The Regimental Medical Officer: His Powers And Duties

Author(s): R. J. Blackham and T. H. Blake

Source: The British Medical Journal , Dec. 25, 1920, Vol. 2, No. 3130 (Dec. 25, 1920), pp.
971-973
Published by: BMJ

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 DEC. 25, 1920o THE REGIMENTAL MEDICAL OFFICER. [ RITIAS 971
So I have apparently come to two contradictory them carried
conout himself by means of certain personnel
clusions, one showing the teeth as a cause of ill of health
the battalion
and which are placed under his control and
the other showing ill health as the cause of supervision-namely,
bad teeth. the so-called "regimental " medical
The conditions, of course, act on each other and sanitary
and con establishment. Consequently his duties range
tinue in a vicious circle. Tile actual commencement over a wide area,
of and comprise not only such purely medical
functions as attending the sick and wounded, but questions
the process of dental caries is probably an inherent lack
of sanitation, water supply, food, etc., and, last, but not
of resistance on the part of the dental tissues least, to infection
the training and organization of the regimental
from the putrefaction of particles of food adhering to the
stretcher-bearers, and the evacuation of the wounded from
teeth. the front line to the aid post.
I want to emphasize once more that, in a normal mouth, The medical officer with a unit in the field unquestion
it is not until the pulp is infected and the tooth " dies" that ably requires to exercise considerable tact, patience, and
any great damage to the health occurs, and our aim must discrimination if he is to carry out his duties successfully.
be-until some wonderful person can feed us with a Tact is especially required in his relations with the
hormone which will increase the resistance of the dental other responsible officers of the battalion. If he is wise
tissues to disease-to treat teeth early, and so prevent he will keep on good terms with the battalion quarter
their getting into such a condition that health can be master. He has to rely on the quartermaster to a large
affected by septic absorption. It is certainly to be hoped extent for supplies, and for getting carpentry for sanitary
that the future army dental service will be adequate work, etc., done by the pioneers, and quartermasters often
have ideas of their own as to how these things should be
enouigh to do this for the troops. done. Here the exercise of tact comes in, and it is
generally obvious to an inspecting officer whether the
medical officer and the quartermaster are "I hitting it off"
THE REGIMENTAL MEDICAL OFFICER; or not.
The regimental medical officer requires also patience
HIS POWEERS A.ND D UTIES. and insistence in again and again bringing to light and
BY pointing out faults, bad sanitary points, etc., as well as
discrimination in discerning when to put his foot down
COLONEL R. J. BLACKHAM, C.B., C.M.G., C.I.E.,
and take a firm stand, and, on the other hand, when to
D.S.O., MI.D., make allowances for the difficulties and exigencies of
military
CHETVALIEPR OF THE LEGION OF HONOURn; service.
AND
CAPTA IN T. H. BLAKE, M.C., LATE R.A.MI.C. 1. Dnties in Campfs and Billets.
Morning Sick Parade.-The time at which this is held
[Abridged.] Is a matter of arrangement between the medical officer
"The Royal Army Medical Corps is maintained, firstly, and the adjutant. It is usually some time between
with a view to the prevention of disease; and, secondly, for 7 and 8 a.m., so that company commanders may know
the care and treatment of the sick and wounded " (R.A.M.C. how men reporting sick have been dealt with before the
Training, page 1, para. 1). principal work of the day begins.
ONE of the greatest difficulties which confronted the Disposal of Sick.-Men reporting sick are brought to the
medical officer serving with a unit in the Great War was medical inspection room under the charge of a N.C.O.,
the fact that he found himself called upon to discharge who has a roll of names in duplicate on the "I sick report."
work which was of a miltary nature, and for which Lie had The medical officer disposes of the sick in the following
received no previous technical training. The officers of manner:
field ambulances had, of course, specialized duties to Cases needing hospital treatment are marked "hospital,"
perform, but they served directly under field ambulance and all further steps are taken by the N.C.O. i/c. Cases re
commanders who were experienced officers well qualified quiring medicine or a small dressing, but who are able to con
tinue their work, are marked "1 M and D," or Medicine and
to instruct them. Duty.
