of these examinations was communicated to me in due course, supplementing, and, I am glad to say, confirming, the conclusions drawn, quite independently, by Colonel Jones.