MEDIA INFORMATION

World War I Pamphlets Collection

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 war and the manner of their solution ..

British medical journal

British Medical Association

text

London,

The British Medical Association

1917

monographic

electronic

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x, 138 p. illus., col. plates, diagrs. 29 cm

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Medicine, Military

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Surgery, Military

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World War, 1914-1918 -- Medical care

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RC971 .B7 1917

British medical journal

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British Medicine in the War 1914-1917 JAM REBUS QUISQUE RELICTIS NATURAM PRIMUM STUDEAT COGNOSCERE RERUM. LONDON: THE BRITISH MEDICAL ASSOCIATION. 1917. PRICE HALF A CROWN. 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 War and the manner of their solution. Collected out of the British Medical Journal, April—October, 1917. With Coloured Plates and Numerous Illustrations in the Text LONDON: THE BRITISH MEDICAL ASSOCIATION. 1917. PREFACE. Felix qui potuit rerum cognoscere causas. A characteristic of British medicine from the 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 British medicine, in his 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 British 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 physiology 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, brought 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 the 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 the 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 times its greatest extension and severity in them. It was the main cause that so many of the richest tracts on the earth's surface were 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 with the presence of a parasite in the blood; later it was ascertained that the paroxysms of the disease coincided with a certain stage in the 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 IV 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 Suez Canal zone under the direction of Eoss, at the request of Prince d'Arenberg, and on a still larger scale during the 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. The main 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 contributed 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 officers with, under their command, non-commissioned officers 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 special subjects, including tropical diseases, at the Royal 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 officially contemplated. In the case of the army this numerical insufficiency quickly became very great. The Navy and Army Medical Services both had small reserves of officers who were immediately called up. The Territorial Force, raised for home defence by voluntary enlistment during peace, had its own medical officers, civilian practitioners who had 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-General 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 his scheme obtained the cordial co-operation of all the leading practitioners throughout the country. It provided regimental medical officers and divisional staffs and the 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 were raised by voluntary recruitment, and civilian medical men volunteered 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 large 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 Boyal 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 Army Medical Services, who had removed his 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 the field, consulting surgeons and physicians were appointed to each, and for areas in which base hospitals were established. The plan was extended to armies acting 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 be gained of tendencies to disease and in treatment: they are able to advise the chief administrative medical officers as to means that should be taken to prevent disease or anticipate infection, and to afford opportunities for efficient treatment at v the earliest possible moment. Experiences are collected 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 officers 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 special problems in research and administration, and these 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 that 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 wbich, 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 the infecting microbe, much more might have been 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 Francf 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 the front for inefficient 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 the 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 the heavy manuring of the soil which 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 improved administrative action for prevention of disease and infection and their better treatment are afforded in Chapters X and XII, in which Sir John Rose 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 means 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 the use of mixed vaccines for their prevention. He gives a summary of the long series of researches into the bacterial causes of wound infections, and of the principles of the various methods devised to counteract them. 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 were 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 building—of clinical laboratories attached to hospitals, and of research laboratories at the 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 research on a large scale. By a short clause in the Insurance Act of ign 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 wyorkers 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. This Committee was able 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 manhood of the nation had been recruited. It is perhaps not too much to say that by the initiation of many organized inquiries in the 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 the 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 under 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 methods 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 analysis, will remain after the completion of military medical statistics an invaluable reference index for the checking 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 hospitals by ambulance trains and by hospital ships on the narrow seas. These 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 the 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 the prompt collection and examination of the later results of the methods of treatment they were following, for without it they could not improve them in the light of experience. At the same time medical officers at home were handicapped by lack of knowledge of previous stages of treatment. The Medical Research Committee has been able, with the sanction and support of medical head quarters, to do much towards filling up of this gap. The after-histories of cases first treated in France are collected in groups, according to official request, by means of a post-card and schedule system, and the results so collected are supplemented by reports made from time to time upon the basis of the classified medical case-sheets in charge of the Committee. By these collections and reports, and their transmission to France, precise knowledge has become available there of the later results of treatment as reflected in the subsequent hospital history in this country of many groups of cases, as, for example, wounds of the abdomen and chest,, amputations, knee-joint injuries, and nephritis. Vll Information of the greatest practical value for the guidance of treatment has also been obtained by quite a different method, namely, the segregation in this country of particular groups of cases for intensive study. The first example was the assignment of neurological cases to specialists and the establishment of institutions organized for the treatment of the manifold forms of functional nervous disorders produced by the shocks and strain of war. A system of labels provided, with official sanction, by the Committee Was introduced to ensure that such cases should be sent to the special institutions, and with it was coupled a mechanism for the interchange of information between medical officers responsible for the early treatment abroad and for the later home treatment. Other groups of cases segregated for