i/re ■< THE CARE OF THE WOUNDED IN THE BALKAN WARS By MAJOR CLYDE S. FORD Medical Corps, U. S. Army SANITARY INSPECTOR GENERAL ABDUL SELIM PASHA AND MAJOR FORD WITH ESCORT AT CHATALJA The Care of the Wounded in the Balkan Wars1 By MAJOR CLYDE S. FORD MEDICAL CORPS, UNITED STATES ARMY THE appreciation of the value of human life is the measure of pro- gress in the march of civilization, as accurate perhaps as any other standard. When man was primitive and there was little he knew which enabled him to protect himself against adverse elements, he accepted his risks with only an animal instinct to preserve his life; and although he may have known always some grief in the loss of a mate, a brother, or a comrade, the destruction of an enemy was a joy and the death of a fel- low creature a casual event. The march of civilization has been long, but it has brought us to this day of hu- mane ideals more by a realization of economic loss in the destruction of human life than by appreciation of sentimental values. In countries that are now called primitive by those which claim to bear the standards of culture, systems of car- ing for the bodily afflictions of the in- dividual still have about the same ratios to their respective communal resources, and the conventional attention given to a fatal illness in one country would be a death by neglect in the other. As the practice of the healing art has extended in civil communities, it has been applied to armies. Army com- manders have always complained of the loss of military strength from the wounds and diseases of their soldiers. Although in the thirteenth century the practice of surgery became common in the hands of barbers, after it had been taken from the monks by papal decree, things still moved so slowly that the first attempt at an or- ganized medical service in any army was made by the French only in the fifteenth century and by the Germans in the six- teenth. These two countries have since been so much the leaders in all branches of military art that today their most efficient sanitary organizations have been imitated or copied in the other armies of the world. The Ottoman army has adopted the German sanitary organization bodily. 'Reprinted from "The Survey", January 2,1915. THK CARE OF THE WOUNDED 1 N T II K B A L K A N W A R S The Bulgarians had a sanitary system based on French principles, which was considered consistent with the needs of their soldiers and the resources of the country. But it must be observed that all continental armies are nations in arms, and that their organizationsarebased upon universal service in which all able-bodied men have military training and take a certain place in the army in time of war. A large part of the sanitary service in French and German armies is performed by Red Cross societies which have or- ganizations as well trained as our militia and at least as well prepared to take a definite place in the sanitary service of the army as our militia is prepared to increase our regular army. While Tur- key and Bulgaria have volunteer aid societies, known by the name of ''Red Crescent" in Turkey and "Red Cross*' in Bulgaria, they were both untrained for war and their service was confined to the base hospitals inConstantinople andSofia. The desire of the sanitary service in all armies is to give to every soldier who is not killed, as efficient care for his wounds and diseases as he would receive in time of peace; but the duty of the service is to do only the best in this way that its well- directed resources and the military con- ditions will permit. The general principle employed is to remove the wounded and sick as speedily as possible from the battle-line and theater of operations, which they heavily encumber, and to dispatch them beyond the zone of mili- tary activity where they can be received by the volunteer aid units, whose service properly begins at this point. Clearing an army of its casualties is not a matter of sentiment, not a mission of mercy; it is just as plain and material an under- taking as providing its food, clothing or ammunition. And all these functions demand the same organization and prepa- ration for their efficient discharge. I know an agent who tried to sell ambulances to both the Turkish and the Bulgarian governments some time before the war began; but it was decided in both cases that the funds available for the purchase of guns and ammunition, at a time when every fibre of military 2 strength was being strained, could not be diverted to provide such impediments as special transportation for the wounded. Yet isn't it only sane and logical to de- termine in time of peace just what ar- rangement and apportionment of mili- tary resources for sanitary service will be made in time of war? The two armies had practically no ambulances to carry their wounded from the battle-line to the base, but they were prepared for and resigned to the employment of the wagons which brought supplies to the front to carry the wounded to the rear. Therefore it must be remembered that whatever organization and equipment a sanitary department may have, the man- ner of its utilization is limited by the success or failure of the military cam- paign in which it is employed. In the first Turko-Balkan war in Thrace, the entire Turkish force of about 150,000 men, except the beleagured garrison of Adrianople, was routed and driven back in disorder to the defenses of Constanti- nople in about seven days. Whatever the previous preparation of the sanitary department may