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British Medicine in the War



1914-1917



Being Essays on Problems of Medicine, Surgery, and Pathology

arising among the British Armed Forces engaged in this

IVar and the manner of their solution.



Collected out of the British Medical Journal, April — October, 1917.



With Coloured Platks and Numerous Illustratioxs ix hie Text



LONDON :

THE BRITISH MEDICAL ASSOCIATION.

1917.



7



[jSiSAa^



PREFACE.



Felix qui poluit rerum cognoscere causas.

ACHARACTEEiSTic of British medicine from tlie sixteenth century to the present day has been its readiness
to test all theories by the appeal to Nature. This disposition was in accord with the instinct for
practical affairs of a race which has been compelled constantly to engage in war and has endeavoured
always to wage war humanely. Three centuries ago Harvey, the greatest name in Britisli medicine, in liis
oft-quoted injunction " ever to search out and study the secrets of Nature by way of experiment," struck the
note which has been dominant ever since. The purpose of the following pages is twofold. It is intended to
give a brief account of the manner in which the spirit that has inspired Britisli medicine since the days of
Harvey has, by the application of scientific principles to practice and administration, mitigated the hardships
and sufferings of those engaged in this war, and it is intended also to point out how, by the wise utilization
of the services of members of the British medical profession, as practitioners of the art or students of the
sciences on which it depends, problems rendered acute by war or newly brought to light by it have been
studied, and in many instances partially or completely solved even during its continuance.

Harvey's injunction has been the watchword of British pliysiology and pathology. The principle it
embodied was handed on by a long line of successors through Hales, Priestley, Young, and Hunter, to Lister,
who, guided by the fundamental observations and doctrines of Pasteur, brouglit about by experiment and trial
a revision of the institutes of surgery. The story in its main aspect is told by Sir Berkeley Moynihan in the
eloquent essay, remarkable for its philosophic grasp, its learning, and its cordial tributes to the work of men of
other nations, which forms the first chapter of this volume.

At about the time when Hunter by his direct appeal to Nature was giving so great an impetus to
the study of pathology, and helping to found the science of comparative anatomy, there arose in Great Britain
a school of investigators which sought out the causes of epidemic diseases by observation of tlie conditions under
which they spread and by the study of statistics of their incidence. Guided by these investigations methods of
prevention were devised which, when tested in the Navy, the Army, and among the civil population, were not
found wanting. The problem of scurvy, the scourge of navies and commercial shipping, was attacked and solved ;
the problems of typhus and relapsing fever were attacked, and the relation of these diseases to overcrowding,
dirt, and famine established. Another great step forward was made when it was shown that by the application
of administrative measures founded on inquiry and observation — by ensuring tlie purity of water supplies,
by the canalization of sewage and the removal of refuse — the incidence of typhoid fever might be enormously
diminished. The new science of bacteriology, due at its inception mainly to the prescience of Pasteur,
put a new weapon into the hands of civil and military medical administrators, and in its effective use
this country has not been backward. Pasteur, when giving to the world his doctrine of artificial immunity
through the inoculation of attenuated virus, paid a generous tribute to the achievement of Edward Jenner
in devising vaccination against small-pox — a means of preventing that disease so effective that the horror
it inspired a century ago is now completely forgotten. It is in accordance with historical fitness that
antityphoid vaccination, which has proved so efficient a prophylactic in this war, should have been conceived
and perfected by another British physician. Sir Almroth Wright. The system, severely tested before the war
in the British Army in India, and, with some independent differences in method, in the French Colonial Army,
has been applied on a large scale to the armies of both nations with remarkable success since the war began,
and even by the enemy to theirs.

