Medicine_And_Surgery

"Medicine And Surgery 18.41 and 26.125). - By the year 1910 medical thought had reached one of its turning points, though this fact was not immediately evident. The great age of bacteriology had so vastly enriched our knowledge of disease that other aspects of work had been somewhat neglected. The belief prevailed that every disease was due to the presence of some microorganism, and that patient effort was bound, sooner or later, to find the specific microorganism in each case and enable a great work of prevention to be undertaken. In consequence bacteriology attracted the best brains in medicine, and enormous labour was expended in the search for organisms and in the study of their methods of growth. The fruits of this labour look smaller in the retrospect than the hopes concerning them which were entertained. A few new organisms have, it is true, been discovered, for example the spirochaete of infective jaundice (Weirs disease), the so-called filter-passers, and the still rather dubious rickettsia bodies supposed to be associated with typhus fever, trench fever and other conditions. Some differentiation, too, has been made between various " strains " of bacteria, notably in connexion with cerebro-spinal meningitis and bacillary dysentery (see Bacteriology). But an impression has gradually arisen and is growing that the greatest conquests in this field belong to the past. The trend of modern ideas is rather towards the application and elaboration of the knowledge newly obtained, and its absorption into the general body of medical thought.

I. General Progress In Medicine, 1910-21 In any review of recent progress the above considerations must be borne steadily in mind. The mere circumstance that many common diseases - for example measles, scarlet fever, rheumatic fever - are still unrelated to a specific causative organism is much less significant than the fact that the after-effects of these complaints have been intensively studied and that the application of the laws of bacteriological invasion and growth has saved many victims who in other days would have perished.

One of the first results of the new orientation was a conception of disease as a process dependent on another parallel process - the course of an infection. The human body reacts in various ways to various assailants. This reaction is expressed in symptoms which tell us of the struggle going on, and may enable us, if we understand their mechanism, to arrive at conclusions about the nature of the attacking force and the strength of the defences. The researches of the laboratory are available here as an additional source of enlightenment, and so fall into their place in the general scheme of clinical medicine.

## Importance of Prognosis

When the World War broke out in 1914 this was the point which had been reached. Sir James Mackenzie and other thinkers, whose outlook was primarily clinical, were recalling attention to the lack of knowledge of symptoms and the lack of understanding of their importance. Medicine, they declared, was concerned too much with the gross signs of disease, too little with its earlier manifestations. The post-mortem room had too great an influence on opinion, and even the laboratory had failed to perceive that a vast body of truth lay beyond its reach. The positive side of this teaching was the setting-up of certain functional tests to replace the physical ones then in vogue. It was argued that, no matter what deviations from the normal form an organ or system might show, if it remained functionally efficient it could not, on account of such deviations, be condemned out of hand.

This doctrine was really a challenge. It demanded a restatement in the name of prognosis. The physician must be able to interpret symptoms and laboratory findings in terms of life. He must be in a position to tell his patient what a particular sign betokened, how it would affect him, and how its cause might be removed or rendered harmless. In short, the physician must draw upon all the sources of information available, yet must not abrogate his place as interpreter.

The position taken up was assailed from several quarters. But the outbreak of war served almost immediately to reveal its strength. When that event took place the medical profession was called on suddenly to examine a vast number of men and express views as to their fitness for field service. These views were stated with the knowledge that they would be put to the test immediately and that if they were erroneous the fact would soon be discovered. A test of this kind constitutes a great event in medicine. It will certainly be seen in the retrospect as one of the turning-points of the science. For it brought the whole body of knowledge to trial; it brought the exponents of every theory to account. More than this, it revealed the key to the problem of future progress - prognosis. The doctor was asked to say what the patient could do; it was not enough merely to recount symptoms or signs. Looked at in this way every medical board paper was a kind of forecast.

Almost at once the deficiencies in knowledge began to be apparent. It was found by experience that the organic view "was not equal to the strain imposed on it. Those who had been content to recognize a sign and give a name to it perceived that this was not nearly enough. It was not enough even to find a particular germ in a laboratory, nor to discover by the use of X rays some abnormal condition. The laboratory, with all its.

intricate and beautiful machines, was unable to answer the great new question: " What effect will this symptom or sign exercise on the field of battle?" The whole weakness of the purely laboratory point of view was exposed in a flash. As a means of diagnosis this branch of medicine was of enormous value; as a means of arriving at a prognosis its value was much less. The new task of medicine was to interpret the findings of the laboratory and of the senses in terms of active life.

At the beginning there were many failures, and an outcry against the medical boards arose. Instances were cited of men who had broken down badly, though they had been passed " fit," and these made a considerable effect on the public mind. Nor did the retort that medicine had failed to find any sign of disease avail much. The layman replied that it was the doctor's duty to make a reasonable prognosis.

## Clinical Medicine

This difficulty led with great rapidity to a new orientation. Clinical medicine - the study of abnormal functioning at the bedside of the patient - became really important again; and the clinical revival which began at that time spread with amazing rapidity. Within a few years workers in every school of thought were adopting what are spoken of as " functional " standards.' Heart Disease. - In no direction was progress so rapid as in the study of heart disease. This disease had escaped to some extent the bacteriological obsession. It remained a clinical problem because no definite infective agent had been found. In consequence old ideas prevailed and the shadow of the postmortem room lay over every sign and symptom.

Popular apprehension of heart disease caused physicians, moreover, to stickle at sending any patient with a " murmur " to the fighting line. Happily, the British army medical authorities took a firm line, called to their help the leaders of what was then spoken of as the New Cardiology, who boldly applied their functional tests, and on the strength of them formed conclusions as to fitness for service. In spite of some anxious protests the views expressed were carried into effect, and men sent to fight who, in peace time, might possibly have been sent to bed. The result fully justified the method. Heart diseases, instead of proving the bugbear they had been in the early days of the war, 1 There was founded in 1920 by Sir James Mackenzie in the town of St. Andrews, Scotland, an Institute for Clinical Research which had hitherto no counterpart in the world. The reasons for taking this step were twofold: (1) While the signs of organic disease are well known and more or less easily recognizable, those of disease before organ damage occurs are almost entirely unknown. Disease before organic breakdown is thus an uncharted country. (2) In order to chart it, it is necessary to study carefully and extensively the so-called " trivial " symptoms. Only by such an investigation can light be obtained on the real meaning of those symptoms. The town of St. Andrews was chosen for the site of the work because it is small and self-contained. It was felt that, if the history of any given symptom was to be followed up, and its progress into the future - the only final proof of its seriousness or triviality - to be determined, a resident and non-shifting population must be studied. Moreover, the work must be carried out by general practitioners because they alone are consulted by sufferers from trivial ailments, and so alone see the earliest manifestations of disease.

Sir James Mackenzie gathered around him the local medical men at St. Andrews, and they all became research workers in the institute. The methods employed are those of the bedside amplified and extended. Every symptom of which a patient complains is carefully observed and noted down and the records are filed, indexed and classified. Any laboratory examination which may be necessary can be carried out in the institution, but for the most part such instruments as the X rays are inapplicable, there being no objective signs of disease. Periodically a particular symptom is studied intensively, for example exhaustion. By 1921, several important papers had come from the research workers. Their work revealed the fact that all symptoms depend for their production on disturbances of the normal reflexes of the body, another way of saying that they are exaggerations of physiological events. As most reflexes depend on the presence of a stimulating agent, a nervous mechanism and an organ or region stimulated, it is evident that a new pathway to the study of disease had been suggested. Thus, a morbid condition may fall under the heading of one or other of the three factors mentioned: it may be an excessive or extraordinary stimulus (a stone in the ureter), or an agent acting in the nervous mechanism (the toxin of a disease) or actual involvement of organic structure.

ceased to give much trouble. This news spread rapidly, and a new era in the medical study of the heart began. Incidentally it was found that exercise greatly helped many sufferers from so-called heart affections, and later still many of those affections were traced back to bacterial diseases. Thus the so-called toxic theory of heart disease was strengthened. It came to be understood that with the advent of an infection disturbances take place in the mechanism of the heart and result in a depreciation of functional efficiency. This can be restored by two methods: - destruction of the invading germ (e.g. in syphilis) or increase in the human resisting power (e.g. exercise).

Thus modern medicine achieved its two great principles - the understanding of the meaning of signs and symptoms in terms of active life, and the necessity of conserving and building up natural resistance against the enemies of the body. These principles, it will be seen, are complementary to one another. For prognosis Must always vary with treatment. In the days before antidiphtheria serum was discovered the prognosis in diphtheria was very bad. Since the use of serum has become general it is, on the whole, good.

## General Immunity

The early days of the bacteriological period had seen a movement away from drugs whose uses are directed to restoring the patient's strength. Instead, great search was made for substances capable of killing bacteria in the human body, and antiseptics and specifics of many kinds were introduced - e.g. salvarsan, new combinations of quinine, sera.  Later still the extension of methods of vaccination, for increasing specific natural immunity, occupied the forefront of research. Now general immunity, health in the broad sense, commanded attention. There was a revival of physical culture, and this was applied to the diseased as well as to the healthy.

Inevitably such a movement brought the study of physiology into new prominence - and this indeed is another of the landmarks in a very interesting period. One of the applications was the work of Sir Almroth Wright and his assistants in war wounds. When the war began, surgery had passed back again from antisepticism to asepticism. It had been found that the technique introduced and used by Lister was not necessary, that antiseptics were troublesome, and that absolute cleanliness secured all the advantages which these bacterial - and protoplasmic - poisons had gained for us.

## Treatment of Wounds

The treatment of wounds made by a surgeon in a modern hospital and the treatment of wounds made by shells on the battlefields of France were two very different things. Asepsis was no use when sepsis was already present. As a consequence the cry " Back to Lister " was raised, and the wounds of war were deluged with strong solutions of carbolic acid, iodine and other substances. This procedure naturally resulted in some trouble, and at length Almroth Wright was commissioned to make an investigation of the whole subject.

His conclusions were that antiseptics are largely useless because they fail to kill the germs of septic poisoning but do injure and weaken the tissues in which these germs are embedded. They thus interfere with a physiological process of repair and cleansing. Wright conducted some most delicate experiments, the object of which was to determine how wounds tend to heal and how deleterious matter is got rid of. He studied the lymph, or natural fluid, which flows out when a wound is made, and came to the conclusion that this, so long as it is fresh and uncontaminated, is an agent capable of destroying bacteria. If, however, the flow of lymph is dammed up, the fluid becomes corrupted and then forms an excellent pabulum for bacteria.