have been, it is plainly to be seen that it must have suffered the same disorganization that affected the whole army and that it could not render any aid beyond the occasional attention which its hospital personnel may have given. As a matter of fact, all the medi- cal equipment was lost. Under such circumstances horses are not taken out of batteries or ammunition wagons to pro- vide transportation for wounded. I saw many wounded soldiers, later, in Constantinople and each man told me that he had to make his own way to the rear alone or with the aid of comrades or with animals or vehicles which were personally appropriated in the disorder. The duty of the doctor or of the nurse, to give personal attention to the wounds of the soldier, is the easiest sanitary function to perform; but it is of the least benefit to the patient, who profits more by the food, shelter and transportation, without which his succor cannot be se- cured. After the defeat on the Thracian plains, the Turkish army was in fixed position By MAJOR CLYDE S . FORD, MEDICAL CORPS, U. S. ARMY INDIAN RED CRESCENT HOSPITAL NEAR CONSTANTINOPLE behind field fortifications, and the sani- tary problem was simple. Fixed hospitals were established which could be readily evacuated by rail to Constantinople, where the problem of caring for sick and wounded was one of civil hospital ad- ministration. But it takes material as well as personnel to care for sick and wounded, and many of the provisional hospitals could not command the re- sources necessary for efficientadministra- tion. The most important part of the treat- ment of the wounds of war is the appli- cation of a dressing, regardless of the nature of the wound. This protects the wound from infection or blood-poisoning which, in the great majority of cases, does not exist in the wound at first. Provision is made for this protection by furnishing each soldier with materials for such a dressing which he himself, a comrade, a sanitary soldier or a surgeon, may apply. The dressing is well known as a "first-aid packet,'" but in the begin- ning of the war neither the Turkish nor the Bulgarian army was adequately sup- plied. It was surprising to observe how quickly the soldier himself appreciated its value, after he has had some exped- ience in an active campaign in which he himself had been wounded or had seen his comrades in similar distress. Of the many Bulgars who had been in America and had returned to their native country for the war, I talked to one who carried his first-aid packet in conspicuous evidence. He said it was "good stuff" and then continued with the wise advice: " You give every soldier first his first-aid packet; afterwards his gun." The packets of all the men in his command had been secured from a captured Servian wagon-train and they were the most highly prized of all the booty. An exhibition of an active field sani- tary service was found in the second war, in which Bulgaria, opposed by Servia, Montenegro, and Greece, met her ene- mies in the Macedonian Mountains, broken by deep valleys and tortuous streams, where roads are few and bad and where many of the positions were reached by crooked trails impassable to wheel transportation. The Bulgarian army had to move into this position with all possible expedition by long, forced marches after a campaign of eight 3 THE CARE OF THE WOUNDED IN THE BALKAN WARS months, carried through the rigors of a hard winter which had consumed much of its equipment and supplies. Medical Resources There are only 600 doctors of all ages and physical conditions in Bulgaria. Even the extreme limits of apportion- ment to her army of 400,000 could not provide more than one doctor to 700 sol- diers. In our own army today, in its state of peace, there are about 500 doctors and 85,000 soldiers, a ratio of one doctor to 170 soldiers. This comparison should be borne in mind when it is said that in some Bulgarian regiments there were only dentists and medical students acting as doctors, although in others there was a very creditable medical personnel and equipment. I saw one hospital situated down in the valley more than a mile from the posi- tion of its regiment on the mountain-top. Even there a shell exploded and destroyed one of the wagons. Although a telephone line connected the hospital with regi- mental headquarters and one or two of the three doctors were on the firing line during engagements, one can easily ap- preciate the difficulties attending the care of wounded under such conditions. In some positions there was no shelter for either the well or the wounded except that made from boughs of trees or by digging into the hillsides. As the ration of the army for some periods consisted solely of a two-pound loaf of whole-wheat bread, there were no delicacies for the wounded. The surgeon general of the Bulgarian army told me that he was well enough supplied with medicines and dressings, but that he needed suitable food for his patients even more than he needed doctors and nurses. In this second war the Bulgarians were plentifully supplied with first-aid packets, and they were so employed that the wounded were invariably under my ob- servation dressed at the aid-stations or regimental hospital behind the firing line, where they lay often with very little shelter until the transportation which brought up ammunition and rations could carry them to the field hospitals some miles in the rear. Such attention as facilities afforded was given in the field hospitals which, in some cases, when SANITARY