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 some- thing 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 per- meable vessels. His choice fell on solutions of gum arable, 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 " oxy- gen 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' certifi- cates 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 1,000 medical officers. At the end of the war its personnel num- bered 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 de- ficient. It is true that the frequent changes of base, from Boulogne to Havre and again to St. Nazaire and then back again to Bou- logne, 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-director- general 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 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 cas became the basework of the whole organization. All through th war the medical service had three main areas of work -the front the base and home. The idea was always to use the base fo two purposes: the treatment of cases too ill to be taken acros the English Channel immediately, and the treatment of cas which might be expected to recover within a short space of time. Thus evacuation to England was used for the most part in cas where immediate recovery was improbable, yet where the natur of the injury or disease was not such as to preclude a voyage.