The extension of British commerce and the acquisition of territory in tropical and subtropical
countries early compelled attention to the epidemic diseases of hot climates. The chief of these was
malaria, which, though not peculiar to hot countries, attained in modern twines its greatest extension and
severity in them. It was the main cause that so many of the richest tracts on the earth's surface wore
uninhabitable by the white races, and were only governed by them at a heavy cost in life. Even after
it was proved that extensive drainage schemes might diminish their incidence, malarial diseases continued
the despair of administrators. Here again the clue was afforded by a French observer when Laveran, in
Algiers, showed that malaria was associated witii the presence of a parasite in the blood ; later it was
ascertained that the paroxysms of the disease coincided with a certain stage in tlie life-cycle of the
parasite, and that different types of the disease were attended by different varieties of the malarial
haematozoon. Striking as these observations were, they did not afford effective means of prevention until
the brilliant hypothesis of Manson, founded on the observations on filaria made by him when practising in
China, that the mosquito was the intermediate host of the haematozoon, was verified by Ronald Ross, then
an officer of the Indian Medical Service. The identification of the species of mosquito that acted as host, and
2



the study of its life-cycle and habitat quickly made plain the main lines prophylactic measures should take.
Among the first applications of the new knowledge were those made in the Sue/, Canal zone under the direction
of Ross, at the request of Prince d'Arenberg, and on a still larger scale during tlie construction of the Panama
Canal, where the results were even more striking.

The impetus given to the study of medical entomology by these observations and their practical outcome
in the case of malaria was very great. Themain incidents in the course of the astonishingly rapid development
of this new field of medicine are sketched in Chapter XI by Sir Patrick Manson himself. The whole story is
comprised within his lifetime, and to the progress made he has largely contriljuted not only by his own
untiring studies, but by the inspiration he has given to his pupils to search out these secrets of Nature by way
of experiment and observation.

At the outbreak of the war the Medical Services of the British Navy and Army each consisted of a
corps of commissioned oflicers with, under their command, non-commissioned otlicers and men trained,
after enlistment, in their special duties. The officers were recruited from among young men who had
completed their education in the universities and civilian medical schools and entered the service by
competitive examination. The Indian Medical Service, recruited in the same way and containing officers
of British or Indian birth, is organized on a military basis, but the majority of its members in peace
are employed in civilian posts. Along with subordinate medical services, military and civil, recruited
entirely in India, it formed the medical war reserve for India.

The officers of the Naval, Army, and Indian Medical Services underwent, during a period of probation,
courses of instruction in sj)ecial subjects, including tropical diseases, at the Eoyal Naval or the Royal Army
Medical College, and were trained in administration at military hospitals and in camps. of instruction. Thus
these services consisted of medical officers, experts in their special duties, but numerically insufficient for the
great expansion in the armed forces necessitated by a war on a scale larger than had ever been ofticially con-
templated. In the case of the army this numerical insufficiency quickly became very great. The Navy and
Army Medical Services l)oth liad small reserves of officers wiio were immediately called up. The Territorial
Force, raised for liome defence by voluntary enlistment during peace, had its own medical officers,
civilian practitioners who liad voluntarily accepted the obligation to undergo annual training and to serve
with the Force when mobilized. In 1907 Sir Alfred Keogh, G.C.B., then Director-Cieneral of Army Medical
Services, propounded a scheme for the organization of the Territorial Medical Service. Thanks to his great
powers of organization and the confidence felt in his character and attainments by the medical profession
liis sclieme obtained the cordial co-operation of all the leading practitioners throughout the country.
It provided regimental medical officers and divisional staffs and tlie personnel and equipment for
twenty-two General Military Hospitals in various centres officered for the most part by the members of the
staffs of the large local civilian hospitals. The Territorial Medical Service was mobilized with the rest of the
Territorial Force in the early days of August, 1914, but it was realized from the first that the war would be
long — Lord Kitchener gave a minimum of three years — and on an unparalleled scale of magnitude. Large new
armies wore raised l)y voluntary recruitment, and civilian medical men vohmteered so freely that it was not
until the spring of 1916 that any form of compulsion was necessary to obtain an adequate supply of medical
officers for the new armies.