particular inquiries, at the instance of the Committee, have been those of nephritis, certain gassed cases, cases of malaria, and men suffering from disordered action of the heart. In Chapter IX Sir Clifford Allbutt, Eegius Professor of Medicine in the University of Cambridge, in discussing the investigation of the significance of disorders and diseases of the heart in soldiers, founds himself on the report made by Dr. T. Lewis to the Medical Eesearch Committee, with regard to the work done at the special hospital for such cases established at Hampstead. In this hospital scientific investigations are being pursued which not only have at once led to important changes in treatment and a great reduction in the average duration of the stay in hospital of these cases, but will be of permanent value to civil medicine. The principle of specialization for particular purposes has now won its way. Besides its value in allowing the rapid collection of information, it has been found in suitable cases to encourage increased energy and efficiency in treatment. It has, with one exception, been possible to make only incidental references to the elaborate organization built up for the treatment of the disabled soldier returned to the British Isles or to his overseas home. The success attained has not been equalled or even approached in any previous war. The Territorial and other general military .hospitals, originally planned each to provide beds for 520 patients, have been greatly extended, auxiliary military hospitals and convalescent homes have been set up throughout the length and breadth of the countries, and many camps for physical reconstitution and training established. Special institutions have been organized for the training of men who have lost sight or hearing as the result of wounds. All this organization has been brought into existence in order that the disabled soldier shall be helped to help himself. The great importance of military orthopaedic surgery—the surgery of disabilities and deformities of limbs resulting from war wounds—justifies the inclusion of a separate chapter on this subject. In it Dr. Colin Mackenzie, an Australian surgeon and anatomist, discusses the object and the methods of orthopaedics, and shows how principles evolved by the labours of many surgeons, particularly in this country and America, for the rectification of congenital or acquired deformities in children have been applied for the benefit of the crippled soldier. In the second part of this chapter he describes the military orthopaedic hospitals and auxiliary institutions already at work. Large as is the organization he depicts, it is being continually extended, and must continue to grow until peace is restored. One of the difficulties encountered is to find an adequate number of surgeons possessed of the special experience and skill required. It is a gratifying instance of international comity that when in this difficulty Sir Robert Jones, the British Inspector of Military Orthopaedics, appealed to the orthopaedic surgeons of the United States to come over and help us, they organized within a fortnight a body of twenty-two experts, who at once came to England, and, with the sanction of the United States Government, placed themselves unreservedly at his disposal to do duty in British military orthopaedic hospitals. Hospitals have been set up also in England, Wales, and Scotland where men who have lost an arm or a leg are fitted with artificial limbs made in .the hospital workshop. These are permanent institutions, and to them the men will be able to return at any time during their lives, should their artificial limbs cease to fit well or wear out. British medicine by an appeal to results is justified before the nation. It has yielded an army free from sickness. To the wounded it has brought instant and sustained relief. The guiding principle through which it has achieved this end in military surgery, medicine, and hygiene is disclosed in these pages. The principle is not new, but it can never grow old, for it is " ever to search out and study the secrets of Nature by way of experiment." TABLE OF CONTENTS. CHAPTER PAGE PREFACE .. .. .. .. .. .. .. .. .. .. .. iii I. THE INSTITUTES OF SURGERY. Sir Berkeley Moynihan .. .. .. .. .. 1 II. BRITISH PATHOLOGY IN RELATION TO THE WAR. Professor F. W. Andrewes, F.R.S. .. 6 III. BACTERIOLOGY AT THE FRONT. Colonel Sir Wilmot HeRringham, A.M.S. .. . . .. 9 TRENCH FEVER AND ITS ALLIES. Colonel Sir Wilmot Herringham, A.M.S. .. .. .. 10 IV. BIOCHEMISTRY AND WAR PROBLEMS. H. D. Dakin, F.R.S. .. . . . . . . 11 V. MEDICINE AND THE SEA AFFAIR— Introduction. Sir Arthur May-, D.G., R.N. .. .. .. .. .. .. 15 Medicine and Clinical Pathology. Fleet Surgeon P. W. Bassett-Smith and Surgeon-General H. D. Rolleston, R.N. .. .. .. .. .. .. .. .. ..15 Surgery'. Deputy Surgeon-General W. G. Axford and Surgeon-General G. L. Cheatle, R.N. .. 17 Hygiene. Fleet Surgeon R. C. Munday, R.N. .. .. .. .. .. .. 19 The Service Afloat. Deputy Surgeon-General R. Hill, P.M.O. Grand Fleet, and Fleet Surgeon E. A. Penfold, R.N. .. .. .. .. .. .. .. .. ..21 Hospital Ships. Fleet Surgeon E. C. Lomas, R.N. .. .. .. .. ″″ ..24 Land Medical Transport Arrangements. Surgeon-General Sir James Porter, R.N., and Staff Surgeon A. Vavasour Elder .. .. .. .. .. .. .. 27 VI. THE DEVELOPMENT OF BRITISH SURGERY AT THE FRONT. Surgeon-General Sir Anthony Bowlby and Colonel Cuthbert Wallace, A.M.S. .. .. .. .. ″ ¦ 30 Field Ambulances .. .. .. .. .. .. .. .. .. 30 Casualty Clearing Stations .. .. .. .. .. .. .. .. 31 Special Hospitals .. .. .. .. .. .. .. .. ¦ ¦ 32 X Rays .. .. .. .. .. .. .. .. .. .. ., 33 Anaesthetics .. .. .. .. .. .. .. .. .. .. 33 Antiseptics .. .. .. .. .. .. .. .. .. .. ^ .. 33 Shock .. .. .. .. .. .. .. .. .. .. .. 34 Wound Infections .. .. .. .. .. .. .. .. ″ ¦ 35 Bacteriology .. .. .. .. .. .. .. .. .. ... 36 Abdominal Wounds .. .. .. .. .. .. ' .. .. .. 39 Wounds of Heart and Blood Vessels .. .. .. .. .. ″ ¦ 43 Injuries of Joints .. .. .. .. .. .. .. .. ¦ ¦ 43 Head Injuries .. .. .. .. .. .. .. .. .. ″ ″ 44 Fractures .. .. .. .. .. .. .. .. .. ″ ¦ 45 Penetrating Wounds of the Chest. Colonel Sir Wilmot Herringham, A.M.S. .. .. 46 Anaesthetics at the Front. Captain G. Marshall, R.A.M.C. .. .. . ″ .. 47 gas gangrene-colour Changes Seen in Skin and Muscle. Colonel Cuthbert Wallace, A.M.S. .. .. 50 Method of Spread into Living Muscle. Captains J. W. McNee and J. Shaw Dunn, R.A.M.C. 52 Conservative Treatment by Resection of Infected Muscles. Lieutenant-Colonel C. H. S. Frankau, and Captains Hamilton Drummond and G. E. Neligan, R:A M C .. .. 54 VII. THE DEVELOPMENT OF BRITISH SURGERY IN THE HOSPITALS ON THE LINES OF COMMUNICATION IN FRANCE. Surgeon-General Sir George Makins, A.M.S. .. .. 58 Hospital Trains and Motor Ambulances .. .. .. .. .. .. 58 Wound Treatment .. .. .. .. .. .. .. .. .. 59 Secondary Haemorrhage .. .. .. .. .. .. .. .. 60 Gas Gangrene .. .. .. .. .. .. .. .. .. .. 61 Tetanus .. .. .. .. .. .. .. .. .. .. 62 Injuries to Great Vessels .. .. .. .. .. .. .. .. 63 Fractures .. .. .. .. .. .. .. .. .. .. 64 Wounds op the Joints .. .. .. .. .. .. .. .. .. 67 Injuries to the Head .. .. .. .. .. .. .. .. .. 69 Injuries to the Spinal Cord .. .. .. .. .. .. .. .. 71 Abdominal Injuries .. .. .. .. .. .. .. .. .. 71 Radiography .. .. .. .. .. .. .. .. .. .. 72 ANAEROBES IN WOUNDS. Captain Herbert Henry, R.A.M.C. .. .. .. ..75 VIII. MILITARY ORTHOPAEDIC HOSPITALS. Dr. W. Colin Mackenzie .. .. .. .. 78 Principles and Treatment .. .. .. .. .. .. .. .. 78 Military Orthopaedic Hospitals in Great Britain and Their Equipment .. .. 84 ARTIFICIAL limbs-Amputations op the Upper Limb .. .. .. .. .. .. .. 87 A Table for Armless Soldiers .. .. .. .. .. .. .. .. 88 IX. DISORDERS AND DISEASES OF THE HEART IN SOLDIERS. Professor Sir T. CLIFFORD Allbutt, F.R.S. .. .. .. .. .. .. .. .. .. 90 X. GUNSHOT INJURIES OF THE CHEST AT THE BASE HOSPITALS. Colonel Sir J. Rose Bradford, F.R.S .. .. .. .. .. .. .. .. .. 92 XI. TROPICAL MEDICINE AND HYGIENE. Sir Patrick Manson, F.R.S. .. .. .. ..98 INDIA AND MEDICAL PROGRESS. Major R. McCarrison, I.M.S. .. .. .. ..104 XII. INFECTIVE JAUNDICE (SPIROCHAETOSIS ICTEROHAEMORRHAGICA). Colonel Sir Bertrand Dawson, A.M.S., Lieut.-Colonel W. E. Hume, R.A.M.C, and Captain S. P. Bedson, R.A.M.C. 108 XIII. THE PART PLAYED BY BRITISH MEDICAL WOMEN IN THE WAR. Mary H. Frances Ivens, M.S. .. .. .. .. .. .. .. .. .. .. ..117 XIV. THE BRITISH ROYAL ARMY MEDICAL CORPS AND ITS WORK .. .. .. .. 121 THE CANADIAN ARMY MEDICAL SERVICE. Surgeon-General J. T. Fotheringham, C.A.M.C... 135 CHAPTER I. THE INSTITUTES OF SURGERY : AN HISTORICAL REVIEW. BT