The case against antiseptics was that they tended to cause coagulation of the lymph and so produced " crusts " which dammed up the lymph flow. Thus more harm than good resulted. Wright, on the contrary, used salt solutions of various strengths, which increase lymph flow, and was able by this means to make wounds cleanse themselves. His views were received with immense interest, and were soon under discussion in every theatre of war and indeed in every civilized country. By some they were hotly contested, but they served effectually to put an end to the rash and indiscriminate use of antiseptics. Meanwhile, however, another worker, the Franco-American surgeon Alexis Carrel, had introduced with Prof. H. D. Dakin an antiseptic not formerly much employed. This was a hypochlorite solution which had been christened " ensol " or " Dakin's solution." The technique employed was more important than the antiseptic, and to some extent justified the views of Wright. It was a continuous drainage secured by the use of cans and rubber tubes. The wound was thus kept flushed and all its discharges were washed away. This system found many supporters but was attacked by Wright. Finally a third school dealt with the problem and brought to its solution the methods of the great German biochemist Paul Ehrlich. Ehrlich's idea was that a drug possessing a specific effect on specific forms of protoplasm might be found in connexion with any bacterium. He proved his case with his own discovery " salvarsan " or " 606," which possesses a special destructive power where the spirochaetes of syphilis are concerned.

In the case of the bacterial poisons of wounds another substance, flavine, was brought forward. This preparation belonged to the same group as salvarsan; it was used in the first instance by Prof. C. H. Browning. Very good reports of its efficacy were received. But again Wright and his followers attacked it on the ground that it failed of its object, the destruction of bacteria, and interfered with the physiological processes of nature.

It cannot be said that any permanent settlement of this dispute has as yet been reached, but it does seem clear that the foundations of Wright's work - physiological study - will be hard to shake. Indeed he has here an advantage over all his critics, the nature of which they did not seem at first to realize.

## Vaccine Methods

To Wright indeed belongs the credit of having brought the laboratory to the bedside. He saw that no method can succeed unless it is based on practice. Practice in this sense means physiological principle. It was recognition of this fact which inspired his antiseptic studies. Further, though this has not been sufficiently appreciated, it was recognition of it which enabled him and those who worked with him to bring the anti-typhoid vaccination to the high pitch of perfection it had reached when war broke out.

## Typhoid

Of the single facts of medical history during the war period the success of this anti-typhoid vaccination is certainly the most conspicuous. Such a success was indeed undreamed of, for of all the enemies of the soldier typhoid fever ranked first.

A study of earlier campaigns reveals the fact that this scourge usually swept away large proportions of the armies engaged in European warfare, and in some cases the casualties by bacilli - chiefly typhoid - stood to the casualties by bullets in the proportion of So to 20. Thanks largely to the preventive inoculation against typhoid this condition of affairs was reversed in the World War, the proportion being gun-shot wounds (including all forms made by all manner of missiles) 80 and disease 20. The credit for this result is due largely to Sir Almroth Wright and Sir Wm. Leishman, who devoted endless trouble to the work of perfecting this brilliant application of bacteriological and physiological principles to preventive medicine.

## Tetanus

Not less striking, though less dramatic, was the success achieved in the prevention of tetanus or lockjaw. This dreaded disease began to manifest itself almost at the beginning of the campaign. Before the battle of the Marne was fought it was relatively prevalent and was causing great consternation, for it was recognized that the intensively cultivated soil of Europe was impregnated with tetanus bacilli, and that thus every wound was dangerous. Moreover, up till this time the treatment of tetanus had proved singularly ineffective, so much so indeed that the patient was regarded as doomed.

As the tetanus bacillus presents many features in common with the diphtheria bacillus, and as the antidiphtheria serum had proved a very great success, it was thought that a serum prepared in the same manner might solve the tetanus problem. This hope had not been realized in practice at the time of the outbreak of war. Nevertheless, there was some reason to think that, though the serum failed when given after the disease had declared itself, it might not fail if administered at the time of actual wounding.

Tetanus, as is well known, takes several days to incubate. In consequence, there is available a period in which measures for its suppression can be carried out. This fact was the basis of the antitetanus inoculation which was begun experimentally in 1914. From the outset the experiment succeeded beyond the expectation of those who had planned it. Tetanus became a rare disease, thanks to the fact that every wound, no matter how trivial, was regarded as a possible source of danger. It was an order that as soon as a soldier got even a scratch of the skin he must report to his medical officer. A prophylactic dose of serum was then administered.

At a late period the War Office set up a Tetanus Committee under the chairmanship of Sir David Bruce. This committee investigated cases of so-called " delayed " tetanus, and also those cases in which tetanus made its appearance at long periods after the initial wounding when surgical measures had been carried out on the wound. The view which was formed was that the bacilli in such cases were walled in and rendered innocuous; but manipulations of the wound were apt to break down the walls and so release the toxins.

Shell Shock. - Meanwhile the circumstances of war were directing attention to a series of new disease conditions which the peace-time physician had not encountered in so severe a form. Chief perhaps among these was the nervous disturbance caused by high explosive shells. At first a number of wild statements were made and believed, but presently, and thanks in no small measure to the common sense of Sir Frederick Mott and other distinguished neurologists, some light on the darkness was obtained. Mott pointed out that among the large group of cases classed as shell-shock patients there were a number who had suffered actual physical injury of the brain as a result of explosives. If these people died, punctiform haemorrhages were found in the brain substance.

These cases were not psychopathic, they were organic lesions - cases of injury. After elimination of this group there remained a large group of individuals, considerable numbers of whom had not received any injury. These cases were often very severe, but they differed in no material respect from the neurasthenics and victims of functional neuroses well known in civil life. The question was asked why these patients should break down whereas other men could be severely wounded and yet show no sign of nervous disturbance.

Various answers were given to this question, and probably all of them contained a germ of truth. Thus it was pointed out that hereditary influences played a part in some of the cases. The men came from mentally unstable families; they themselves had only just managed to support the conditions of ordinary life. The conditions of life in the trenches broke them down. Again, many of these patients were clearly the victims of chronic infections such as rheumatism, which exercise an irritant effect on the nervous system. Thus the men were more easily stimulated than in normal cases, and so more easily fell victim to the excessive stimulation of war.

Thus new recognition was given to relationship existing between disease and temperament, between the nervous system and the functional activity of the body. It was seen with a clearness not before achieved that the mental case may be the case of disease, slight, unrecognized, yet perpetually active. The treatment of these cases occupied a large number of distinguished workers. Little by little a process was evolved whereby disease elements were eliminated so far as possible before mental conditions as such were pronounced upon. Thus the patient's general health was made the subject of careful study, while at the same time his mind was being dealt with.

## Psycho-analysis

The purely mental aspect of the subject forms one of the fascinating chapters of modern medicine. Never before was so vast a material presented to scientific workers. This material, too, came at an hour when a great upheaval in mental medicine was in process. The writings of Sigmund Freud of Vienna had just begun to find adherents among British psychiatrists. They were the subject of hot dispute; but the .first wave of incredulity was spending its force. Thus Freud's methods were applied to many cases of shell shock and their value put to immediate test.

These psychic methods were founded on recognition of a mental field operating below consciousness and charged with various " repressions." A repression is a desire which for one reason or another cannot be fulfilled and so is forgotten. It does not again enter consciousness; but it nevertheless remains active and unsatisfied, and under various disguises attaches itself to desires which are permitted to become conscious and greatly intensifies those. Thus the patient shows abnormal reactions to certain stimuli and evinces abnormal likes and hatreds which cannot be explained in terms of his evident circumstances. This man has an unbalanced mental outlook, and, given circumstances such as warfare, will evince symptoms of nervous breakdown. The method of treatment suggested by Freud was to analyze his mental state, discover the repressed wish, and bring it into consciousness. Once the patient knows it and realizes it, it is said to lose its power over him.

The method is called psycho-analysis, and in some hands has yielded important results. It is now being widely practised. Unhappily, while in some directions perversely applied by Freud himself, it lends itself also to the uses of unqualified persons and also of mere charlatans. On this account it has to some extent fallen into evil repute. That it is, when properly applied, a great contribution to the study of the mind is nevertheless evident. Its application to shell shock did much to convince the medical profession of the necessity of seeing its work as a whole and not in little bits. It also helped to convince physicians of the importance of the " imponderabilia " in every case.

## Mental Hygiene

It had another effect not less far-reaching. There sprang into being a body of physicians who declared that mental effects of warfare could be prevented to a great extent if a kind of mental hygiene was instituted for the soldier. So far as possible the causes operating to lower his physical and mental vitality must be found and removed. Well-being must become a study. Effects of this theory were the rest camps, the convalescent depots, the insistence on games, on baths, on lectures, on medical supervision. Other effects included the care taken to show the soldier that if he fell ill or if he was wounded every sort of effort would be made for his safety and comfort. Thus while the enemy on the one hand was doing all in his power to break the soldier's moral, physicians of the new school were steadily and tirelessly building it up. In a large view of this work we are entitled to include every one of the schemes which had as their object the comfort of the soldiers - we are entitled also to include such appliances as steel helmets and gas masks. These were more than defensive armaments; they were expressions of preventive medicine as applied to the human mind in time of great stress.

That the success which attended these labours has left an indelible impression on modern medicine goes without saying. Circumstances and environment are now receiving a measure of attention never before accorded to them. The demand for playing-fields for the nation's youth, for swimming-baths, for holiday camps, is a part of this campaign. So is the interest which all doctors are exhibiting in food values, in housing, in ventilation, in industrial welfare. Indeed, the science of industrial welfare is largely a war product.

Welfare Work. - This science has made an immense progress in the last few years. Employers of labour have been aroused to the fact that their human machinery is as important, is indeed more important, than their working plant. In consequence, physicians have been called in to act as expert advisers to many great industrial undertakings. Attempts are being made to select suitable candidates for the vacancies in industrial life, and it is becoming a working maxim that to employ unfit persons is both unjust and uneconomic. The study of what is called "welfare " is progressing, and money is being laid out on good ventilation, on rest-rooms, on workers' canteens, on bathing facilities and other amenities. All this expenditure is found to return a profit both to employer and employed.