The nucleus of the medical service for the largo British armies now afoot was formed by the small
specialized corps which existed on a peace establishment, but eleven-twelfths of the officers of the Eoyal
Army Medical Corps and of the Canadian, Australian, New Zealand, and South African Medical Corps, now^
serving with the armies in France, Salonica, Egypt and Palestine, Mesopotamia, India, and Africa, were
civilian practitioners at the outbreak of war. The present organization of the corps, and the work it is
doing, is described in Chapter XIV. Happily the services of Sir Alfred Keogh were again available to direct
the necessary expansion. The record discloses an admirable foresight in the creation of a body which
could be so expanded and yet remain co-ordinate in its parts.

At an early stage a plan was formed to appoint distinguished members of the staffs of civilian hospitals
to be consulting physicians and surgeons with the army in France. It was put into force, as soon as the
armies came to fixed positions after the battle "of the Marne, under the direction of Sir Arthur Sloggett,
Director-General Ai'iiiy Medical Services, who iiad removed liis head quarters to France, while
Sir Alfred Keogh took his place in London. As the British forces in France increased until a
number of armies were in tlie field, consulting surgeons and physicians were appointed to each, and for
areas in which base hospitals were established. The plan was extended to armies agting in other parts of
the world, and also to the area of each military command in the United Kingdom. These consultants go to
the military hospitals for purposes of consultation with the medical and surgical staffs, and those with the
armies in the field visit the field ambulances, the casualty clearing stations, and the other medical units in
the advanced or " collecting " zone (Chapter XIV). The nature of the services rendered by them, and their
value, may perhaps be surmised from this brief statement. Passing frequently from one medical unit to
another they carry the experience from one to the other so that a broad view can bo gained of tendencies to
disease and in troatnient : they are able to advise the chief administrative medical officers as to means that
should bo taken to prevent disease or anticipate infection, and to afford opportunities for efficient treatment at



the earliest possible moment. Experiences are collectecl and compared, meetings of the medical officers of an
army are held for discussion, and the consultants of all the armies meet together until finally opinion on some
problem or set of problems can be crystallized into a memorandum of advice which is issued for information
and guidance to all the medical officers of all the armies.

The Royal Naval Medical Service was at the beginning of the war more nearly at war strength than the
army, but the increase of ships and personnel of the British Navy has made it necessary to enlarge the
medical service of the navy, not only by calling up the reserve but by enlisting the services of many temporary
ofiScers and by the appointment of civilian physicians and surgeons of eminence to act as consultants. The
Naval Medical Service, like that of the army, has relied on laboratory investigations to help to the solution
of problems, some of which were similar to those with which the army was confronted, but it has also had
its own speciiil problems in research and administration, and tliese are described by a number of naval
medical officers on the active list in Chapter V, entitled " Medicine and the Sea Affair."

The Medical Service of the British Army went into this war with the advantage of accumulated
experiences of epidemic disease derived in part from military and in part from civil life. The most recent
military experience on a large scale was tiuit of the war in South Africa (1899-1902). In that war, owing
mainly to the climatic conditions, to the scanty population, to the pastoral character of most of the farming,
and to the consequent absence of intensive cultivation of the soil, the surgery was relatively simple, whereas
prevention of epidemic disease proved to be a task with which, under the special conditions of that war, the
Army Medical Service, having the organization and personnel it then possessed, was unable effectively to
cope. As in so many previous wars the army was scourged by typhoid fever, which caused large epidemics,
undoubtedly due to polluted drinking water, and smaller outbreaks of which the cause could not certainly
be ascertained, and which, therefore, could not have been prevented. Probably with our present better
knowledge, gained in the main in laboratories at home and in India, of the etiology of the disease and
its congeners, and of the menace to any military force created by hale carriers of tlie infecting microbe, much
more might have heen done. As it was, commanding officers had to see their plans for the future upset by
epidemics on a large scale, such as that of typhoid fever at Bloemfontein, which presented all the features of an
outbreak due to polluted water.