1C6 In addition to this special work, over 3C0 have occupations allotted to them. ARTIFICIAL LIMBS. 87 Return showing Number and Value of Splints Made in Orthopaedic Workshops. Week ending £ s. d. October : 28th, 1916 ... 35 ... 5 3 0 November 4th ,, 49 ... 7 14 6 „ 11th ,, 75 ... 17 3 9 „ 18th ,, 64 ... 9 11 6 „ 25th ... 86 ... 12 9 0 December 2nd M 21 ... 11 2 6 9th >! 23 ... 13 16 0 „ 16th 67 ... 14 18 0 23rd ,, 26 ... 14 11 6 M 30th ,, 29 ... 8 19 0 January 6th, 1917 ... 43 ... 12 8 0 „ 13th !> 70 ... 20 12 0 20th ,, 55 ... 19 1 0 27 th !> ... 133 ... 34 0 0 February 3rd ,, ... 122 ... 27 9 0 ,, 10th ,, 91 ... 30 0 0 M 17th ,, 55 ... 19 17 6 24th 81 ... 17 16 6 March 3rd M ... 106 ... 31 4 6 " 10th „ - ... 139 ... 34 4 2 Totals 1,371 £362 1 5 Total number of splints made from October 28th to March 10th, 1,371. Cash value at pre-war prices, £362 1s. 5d. Of the above returns 1,013 are stock pattern splints, namely cock-up splints, gutters, club-foot shoes, crab (long and short), Turner's arm, whole hand-splints. The balance (358) are special splints designed in workshops, and made to surgeons' instructions. Quantity of Orthopaedic Repairs by the Bootmaker. The total number of cases requiring orthopaedic repairs by the bootmaker from October 21st, 1916, to March 4th, 1917, was 361. This was apart from ordinary repairs. The work consisted of inside and outside elevations, T-straps, cork soles, bars on soles, crooked heels, surgical boots and alterations according to medical orders. Painting, Drawing, Photographic Department. This department is under the control of Mr. Bird, the distinguished artist, who is assisted in photography by Mr. Lewis. Here not. only photographs and drawings of cases during the various stages of treatment and splints-used are made, but actual paintings in natural colour whenever the surgeon thinks it necessary. In this way can be kept complete records of operation cases, which are especially valuable in demonstration for teaching purposes, X Bays. This department is fully equipped with all the latest methods for x-ray photography under the supervision of Captain Keys-Wells, R.A.M.C., who attends the hospital daily. Plaster Department. This is under the charge of Sister Hurch, formerly of St. Bartholomew's Hospital, who has, as chief assistant. Private Wilde. Casts are made of all deformities admitted and permanent records can be kept of cases before and after operation. In addition to plaster jackets for support and plaster splints, casts are made of limbs and other parts on which splints, both leather and steel, are moulded so as to ensure accurate fitting when finished. Artificial Limbs. In association with the question of military orthopaedics it is important to remember that at Roehampton Hospital for Limbless Soldiers all cases of amputation are being provided with suitable artificial limbs at the expense of the State. I am largely indebted for information relating to the Shepherd's Bush Hospital to the courtesy and assistance of Major Jenkins, R.A.M.C., Officer in Charge, Captain Hill, R.A.M.C., Registrar, and Mr. Poate, Director of Workshops. The medical staff is to be congratulated in having converted within a week what was formerly an infirmary into a modern orthopaedic hospital. RefeRences. I The Collected Works of Sir H. Davy. Edited by his brother, John Davy, F.B.S. 2 The Collected Papers of Ba*-on Lister, vol. ii. 8 Transactions of the American Orthopaedic Association, 1891. 4 The Works of John Hunter. Edited by Palmer. & Anatomy of the Human Body. John and Charles Bell. 6 Phil. Trans. Royal Society, 1833. 1 Position of Sir C. Bell among Anatomists. Lecture delivered by Professor Keith at Middlesex Hospital, January 19th, 1911. Review of ″Arboreal Man, by G. Elliot Smith, Nature, February, 1917. 8 Effective Treatment of Hip Disease, P. B. Bennie, 1907. ARTIFICIAL LIMBS. A few words may be added to the last paragraph of Dr. Colin Mackenzie's article to explain the organization brought into existence for providing men who have undergone amputation with artificial limbs. After the completion of his treatment in a general military hospital such a man often requires special treatment for some condition of the stump which prevents the immediate adjustment of an artificial limb; among such conditions are persistent sinuses, bulbous nerve ends, adhesions limiting free movements of a joint, and flexion of a joint by contraction of scar tissue; in some other cases re-amputation is necessary in order to obtain a suitable stump. Such men are sent to the Pavilion Military Hospital, Brighton; the Alder Hey Auxiliary Hospital, Liverpool ; the Scottish Red Cross Hospital, Bellahouston, Glasgow; the Edinburgh War Hospital, Bangour; or the Welsh Metropolitan War Hospital, Whitchurch, near Cardiff. After the completion of their treatment in these intermediate hospitals they are sent to be fitted with the artificial limb to special hospitals—Queen Mary's Hospital, Roehampton, near London; Erskine House, Glasgow; Edenhall Hostel, Kelso; the Prince of Wales Hospital at Cardiff ; the Ulster Volunteer Force Hospital, Belfast; or the Duke of Connaught's Hospital at Bray, co. Wicklow. Other hospitals for the same purpose are being established at Leeds, Manchester, and Liverpool. For the most part all artificial limbs are made in workshops attached to these hospitals, and the man, before being discharged, is practised in their use and any defe.cts discovered adjusted. It is intended that these hospitals, or some of them, shall be permanent institutions to which men can at any time return for the repair or refitting of their artificial limbs. Steps are being taken for the standardization of artificial limbs, and the branch of the Ministry of Pensions concerned with their supply and renewal has formed a collection at the Royal Hospital, Chelsea. AMPUTATIONS OF THE UPPER LIMB. Many trades are open to a man who has lost a lower limb or even both, but the choice of a man who has lost an arm is more limited, and if he desires to engage in manual labour, such as agricultural or mining, he needs a prosthetic appliance which will stand rough work. An appliance for amputation through the forearm which is considered by experts to be one of the best and most practical yet devised for such men is the invention of Mr. Thomas Williams, who, when working in a Welsh mine forty years ago, met with an injury for which he had to undergo amputation of the right forearm four inches below the tip of the olecranon process. After many experiments he made a hook arm for himself, which has enabled him to earn his living as a collier, a mechanic, and BRITISH MEDICINE IN THE WAR, 1914-17. in other ways. The construction of the limb is illustrated in the diagram, which is taken from the patent specification. The forearm, a, is made in one piece of stout or stiff leather, and the casing for the upper arm is formed in two pieces, b, c, of soft or pliable leather attached to the forearm. These pieces are eye-letted and laced together, so as to clasp the upper arm, soft tongues, d, e, being provided under the laces, f, if desired. This arrangement, besides giving more comfort, renders it possible in most cases for the wearer to attach the appliance in position without assistance. Within the wrist of the forearm casing is a block (g, Fig. 2) of wood or other suitable material, over the outer part of which is firmly fitted and secured a dome-shaped metal cap or holder, h, having a central hole or socket, J, screw-threaded internally. A correspondingly threaded plug, k, provided with an outer flange, l, is adapted to screw into this socket. This plug is centrally bored so that the shank, m, of the C-shaped hook can freely pass therethrough. The part of the bore nearest to the arm has an enlarged part, N, similar to a stuffing-box, to receive a spring, o, which is coiled around the end of the shank when placed therein. This spring is compressed between abutments formed by the shoulder, p, in the plug, and a nut or cap, Q, which is screwed on to the end of the shank, and is small enough to enter the space N. The plug, k, is then screwed into the FiG Z The Williams Welsh Arm socket, j, until the flange, l, meets its seating, e, and the appliance is ready for use. The hook, with its shank, m, is free to revolve axially in the plug, k, after the latter is screwed home, but is prevented from doing so too freely owing to the friction on the ends of the spring and between the base of the hook and its abutment, s. When a sudden pull comes upon the hook, the spring is further compressed and lessens the jar. Dr. W. L. Griffiths of Swansea, in demonstrating this appliance to a local meeting of the British Medical Association, said that the chief points of interest were the shape and action of the hook and the mode of attachment to the stump. The hook was convenient for using tools, for lifting, and for pushing. The attachment of the artificial limb by means of soft leather flaps laced round the upper arm, taking their grip above the condyles of the humerus, allowed free movement of the elbow-joint. The experience of the inventor, who has been using the arm for forty years, showed that there was no risk of pressure sores; the skin was freely movable over the deeper tissues, and it was not appreciably thickened. Mr. "Williams could use a pick and shovel, could lift a weight of 56 lb., could swing a 14 lb. sledge hammer, could use a scythe, could plough, could pitch hay, and do any other work of an agricultural labourer, and could work as a collier, a mechanic, and a carpenter. A Table for Armless Soldiers. The condition of a man who has undergone amputation of both upper limbs is still more unfortunate than that of one who has suffered amputation of both lower limbs. At the hospitals for limbless men many ingenious devices have been tested, and much has been done towards the standardization and simplification of prosthetic appliances for Inventions Department of the Ministry of Munitions. It will enable the man to occupy himself during the absence of his attendant, and as he gains the necessary dexterity it should be possible for him to feed himself, perform various operations, and write. Fig. 1 is a front view of the table, and Fig. 2 a sectional view showing the arrangement of Fig. 1. Fig. 2. the upper limb, A table for the man in the unhappy position of having undergone amputation of both upper limbs, leaving stumps too short for the fitting of a satisfactory arm of the usual type, designed by Mr. C. A. Sheehan, has recently been approved by the Munitions the turntable with its ball bearings and central leg, and of the sliding platform with its actuating lever. Fig. 3 is a plan view of the complete table. Figs. 4, 5, and 6 show details. The appliance is operated chiefly by the use of the legs and feet, with the occasional assistance of the head. A TABLE FOR ARMLESS SOLDIERS. 