Moreover, the study of industrial fatigue has shown that it is in the highest degree wasteful to keep men at work after they have become exhausted. Thus, shorter hours of labour have been instituted on medical advice and have increased instead of lowered output. The method known as motion study has helped to eliminate wasteful movement in particular operations and so has added to the profit of them while reducing their cost. Further investigations have been carried out into the circumstances of what are known as " lost workers," i.e. persons who learn a trade only to leave it, and into those of industrial misfits.

The effects, too, of environment on industry have been studied from a new angle. The whole science of ventilation has been reviewed and restated. Thanks to the work of Dr. Leonard Hill, it is now accepted that ventilation is no mere question of cubic feet of air but is a large and difficult problem involving a study of air movement, humidity and temperature. Stimulation of the skin by moving currents of air is of as great or greater importance as the amount of oxygen available. Moreover, the drying quality of the air depends on its movements, and so the degree of evaporation of sweat on which cooling of the body largely depends. In this work Dr. Hill has employed an instrument of his own, known as the kata-thermometer, a thermometer the bulb of which is enclosed in a glove finger and kept moist. It records rate of temperature-loss in any given room. It is significant that changes in ventilation effected on the advice of Dr. Hill have resulted in a marked increase of output.

Another vastly important series of observations of this kind are those of Dr. John Scott Haldane of Oxford on dust phthisis. He has conclusively demonstrated that silica dust is the real agent of destruction. Coal dust is actually beneficial. Why this should be so is not known, but it would seem that the coal dust excites responses in the body which result in a cleansing of the lungs; silica or rock dust, on the other hand, excites no such response, and the gritty particles in consequence tear the lung tissue and prepare a nidus for the tubercle bacillus. An outcome of the work is the clever method of sprinkling coal dust in rockdust mines. By this means the rock dust is rendered harmless.

The mining industry has further benefited by the work of Dr. Thomas Lister Llewelyn, who has traced miners' nystagmus or blindness to its cause - bad lighting. He has placed this subject on a sure foundation and made it possible to say that if certain changes in lighting are introduced this most costly and disabling disease will be abolished. (See Industrial Medicine.) Orthopaedic Surgery. - The immense strides recorded in this branch of medicine are paralleled by the brilliant advances in another. (See Orthopaedic Surgery.) If the war influenced industrial medicine only indirectly, it actually revolutionized orthopaedic surgery. This study had rather languished in England owing to the relatively small number of cripples. In America, where infantile paralysis is rife, it had advanced farther. English practice, however, was well represented at the Liverpool school, at the head of which was Sir Robert Jones. The War Office called on Sir Robert Jones, and he became the organizer of a rest salvage corps, the duty of which was to mend the broken soldier. The subject soon divided itself up into branches; there was the work for the limbless at Roehampton, from which has come the modern light artificial leg. This appliance almost, if not completely, restores lost function; it is a permanent boon to humanity. Again, there was the astounding development of so-called " plastic " surgery, the result of which has been to render any disfigurement capable of great improvement if not of complete cure. The treatment of severe fractures, too, and especially fractures of the thigh was studied as a new problem and undertaken on new lines. These results are now a permanent gain to surgery.

General orthopaedics evolved from a method to a science. The study of muscle groups and their antagonistic action led to the formulation of new ideas and so to the application of new lines of treatment. Every case was considered on its merits and regarded as a separate problem; yet it was found that the same general laws could be applied to all. We are perhaps entitled to include in this progress the surgery of the heart, which was undertaken on a large scale in the war. As a result a remarkable diminution in death-rate from heart wounds was achieved both in England and France. Further, the advances made in the treatment of surgical tuberculosis are really of an orthopaedic nature. They do not belong to war surgery, but they owe something to the conservative spirit which war surgery inspired. They consist, briefly, in preserving the integrity of the skin in all cases of tuberculous invasion of bones or joints. It has been found that if this is maintained the patient outgrows his disease - provided that he has good food and healthy surroundings. If, on the other hand, operative measures are carried out and so the skin broken, other bacilli and cocci enter the tissues, which, being weakened, form a suitable medium for growth. The severe septic cases are those which have been surgically treated. These new methods owe their origin to Sir Harry Gauvain, working at the Sir William Treloar's Cripple Home at Alton.

Trench Fever.-In the realm of medicine proper the war exerted an influence which must endure. Incidentally several diseases were encountered the existence of which had passed unrecognized before. One of these was trench fever, a condition closely resembling the muscular rheumatism of peace time, but characterized by bouts of fever, severe pain in the shins and great chronicity. This disease was investigated by a committee presided over by Sir David Bruce. Col. Wm. Bryan conducted the investigations. Thanks to the fact that volunteers offered themselves for research purposes it was proved that the disease is carried by lice, and that the infective agent is found in the excreta of these insects. The louse does not become infective until some 8-12 days after it has bitten a trench-fever patient. Thereafter it appears to remain infective indefinitely. Its excreta if scratched into the skin produce the disease after a period of incubation lasting about eight days. The disease spread with great rapidity owing to the conditions of trench warfare. It is calculated that some 500,000 persons were affected. Every effort was made to discover a cure, but in spite of this no success was achieved. The disease seems to run a chronic course and relapses are frequent. It is attended by nervous symptoms and also by some cardiac disturbances. As a consequence many people are now labelled " heart disease " and " neurasthenia " who are in reality sufferers from chronic trench fever.

Another disease of this kind came to be known as trench nephritis. It is a true acute nephritis of short duration but showing a tendency to relapse. The evidence, so far as it is available, points to an infection carried by lice. So far no specific organism has been discovered for either condition, but there is some reason to think that the rickettsia bodies which Arkwright found in infected lice are the causative agent. This view is supported by the entomologist Arthur William Bacot, who contracted the disease himself in Poland and found rickettsia bodies in the lice which had been on his person. These diseases accounted between them for a large proportion of the total war morbidity. Had not the work of disinfestation been very well carried on they must have proved a serious menace.

Wound Shock. - Another condition which received careful and intensive study during the war years was surgical or wound shock. A number of eminent physiologists and pharmacologists took part in this work, the names of Prof. Wm. Maddock Bayliss and Dr. H. H. Dale being noteworthy. Wound shock, it was found, is a complicated condition depending on a dilatation and permeability of the capillary circulation. A stasis or stagnation of blood results, mainly in the abdominal area (see Intestinal STASIs). The blood fluids tend to pass out of the circulation.

Bayliss suggested that this condition might be treated by injections of a viscid fluid which would increase the volume of fluid in circulation and at the same time be retained in the permeable vessels. His choice fell on solutions of gum arabic, which he accordingly introduced. The idea proved eminently successful, and it was found possible by the use of the gum arabic to restore patients who must otherwise have died.

A most interesting feature of this work was the discovery by Dale of a substance, histamine, having the power, when injected, of producing an artificial state of shock with fall of blood-pressure and symptoms of collapse. Dale's work was carried on side by side with that of Bayliss, and thanks to the combined effort a new physiological conception of the capillary circulation was arrived at. The subject nevertheless remains to some extent obscure and still engages the attention of many workers.

## Anoxaemia

Two other advances in medicine remain to be mentioned - the treatment of gas-poisoning and the testing of flying men. To some extent these matters overlap one another because they both gave impetus to a new study of respiration. From the work on poison-gas came Haldane's method of intensive oxygen administration in pneumonia and other conditions. From the necessities of the air was evolved the theory of " oxygen want." The term "anoxaemia " has now been added to medical nomenclature. It signifies not so much impurity of the blood as lack of purity - a negative rather than a positive quality. The chief sign of anoxaemia is cyanosis. The condition is of a most serious character. Arising out of this work came the idea of Haldane and his co-workers that the living membrane of the lungs is able to seize hold of oxygen and actively take possession of it. This quality of oxygen-reception is, it was suggested, capable of cultivation, so that a man might, as it were, develop it in himself to a high degree. More recent work, that of Bancroft, has, however, cast some doubt on the idea.

The medicine of the air (see Aerotherapeutics) is still in its infancy, but already it is clear that candidates for pilots' certificates must possess what is known as a rapid reaction time if they are to prove successful airmen. In other words, action must follow stimulus to action with great speed. This consideration has opened up new vistas in the physiology of nervous response.

(R. M. WI.) II. Medical War Organization When the World War broke out the British Army Medical Corps was a small body with a personnel amounting to about ,000 medical officers. At the end of the war its personnel numbered over 12,000 medical officers, a vast number of orderlies and stretcher-bearers, nurses and laboratory attendants, constituting collectively the most efficient medical service ever created.

The deficiencies of the existing corps were seen within a week of the beginning of hostilities. Indeed, the extreme heroism displayed by the officers and men during the retreat from Mons only served to accentuate their ill-equipped condition. There was not a single motor ambulance; there were no hospital trains in the modern sense; the supply of surgical requisites was deficient. It is true that the frequent changes of base, from Boulogne to Havre and again to St. Nazaire and then back again to Boulogne, made it difficult to obtain supplies. Yet the condition of affairs aroused a great deal of anxiety, and those who saw the earliest ambulance trains - mere collections of wagons - set to work to improve matters.

In the late autumn of 1914 Sir Alfred Keogh, an ex-directorgeneral of the Army Medical Service, was recalled to the head of the service and began the work of reorganization which was to prove so successful. At that time the first battle of Ypres was in progress, and the stream of wounded men which flowed down to Boulogne was overwhelming. It was a case for emergency measures. A large number of officers was hurried to the scene and within about 10 days order was brought out of chaos. The Casino and a large number of hotels were taken over, fitted with beds, equipped and filled. A few motor ambulances were got to work, and as many men as possible transferred to England by the hospital ships which, happily, were available. In this way the beds at Boulogne were kept for the very severe cases which could not at once bear a sea voyage.

This arrangement, formed out of the necessities of the case, became the basework of the whole organization. All through the war the medical service had three main areas of work - the front, the base and home. The idea was always to use the base for two purposes: the treatment of cases too ill to be taken across the English Channel immediately, and the treatment of cases which might be expected to recover within a short space of time. Thus evacuation to England was used for the most part in cases where immediate recovery was improbable, yet where the nature of the injury or disease was not such as to preclude a voyage.

