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 meas- ures 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 prob- lems 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 Roe- hampton, 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 dif- ficulties 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. More- over, 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 cap- able 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 or- ganization 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 psychol- ogists and psychotherapists. The result was a reexamination of functional nervous disorders and the formation of a great depart- ment of army medicine. Instead of being branded as a coward
the nerve-broken soldier was cared for and treated, and so 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 prqved, invariably effective. He be- lieved 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 con- valescent 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, a free 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 won- derful 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 rr 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 invar- iably admirable, and there was a remarkable freedom from epidemic infections on a large scale, especially in France, owing to the excel- lence 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 temperami which does not allow them to know what fear means, the va; majority, including many of the bravest, were terrified when they first approached the front line. Many men became accustomed to it
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