89 The operator sits in front of the table with the mechanical arm a before him, and is thus able to move the sliding platform b by means of the lever e, and the turntable c by means of the leg F, so as to bring objects on them within reach of the tongs, d, of the arm. The turntable c rests on ball bearings, s, and can thus rotate and also move slightly in a linear direction in the plane of the table. The tongs are controlled and the arm moved by the ball of the operator's foot, which is placed in one of the shoes G1 or G2; pressure on the shoe g.2 opens the tongs (which are normally held closed by a spring m and a weight n) by means of a flexible wire, o, passing over guide pulleys. On releasing the pressure on the shoe g2 the sliding weight n falls and closes the tong jaws with sufficient grip for most purposes without any force being exerted by the operator. If, however, a specially strong grip is required, it is obtained by pressure on the shoe G1, which forcibly closes the jaws by means of a flexible wire connexion, p, fixed to the weight n. The arm, which is a rigid, inverted L-shaped member, is universally suspended by a ball and socket joint h, so that by appropriate motions of the foot the arm can be twisted or raised in practically any direc- tion. An article gripped in the jaws can thus be raised even to the top of the head of the operator. The ball and socket joint h, together with the arm a, can be moved slightly relatively to the table along a slide. Vessels and cutlery for use with the table require to be specially shaped or adapted in order that they may be firmly gripped by the tongs; for example, the cup (Fig. 5) is a conical vessel, and is gripped close to the bottom flange, and the knife J (Fig. 6) is held by the rubber-faced attachment k. A sheet metal attachment, r, is provided on the arm a for turning over the pages of a book, and for dealing with sheets of paper, and a shaped attachment, t, for a cigarette, etc., is provided. Fig. 4 shows a writing easel. The writing-pad is laid on the front face after having been folded round a wire frame, projections of which rest in the notches of the plates, so that the frame can be pushed up notch by notch as each line of writing is completed; the easel is hinged at the bottom and supported by a saw-toothed bar resting on a curved spring. Under the pressure of the pencil, which is held in the tongs, the easel yields slightly, and this movement facilitates the formation of the upstrokes necessary in writing. CHAPTEE IX. THE INVESTIGATION OF THE SIGNIFICANCE OF DISORDERS AND DISEASES OF THE HEART IN SOLDIERS. Sir T. CLIFFORD ALLBUTT, K.C.B., M.D., F.R.S., Regius Professor of Physic in the University of Cambridge ; President of the British Medical Association. Dr. Lewis's Report on the work done at Mount Vernon on Disorders of the Heart1 as seen in the soldier is so careful and complete that there is little, at present, to add to it, and the comments I am requested to make upon it can be but few.- One main result of the investigation is to strengthen the opinion which, before these researches were established, was gaining ground—namely, that "heart strain," a phrase a few years ago in common use and application, is a rare event. In the article on Stress on the Heart in Allbutt and Rolleston's System of Medicine, an article which expressed the opinions at that time of Roy, Michel], and myself, we likewise had affirmed that " for one case of disability due to strain, or even of sharp overstress, there are fifty of secondary and incidental derangement." And again: "As the animal mechanism attained many wider and more various powers of survival yet scarcely even a momentary independence of the heart, this organ must itself have attained to an enormous endurance, and resources almost illimitable." But in the same essay, under " Infections," I said that " stresses upon hearts under this detriment result only too often in (heart) strain ..." " experience inclines me more and more to refer cases of heart strain to this category"; and I quoted Dr. Arthur Lambert of Harrow who " regarded (in 1904) the specific fevers as the determinant of heart strain in schoolboys; anaemia, general debility and lack of training being subordinate causes. Up to 1903," he added, " I was able to collect a number of cases of ' heart strain,' and during those years influenza was always with us. After 1904 we saw very little of heart strain." With acute cardiac dilatation after such obvious infections as of scarlet fever and diphtheria we are all familiar, and in the article from which I am now quoting.I stated that even a "bad cold " might have some such consequence, if during the brunt of it excessive exercise were undertaken. It was in 1903, when de la Camp's paper2 came into our hands—a paper in which the author reported, rather to our surprise, that the heart, far from expanding during muscular effort, diminished in mean diameter—that, infection apart, we began to take a different view of cardiac conditions under effort; that, instead of working under dilating stresses, the heart under exertion is normally smaller. Yet had we considered cardiac physics more intimately, we need not have been surprised. It is true that in exercise beyond the capacity of the myocardium the blood is heaped up in and near the right heart at the gates of the lungs; and this the more when the individual is imperfectly trained, or is becoming stale. But as rate and velocity increase, and the periphery expands, the output per beat must be less; and therewith the cardiac diameter. Furthermore, as the heart lias its own blood supply, blood runs round the heart many times for once round the systemic area. The heaping up of the blood in the right heart and veins is heavier, and tarries longer, in the untrained. Training is something far more than dietetics and muscular exercise ; in the circulatory concert it means a development of the thorax, an unfolding of the lungs, and a swifter interplay of vascular, nervous and chemical responses. In former papers I have described how in the first few minutes of increased effort—for example on starting to climb a steep hill—the arterial tree, as represented by its radial branch, opens out, not gradually but suddenly; and the better the training the sooner this expansive readapta-tion takes place. Under this change—this great reduction of friction—it is intelligible that the diameter of the left ventricle should diminish, or the chamber empty itself more completely. But in a man growing stale under training the vasomotor mecha,nism loses its tone, and its responses are enfeebled. There is no better test of the " fitness " of an athlete than to draw the finger-tip sharply down his cheek, when, if he be "stale," the red line will be strong and persistent. In many cases of " D.A.H." at Mount Vernon this loss of vasomotor tone is conspicuous The hand when hung downward turns a duskier blue, and its vessels empty when it is held above the head. If the finger be pressed upon such a hand and removed the white patch is long in recovering its colour. But the researches of Dr. Lewis and Mr. Barcroft at Mount Vernon raise quite a new and a very interesting problem : setting aside for the while poisoning of the myocardium, may incidental infections produce any other effects in which the heart is concerned ? The answer appears to be in the affirmative. These researches (p. 19) seem to discover a new disease, or rather to discriminate more exactly the features and nature of a disease less clearly apprehended already, by Da Costa and others, as " soldier's heart " ; or by those of us who have written upon " neurasthenia " as " cardiac neurasthenia." The disease is one which is not uncommon in the civil population; but under the stress of the soldier's training, and amongst the aggregations of men in modern armies, it is more conspicuous and inconvenient. It is of the kind of diseases known to our fathers as " morbi sine materia"—a disease without a lesion. " Disease" is a clinical not a pathological term, and consists in a series of symptoms recurring with a fair uniformity. At Mount Vernon I have been much impressed by the uniformity of the series now chiefly under consideration. It consists in the main of the following terms or symptoms:—submammary pain, palpitation and quickened pulse, shortness of breath on exertion, tremor, exhaustion, " dizziness," and