This basework remained, but was subject to some important modifications as the campaign progressed. One of these was the tendency to move the operating surgeon nearer and nearer to the front. It was a recognition of the fact that in war-wounds every hour of delay prejudices the chances of recovery. A few experiments carried out at first tentatively showed, for example, that the mortality from abdominal wounds was greatly reduced when these were operated on within a few hours instead of within a few days. The success of these experiments led to the development of the field hospitals, situated close behind the lines. Thus, after a wounded man had been brought from the first-aid post to the casualty clearing-station, he was " sorted out " by a medical officer, and, if he seemed to require immediate attendance by an experienced surgeon, was sent direct to the field hospital, which might adjoin the clearing-station. Cases not so urgently requiring operation went by ambulance to the railhead and from there, by train, to the base.

Another modification was found in the introduction of convalescent camps. Experience showed that if a man was to make a good recovery he must be followed through all the stages of his convalescence. If he was allowed the freedom of the base town he often did himself hurt and always found it a great strain to get ready again for the life of the trenches. If, on the contrary, he was " kept in the machine," taken from hospital to what was a great military camp equipped with every conceivable means of healthful amusement, he recovered much more rapidly and never fell out of the army spirit.

These convalescent camps were therefore established in the near neighbourhood of the base hospitals. They combined sport and pastime with a certain measure of physical culture. Discipline was fully maintained. On coming to the camp a convalescent man found himself in the company of hundreds of other men all in process of recovering and all making ready for the fighting ahead. He lived in the war atmosphere. He trained for war. At the same time he was able to enjoy many different kinds of entertainments and to play any games he chose. He might also engage in gardening or less strenuous pursuits while strength was returning. At all periods of his stay he was under careful medical scrutiny. The camps relieved the burden on the hospital ships and also on the base hospitals themselves. They prevented an undue loss of fighting material, and, moreover, gave to the active forces the sense of being well cared for in the event of wounding, which is an important moral support.

Yet a third modification was the introduction of special methods of treatment in the field. An illustration is furnished by the camps for cases of soldiers' heart or nervous heart. This condition was investigated at the request of the War Office by a group of specialists in England who declared that it was not heart disease and that it could be benefited by a course of graduated exercise. Instructors were therefore obtained and trained in the application of the special exercises and were then sent out to France to work under the direction of highly qualified medical officers. Heart cases of all kinds were forwarded at once from the hospitals to the heart centres. Here they were sorted out into serious and non-serious types. The first class were sent to England forthwith to be discharged from the service as permanently unfit; the second class began at once the course of treatment training. By this means an immense relief was afforded to hospital accommodation - there were vast numbers of these cases - and a large number of useful soldiers were retained in the active force.

In the meanwhile Sir Alfred Keogh inaugurated, in conjunction with the Medical Research Committee, his famous system of team-work research on war diseases. He called to his assistance all the best British brains in medicine and he made it easy for any physician or surgeon with an idea to approach him. Very early in the day anti-typhoid vaccination was enforced throughout the whole army and every recruit received his dose of the vaccine as a matter of routine. Then came the Gallipoli campaign and with it the discovery that, while the vaccination protected against the typhoid bacillus, it did not protect against its prototypes, the paratyphoid bacilli A and B. This discovery was made the basis of an immediate inquiry, and the result was the introduction of a new vaccine giving protection against all the typhoid group of organisms. After this the typhoid fevers steadily declined and became a minor problem.

Another routine which was instituted was the administration to every wounded man, no matter how slight his wound might be, of a dose of anti-tetanic serum. This measure soon made tetanus a negligible factor. Methods of dealing with the infections of wounds also engaged attention and resulted in much greater care being bestowed on the cleansing and treatment of wounds near the front line. Teams of workers were also set to solve the problems of cerebro-spinal meningitis, which broke out severely in various camps, trench fever, trench nephritis, wound shock, gas gangrene, the treatment of fractures and so on.

In almost every instance valuable knowledge was acquired. So perfect had the organization become that it was possible to apply this knowledge forthwith. Thus a better spacing of sleeping accommodation reduced the incidence of cerebro-spinal fever, while the preparation of a serum having powers against all the four strains of meningo-cocci present reduced the mortality by some 30 per cent. As soon as it became known how great a part lice were playing in the spread of trench fever a campaign of disinfestation was started. The services of distinguished entomologists were secured, and these were commissioned and sent out to France to examine and report. The result was an added care of the bathing facilities for men behind the lines and a very perfect system of disinfestation of clothing by heat. In this way enormous numbers of lice and nits were disposed of and the incidence of the disease restricted. Sleeping-quarters were also taken under expert care, and blankets and night attire subjected to careful and continuous scrutiny.

The entomologist indeed became a part of army organization and had plenary powers which were undreamed-of in earlier campaigns. Acting in conjunction with the sanitary corps, he stood between the soldier and the deadly pest which threatened him. Large fly-destruction campaigns were inaugurated and every measure calculated to prevent the breeding of flies in or around camps was put into force. The results were exceedingly good, more especially in the East, where flies constituted a serious menace. In the same way, in the Struma valley, pools containing the larvae of mosquitos were drained or treated with paraffin and the troops thus protected against malaria. In Egypt, too, Col. Leiper was set to solve the riddle of that troublesome disease bilharziosis, and was so successful in his quest that within three months he had located the intermediate host of the parasite, a water snail, and suggested means for its destruction.

Indeed, the organization of preventive medicine in the war was as good in every way as the organization of curative measures. The sanitary corps developed to a state of efficiency which has probably never been equalled. Methods of chlorination of water were brought to high perfection, so that if the men obeyed the instructions issued to them - and most of them did - all danger from imbibing contaminations was eliminated. Cholera threatened, but it never became serious; even dysentery, though it claimed enormous numbers of victims at Gallipoli and elsewhere, was brought under a great measure of control. Nor was food inspection less successful. The army ate well throughout the whole war; it ate safely, thanks to the unremitting vigilance of this most capable body of officers and men.

An organization of this kind was ever ready to seize on and apply new methods. Thus the use of steel helmets was early suggested by surgeons in France and was finally enforced by the demands of the R.A.M.C. These helmets represent a very good example of preventive surgery, since head wounds, before they were introduced, had claimed great numbers of victims. The reduction in the number of those wounds after the helmets were obtained was a complete justification of everything urged in their favour. The small cuts and scratches, the scalp wounds, the bruises, which before had killed many useful soldiers, became things of the past.

Nor was the work accomplished in connexion with poison-gas less triumphantly successful. It is difficult to realize the immense confusion occasioned in the ranks of the medical corps by the introduction of this method of warfare. The problem presented was new and terrible. Men who had been exposed to the fumes were brought in hundreds to physicians who had small idea of how to help them. Yet within a space of some three days measures had been devised. The medical authorities in England had obtained respirators and sent them out. The doctors in the field had learned to use them. Moreover, a body of expert chemists and physiologists were at once set to work to devise better protection and also to seek for efficient means of treatment. The extraordinary elasticity of the organization is shown by the way in which, within a very few weeks, anti-gas measures had been perfected and the treatment of gassed patients reduced to a routine. In this connexion the work of j. S. Haldane, of Oxford, must be mentioned. He introduced his intensive method of administration of oxygen, thanks to which the sufferings of gassed patients were greatly alleviated.

The organization was concerned at first wholly with the task of getting men back to the front. In course of time, however, it was seen that this policy would require to be extended in order to deal with the broken soldier. The reason was that the army had absorbed so many doctors and surgeons that outside of it means were lacking of giving adequate assistance.

The War Office was at first reluctant to add to its labours the care of many hundreds of thousands of disabled and sick men, but in the end consented. Thereafter the rule was that no man should be discharged from the service so long as it was possible to do anything further to help him. In this way there sprang up an immense " repairing " organization collectively described as orthopaedic surgery. It was divided into many sections. There was the central orthopaedic work concerned with problems of restoration of a non-special kind. There was, further, the work of facial reformation known as plastic surgery. This work achieved a series of triumphs which are among the brightest episodes of the war period. No disfigurement was regarded as hopeless, and by a series of carefully planned manoeuvres results were achieved which had seemed beyond the scope of possibility. This department of restoration included surgeons, nurses, artists, sculptors and various workers in plastic materials who planned the " new faces " which it was the doctor's duty to create.

Another great department of this work was founded at Roehampton, where limbless men were dealt with. The problem here was the production of a suitable limb at a reasonable price, its accurate fitting and its subsequent care. At first very many difficulties were encountered, for no one possessed the necessary experience. The early limbs were much too heavy and were found by wearers to put a great strain on their energies. Moreover, all kinds of technical troubles arose. Finally, however, a light limb was devised and, under the Ministry of Pensions, standardized. This limb has the great advantage of being capable of manipulation by the muscles of the stump; shoulder action in lifting it is eliminated.

These various branches of orthopaedic surgery necessitated the employment of a great number of masseurs and of attendants. They also necessitated the training of surgeons and nurses in the special methods employed. It speaks for the success of the organization that at the end of the war there were expert staffs in every region of England. Moreover, the so-called manual curative workshops were conducted as a part of the orthopaedic surgery method. The idea was that a man who required to exercise a stiff limb might do this and at the same time learn a trade, e.g. by swinging a hammer instead of a club. So great was the success achieved that a curative workshop was soon to be found in proximity to each orthopaedic hospital. This was first suggested by ex-King Manoel of Portugal.

Equally important was the branch of restoration which gained the name of " medical orthopaedics " - the work on behalf of the soldier with broken nerves. The War Office took this matter in hand at a very early period and called to its help noted psychologists and psychotherapists. The result was a reexamination of functional nervous disorders and the formation of a great department of army medicine. Instead of being branded as a coward the nerve-broken soldier was cared for and treated, and so in many cases saved from the loss of his reason. Here again the method employed was to take advantage of all the available knowledge and attempt to increase it by research work. There were practising side by side, in the military hospitals set apart for nerve cases, physicians of different schools of thought and even of opposite views. Yet so elastic was the organization that no difficulties arose. On the contrary, an immense stimulus to new work was afforded.

This vast organization of British army medical work grew up under the hands of Sir Alfred Keogh. His methods were simple but, as the event proved, invariably effective. He believed that the more complete the organization of the medical corps became the better was the effect exercised on the moral  of the common soldier. Thus, not only was every effort made to secure personal health and protection against disease and injury, but even personal comfort and happiness became the doctor's business both in the line, in hospital and at the convalescent camps. The soldier, too, knew that if he was broken in mind or body all the resources of medicine would be exhausted over years to save him.