In this war the surprise in store for the medical service in France was the frequency and severity of
wound infections. A difficulty besetting bedside medicine and surgery is to eliminate the uncertainties due
on the one hand to variations in the constitutional vigour of the patient and his power of resisting disease,
and on the other to the varying skill and experience of the physician or surgeon. As all the men in the
British armies were in the prime of life it was thought that the first cause of uncertainty might
be eliminated. Consequently when, in the winter of 1914, there began to be seen both in France
and among the men sent home many cases of wound infection of a kind and severity unknown
to surgeons trained in the Listerian era, there was a disposition to blame either the military
administration for delay in collecting the wounded, or the surgeons near tiie front for ineflicient
methods of treatment. Whatever the cause, these disabilities have disappeared. They were due in
reality to the first shock of the war falling upon a peaceable people, but tlie position in the beginning was
not at all clear. Both the causes suggested probably had their effect, but a broader inspection of the facts
showed that another influence was at work more potent than either of the other two. A problem cannot
be solved until it has been fully stated, and only when this stage had been reached could this problem be fully
stated. It was then seen that the attempt to solve it must include administrative measures, novel clinical
action, and bacteriological investigation. Investigation showed that the severe wound infections were due
to anaerobic organisms derived from tlie lieavy manuring of the soil whicli is an essential part of intensive
cultivation. The articles in Chapter- VI by the consulting surgeons, the clinical surgeons, and the
bacteriologists, describe how they worked together in tackling the terrible problem of gas gangrene. Others
are afforded in Chapter VII, in which Surgeon-General Sir George Makins gives an account of the
developments of British surgery in the hospitals on the lines of communication in France.

■ Other examples of co-operative inquiry at the bedside and in the laboratory leading to impro\ed
administrative action for prevention of disease and infection and their l)etter treatment are afforded in
Chapters X and XII, in which Sir John Eose Bradford discusses gunshot injuries of the chest, and Sir
Bertrand Dawson that strangest malady of all — infective jaundice.

In Chapter II Professor Andrewes sketches the mffans taken to organize research into the cause, mode of
dissemination, and treatment of the dysenteries, of bilharziasis, and of cerebro-spinal fever; and into the mode
of dissemination of the various types of the enteric group of diseases, and tlie use of mixed vaccines for their
prevention. He gives a summai-y of the long series of researclies into the bacterial causes of wound infections,
and of the principles of the various methods devised to counteract tiiem. In Chapter IV Dr. H. D. Dakin
discusses the relation of biochemistry to war problems, dealing particularly with the chemistry of disinfection
and the value of chlorine disinfectants, in the investigation of which he has taken a large part. Since the
chapter was written he has proceeded further, and, working with Major E. K. Dunham, of the United States
Army Medical Service, has introduced certain chloramines which possess high disinfecting powers, while their
unirritating character renders them specially suitable for the treatment of wounds.



VI

Many problems had been foreseen, and had been successfully studied by the pathologists of the Army
Medical Service, but a succession of others wore rapidly presented, some of them new, others old but under
new aspects. For all it was of the utmost importance quickly to find solutions. It would have been
interesting, had space permitted, to have given a full account of the organization of the intensive combined
researches instituted. Only incidental references to this will be found in the following pages, and it must
suffice here to say that it consisted of mobile laboratories not far behind the front — mobile in the sense that
the whole equipment could be carried in a motor van, although usually the director transferred his apparatus
to an improvised laboratory in a permanent ))uilding — of clinical laboratories attached to hosjjitals, and of
research laboratories at tiio bases abroad and at home. The problems came thick and fast from the hospitals,
and admirable as has been the work done in the field laboratories, it was necessarily of a pioneering kind,
the main attack requiring larger forces and equipment than they possessed. The laboratories and staffs of
the Army Medical Service at home are fully occupied in routine work and in the study of certain special
problems of which the prevention and treatment of tetanus, and precautions against the effects of poisonous
drift and shell gases, only need be mentioned.