certain vasomotor phenomena. This group of symptoms is too uniform to be fictitious or fantastic. Now it will be seen from the Report that in these cases —in this disease—although not rarely an infection takes some place in the history, the heart is mechanically unaltered. I am glad to add my testimony to the great care and precision with which these mechanical appreciations were carried out ; the orthodiagraphic observations of Major Meakins and his colleagues being especially diligent and valuable. The outcome so far then is that the fretful heart, known as the " soldier's heart," is not cardiac strain; and, whatever the explanation may be, for this I refer to the Report, there is this gain to nosology—that although, in the past, heart strain and what for temporary convenience I may call still " soldier's heart " have been confused, and even classed together, this disorder and that are now made separate and distinct. For " soldier's heart" we need a better name, and, if it is to be Greek, I have suggested ponopalmosis, a compound word which means palpitation on effort. Therefore, with a few chance exceptions, from the Mount Vernon category " heart strain " is dismissed. Now by this selection I do not mean that heart strain does not occur; but that it is generally a result of some infection, is relatively infrequent, and does not constitute the bulk of the cases invalided from the army as" D.A.H. " (see Report, p. 54 f.). With the gradual and inevitable deterioration of the myocardium after maturity—say in man from the age of 35 to 40 onwards—I have not now to deal. I have discussed this grave question in my Diseases of Arteries* At Mount Vernon nearly all the patients are under this period of life. This is one, and the first in importance, of the principles obtained under Dr. Lewis's research and direction. In the article referred to in the System on Overstress of the Heart the two classes of cardiac disorder were more or less confused ; the cases which Roy and I and Michell studied were, many of them, it is true, cases of actual heart strain; but effects for the most part, if net in all instances, brought about under the influence of some (90) SIGNIFICANCE OF DISOEDEES OF THE HEAET IN SOLDIEES. 91 infection. Moreover, in them the heart, the right side of the heart usually, was definitely dilated and the valves for a while often incompetent. In " D.A.H. " the form of the heart is unaltered and the dyspnoea seems not to depend directly upon the heart. Here however I would venture on some demur to the disrespect with which certain cardiac murmurs have been treated by Sir James Mackenzie—to whose researches we are all so deeply indebted—and by his disciples. This is an extreme reaction against the obsequious regard for these signals which not unnaturally prevailed in the generations immediately after Laennec. It is true that in concluding "that the presence or absence of murmurs (wherever they may be audible) is of no value in estimating the soldier's capacity for work " Dr. Lewis premises that he concerns himself only with the capacity of a man for military service for a subsequent period of undefined duration. This I agree is true; under my care at this moment is a man, aged 32, suffering from mitral regurgitation, now to the degree of large dropsy and dyspnoea, and in a condition beyond substantial remedy. He had rheumatic fever at the age of 6, and was then told that his heart was affected. But thereafter nevertheless for some twenty years or more he had been at work as a labourer. Last year I had a similar case in a man who, after rheumatic fever, with damage to the mitral valve reported at that time, had notwithstanding been occupied since as a coal-heaver for sixteen years; and for the while with impunity. Of such cases I think we must admit that though for many years the mitral regurgitant murmur had not indicated immediate physical incapacity, yet it did indicate cardiac disease, and sooner or later cardiac failure. That out of such a man the State may nevertheless get a few years' work, is a decision which at Mount Vernon we may very properly make without cynicism ; as Dr. Lewis says, at Mount Vernon our business is only with capacity for farther service; still, as he admits, the diagnosis, or prognosis, is "open to criticism on academic lines";—that is to say, from the patient's point of view? And not the diagnosis only but also the rule of life. Here may I remark that the phrase " back pressure," in common use even by expert writers on affections of the heart, is to me unintelligible. Surely by an increase of resistance in front the blood pressures must be raised in the whole area concerned ; and equal in all directions, fore back and lateral. To students at any rate, not to mention some of their seniors, this fallacious phrase suggests that the blood stream is reversed ! In the generation of many a loud murmur the regurgitant wave, in the strict sense of the word, may be very small; possibly none, as a fluid vein and turbulent collisions of the particles of the blood may be caused by changes in the relative diameters of the chambers only. Or again, like a stream from a tap which when turned slightly on may be noisy, but when " full on " almost inaudible, so the slenderest thread of regurgitation may make a loud murmur. Constancy in the degree and quality of a murmur, as it suggests stability of structure and compensation is therefore, on the face of it, a good sign. In all cases of definite systolic murmur at the apex I believe there is regurgitation, whether the condition be temporary or permanent. I see no other explanation of the change of linear into turbulent motion. In the class of cases we are considering, functional "murmurs"—that is murmurs dependent upon transitory causes—are very common ; and I think we are bound not to ignore them but to do our best to analyse them and discriminate between them. This I think is not so difficult a task as it is often said to be. On the one hand in the "soldier's heart," as Dr. Levy pointed out to me, a systolic murmur having its chief seat along the left costal arch is very frequent; one would guess it to be but a whiff of air expelled at each jerky heart stroke from the lappet of lung. So again in the healthiest young man we may hear a systolic murmur over the area of the pulmonary artery; by this idle noise, although usually due merely to a slight impingement of the vessel upon the wall of the chest, and of no importance, many a lad has been kept out of the football field. Let us first eliminate all these insignificant noises from the list, and then on the other hand concentrate our more serious attention upon murmurs dependent on altered mechanical states of the heart; though, as even these are often transitory, a farther subdivision is necessary. And for the present let us leave out of reckoning murmurs about the base of the heart, and direct our attention to those referable to the mitral and tricuspid areas. Even when these are transitory, as for example during convalescence from an infection, it seems certain that when systolic they signify valvular disorder; the valve, or more probably, in transitory cases, its bed, is awry; and the patient, so long as the murmur remains, should be treated on this assumption. For a murmur signifies the existence of an abnormal fluid vein, and an abnormal fluid vein means abnormal friction, and friction is a waste of energy. A young, vigorous, and normal heart, with some readjustment, may afford to waste this energy—for a while; but a perpetual waste, in an organ whose reserve is so precious, cannot go on without ultimate harm. It is a handicap, and the efforts cast upon such a heart should not be immoderate. In looking back upon many years of practice I recall very vividly, in respect of the present subject, the subsequent lives of many a patient in whom a mitral regurgitant murmur was for years the precursor of subsequent cardiac incapacity and ultimate failure. For the change from linear to vortex motion meant a fall in velocity, save in so far as the muscular structure of the heart at the part was buttressed. For many a year perhaps a young or comparatively young heart, out of its abundant stores, can meet excessive demands, and build itself up at threatened points; but if the interval is often a long one the event is none the less manifest. The murmur in crucial cases has been discovered accidentally ; as for example in an examination for some temporary disorder, or for life insurance; though cardiac incapacity may not have ensued for years afterwards. After an uncertain period however the heart begins to enlarge, and the patient to feel a little transient dyspnoea on unusual effort; this symptom increases, and the heart begins to make itself felt; yet even thus the patient may live still for a few more years, and under due precautions do not a little work of a sedentary kind. It is then that effort tests may betray myocardial default, but the patient has then entered not upon his disease but upon the last stage of it. Then nocturnal dyspnoea will appear, the ankles puff up, and other symptoms of the final phase of the malady accumulate. Perhaps after this lapse of time I may refer to the first case of this kind of which I had any knowledge—that of my old master and friend Bence Jones. He bought a flexible stethoscope, then a novelty, and tested it first upon himself ; unhappily a mitral regurgitant murmur made itself heard, and although this distinguished man lived on without suffering for a while, and in his impulsive way would still forget himself so far as to fly up the staircase at St. George's two