This great effort could never have been achieved had not Sir Alfred Keogh called to his aid the leaders of every branch of medicine and surgery and given them, so far as possible, afree hand. Nor could he have achieved what he did without the assistance of the Medical Research Committee. He saw that research work is as urgent in war as in peace; and he reaped great rewards for this foresight. Indeed, his organization was as strong on its constructive as on its executive side. (R. M. WI.) III. Diseases In The World War The medical diseases of the World War fall into two main groups. In the first are the neuroses or nervous disorders which resulted from the stress of active service, and in the second are the diseases which resulted from infection with disease-producing organisms. Whereas the former were infinitely more common than in any previous war, owing to the far greater strain to which the soldier was subjected as a result of modern methods of warfare, the latter were unexpectedly rare owing to the wonderful improvements in military hygiene, resulting from medical research in the comparatively short period of thirteen years which had elapsed between the conclusion of the South African War and the outbreak of the World War in Aug. 1914. While the neuroses opened up new and perplexing problems to the neurologist, the relative frequency of the various infectione differed greatly from that of previous campaigns and presented many subjects for research, which were studied with great enthusiasm and success, especially by the large body of British civilian medical officers who were called in to assist the regular R.A.M.C., whose hands were generally fully occupied with administrative details.

(A.) War Neuroses. - The frequency of neuroses in soldiers during the war compared with their comparative rarity in men in civil life was due to the exhaustion and emotional strain inseparable from active service. The exhaustion caused by long days of forced marching and strenuous fighting, followed by nights with little cr no sleep, combined in some cases with insufficient food, and, especially in eastern campaigns, with a great variety of infections and exposure to extreme heat, naturally led to a more profound condition of nervous exhaustion or neurasthenia than is commonly seen in civil life. It was not, however, as frequent as might have been expected, as exhaustion was largely prevented by the intervals of rest and opportunities for relaxation, which became increasingly common as the war progressed and the need of adapting conditions to fit in with the psychology of the soldier was more fully understood by those in authority. At the same time the supply of food was almost invariably admirable, and there was a remarkable freedom from epidemic infections on a large scale, especially in France, owing to the excellence of the sanitary arrangements. More important perhaps than the actual production of neurasthenia was the increased liability to the development of hysteria and psychasthenia and the aggravation of incipient organic diseases, such as locomotor ataxia, general paralysis, and epilepsy.

Though a few fortunate individuals are born with a temperament which does not allow them to know what fear means, the vast majority, including many of the bravest, were terrified when they first approached the front line. Many men became accustomed to it in time, though never to the horrors of a heavy bombardment, but sooner or later the exhaustion of active service often resulted in a gradual failure of the adaptation, so that not only the constitutionally timid - the martial misfits - but also some who had faced the life cheerfully for months or years broke down from the longcontinued emotional strain.

The emotion of fear acted in three ways. In the martial misfit, who is by nature very suggestible, it gave rise at once to such physical symptoms as tremor, inability to speak and inability to move, which might be perpetuated by auto-suggestion as hysterical tremor, mutism and paralysis, the three together constituting one form of the condition often called shell-shock, though it rarely had anything to do with actual shell concussion. In other cases it resulted in a man passing into a dazed condition or stupor, which might lead him to wander from his post of duty and run risk of being court-martialled as a deserter. Finally, it might result in such a disturbance of the suprarenal and thyroid glands that a condition of continuous over-activity, with symptoms not unlike those of Graves's diseases (exophthalmic goitre), might follow.

The acute emotion caused by a single exceptionally terrifying experience sometimes led to such a change in an individual that he became for a time extremely liable to develop hysterical symptoms by suggestion, especially if the experience led to actual physical results. Thus, when a man was gassed he became temporarily unable to see or to speak owing to irritation of his eyes and his larynx, and he often vomited owing to irritation of his stomach. Any of these symptoms might be perpetuated by suggestion - hysterical blindness, inability to make any sound at all or more commonly inability to speak above a whisper, and vomiting being the respective sequels. If a man was blown up or buried, the loss of memory, headache, paralysis, deafness and convulsions which might result from the concussion of his brain were often perpetuated as hysterical symptoms long after the actual changes in the nervous system had so greatly diminished that the symptoms should have completely disappeared. After much study of the problems presented by these hysterical symptoms, which became increasingly frequent as the war progressed, psychotherapeutic methods, consisting of explanation, followed by persuasion and reeducation, were devised, which resulted in extraordinarily rapid recovery, the majority of cases, even after the symptoms had persisted for many months, being cured at a single sitting.

An exhausted officer, who was constitutionally unsuited to the life of a soldier, was more likely to develop psychasthenic symptoms than his men owing to his greater responsibility. He found it increasingly difficult to decide between two possible lines of action, and, when at last he had adopted one, he was full of doubt as to whether he had decided rightly. His power of concentration became deficient owing to his mental energy being largely taken up, without his fully realizing it, in repressing painful thoughts and conflicts, which he kept in the background of his mind in order to avoid distress.' He consequently showed want of confidence in his actions, and became terrified that he would be unable to perform his duties in an emergency. His sense of duty urged him to carry on, but this was in acute conflict with his instinct of self-preservation, which urged him to get away from his hateful surroundings. In the daytime he might become suddenly overwhelmed with apparently causeless dread or terror, and he often found it difficult to fall asleep at night owing to the need of active thought to keep his distressing memories and conflicts buried. When at last he fell asleep and the controlling influence over his thoughts was relaxed, they came into consciousness in a distorted form as nightmares, with the result that he would wake in a condition of terror. The disturbed nights increased his exhaustion, until it was no longer possible for him to carry on with his duties. In early cases improvement rapidly followed a change to more favourable surroundings, especially if, instead of receiving the old-fashioned advice to forget his worries and occupy his mind with more pleasant matters, which it was totally impossible for him to do, he fell into the hands of an understanding medical officer, who, after gaining his confidence, helped him to solve his difficulties by freely discussing the thoughts he had been attempting to repress, however painful they might be. It was remarkable how rapidly persistent war nightmares, long-standing phobias and obsessions, and hitherto inexplicable emotional crises disappeared directly the patient understood the mental processes which had given rise to them.

(B.) Infective Diseases: (a) Typhoid and Paratyphoid. - In the South African War of 1899-1902, 60,000 cases of typhoid fever with 8,227 deaths occurred in the British army. In the far larger British army in France and Flanders only 4,571 cases of typhoid and paratyphoid fever occurred between Aug. 1914 and Nov. 1916, and the incidence of these diseases steadily diminished after the first few months of the war in spite of the steadily increasing size of the armies. This was almost entirely due to the remarkable success of the prophylactic inoculation with typhoid and, later on, with mixed typhoid and paratyphoid vaccines.

Paratyphoid fever was throughout much more common than typhoid fever both in France and in the East. There were probably 6,000 cases of paratyphoid fever among the 300,000 troops who were at Gallipoli, but the disease was comparatively rare in all other theatres of the war owing to more thorough protective inoculation after the end of 1915. The mortality in France was only 1.3%; in Gallipoli and Mesopotamia it was higher, but much below that of typhoid fever in the South African War.

## (b) Cerebro-spinal Fever

An outbreak of cerebro-spinal fever occurred among the Canadian troops on Salisbury Plain in 1915.

A wide-spread and very fatal epidemic followed in many homecamps, and shortly afterwards the disease appeared in France. By the end of the year a number of cases developed on the eastern fronts. Investigation showed that the disease was caused by different types of the same bacteria, and when sera were introduced which were specific for each of these types, the very high initial mortality was greatly reduced, particularly when the disease was diagnosed early and serum given without delay.

## (c) Trench Fever

In the early summer of 1915 a form of fever was observed in the British army in France, in which two or more periods of raised temperature were separated by normal intervals of a few days. Similar cases were recognized with increasing frequency, and the disease soon became widely known as trench fever. Thousands of cases occurred in France and Flanders between April and Oct. 1915; it was comparatively rare in the winter, but increased again each spring. Trench fever did not occur in Gallipoli, but was introduced into Salonika by troops arriving from France in Dec. 1915. It was first recognized in the French army in May 1916 and in the Italian army in Oct. 1917, and it was common both in Germany and Austria from 1916 until the end of the war. The characteristic fever and painful shins of trench fever appear to constitute a disease which had never before been described, but it is conceivably identical with a disease mentioned by Hippocrates, Galen and Avicenna, in which relapses occurred at five-day intervals. The organism which causes trench fever was never isolated, but it was proved that the disease was spread solel y by means of lice, which had fed on the blood of patients suffering from the disease and had then bitten other men. The frequency of trench fever thus varied with the prevalence of lice, and if they could be exterminated in an army, the disease would disappear as surely as the lice-borne typhus fever disappeared from the Serbian army when it was freed from lice in 1915. The disease had nothing to do with the trenches beyond the tendency for men to become lousy when herded closely together. It appears to have died out completely since the Armistice. Trench fever was never fatal, but it caused an enormous amount of sickness; it was indeed the only infection which gained any hold on the British army in France and Flanders, except for the wide-spread and very fatal influenza epidemic in the summer of 1918.

## (d) Dysentery

Amoebic dysentery, though common in tropical and sub-tropical countries, had never occurred in epidemic form in Europe until the summer of 1915, when nearly every soldier in the British army at Gallipoli suffered from it, and a large proportion of the thousand sick men who were daily removed from the peninsula during Aug. and Sept. had amoebic dysentery. It was less common in Oct., and the cold and rain in the great gale at the end of Nov. were quickly followed by the disappearance of the epidemic. But no sooner had amoebic dysentery abated than bacillary dysentery became increasingly frequent. Amoebic dysentery was probably conveyed to Gallipoli by troops coming from Egypt, where 13% of healthy natives harbour the amoeba of dysentery in their intestines and where large numbers of cases occurred among British soldiers. Amoebic dysentery was also very common in the army in Mesopotamia. A few cases occurred in France after the autumn of 1915 owing to the arrival from India, Morocco and Senegal, and later from Gallipoli, of men infested with the amoeba, though not actually suffering from dysentery. The disease was spread mainly by flies which swarmed in enormous numbers wherever there was any food and in every latrine. As flies always defecate each time they feed, amoebic cysts are deposited on jam and any other human food upon which they settle within twenty-four hours of feeding on the stools of dysenteric patients. During the hottest months in Mesopotamia flies were uncommon and dysentery very rare; when flies were present in enormous numbers - in the spring and autumn - dysentery became epidemic. As soon as it became recognized that the predominant form of dysentery on the Gallipoli peninsula was amoebic and men were treated with emetine from the moment of onset, the symptoms rapidly disappeared, but reinfection was common. It was the universal sickness caused by dysentery rather than the occasional death that mattered at Gallipoli, and it can be truly said that dysentery was one of the deciding factors in the failure of the campaign. Cases of inflammation and abscess of the liver due to the amoeba of dysentery continued to occur even three and four years after infection in men who had not been adequately treated.