It was fortunate that there had then recently come into existence a body with considerable financial
resources designed to organize and direct collective researcli on a large scale. By a short clause in the
Insurance Act of 191 1 Parliament undertook to provide annually a sum of between fifty and sixty thousand
pounds for the advancement of medical knowledge, and in 1913 a committee of experts was appointed to draw
up and administer schemes of research. In this committee — the Medical Research Committee — the country had
a disinterested body of experts charged with the duty of expending public funds on medical investigations,
possessing a staff of laboratory workers already organized, and commanding the services of a secretary
who had previously won high reputation as an independent investigator, and who, in this emergency,
has shown eminent capacity in directing inquiries into the large and complicated problems that
have arisen.

Tills Committee was aljle at the beginning of the war to turn aside from the schemes it had formulated
and at once to institute comprehensive researches into the new problems affecting the military forces into
which so large a portion of the maniiood of the nation had been recruited. It is perhaps not too much to say
that by the initiation of many organized inquiries in tlie earliest months of the war the Committee succeeded,
directly and indirectly, in creating an atmosphere in which, as in no previous campaign, there has grown up an
emulation, especially well marked among the younger workers, to improve tlie knowledge by which military
medical work must be guided. The natural tendency in time of war is to assume that research must stand still
while existing knowledge is applied to the immediate task of defeating the enemy. Looking back now upon
three years of war in which the whole activities of the nation have been mobilized we can see how effective
from a purely military point of view have been many of the advances in knowledge secured imder war
conditions. It is such advances of knowledge that stand out among the wastage of war as benefits of
permanent value for the future.

Two other phases of the work of the Medical Eesearch Committee are likely to make the medical history
of the present war especially noteworthy. From the beginning the Committee has undertaken for the Army
Council the compilation of the medical and surgical statistics of the war from the books of all hospital units at
home and abroad, and in supplement to this has arranged for the classification and indexing of the "medical
case-sheets " of all sick and wounded. Scientific metliods only recently developed have been applied to the
collection and analysis of the medical statistics. It will take many years to finish this work, but the complete
Card Index of all sickness and casualties which is now being formed, as a preliminary to the future use of
modern methods of sorting and aiialvsis, will remain after the completion of military medical statistics an
invaluable reference index for the cheeking of those claims upon the State which must be expected, during this
and the next generation, in respect of future disability alleged to be the secondary result of war service.

A special characteristic of this war, novel in the experience of the British Army Medical Service, is that
the nearness of the chief fighting area and modern methods of rapid transport have made it possible quickly
to transfer wounded from the front to home hosjjitals b}- ambulance trains and by hospital ships on tlie
narrow seas. Those conditions have combined to bring about, speaking generally, the concentration in France
of early medical and surgical treatment and of later treatment in hospitals in tiie United Kingdom. An official
mechanism was needed to link up these two stages of treatment. Workers in France urgently needed the
knowledge to be derived from tlio pi'onipt collection and examination of the later results of the metliods of
treatment they wore following, for without it they could not improve them in the light of experience. At the
same time medical oHicers at home were handicapped by lack of knowledge of previous stages of treatment.
The Medical Kescarch Committoo has boon able, with tlie sanction and support of medical iiead quarters, to do
much towanis filhng up of this gap. The aflor-historics of cases first treated in Franco are collected in groups,
accor(niig to ol'licial request, by moans of a post-card and schedule system, and the results so collected
are sapjiloinentotl by reports made from time to time upon the basis of tiie classified medical case-sheets
in charge of tiie Committee. By tliese collections and reports, and their transmission to France, jirecise



Online LibraryBritish Medical AssociationBritish medicine in the war, 1914-1917, being essays on problems of medicine, surgery, and pathology arising among the British armed forces engaged in this war and the manner of their solution .. → online text (page 1 of 43)