steps at a time, yet gradually the increasing friction in the blood, and the consequent fall of velocity, made themselves felt, and brought about his premature death. Scores of such cases arise in my mind as I turn my eyes to the past; some of mitral regurgitation consequent upon an infection, some upon slow athero-sclerosis of the valve, and so forth. For, I repeat, an endocardial murmur means a fluid vein, an eddy; and an eddy means friction and a disturbance of linear motion; these, unless in some indifferent area, mean sooner or later a breakdown of the machine. On one other point I would spend a few words—namely, on latent mitral stenosis. In consultation the question often arises whether or no in a particular case there is a murmur at the apex. " Murmurish," says one; another that the first sound is prolonged; another that the first sound is reduplicated, but no murmur. No " murmur," it is true; the added sound may not be murmuring nor whispering, but an addition to, or a hitch on the ordinary first sound. The first sound may seem divided, with a notch as it were, in the middle of it. Now the addition may be before or after the true first sound ; in the latter case, sooner or later it murmurs more definitely, and betrays a mitral regurgitation. With this I am not now concerned ; in the former case it is a sign of a mitral stenosis, slight in degree and u compensated." Now in this case a thrill —short perhaps, and narrow in area, but unequivocal—¦ may, if carefully sought for, be detected. But in the absence of cardiac deformation, of definite murmur, and of proper symptoms, this thrill may not be looked for. These latent cases turn up in practice, civil or military, and, if not readily picked out, may be reckoned among " our failures." As an illustrative example of latent mitral stenosis I may take the case of Mr. B., a patient of Dr. Johnson of 92 BRITISH MEDICINE IN THE WAR, 1914-17. Cambridge whom I had seen some years before for neurasthenia with irritable heart, to which he was, and still is, liable. Dr. Johnson sent him to me, in respect of a call to military service, with a note of a faint and variable presystolic murmur. He had had rheumatic fever but with no record of cardiac affection. The first sound was short and snappy, but his" heart had always been irritable, and on this visit I could not hear any murmur unless it were, for a beat or two after putting him through some exercises, a very fleeting presystolic sound—so fleeting as to be hard to define or record. The heart's dimensions were to percussion normal. While murmur hunting I forgot till the last moment to feel for a thrill; but then I found a short apex thrill clearly perceptible, and presystolic in time. Some ten days later I examined him again, and on this occasion a presystolic murmur was audible, brief and soft but decisive. Oddly enough, now the thrill had vanished; again and again I tried to find it but in vain. So capricious is this disease in its physical signs, and so elusive are its signs, in respect of military service or of life insurance. I am not as yet ready to accept a definite distribution of stenosis murmurs into early, middle, and late. Again, a young friend of mine, very active both in mind and body, and anxious to serve in the army, has been rejected on two occasions for "soldier's heart." He has a slight addition to the short first sound and a short presystolic thrill. He has never had rheumatic fever nor other illness. We have had a complicated illustration of this phase in the Mount Vernon Hospital. With Dr. Wilson and another colleague I examined a man with the obvious signs of aortic regurgitation. The question arose whether or no a divided first sound, audible at the apex only, signified a reduplication of the first sound. This it scarcely seemed to be; the taps were too close and the first one too light and brief; but I thought I recognized in it such a split in Wounds of the chest do not as a rule reach the bases in France until the fourth day after the infliction of the wound, except in periods of heavy fighting, then they may arrive much earlier, that is, on the second day. The observations recorded in this paper deal more especially with cases observed from the third or fourth day up to about three weeks after the occurrence of the injury, and thus they deal with only a portion of the subject. Gunshot wounds of the chest are usually divided into those penetrating and involving the lungs or other thoracic viscera, and the non-penetrating, although it is not always possible to be certain during life that an apparent non-penetrating wound is really such. Non-penetrating wounds may, however, give rise to pleural and pulmonary lesions, and in a certain proportion of cases of simple clean perforating bullet wounds of the chest the positions of the entry and exit wounds suggest that the bullet does not only pass through the chest but also through the lung, nevertheless there are no signs or symptoms indicating the presence of either air or fluid in the pleura, and such cases may recover rapidly and apparently completely. Pleurisy and empyema are the most common pleural lesions produced by wounds of the chest wall not involving the lung. The pleurisy is often at first dry, but not uncommonly an effusion follows, and since such lesions are often due to streptococcal infections spreading from the wound track in the chest wall to the pleura, an empyema of the usual type develops and requires the usual treatment. Haemoptysis, haemorrhagic infiltration of the lungs, and pneumonia of a septic bronchopneumonic type are the pulmonary lesions that may follow on a wound limited ±0 the chest wall. In addition to these, collapse of the the first sound as I have described. The carotid beat being, as usual in such cases, only too definite, we were-able to conclude that the first tap of the duplex sound was presystolic. Following this up we detected a presystolic thrill, short and light but quite distinct. A thrill must be very carefully placed and timed, for in many of these irritable hearts a systolic thrill can be felt; perhaps in most of them if some effort be made just before examination. It is short but often very distinct to the touch. It is not felt about the base of the heart, and is therefore not due to a slack aorta. How the thrill is generated it is not easy to say. Very often in these cases a systolic murmur at the apex is recorded, an alteration of the first sound, more like a prolongation of it with some change of quality than like a definite murmur of mitral regurgitation. To suggest the cause of this thrill is but to guess; but, if I may guess, my suggestion would be that in these cases the papillary muscles and their chords may be a trifle slack, so that the mitral sheets shiver a little in the current, as a sail shivers when the boat gets near the wind. Such a quaver would be transmitted to the ventricular wall, and thence to the thoracic. In such a condition there might well be a minute, inconstant, and insignificant regurgitation also ; though ordinarily in mitral regurgitation there is no thrill. In conclusion, I hope it may not be unbecoming in me as a member of the staff, but rather an onlooker than of effectual service, to offer my tribute of praise to the author of this Report; a brief summary of infinite pains, of his own and of those of his colleagues who are and have been on resident duty at the hospital. REFERENCES. 1 Medical Research Committee's Report upon Soldiers returned as Cases of " Disordered Action of the Heart," or " Valvular Disease of the Heart." Spec. Kept. Ser., No 8. 2 Zeit. f. klin. Med. 3 See C. Allbutt's Diseases of ihe Arteries, ii, 475. lung of a massive type may occur on the side opposite to the injury even when the latter causes no pleural or pulmonary lesion on the side injured. The haemoptysis and the septic pneumonia are both directly associated with the bruising and consequent bleeding into the lung produced by the impact of the missile on the chest wall and the resulting injury to the chest wall and lung. The haemoptysis may not only be severe, but may also run a long course, and some of the most severe cases of haemoptysis seen by the writer in a very large series of chest cases were those in which the missile only bruised the chest and had not only not produced any wound, but where there was no evidence of any fractured ribs. The bruised and blood infiltrated lung is very prone to become infected either from the lung or by the spread of infection from the wound track in the chest wall, and hence pneumonia of septic or of a bronchopneumonic type develops. In some cases wounds of the chest wall lay open the pleural cavity but do not involve the lung, a portion of the chest wall, more especially in its lower parts or at the back, is carried away and a gaping hole, often of considerable size, is left. In such cases the lung does not as a rule undergo complete collapse, although the pleural cavity is in free communication with the air. In fact, the volume of the lung seems to approximate to that seen after death when the pleura is open, and therefore the pulmonary collapse is markedly less than that seen in ordinary pneumothorax where, as is well known, very complete collapse occurs, yet in the latter cases the intrapleural pressure may not be above that of the atmosphere. Penetrating wounds of the chest usually produce one or CHAPTER X. ON GUNSHOT INJURIES OF THE CHEST, With Especial Reference to Haemothorax. BY Sir JOHN ROSE BRADFORD, K.C.M.G., C.B., F.R.S., Temporary Colonel A.M.S., Consulting Physician, British Expeditionary Force. GUNSHOT INJURIES OF THE CHEST. 93