Medical officers were detailed for duty with various Men who are not well enough to drill, but who can do light
military units such as battalions, brigades of artillery, work in the barrack room, are marked "1 L D " or Light Duty.
divisional engineers and the like, and here the R.A.M.C. Men reporting sick without a cause should be warned, and if
they persist in reporting, their sick report should be marked
officer stood alone, and neither the commanding officer of "Duty." The medical officer must realize that if he marks a
his unit nor any of his comrade officers were capable of man's sick report " Duty," he is making a definite charge of
tellina him what to do or how to do it. In this paper we malingering, and will have to substantiate his opinion before
wvill refer to these medical officers as the "regimental the commanding officer, who will charge the man under Army
medical officer." Tile name is a misnomer, but it was used Act, Section 18. In doubtful cases a dose of castor oil or a No. 9
throughout the war, and it is honoured by usage if not by tablet sometimes works wonders in cooling a man's ardour for
sick parade.
accuracy. These officers soon found out the fallacy of the
popular impression that the possession of a medical degree The following is a list of the duties of a unit medical
officer: W
qualified its lholder for any medical post, and blundered
hopelessly, until finally they worked out a daily and (a) Sanitary inspe
ablution places, rat
weekly routine for themselves. Realizing their difficulty, water carts, etc.
aud havina served with fighting formations throughout (b) Choosing and i
the war, we think 't may be of interest to discuss briefly (c) Scabies inspect
the position occupied by a medical officer in charge of a or courses, or prop
battalion or other military unit on active service, and then (d) Classes in fir
reserve.
to pass on to consider various points and difficulties which (e) Training of san
arise in the carrying out of his duties under the following to replace casualt
headings: (f) Clerical work
1. In camps and billets. The medical off
2. In ordinary trench warfare. the front tren
3. In active operations. enemy. He is th
4. In relation to medical statistics and records. important part o
Some notes, originally compiled in 1915 for the division and hygiene.
one of us (Colonel Blackham) took to France, were re (a) Sanitary IRspections.-On occupying a newarea, in addition
written years later with the assistance of Captain T. H. to making out a'report to the A.D.M.S., detailing his exactposi
Blake, M.C., who had extensive experience with a battalion tion on the map, the medical officer should write a short report
of our division in France. to the commanding officer of his unit drawing his attention to
any bad points, and making suggestions for Improvements. In
some cases very unsuitable places are chosen by billeting
officers as medical inspection rooms, and it is advisable, it
Position OccuZpied by a Medical Officer in Charge of a
Battalion. possible, to send on a medical orderly or corporal ahead with
The medical officer occupies an advisory position in the
hisbilleting officer to look out for a suitable spot.
battalion or other unit. He is responsible for advising (b)) Waster Supply.-Immediately on arrival in af new area the
medical officer personally should investigate and mark the
his commanding officer on all matters that concern thesources of supply. All water for drinking and cooking must be
health, and even to a considerable extent the comfort,drawn
of from these selected sources. All drinking water must be
the troops; but it also lies with him to see that the chlorinated, the amount of bleaching powder required being
measures he suggests are carried out, and even to haveascertained periodically by the iodine test. All water from

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 972 DEC. 25, X1920] NAVAL AND MILITARY SECTION. T iEm BRITISS

rivers, streams, and ponds should be passedreserve through the

stretcher-bearers. If any difficulty is put in the way of
clarifier. No source is to be chosen which is liable
havingtothese
pollution
latter men it is the duty of the regimental medical
by privies, cesspits, middens, or which is in close proximity
officer to insist veryto
strongly on the absolute necessity of having
a cemetery. Water from a river source must be drawn
them, and if as
thefar
commanding officer still declines to supply
as possible up-stream to prevent pollution fromthemvillages,
he shouldAte.;
appeal to the -A*D.M.S. of his division.