SERVICE CONTEST By MAJOR CLYDE S. FORD, MEDICAL CORPS, U. S. ARMY TURKISH HOSPITAL CORPS AT DRILL immobilized, were able to keep a few seriously wounded patients indefinitely, although it was the purpose to forward them immediately to the evacuation hos- pitals on the railway or a metaled road having direct connection with Sofia. I was attached to an evacuation hos- pital located near the southwestern fron- tier, in the little town of Kustendil, the headquarters of the Fifth Field Army whose lines were ten miles away. The Fourth Field Army had its headquarters and center more than thirty miles away, but on account of the topography of the country we received almost all our pa- tients from the more distant location, in bullock-carts after a four days' journey. This hospital cared for wounded only. It was rated with a capacity of 700, but there was actually less than 500 beds, though as many as 1,000 patients were present at one time. One day, almost 500 cases were admitted; 4,000 were received in less than two weeks; 10,000 passed through as the result of one month's military campaign. But although the number of major operations received under these conditions was not more than 2 or 3 per cent of the total number of cases admitted, the best surgical judgment is required in the discrimination and management of these cases. The Evacuation Hospital The evacuation hospital is the most important unit in the sanitary service at the front. It is there that substantial care and surgical service for essential operations must be provided in order to prepare patients for transportation to base hospitals, where their fate may be definitely determined. At the base hos- pital, the skilful volunteer surgeons and nurses, untrained in military service, may find their most useful employment. The romantic fancy that Red Cross doctor and nurse softly wind their ways among the wounded on the battlefields to minister gently to their suffering, is a delusion. Yet this delusion unhappily prevails to such a comforting extent among both untrained volunteers and those who direct their worthy efforts, that neither seems fully to appreciate the necessity for preparation and organiza- tion. The so-called and oft-heralded "front" is the lure alike of the nurse and THE (ARE OF THE WOUNDED IN THE BALKAN WARS the soldier; it is the spirit of adventure, tempered by the love of humanity in the one and the love of country in the other, but its inspiration leads to failure of the nurse's mission though it gives strength to the soldier's battle. The American Red Cross Society has not prepared to render any organized assistance to the army in time of war and the little lessons of the Balkan Wars, as well as the greater ones that now come to us each day from the battlefields of Europe, teach that it is service, not sen- timent, that ameliorates the condition of the wounded in time of war. In conclusion, I must dismiss that part of the subject which refers to the or- ganization of the sanitary department of an army as too technical for this discus- sion. This phase, however, merits the attention of any scientific student, but it is no fit subject for a sentimentalist; for the number of ambulances must be con- sidered in connection with the relative number of guns, bayonets, and sabres of an army. The lessons to be learned, by which volunteer aid can most expeditiously help the wounded in war, can easily be read in the preparation that all European Red Cross societies have made for their ser- vice in war. These may be summarized as follows: 1. General organization for the care of the wounded after they have been passed back from the zone of operations by the army sanitary department. This division of labor is arranged with the sanitary department under the direction of the war department. 2. Accumulation of large capital sums which cannot be expended unless the country is at war. Only the income is available for administration. Special subscriptions only, are applied to general relief work. 3. Organization of various aid units, such as field hospitals, base hospitals, field rest stations, railroad rest stations, hospitals trains, hospital ships, transport columns, organization for distribution of patients, information bureau and the establishment of depots of supply. 4. Accumulation of material for the equipment of their various units. 5. Training of personnel for their spe- cial duties. There is scarcely any limit to the in- dustry which maybe applied by volunteer aid societies for the relief of wounded in time of war, but efficient results can only BULGARIAN FIELD HOSPITAL KITCHEN By MAJOR CLYDE S. FORD, MEDICAL CORPS, U. S. ARMY be obtained by the preparation and or- ganization in times of peace and hours of reason. The relief of the wounded in time of war is a problem of preparation and organization of a military character; and when it is left to the very time when relief is urgently needed, so many mis- guided efforts are made by those who have nottaken the pains to acquaintthemselves with actual conditions or who have no conception of organized methods, that, to say the least, results are disappointing. But it seems probable that the anti- military spirit of the American people will hardly be aroused to such activity; and in event of war—which, of course, we hope will never come the wounded soldier cannot expect to be much more than he always has been,—namely, a poor devil out of luck. TURKISH SANITARY COMPANY 4 I « PRISS OF THE ARMY SIRVICC SCHOOLS. FT. LIAVINWORTH, KAS