more of the following conditions : subcutaneous emphysema, haemothorax, pneumothorax, laceration of the lung. These conditions may not only arise where the wound is one obviously involving the chest, or where the wound of entry is near the chest—-for example, the neck or the abdomen especially in its upper part; but wounds in other regions—for example, the face or arm—may also give rise to haemothorax or pneumothorax from the course of the bullet being peculiar owing to the position of the soldier at the moment he is struck. In such cases there is often only a wound of entry, and this may be small and inconspicuous, but yet a large haemothorax or even a pneumothorax may be present. Further, in wounds of the chest the haemothorax or pneumothorax may be on the side opposite to the wound of entry; the missile taking an oblique course may enter on one side, more especially in wounds of the back, and follow such a course that it does not open the pleural cavity on the side of entry, although opening that on the opposite side without or with a wound of exit. Again, in some instances a bullet may enter and leave the pleural cavity on one side without causing any appreciable lesion ″on that side, and yet so wound the pleura and lung on the opposite side as to cause marked lesions. Bilateral haemothorax is sometimes seen as a result of a single wound the track of which is transverse or oblique, and haemopericardium may occur in association with either unilateral or bilateral haemothorax. Unilateral wounds, however, may cause bilateral effects owing to the development of contralateral collapse or contralateral pneumonia. The subcutaneous or so-called surgical emphysema so often present in chest wounds is usually limited to the vicinity of the wound or to an area of the chest wall adjacent of variable size. In exceptional instances its distribution is more extensive, and it may sometimes involve not only the trunk but even the whole body, including the face and extremities. Haemothorax. Haemothorax is the most common result of a chest wound ; both pneumo-haemothorax and pneumothorax are relatively rare, and in a series of 328 cases of gunshot wounds of the chest only 8 cases of the former and 4 cases of the latter were observed.1 The haemothorax may be either sterile or infected, and if the latter the infection may be either early or late. If early, the infection occurs within the first few days after the infliction of the wound, and is doubtless dependent upon infective material being not only carried in with the missile, but directly infecting the effused blood generally and rapidly. In such cases exploration of the haemothorax reveals the presence of organisms in the fluid withdrawn. Infection, however, may occur later, that is, in the second or third week after the receipt of the wound. Such cases may at first run the course of a sterile haemothorax, with but few symptoms, and the fluid removed by paracentesis may fail to show the presence of any organisms. Suddenly urgent symptoms, such as increasing fever, dyspnoea, pain, rapid pulse and jaundice, arise, and paracentesis then reveals the presence of organisms in the fluid withdrawn. The infection may be more or less localized, and more especially so in the lower portions of the chest, and in such cases paracentesis may yield different results according to the site explored; at one spot a sterile fluid may be obtained and at another at no great distance from the first a fluid of a totally different character containing abundant organisms. This is especially the case with anaerobic bacillary infections. It is probable that in many cases the explanation of the rapid development of the clinical picture of infection, in the course of what seemed for some days to be a case of simple sterile haemothorax, is to be sought in the fact that the infecting agent, that is, fragment of clothing, etc., was shut off by blood clot from the general mass of haemothorax fluid in the chest. Later, owing to the spread of infection through the clot, the haemothorax becomes infected as a whole, and hence the rapid development of urgent and very dangerous symptoms. In a series of 450 cases of haemothorax observed by Bradford and Elliott infection was present in 117—that is to say, roughly, in 25 per cent.; and Captain H. Henry, who carried out the bacteriological investigation, found that lung organisms such as the pneumococcus, B. influenzae and M. tetragenus, were present in some 20 per cent, of the infected cases, and that in the remaining 80 per cent, streptococci, staphylococci, and anaerobic gas-forming bacilli were found. In approximately 50 per cent, of the infected cases anaerobic bacilli, either alone or in association with cocci, were present; hence it would seem that infection of a haemothorax is much more frequently derived from the skin or clothing than directly from the lung. In some instances the pleural infection arises from direct extension from the infected wound track in the chest wall, and such a mode of spread may lead to the development of pleural and pulmonary complications in cases of wounds limited to the chest wall, and not directly involving either the pleura or the lung. Henry and Elliott have studied the morbid anatomy of wounds of the chest in a series of 100 cases observed in hospital at one of the bases in France. These observations deal only with cases that succumbed from the third day to the third week after the infliction of the wound, and one of the most striking facts ascertained was, that within these limits of time, death from haemorrhage as a result of a wound of the chest was very rare. Thus, in a series of 78 fatal cases of simple haemothorax there were 70 in which either infection or an additional visceral complication, or both, were present. In the remaining eight cases, where death might have been due to haemorrhage, purulent bronchitis was present in three, and in four cases no record existed as to whether sepsis was present or not, thus leaving only one case in which haemorrhage alone could be definitely asserted to be the sole cause of death. Septic infection is by far the most frequent, and therefore the most important, cause of death in cases of haemothorax that survive the first few days immediately following the wound. ' Secondary haemorrhage is also extremely rare, and in this series of 100 fatal cases only three instances were recorded; in two cases the haemorrhage took place into the pleural cavity, and in one a fatal haemoptysis occurred from a vessel in the vicinity of a small abscess in the lung round a fragment of shell. The writer has only seen one other instance of fatal haemoptysis due to secondary haemorrhage in the course of observations on many hundred cases of gunshot wound of the chest, and here also it was due to the lesions produced by a fragment of shell embedded in the lung. The more important points in the morbid anatomy of haemothorax are the following : The degree of collapse of the lung, and especially of the lower lobe, is very marked, and would seem often to be greater in amount than that usually seen in pleural effusions. The over-distension and so-called emphysema of the upper portion of the lung above the fluid is certainly far greater than that seen in cases of pleural effusion. The anterior part of the upper lobe of the lung is frequently pressed up against the chest wall, and the anterior margin of the lung frequently extends beyond the middle line. There may be a line of loose fibrinous adhesions gluing the surface of the lung to the chest wall at the upper limit of the effused bloood. The parietal pleura in the area corresponding to the effused blood is coated with a layer of fibrin one-eighth to one-quarter of an inch thick, and the surface of the collapsed lung is similarly covered to a greater or less extent with a layer of fibrin. The collapsed lung on the side of the haemothorax rarely, if ever, presents signs of inflammation except in the immediate vicinity of the wound track in the lung or round any retained foreign body. Pneumonic consolidation is not found in the lung beneath the haemothorax. Purulent bronchitis may be present not only in the contralateral lung but also in the emphysematous portion of the lung on the side of the haemothorax, but above the fluid. The great collapse of the lung would seem to be not only a safeguard against further haemorrhage in cases where the lung is wounded, but also a very efficient protection against the development of inflammatory complications. There is some evidence to suggest that wounds of the apices of the lungs— that is, the portion that would collapse last—are associated with large collections of bloody fluid in the pleural cavity. The bloody fluid present in the chest in cases of haemothorax consists in the main of defibrinated blood—that is, a mixture of serum and blood corpuscles, often presenting to the eye a considerable resemblance to blood, but differing 94 BRITISH MEDICINE IN THE WAR, 1914-17. from it in that it does not usually undergo massive clotting after removal from the chest. The parietal and visceral pleurae are covered to a greater or less extent with a layer of fibrin, and it is probable that the defibrination of the blood occurs as a result of the movements imparted to it by the respiratory and cardiac movements, and that it usually takes place very soon after the blood is poured out into the chest. Direct experiment has shown that the bloody fluid in haemothorax contains no fibrinogen, and hence, that although it resembles blood to the eye, clotting has really taken place, and that it is in reality defibrinated blood (Elliott and Henry). Even in cases of sterile haemothorax the whole of the fluid in the chest is not defibrinated blood. This is shown by two facts: first, the cell content of the fluid is different from that of defibrinated blood in that an increased number of lymphocytes may be present together with endothelial cells, eosinophile cells sometimes in considerable numbers, and marrow cells ; secondly, the quantity of fluid is sometimes very large, that is, four to five pints, and even then the patient may not show any gross or obvious signs of anaemia. Hence it is evident that there is some pleural exudate as a sequel to, and result of, the presence of the blood in the pleural cavity. In some cases further evidence of the presence of pleural exudate is afforded by the occurrence of a slight and peculiar clotting in the fluid removed from the chest by paracentesis. This clotting resembles that seen in the fluid of ordinary pleural effusions, but differs from it in that the coagulum contains abundant red corpuscles. This clot, although containing red corpuscles, is often scanty and generally gelatinous in consistence, and hence quite different in appearance from the clot formed from normal entire blood. The superficial resemblance of this " secondary clotting," as it is termed by Elliott and Henry, to true clotting is readily explained, inasmuch as the pleural exudate has added coagulable material to the defibrinated blood present in the pleural cavity and the abundant red corpuscles present have been entangled to a greater or less extent in the coagulation. In a small number of cases defibrination of the extravasated blood would seem not to occur, and paracentesis then reveals the presence of a mass of soft jelly-like clot that blocks the needle and prevents satisfactory aspiration; presumably in such cases more or less massive clotting has taken place. In infected haemothorax the pleural exudate is much more abundant, and hence numerous polymorphonuclear leucocytes are found on microscopic examination, and the fluid removed by exploratory puncture may yield a deposit of pus visible to the naked eye. The fluid itself is often of a crimson colour from the haemolysis that has taken place. Massive clotting would also seem to be more common in infected cases, since, both at