The dysentery which has been common in armies on active service since the Peloponnesian War has probably always been of the bacillary variety. Out of 30,000 British troops who fought in the Crimea, 7,883 suffered from dysentery, and of these 2,143 died; in the South African War there were 38,103 cases with 1,342 deaths. Bacillary dysentery made its first appearance in the early weeks of the World War in East Prussia and Galicia and was brought to France by von Kluck's ill-fed and tired soldiers on their march on Paris. It was present on every front whenever the weather was hot, and caused an enormous amount of illness in Salonika, Mesopotamia and Palestine as well as in Gallipoli. The disease was spread by flies in the same way as amoebic dysentery.

The chief means of combating both forms of dysentery is to destroy flies and to destroy or disinfect infective faeces directly they are passed. Anti-dysenteric serum was shown to be as valuable in the treatment of bacillary dysentery as emetine was for the amoebic form, but unfortunately the supplies of serum were totally inadequate, and in none of the eastern theatres was there any central bureau of information which could inform the scattered medical officers about recent advances in the treatment of the diseases they were called upon to fight. It is probable that in the future an antidysenteric vaccine will be produced which will have as powerful a protective action against bacillary dysentery as anti-typhoid vaccine has against typhoid fever, but very little satisfactory vaccine was available for use during the war.

## (e) Epidemic Jaundice

A mild form of jaundice was very common in the Gallipoli campaign between Aug. and Dec. 1915, and in Mesopotamia during the hot weather of 1916 and 1917. The symptoms were similar to those of the catarrhal jaundice, which occurs sporadically among civilians in peace-time, and the condition appears to have been of the same nature as the epidemics in the American Civil, Franco-Prussian and South African wars. It appears to have been due to infection with an organism allied to the bacillus of paratyphoid fever, and numerous investigations failed to reveal the presence of a spirocha te. The mortality was so low as to be almost negligible; many men continued on duty though jaundiced, especially at Gallipoli, but the majority were not fit until six or eight weeks had elapsed from the date of onset.

From the spring of 1916 until the end of the war an entirely different form of infective jaundice occurred among the troops of all the armies engaged in France and Flanders. It was caused by infection with a spiroch ae te, and was identical in nature with a disease which every year attacks between 3,000 and 4,000 miners in Japan. It is best described as spiroch ae tal jaundice rather than by the older name of Weil's disease, as it was accurately observed amongst French soldiers by Larrey at Cairo during Napoleon's Egyptian campaign in 1800, and by numerous other French physicians before Weil's paper appeared in 1886. The spirochete was discovered in rats caught in trenches in which the disease had occurred; the infection in rats is chronic, the organism being excreted in the urine, which is probably the source of infection in man. The disease could be prevented if adequate steps were taken to drain trenches and exterminate rats. The symptoms were much more severe than those of the bacillary jaundice of Gallipoli and Mesopotamia; the mortality, however, was only about 4% in the British army, though it was 13% in the German army and is about 30% in Japan.

(f) Malaria. - Malaria had the same effect on the operations in Macedonia that dysentery had in Gallipoli. Few men in the Salonikan army failed to become infected with malaria during the summer of 1916, and there is no doubt that throughout the campaign the mosquito was a far more formidable enemy than the Bulgar. Prophylaxis by means of quinine completely failed and it was found quite impossible to reduce the numbers of malaria-carrying mosquitos to any appreciable extent. The conscientious use of mosquito nets was, however, very effective. The disease was of a particularly virulent form, the mortality being exceptionally high. Even after the Armistice it proved a matter of great difficulty to exterminate malaria in men who were infected in the Struma valley.

The Mesopotamian army also suffered greatly from malaria but not quite to the same extent as the army in Macedonia. The disease was very common and very severe in the army in Persia. The number of cases in France was quite trivial, most cases being due to relapses in men who had been in one of the eastern theatres of war.

## (g) Infective Nephritis

Acute nephritis, or inflammation of the kidneys, is a comparatively rare disease in civil life. It does not appear to have been common in any previous campaign except the American Civil War, in which over 14,000 soldiers of the Northern armies were invalided for nephritis, and to a less extent in the FrancoPrussian War. A considerable number of cases occurred among British troops in France throughout the World War, and a slighter outbreak occurred in Gallipoli and Salonika. It appears to have been less prevalent among the French and still less among the Belgians. It was very common among the German and Austrian soldiers on every front, though not a single case was observed by German medical officers among the Turks. It was very rare among officers of all nationalities, and was never sufficiently common among the men to be of any real importance to the strength of the army, the maximum incidence (in Dec. 1916) being only 104 cases per 100,000. All attempts to discover the cause of the disease failed, but there appeared to be something about the conditions of life of the soldier, as distinct from those of the civilian, which made him specially liable to develop nephritis, as it never occurred among the civilian population or refugees of Belgium and France, who lived in the midst of soldiers and with many soldiers billeted on them. This was in striking contrast to the parallel incidences of most of the epidemic diseases among civilians and soldiers.

The mortality of the infective nephritis of soldiers is much lower than that of the ordinary nephritis of civil life, being approximately 1% in the early stages, though a few additional deaths probably occurred in relapses some months after apparent recovery. Most patients got well within a month, but the complete disappearance of symptoms was sometimes delayed for a year or even longer.

(C.) Soldier's Heart. - Soldiers not infrequently suffer from symp toms due to functional circulatory disturbances during their period of training and still more often whilst on active service. In neither case do the symptoms differ from those which may occur among civilians, but their relative frequency has led to the adoption of the term " soldier's heart." The effect of active service on the heart was first studied during the American Civil War, and a great many valuable investigations were carried out during the World War.

Already by the end of May 1916, 2,503 out of the 33,919 soldiers (7.4%) invalided from the service since the beginning of the war had been discharged on account of " heart disease," and this proportion was maintained until the end.

Soldier's heart was most commonly caused by over-exertion, often associated with prolonged mental strain and insufficient sleep, acting on a heart and nervous system which were already weak before the war or which had become weakened on active service as a result of an infection or other form of poisoning. Some men are born with a circulation sufficient for ordinary purposes, but with insufficient reserve power for increased strain. They generally know their limitations, adopt a sedentary occupation in civil life, and do not indulge in out-of-door sports. Many of them break down during training, but even if they develop into efficient soldiers they are likely to develop cardiac symptoms on active service. Thus nearly 60% of men suffering from soldier's heart were recruited from sedentary occupations.

In most cases the symptoms developed during convalescence from some acute infection, such as typhoid and paratyphoid fever, epidemic bacillary dysentery as well as non-specific chronic diarrhoea, malaria and influenza. Excessive smoking was undoubtedly a contributory cause in many cases, and gassing was frequently followed by cardiac symptoms. In a small proportion of cases the excessive activity of the thyroid and suprarenal glands which results from prolonged mental strain was a further factor.

Over-exertion is a relative term. A well-trained man can do work which would be impossible in the early stages of his training and which again becomes impossible if his heart and nervous system are damaged by the poisons produced by an infection, excessive smoking or incursive activity of the thyroid gland. But in the absence of these factors a trained soldier rarely develops cardiac symptoms.

In addition to the effect of nerve-strain on the circulation through its influence on the thyroid and suprarenal glands, the nervous exhaustion or neurasthenia, which results from the combined effect of physical fatigue, mental strain and infection, gives rise to a condition of nervous irritability, which causes slight circulatory disturbances to produce palpitation and discomfort and pain in the region of the heart, although the actual condition is such that subjective symptoms would not occur in a man with a normal nervous system.

The commonly accepted official diagnosis of " D.A.H." or " disordered action of the heart " for soldier's heart is most undesirable, as it at once makes the patient believe that he has " heart disease." Some indifferent diagnosis such as " debility " would be preferable. Treatment by graduated exercise instead of prolonged rest in bed was almost invariably followed by rapid improvement if undertaken at a sufficiently early stage, and whenever the comparatively innocuous nature of the condition was widely recognized by medical officers most men suffering from " soldier's heart " were able to return to duty after a few weeks in special training camps. When, however, it was regarded as if it were due to a serious disease of the heart and treated for long periods in hospital, the outlook was much less hopeful, and many men were invalided from the service and became chronic invalids as a result.

(D.) Heat-Stroke. - Heat-stroke occurred very frequently among the British troops in Mesopotamia during the hot summer months. It did not in any way differ from the heat-stroke which sometimes occurs in India. In Mesopotamia it was, however, more common owing to the less favourable conditions of life.

During the earlier years of the campaign heat-stroke was very nearly always fatal, mainly owing to the lack of facilities for treatment. By 1917, however, great progress had been made both in prevention and treatment, and the proportion of recoveries was much increased. The most important precautions for avoiding heatstroke were the provision of large quantities of cool drinking-water and of suitable clothing and equipment. Men suffering from other illnesses, such as malaria, sand-fly fever and gastro-intestinal disorders, were specially liable to fall victims to heat-stroke.

The disease was always dramatically sudden in onset, and usually within an hour the patient was completely unconscious and in convulsions. In untreated cases death occurred within a few hours with a body temperature of I io° or over. The one essential for treatment was found to be an ample supply of ice. The establishment of special heat-stroke stations in all camps and depots proved most effective in reducing mortality. Those who recovered, however, were seldom fit for further service in Mesopotamia and in most cases were eventually invalided to England. (A. F. Hu.) IV. Surgery During The War Military surgery during the progress of the World War reached unexampled levels of efficiency and width of scope, and the general results attained exceeded any limits which had been anticipated. Yet this consummation was not arrived at by a smooth and easy path, neither were the full fruits rapidly gathered. Experience indeed was but a repetition of that gained in all previous campaigns. In Aug. 1914 time had been allowed for collation and digestion of the observations made in the more recent wars, while in civil life progress in surgery had been continuous and considerable. Hence the military surgeon entered upon his duties with confidence in the methods at his disposal and with fair hope of eliminating more or less completely many of the mischances from which his predecessors had suffered. These anticipations were not promptly realized; in spite of the perfected technique which was considered to have been acquired in the general treatment of wounds, and the accurate knowledge which had accumulated as to the characters of the injuries inflicted by modern rifle bullets, it soon became evident that this war, like all its predecessors, would have to teach its own lessons. This experience depended chiefly upon two factors: (1) bullet wounds did not form the preponderating element, but were less frequent than those produced by fragments of shells and bombs, which latter were of a severity and extent scarcely conceived beforehand; (2) the forms of infection met with were more varied and virulent than those commonly dealt with.