horse troughs and ablution places mlust- be down-stream. dIn
In a modera attack there is generally a rush of casualties at
an advance, owing to possibility of poisoning -bythe the enemy,
beginning, and if there are not plenty of stretcher-bearers
flowing water should be obtained in preference to stored,
(and stretchers) available, cases may be left on the field for hours
still water or wells. Dead fish and cases of poisoning
oievesn days among
before being removed to the rear, an occurrence
inhabitants should be looked for. which has a bad effect on the moral of the men and is contrary
'(c) Scabies aid Other Inspections.-The unit is paraded a com
to all dictates of humanity and prospects of recovery for the
pany at a time with shirt sleeves rolled up andpatients
shirts open at
concerned.
the chest. The medical officer then passes rapidly down themay be distributed either (a) equally.
Stretcher-bearers
lines, the men holding out their hands and turning
amongstthem over
the four companies, or (b) about half may be detained
as lie arrives in front of them. Any man whoat has suspicious
the aid post for subsequent disposal by the medical officer,
lookinig spots either on his hands, arms, or chest, is told
according to fall
to circumstances, and the remainder distributed with
out after the inspection, and go to the medical inspection room.
their companies. The corporal in charge should remain with
There lie is stripped and thoroughly examined. If the
the medical comThe method adopted must necessarily be
officer.
paniies parade at twenty minute intervals, the inspection of nature
influenced by the an of the operations to be undertaken,
entire battalion can be got through in an hour andandatherefore
half. the unit medical officer should make himself
(I) and (e). Training of Stretcher-bearers, Jfater Ditty
familiar Men,with all the.essential details of the attack,
beforehand
and Sanitary Men.-It is well worth taking trouble tomay
so that he train
make arrangements most suitable for the
stretcher-bearers thoroughly in first aid. The more they
occasion. get tospeaking, the second of the two disposi
Generally
know of the work the more interest they taketions in isit, and the
best.
more likely are they to do well when it comesBefore to a the
" push,"
attack begins the medical officer takes up his
when the efficient performance of their duties becomes
position at an aid of
post, which has been decided upon before
paramount importance. It is advisable to have ahand if possible. Reserve bearers will be at close call. He
lance-corporal
in charge of each company squad. All experience mustgoes tothe
let all prove
battalion stretcher-bearers know where- his
that in battle at the very least thirty-two stretcher-bearers aid post is, eitherper
by messenger, or through battalion head
battalion are required. It is therefore not sufficient quarters.to train
In all probability casualties will begin to arrive at
only the regular stretcher-bearers. Sixteen reserve the aidmen must operations commence, or even before,
post directly
be thorougTly trained to meet emergencies in andaddition,
he will be keptandbusy attending to and evacuating cases
also to fill up vacancies from casualties or sickneess as they
for some hours.
arise. Not less than two extra water duty and sanitary men
should be trained as a reserve to fall back upon in On the case of
the medical officer lies the responsibility, not only of
casualties. attending to the wounded of his battalion, but of satisfying
himself, as far as it is possible to do so, that all wounded
2. Ditties in Trench W'aifare. are brought in-a far more important responsibility than
In the trenches the life of the unit medical officer centres that of merely attending to the wounded. If what we
largely in his aid post, to which are brought the wounded have said above about training in first aid has been done
and sick for treatment and evacuation if necessary. The satisfactorily, there will be less necessity for the medical
stretcher-bearers are with their companies, and they are officer to re-dress the cases himself, and many of them
informed of the situation of the aid post, which should be can remain as they are until the patient reaches the field
on the direct line of evacuation from the front line. If the ambulance, provided that haemorrhage is arrested and
carry is not too long everything works smoothly, and as a broken limbs are adequately supported in splints. Time
rule ordinary casualties can easily be dealt with by the will thus be saved, and the medical officer will be able to
sixteen regular stretcher bearers. keep in touch with his battalion headquarters, which will
There is also a squad of R. A.M.C. bearers at close call for in most cases have moved forward considerably, following
evacuating cases from the aid post. In addition to attending the course of the attack.