Thus in the earlier stages of the war the entire field of surgery was necessarily dominated by the elementary but fundamental question of appropriate treatment of the mere wound, to an extent which materially prejudiced advance in the management of individual injuries. The actual starting-point of real advance was relegated almost to the pre-Listerian period, and a vast amount of past experience required to be repeated and controlled before a firm foundation for progress was established.

When definite principles had been laid down to guide the routine treatment of infected wounds, a second great question still demanded settlement: At what stage in relation to the fighting-line should the definite treatment of gunshot injuries be undertaken? The result of all previous experience had been to the effect that field hospitals were unsuitable for any but temporary measures except in the case of great urgency. The casualty clearing-stations, a recent introduction into the British establishment, were originally intended to act mainly as sorting and distributing centres, and it was laid down that the great bulk of the wounded men should be transferred to the stationary and general hospitals on the lines of communication.

A short time sufficed to prove this arrangement to be defective, since, in spite of the efficient means of transport which had been rapidly developed, it became evident that the primary treatment of the wound needed to be more radical than had been anticipated; when only provisional measures were adopted the patients were in little better condition for the procedure on their arrival at the stationary and general hospitals than if treatment had been entirely omitted. The progress of the infections, in fact, was far more rapid than any means of transport, and such preliminary steps as had been taken required to be repeated upon wounds already increased in extent, with very definite disadvantage to the patient. At this stage the settling-down of the form of warfare to a stationary character allowed for the development of the casualty clearing-station into a potential stationary hospital, while in addition it was found practicable to establish small advanced operating units still nearer to the front to deal with injuries to the abdomen, head, etc. To this development, and in great measure as a result of the bravery and efficiency of the bearers who brought in the wounded men, the whole of the advance in the primary treatment of gunshot injuries is referable. Such conditions may not often recur, but one result of the work done must remain and exert a permanent influence on military surgery. The efforts and firm convictions of a band of enthusiastic and capable surgeons demonstrated for all time that results of equal excellence can be obtained by the military as by the civil surgeon if only sufficient initiative, care and resolution be maintained. The bugbear of " the exigencies of warfare " has been in fact displaced from the commanding position which it has held heretofore.

## The Treatment of Wounds

At the outbreak of war it was generally held that the treatment of gunshot wounds should approximate itself in procedure to the methods in use in civil practice, purely aseptic measures being supplemented by the addition of some antiseptic medium in the case of open wounds fouled by contact with the clothing, the missile or the soil. It was believed that this addition should suffice at the primary dressing to check the progress of the initial infection. This view was founded upon experience gained in recent wars, in which the great majority of the injuries were inflicted by bullets of small calibre. It had been observed that many of these healed well even in the absence of any surgical aid, while the great majority closed without any serious accidents when protected by an occlusive dressing adjusted either by a bandage or some sort of adhesive such as collodion or mastisol. Too little attention indeed was given to the further observation that the comparatively rare shell wounds always suppurated even under the favourable conditions which attended the S. African War of 1899-1902. In the early days it was assumed that the ravages induced by infection were to be explained by the conditions then existing, such as the long distances the patients had to travel, the impossibility of sufficiently frequent changes of dressing, and the want of proper rest. The pernicious influence of these conditions is obvious, but it was rapidly grasped that they should not be held to be an insurmountable element of failure. An attempt was at once made to combat the primary infection more efficiently by mechanical procedures, consisting of free excision of bruised, soiled or devitalized tissue by the knife or the scissors, followed by drainage of all recesses of the wound by india-rubber tubes and a completely " open " method of treatment.

At this period two principles concerning the management of an open infected wound were freely debated. By Almroth Wright and his school it was maintained that the extinction of infection was most rapidly effected by attempting to increase the activity of the normal factors in the process of healing. The method adopted was called the " physiological or phylacogogic," and an endeavour to accomplish the desired aim was made by flooding the wound with a saline solution of a higher specific gravity than that of the fluids permeating the body tissues and thus to " draw " an abundant flow of lymph towards the free surface. By this means also the tissues were "lavaged" by a stream of lymph, the current of which flowed in a direction opposed to the spread of infection inwards. Later the " hypertonic " solution, while accomplishing this end, was found to check the migration of leucocytes to which Wright eventually ascribed the chief place in subduing the infection; hence at a certain stage in the course of healing an isotonic was substituted for the hypertonic solution.

The second school, influenced by the early work of Lister, retained allegiance to the use of antiseptic media of varying kinds. By many the hope was cherished that an agent might be discovered that would not only cleanse and disinfect the exposed surface of the wound, but would also penetrate the underlying infected tissue and thus hasten the natural process. This dream, emanating from an imperfect appreciation of the " preventive " nature of Lister's work, was not fulfilled. Nevertheless, the supporters of the antiseptic theory played a highly important part during the period of argument and uncertainty both as to principle and practice. The most important of the media employed consisted in perfected solutions of the hypochlorites, and certain anilin dyes, particularly flavine and brilliant green. It may fairly be stated that the application of an antiseptic to the wound, or in the dressing, in itself played a minor part, the real advance which followed depending not upon the antiseptic which was employed but upon the development of an efficient system. In the Carrel-Dakin system, although great importance was attributed to the hypochlorite solution, yet the success which it attained was really due to exact observation of the nature and course of the infection concerned, careful initial preparation of the wound, meticulous precaution against stagnation of infective material in recesses in the cavity, and the prevention of reinfection of the surface. It was the experience gained from the practice of this method in the treatment of compound fractures of the bones that clearly demonstrated the possibility of the routine secondary closure of the accompanying open wound, an achievement only second to that of Lister in his early treatment of similar injuries. This result attained, the practicability of resort to secondary suture in most wounds was established.

Subsequent advance proved the practicability, under favourable conditions and environment, of primary closure of the compound fracture without the aid of any antiseptic medium. This ideal was reached by a rational extirpation of the infected tissue by mechanical means, followed by a sufficient period of rest to the patient and to the injured part.

The net result, therefore, of a period of strenuous work and argument was to reaffirm the principles with which surgeons were already acquainted at the commencement of the war: (I) that sterilization of living tissue can only be effected by the natural vital process; (2) that no chemical agent is known capable of penetrating the tissues of the body and destroying microorganisms which is not at the same time deleterious to the tissue itself, and that the sole means of procuring abortion in an infected portion of the body is radically to remove the infected tissue. Again, no novelty in principle was introduced by the practice of either the primary or secondary closure of compound fractures, or of wounds in general; the triumph consisted in the translation of these occasionally used methods within the limits of routine practice. It may be added that the method of secondary suture is to be regarded as the more valuable of the two, since it is but rarely that conditions will not allow its adoption, while in military surgery it is generally difficult to ensure the requirements essential to the success of primary suture. Paradoxical as these conclusions may appear, success was only gained after strenuous effort and the development of a technique and degree of judgment equal to those required for the most exacting operations in the entire realm of surgery.

## Nature of the Infections

It can hardly be said that any novel form of wound infection was discovered, but knowledge was extended in many directions. The hourly progress of mixed infections was investigated, and the vital tenacity of the different organisms determined, while a still more fruitful series of observations was made in the effort to determine the moment at which a wound with a fouled surface became an actually infected one. The result of the latter investigation allowed a general assumption to be made that during an interval of from four to eight hours the multiplication of organisms in their new environment was slow and penetration of the living tissues by them unlikely. Thus a definite time-limit was assigned, beyond which primary closure should not as a rule be attempted. It was shown that only the staphylococci and streptococci as a rule remained present in the terminal infection, and that of these the streptococcus was the more undesirable occupant of the wound. Further, the power of haemolysis possessed by some forms of streptococcus marked them out as the more dangerous to the progress of the wound and to the life of the patient.

The unusual frequency of anaerobic infections afforded opportunity for an extensive investigation of the microorganisms concerned, the special characters of the changes produced by each, also of the importance of symbiosis in these phenomena, thus accentuating the importance of suppuration in the development of such diseases as tetanus, or in the causation of gangrenous cellulitis.

Although acute traumatic gangrene was well known in civil practice, yet it seems doubtful whether it has played such a prominent part in any previous war. There is good evidence that it was rare in the American Revolutionary War, and in the S. African War it was certainly but very rarely met with. One very distinct advance was made in the treatment of the condition. It was observed that the spread of the infection tended to be limited by the fascial envelopes of the muscles, particularly in the case of B. perfringens (the organism which specially attacks the muscle fibres), and that, if the vitality of the muscle was lowered by cutting off its blood-supply, the entire muscle rarely escaped destruction. Hence the practice of complete excision of a muscle from within its sheath was introduced, and proved most successful in limiting the spread of the gangrene in the limb, especially when the long muscles were affected.

Little success attended any but the mechanical treatment of anaerobic gangrene, but the treatment of tetanus afforded one of the great triumphs of preventive medicine - in fact, the result attained must be placed upon a level with that reached in the preventive treatment of enteric fever. It was recognized at an early date that every breach of surface with which the intensively cultured soil of northern France had come in contact was potentially infected with B. tetanus. Hence it was laid down that in the case of every serious wound the man was to receive an injection of tetanus anti-toxin, and this rule was shortly extended to every wound, and even to chilled feet, especially when vesication had occurred.

Further, since the protection afforded by this measure is known to disappear rapidly, a second injection was given at the end of seven days, and in severe injuries at similar intervals for the succeeding two or three weeks. Again, in view of the known fact that B. tetanus may lie latent in a healed wound for indefinite periods, a prophylactic injection was administered to many of the patients in whom late secondary operations became necessary.