the sick and worunded at the aid post the regimental medical He will fromt battalion headquarters gain information as
officer carries on, as far as lie is able to do so, his sanitary and to where most of the casualties have occurred, and will be
other duties, miahing from. time to time a tour of the trenches in able to organize and dispatch his reserve stretcher-bearers
his battalion sector and inspecting latrines, dug-outs, etc. The
corporal in charge of the stretcher-bearers should be stationed to any points where help is most urgently required. If the
at or near the battalion aid post, and his duties are to go round casualties should be exceptionally severe, he can request
daily to the stretcher-bearers, see that they are supplied with additional assistance either from brigade headquarters or
dressings, etc., and also to arrange under the direction of the from the field ambulance. He must then reconnoitre the
medical officer ad(litIonal help or relays of bearers in carrying ground for a more advanced aid post. As soon as he
cases down should occasion arise, and to give any other help has established this he should inform his battalion head
which may be required in bringing clown and dressing of cases. quarters of his new position and ask them to communicate
Occasionally the placid course of trench life is interrupted by the position by wire or runner to the several company com
raids. A decision is taken to raid a portion of the enemy's manders for the information of the stretcher-bearers. He
trenches by a party which may consist of anything from 10 to
100 men or even more, and the medical officer is probably asked must also inform the field ambulance commander of his
by the commanding officer to make special arrangements in change of position, in order that R.A.M.C. bearers can be
view of a larger number of casualties than usual. The best sent up to him.
procedure is to place all stretcher-bearers of the battalion at There is still one more "activity " to which he can
the disposal of the company-or companies carrying out the raid. apply himself, and that is the sending out of bearers
Only a very limited portion of the front is involved in these to search the ground over which the attack has passed
operations, and if there is a good dug-out available close to and bring in any cases which have been missed by the
that portion of the line, it should be taken over and made into stretcher-bearers.
an advanced aid post, where the medical officer can collect the
wounded, attend to them, and evacuate them when the opera
tion is over, If no dug-out is available where the wounded can 4. Dutice in Relation to. Medical Statistics and
be collected, the medical officer must remain at his aid post Records.
and await developments. - He must bear in mind that he may The daily routine of a regimental medical officer entails
be cut off from the front line for a considerable time by the
enemy's barrage, and that it may be impossible for him to a certain amount of clerical work. The objects of routine
reach the wonulded, or the wounded to get to him. clerical work are:
1. For Referece in the Evenzt of Inquiries.-On account of tihe
It will be seen that the unit medical officer in ordinary many duties and constant movements of the medical officer it
trench warfare is rather a " passive I individual, who is impossible for him to remember the details of the various
remains in or near his aid post and awaits for cases to incidents which may require investigation at a later period.
be brought to him. By taking notes of any interesting case or incident he has a
record to which he can refer if anyy inquiry is made.
3. Dittics in Active Operations. 2. lao feep a Record of Cases Passing through his Hands.-This
The picture now undergoes a considerable change, and is important from a professional point of view, as it stimulates
the activity with which his battalion is suddenly imbued clinical research and enables a medical officer or his successors
to follow up a particular disease. One of our officers wrote the
spreads to the medical officer. First let us consider what thesis for his M.D. from his rec6rds as a battalion medical
regimental arrangements are usually made for dealing officer.
with casualties, bearing in mind that the battalion is 3. To Ezlsure Conitin'uity of Work.-There is nothing more
responsible for the treatment and evacuation of its own annoying for a medical officer than to take over medical charge
woundedl from the front line to the aid posts, at which of a unit and to find- that his predecessor has left no recor-ds of
points thecy are handed over to the R.A&.MS.C. bearers and any kind. In many cases the "Stick " Corporal canl assist the
the regimlenltal responsibility ceases. new medical cificer, but it may happen that the " Sick '.' Cor
poral has left the unlit also, and there is no one to. give the
The unlit medical officerl will hlave at his disposal sixteen medical officer any information, and he has to find out every
regular strectchler-bearers (inccluding one N.C.O.) anld sixteen thing for himself.'

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 * DEC. 25, f920] AUTO-HAEMAGGLUTINATION. . . - [MIcJ A 973
Clerical work may be classified as follows: An entire absence of clumping wags recorded as a minuts.
1. Correspondence with AD.M.-S. reaction.. ;
2. Correspondence with field ambulance and battalion head-. .These results were controlled in some of the.p8u
quarters. This includes (a) sick report for every sick man sent
samples by washing the red cells. in normal sali
to a field ambulance; (b) tallies for all wounded; (c) indents
for stores. mixing them with 1the serum. The results were
. 3. -The Regimental Aid Post Diary, recording the diagnosis, as in the unwashed cells. A review of these
treatment, and disposal of sick men dealt with by the medical shows that although the proportion of cases wh
officer; and the Sanitary Diary, whieh, should be handed in marked auto-agglutination reaction was nearly
daily to the orderly room for inspection and initials of the the positive as compared with the negative case
commanding officer.
4. Other records include (a) nominal rolls of all officers and numbers in the "trace" heading and in the min
other ranks in the unit who have had dysentery or enterica, were in like proportion, there is no constant a
and of all cooks and men employed in the handling of the food. between a syphilitic's blood serum and auto-agg
supply. These are kept in order to trace " carriers." (b) Record of the red cells by that serum. On the othe
of inoculations. (c) Notes of all self-inflicted and accidental careful investigation into-the history and other
wounds, which should be made at the time the medical officer
sees the case. factors in both negative and positive cases soon
The foregoing sketch should, we thinks not only give the that auto-aagghtination of red cells by nat
young surgeon a clear conception of his importance in the occurred for the most part ii. those blood s
chain of medical responsibility in wvar, but demonstrate to which either the positive reaction was high (in
other readers that the unit medical officer is the keystone marked reaction), or in which somne ulcerating
of the arch on which was.built up the finest service which focus could be demonstrated which afforded a
ever served with an army in the field. infection by pathogenic organisms.
As we shall see later, it is this presence of an
focus and the defensive reaction made by the or
ON AUTO-HAEMAGGLUTINATION: the bacterial toxins formed there which accoun
auto-agglutination in those blood samples wh
A CONTIIBUT'ION TO THE PHYSIOLOGY negative Wassermann test.
AND PATHOLOGY OF THIE BLOOD. This examination of these 500 samples of b
BY different individuals, all coming under medical
C. J. BOND, C.M.G., F.R.C.S., HON. COLONEL A3M.S., for some form of ill health, showed that a we
auto-agglutination was present in about 9 per
VICE -CHAIRMAN OF THE MEDICAL CONSULTATIVE COUNCIL, MINISTRY
OF HEALTH; HONORARY C0NS'LTING SURGEON TO THE
LEICESTEB ROYAL INFIRMA tY; MEMBER OF the cases, and a slight degree or trace of the sam
THE MEDICAL RESEARCH COUNCIL. in nearly 19 per cent.
The marked auto-agglutination present in som
PART II.-CLINICAL. syphilitic samples must therefore be regarded
WEt have already seen in Part I that shed human red bloodcation of a reaction by the body against invasi
cells and those of the sheep, guinea-pig, and other animalsspirochaete of syphilis, in common with the rea
when standing in vitro under suitable conditions passto other forms of infection in negative as
throuoh certain degenerative clhanges during which theypositive cases.
form non-specific agglutinogens, and thus become agglu A number of control observations carried o
tinablo by their. own native serum and by foreign serumsblood of presumably healthy individuals showe
with which they do not react when freshly shed. most part an absence of the auto-agglutination
We shall now proceed to consider certain tendencies on in the freshly shed blood. In a few cases in
the part of the red cells to become more agglutinablereaction was present in slight degree and in the "
during life as the result of disease. This change can beform careful inquiry revealed a previously un
recognized in freshly shed blood by the same auto. focus of infection, such as the presence of o
intestinal, or genito-urinary sepsis.