In the curative treatment of tetanus it cannot be claimed that any very important advance was made. The chief variation in method consisted in the administration of greatly increased doses of antitoxin. While it remains doubtful whether much advantage was gained by this procedure, it was demonstrated that in some instances the dosage had previously been insufficient. In base hospitals in England, as a result of mainly intra-thecal injections. the average mortality of the disease was reduced from 57.7 io to 19%. In France, where a more acute series of cases had to be dealt with, the reduction only reached equivalents of from 78.2% to 67.4%.

With regard to the route for the injections, many surgeons considered the spinal intra-thecal the best, but clinical observation does not appear to give strong support to this view, although experimental evidence from animals is adduced in its favour. Intra-muscular injectionsprobably gave the most consistent results, while subcutaneous injections proved sufficient for prophylactic purposes.

In connexion with the prophylactic treatment, mention should be made of the fact that, if it failed to prevent, it was still capable of modifying the disease, and local phenomena were much more common than would otherwise have been the case. Except in the splanchnic form, although the local might be only the commencement of a general attack, the prognosis was much better.

## Shock and Haemorrhage

The circumstances attendant on active warfare, such as anxiety, heated and ill-controlled emotions, fatigue, want of sleep, hunger and thirst, exposure to cold and wet and, lastly, severe injury, often combined with loss of blood and pain, afford every condition with which we are accustomed to associate the occurrence of shock. In spite of the arduous investigations undertaken it can hardly be said that the actual explanation of the phenomena has been unveiled. Observations, however, tended to negative certain theories, such as those of acapnia, acidosis, suprarenal incompetence, exhaustion of the vasomotor centres or cardiac weakness, as a primary factor. Hence we must still be content vaguely to regard the phenomena of shock as nervous in origin. In one particular a definite advance was made in the realization that the fall in blood-pressure, which is so prominent a feature in the condition of shock, is strictly comparable to the fall attendant on haemorrhage, the volume of blood within the arterial system being reduced not by external escape from the open vessels but as a result of stagnation in the capillaries. The older theory of stagnation in the visceral veins of the thorax and abdomen was not only exploded by experimental observation, but its error was also demonstrated by the appearances observed during the performance of numerous operations for visceral injuries during the period in which the state of shock was in some degree persisting.

The condition known as " secondary shock," in which the phenomena develop hours or even days after the initial injury, perhaps after primary shock has already been recovered from, had since the Listerian era been regarded as an evidence of toxaemia. The similarity was well illustrated in the cases of acute toxaemia in connexion with anaerobic infections, with which the war made everybody familiar. The experimental work of Dale and others on the action of histamine when introduced into the circulation of animals led to an investigation which seems to prove that the phenomena of shock may be produced by absorption of the metabolic products resulting from the mechanical destruction of muscle fibre, a common result of gunshot injuries.

The outcome of the observations made was to show that the first principle in combating shock is to attack the most prominent of its phenomena, i.e. lowered blood-pressure. The effect of infusions of normal saline solution for this object was known to be evanescent, and successful attempts to prolong the effect and at the same time to diminish the volume of fluid required were made by adding a colloid constituent to the solution. In order to place the patients under the most favourable conditions possible, a heating-system was added to the ambulances, and special resuscitation wards were equipped, so that the more simple means, such as the application of warmth, the administration of fluids by the mouth or per rectum, and the ensurance of absolute rest, were facilitated. When necessary, these methods were supplemented by infusion of the " umsaline " fluid of Bayliss. This solution contained sufficient of the colloid (6%) to increase its viscosity and endow it with an osmotic pressure comparable to that depending upon the colloid constituent of normal blood. The saline constituent (1.5 to 2%) of bicarbonate of sodium was introduced to counteract the decreased alkalinity of the blood occurring in shock and to prevent haemolysis.

The same solution was employed in the treatment of the slighter cases of haemorrhage. Serious cases were dealt with by the replacement of whole blood. The indication for the latter method was sought for in persistence of a blood-pressure as low as 80 mm. of mercury. In primary haemorrhage estimation of the haemoglobin content of the blood was considered too elaborate a method and unsuitable for use from want of time.

Transfusion became common in consequence of the ease with which donors of blood could be secured from amongst the soldiers. The older method of direct transfusion was found inconvenient from an operative point of view, and unsatisfactory from the fact that it is difficult to estimate the amount of blood which has actually passed from donor to recipient. Hence blood was more commonly collected from the donor into a glass vessel coated with paraffin to prevent coagulation (Kimpton's tube), and thence transferred to the recipient. To meet difficulties resulting from premature coagulation, the blood was sometimes drawn into a vessel containing a solution of citrate of sodium, since it had been found that the addition of 0.5% of this salt to the blood had no deleterious action. In the later stages of the war it was found practicable, in view of the possibility of having to transfuse a large number of men in an emergency, to substitute a fluid containing preserved red blood-corpuscles suspended in a sufficient volume of a 2.5% solution of gelatine to bring the total volume into consonance with that of the whole blood originally drawn from the veins of the donor.

To meet the well-known difficulty that individuals fall into definite classes in regard to their capacity to receive the blood of others with safety, a simple classification was arrived at by means of agglutination tests. Thus suitable donors were previously selected and were always available. Four groups were differentiated, of which it was determined that those belonging to the first (8%) could take blood from either of the remaining three groups. Of the other three, the second group (40%), the third group (12%), and the fourth group (40%) could receive blood only from individuals belonging either to their own group or to the fourth group.

## Special Surgery

One great principle that in the past has governed the application of a ligature to the great arteries of the limbs received considerable modification. It had always been held that, when a main artery was tied, the conservation of the accompanying vein was of the utmost importance for the preservation of the vitality of the limb affected. Experience gained from observation of a long series of cases, in which both vessels were implicated, demonstrated that not only was the integrity of the vein of no vital importance, but that the immediate results were more favourable when both vessels were occluded simultaneously and a better balance maintained between the capacity of the modified arterial and venous systems. Experimental investigation supported this clinical experience, since it was shown that the blood-pressure in the affected portion of the limb was maintained at a higher level.

The substitution of local repair of the wounded walls of arteries for complete obliteration of the vessel by ligature made little progress until the general methods of wound treatment allowed such operations to be made without fear of subsequent infection. In the later years of the war steady progress was made in this direction, and it was shown that ideal results might be obtained, and further that even should the local patency of the vessel not be maintained, yet the result was at any rate in no way inferior to that following successful ligature of the vessel.

The general treatment of compound fractures has been already alluded to, but beyond improvement in the management of the wound, considerable modification took place in the nature of the means adopted to ensure good position of the bones. The change depended on the general introduction of the metal wire splints of Hugh Owen Thomas. These were found capable of adaptation to the great majority of all fractures of the limbs, and also equally suitable for employment in the front line and in base hospitals. It is of interest to note that one of the main principles of their originator was found capable of modification, as well as variations in construction. Fixed extension did not prove convenient or easy of application in military practice, and the substitution of weight-and-pulley extension, or the employment of the weight of the patient's body as a means of counter-extension, was widely and successfully resorted to. In no department of surgery was more initiative and ingenuity shown than in the numerous devices designed to meet the needs of individual cases or different regions of the body.

Infected wounds involving the articulations maintained the reputation of this form of injury as a source of difficulty and anxiety. One heterodox principle was propounded. Absolute rest to the joint has always been regarded as the surest means of checking the spread of infection, but success.attended resort to a method in which active movements of an open articulation were commenced from the outset. It was claimed, and with some justice, that this method favoured the escape of infective exudation from the cavity of the articulation, and that the formation of adhesions and ultimate restriction of the normal movements were minimized. It is perhaps too early to give a definite opinion on this subject.

As regards injuries to the nervous system, it suffices here to say that the advances made in the more accurate knowledge of localization of function in the different parts of the brain and the spinal cord, and increased knowledge of the mode and progress of regeneration in wounded peripheral nerves, took a more important place than those in technical treatment of the injuries.

The book of knowledge concerning the possibilities of thoracic surgery (see Heart And Lung Surgery) may be said to have been opened up by the experience of the war. It was proved upon an extensive scale that the mere laying-open of the great serous sacs of the chest was not the dangerous procedure that had been widely assumed, and that, as Sir W. MacEwen had already demonstrated, no special artificial arrangements are necessary to maintain the normal intra-thoracic pressure during operations. Appreciation of this fundamental fact opened the way to free primary treatment of a large number of thoracic injuries which had formerly proved rapidly fatal not from the hopelessness of the actual injury but from the results of the infection which commonly followed it in consequence of insufficiency in boldness of surgical attack. Thus the way was cleared for dealing with intra-thoracic haemorrhage and its complications, wounds of the lung, retained fragments of infected foreign bodies, and even for dealing on rational lines with wounds of the heart. Of scarcely less consequence than these visceral operations were those rendered possible for removal of foreign bodies from the mediastina, a fruitful source of immediate danger, and of intractable fistula-formation at a later date. It is impossible to estimate how widely this new field of surgery may be exploited in the civil practice of the future.

The technique of the surgery of abdominal injuries had been already so highly developed as to call only for judgment and initiative to elevate military practice to the same level that had been reached in civil life. The difficulties which required to be surmounted were partly administrative, depending on the all-important element of time and the ensurance of as near an approximation as possible to the golden interval of six hours between injury and operation; partly dependent upon the severity of the injuries themselves. Both were overcome, and perhaps the most satisfactory feature of the result is seen in the increased tendency to conservancy in the extent of the operations - the effort to repair rather than to excise the injured part. The most striking in a series of successes was that attained in the treatment of severe abdomino-thoracic injuries, which had previously been regarded as beyond legitimate surgical intervention.

The experience gained during the war is likely to influence the future of surgical practice mainly in two directions. In the first place, the intimate personal association of workers in the branches of pure science ancillary to the practice of the art of medicine with the practical application of the principles laid down by them demonstrated the fruitfulness of this combination and its capacity to lead to rapid advance in elucidation of the problems constantly confronting the medical practitioner. Secondly, the assemblage of vast numbers of crippled men brought forcibly before the medical profession and the public the waste in national power which results from impairment or defect in physical capacity amongst a whole population, and accentuated the fact that in civil life circumstances had not been favourable for following up continuously the history and results of many common injuries. Hence surgeons who in the past had busied themselves particularly in the treatment of acquired defects and deformities extended the scope of their activities to preventive effort, and as a consequence greatly increased facilities have been provided for continuous treatment. (G. H. M.)