agglutination reaction as that previously considered in
Part 1. (BRITISH MEDICAL JOURNAL, December 18th, 1920.) An examination of the blood of a large nu
different samples of the population on these l
The Wassermrann Test in Relation to Auto-agglutination.I feel sure, reveal facts as to the prevalence of
In order to test this point a routine examination was and other forms of ill health which remain
made of 500 samples of blood from 500 consecutiveunrecognized.
patients attending Dr. Mackarell's Pathological Depart Pneunnonia.
iment at the Leicester Royal Infirmary for the Wasser A series of cases of acute lobar pneumonia of pnenmo.
mann test. The result from the haernagglutinative pointcoccal origin were next examined. A few drops of blood
of viewv is given in the following table: drawn from - the finger into a small Wassermann tube
(+ auto-agglutination ... ... 30 = 13 % were either defibrinated by whipping or, generally, allowed
Positive Trace reversible auto-aggluttination. 51 = 22to%clot. A drop of the serum so obtained was then placed
No. of 231 l-auto-agglutination ... ... .15 65 % on a slide and mixed with the red cells obtained from the
Cases,
500 N (+ auto-agglutination ... ... 16 7 7% clot by the method described in the case of the Wasser
Negativ Trace reversible auto-agglutination .. 43 = 38.5%
mann test samples.
In all the cases of acute pneumonia
269 V- auto-agglutination .210 = 91 %
so far examined (generally about the fifth day of the
Thus we see that in 500 samples of blood taken from
disease) a well-marked auto-agglutination of the red cclls
500 different individuals, of which 231 were found to by
be the native serum was obtained. This often amounted
positive and 269 negative to the Wassermann test, 13 per
to + + degrees, and was non-reversible in character.
cent. of the positive cases Showed -well-marked auto Although I cannot at present state at what period of
agglutination, as against 6 per cent. of the negative cases.the disease the, reaction first becomes recognizable,
A trace of auto-agglutination was present in 22 per cent. repeated examinations of tlhe blood of pneumonia patients
of the positive, as against 18.5 per cent. of the negativeat recurring intervals after the attack have shown that
cases. On the other side 91 per cent. of the negative casesthe blood condition does not return to the normal after the
gave no evidence of auto-agglutination, as against 65 per crisis has taken place and the temperature' has become
cent. in the positive cases. normal. The auto-agglutination reaction persists for two
. The clotted blood was used in each case. A drop of theor three months in most cases. It gradually diminishes in
clear serum was placed on a slide. A fine-pointed pipetteintensity and passes in reverse order from the ++ through
was then thrust into the centre. of tAe clot and, by gentlethe " reversible " and "trace'" stages to the "absent"
suction movements, a drop of the concentrated red cellstage.<
suspension was withdrawn and added to the drop of serum.
.These were mixed together with a glass rod and allowed * Since this was written I have had an opportunity Of testing the
to stand for a few minutes, then gently. agitated andblood iu two of the pneumonia cases after an interval of nine months,
T)oth patients being now in ?Ood health. In both the blood has lost
exawained with a hand lens. A well narked non-rever the auto-agglutinable character present during and after the illness,
sible agglutination of the red cells occurring within though
a the power of specific agglutination of red cells from an
individual of another blood group remains unimpaired. In another
quarter of an hour was recorded as a puts reaction. 'A
case of a patient with a positive Wassermann and a suppurating focus
slight degree of agglutination, which disappeared on agita
of secondais infection in the leg, three + + 4- degrees of at?to-agglutina
tion were present in January, and when examined in October auto
tion and reappeared after standing and renewed agitation, agglutination was absent, the blood had returned to normal, and the
was recorded as a reversible trace of auto-agglutination. suppurating focus was healed.

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