operations and in the post-mortem room, large clots may be found, especially in the lower part of the pleural cavity between the diaphragm and the chest wall, and also in the vertebral groove. In these infected cases the inflammatory exudate is apt to be poured out rapidly, and a sudden considerable increase in the amount of fluid in the chest is often strong clinical evidence of the presence of infection, since, as mentioned above, secondary haemorrhage into the pleural cavity in haemothorax is very rare, and then only occurs in infected cases. In sterile cases there is neither secondary haemorrhage nor a sudden copious effusion to cause any sudden great increase in the amount of fluid present in the pleural cavity. In a considerable proportion of these infected cases there is not only a rapid pouring out of inflammatory exudate, but, in addition, there is gas formation, owing to the infection being dependent upon the presence of anaerobic gas-producing organisms. The development of gas is often very rapid, and such cases may present very urgent signs and symptoms that increase rapidly in the course of a few hours. In others the clinical picture is much less urgent, and in a few only slight symptoms are present, and the condition is only appreciated after careful examination. The gas may be iree in the pleural cavity, associated with very considerable collapse of the lung, and a variable but usually large amount of haemothorax fluid. In other instances the conditions are more peculiar; the collection of gas is localized above the haemothorax fluid, and below the emphysematous over-distended upper lobe of the lung. The loose fibrinous adhesions at the upper level of the fluid in the thorax are probably sufficient to tether the upper lobe to the chest wall, but whether this be the correct explanation of the non-collapse of the entire lung or no, the fact remains that the gas forms a localized collection above the fluid of the haemothorax and below the non-collapsed portion of the lung. Such localized collections of gas are usually in the lateral or postero-lateral regions of the chest, and more especially in its lower portions. The gas is usually offensive, and has either a definite faecal smell or else that of rotten eggs. It is often present under considerable pressure, and in the post-mortem room, if a cannula is inserted, the gas issuing from it readily burns, when lighted, with a bluish flame. In cases of this type there is often considerable displacement of the heart, and this displacement may develop with great rapidity—that is, 2 in. in twenty-four hours. In cases where the gas is free in the pleural cavity, the clinical picture is that of pneumothorax or pyopneumothorax; and where the condition develops rapidly the symptoms are apt to be urgent and the error may be made of regarding the case as one of progressive pneumothorax, whereas in reality the phenomena are due to the rapid formation of gas under pressure as the result, of infection of the haemothorax fluid. In infected haemothorax the deposit on the surface of the collapsed lung is much more abundant and thicker than in sterile cases, as a thick layer of lymph more or less organized is often present. This is of considerable importance, inasmuch as this deposit hampers the subsequent re-expansion of the lung after the removal of the fluid by drainage of the pleura. The longer the delay in draining the pleura in such cases the greater is the organization of this deposit, and therefore there is much risk of permanent incomplete expansion of the lung. The deposit on the pleura not only causes the re-expansion of the lung to take place more slowly but also less perfectly,. hence it is most important that cases of infected haemothorax should be treated and thoroughly drained at the-earliest possible moment. Bilateral haemothorax is not very uncommon, and such collections are usually of small or moderate size; they may be either sterile or infected, and cases have occurred of bilateral infected haemothorax that have recovered after drainage of both pleural cavities. In bilateral haemothorax one side may be sterile and the other infected, and recovery has here taken place-after aspiration of the sterile and drainage of the infected haemothorax. Bilateral haemothorax may be-associated with haemoporicardium, or in infected cases-pericarditis may occur as a complication. The pericarditis seen in cases of infected haemothorax is. probably usually of streptococcal origin, but in some instances an anaerobic infection of the pericardium may occur and then very striking physical signs may be present owing to the presence of gas and fluid in the pericardial sac. Two such cases have fallen under the observation of the writer and both recovered after opening and draining the pericardium. In one the condition was recognized as the result of the percussion of the pericardial area yielding a tympanitic note when previously a dull note due to the presence of effusion in the pericardium had been present. Pericarditis probably only occurs in infected cases, although pericardial friction and the signs of fluid in the pericardium may be detected in cases of sterile haemothorax, where, in addition to the^ pleural lesion, there is also the probability of injury to the pericardium and where x-ray examination may reveal the presence of a bullet in close proximity to the heart. The accurate diagnosis of such cases is often difficult, but it is probable, inasmuch as they often have no symptoms indicative of pericarditis, and they recover, that the pericardial physical signs are due to the presence of a haemo-pericardium rather than to a pericarditis with effusion. In the infected cases the presence of pericarditis is a very serious complication; in some there is merely greasy lymph,. in others a moderate effusion, or where an anaerobic infection is present the pericaixlium may contain gas as well as an effusion. If the effusion is at all large in amount it. is usually situated in the posterior part of the pericardium, and is therefore liable to produce some degree of pressure on and collapse of the lower lobe of the left lung. In very large effusions the transverse diameter of the pericardium is greatly increased. When the effusion is posterior in position, the heart may still remain in partial contact with the chest wall anteriorly, and thus, owing to the persistence of friction the presence of even a iarge effusions may be overlooked. GUNSHOT INJURIES OF THE CHEST. 95 Complications. The complications directly associated with haemothorax are few and are most frequently seen in cases of infected haemothorax. Purulent bronchitis, pneumonia, pleurisy, massive collapse of the lung, and pericarditis are the most common complications. Abscess and gangrene of the lung may occur, but these are dependent not on the haemothorax but on pulmonary lesions produced by the missile. One case of meningitis due to streptococcal infection in association with an infected haemothorax has fallen under my observation, but no case of cerebral abscess. The relation of purulent bronchitis to haemothorax is often very doubtful, as it occurs so frequently apart from wounds, but many patients give a history that is suggestive of the onset of the bronchitis after the wound, although even in these it may be dependent on exposure. One of the most striking features of its distribution is its absence in that portion of the lung that is collapsed beneath the haemothorax effusion. Pneumonia, in various forms, may be present, but is not common, and here again the collapsed lung on the side of the haemothorax is not involved. It may occur on the side opposite to the haemothorax, but care must be taken in the diagnosis, as the physical signs of massive collapse present great resemblance to those of pneumonia, and, as will be mentioned later, contralateral collapse in cases of unilateral chest wounds is of quite frequent occurrence. There is, however, clear evidence from autopsy that pneumonia on the side opposite to the wound may occur in haemothorax. Septic bronchopneumonia is common in wounds of the chest wall not accompanied by haemothorax, where, as a result of the impact of the missile, the lung is bruised and haemorrhage into its substance has occurred. Pleurisy, often dry, is also not uncommon on the side opposite to the haemothorax; this occurs most often in infected haemothorax, but some instances have been seen where there was no bacteriological proof that the haemothorax was infected. Pleurisy of a serious type, and often progressing to empyema, occurs as a result of injuries to the chest wall of a tangential character and associated often with fracture of one or more ribs. Septic bronchopneumonia may coexist in such cases. The contralateral pleurisy is especially prevalent in cases of streptococcal infection of haemothorax, and may also progress to effusion and the formation of an empyema. Such cases are necessarily very serious, and if, as is not infrequent, pericarditis is also present they are of the utmost gravity. Source of the Haemorrhage in Haemothorax. There is some difference of opinion as to whether the injury to the chest wall, or that of the lung, is the more common cause of the haemorrhage into the pleural cavity, and it is not possible to dogmatize on this subject. Morbid anatomy does not yield any direct evidence of the bleeding having arisen from the chest wall, but it is obvious that it would be very difficult to exclude the possibility of the wound of an intercostal vessel. On the other hand, it is not unusual to find direct evidence of blood coagulation in the track produced by the missile in its passage through the lung, and the wall of the track is also infiltrated, to a varying depth, by extravasated blood. Henry and Elliott record in their series four cases of perforating wounds of the lower chest wall involving the pleural cavity below the area occupied by the lung and not wounding the lung, and where no haemothorax existed. Many instances of extensive injury to the chest wall opening the pleura have been seen where the lung itself was not involved, and where no haemothorax was present. The great rarity of secondary haemorrhage in cases of haemothorax is also in favour of the pulmonary origin of the bleeding, since the collapse of the lung associated with the haemothorax tends not only to check haemorrhage directly but also to prevent secondary haemorrhage owing to the rarity of septic inflammations in collapsed lung. It is probable, therefore, that in the great majority of cases of haemothorax the source of the bleeding is the injury to the lung, although cases may be seen occasionally where the haemorrhage is derived from a vessel in the chest wall, such as an intercostal or the internal mammary artery, or one of the big vessels at the root of the neck. Injuries of the great vessels of the neck sometimes coexist with haemothorax; aneurysm of the innominate artery has been seen in association with pneumo-haemothorax, but in such cases it is probable that the haemothorax is really independent of the arterial lesion and due to other pulmonary lesions, and the haemothorax or pneumo-haemothorax may be on the opposite side to that of the arterial lesion. In rare instances the haemothorax fluid contains, in addition to blood, bile. The bile is derived from the wound track involving the liver, and in such cases the bile may reaccumulate in the pleural cavity after paracentesis has been performed and the haemothorax fluid drawn off. Repeated paracentesis may be required to draw off the reaccumulations of bilious fluid, and it is remarkable that jaundice does not necessarily develop in such cases, although the amount of bile present in the pleural cavity may be very large. This is further evidence that the pleural cavity in cases of haemothorax does not readily absorb fluid, and the lack of absorptive power is probably in part dependent upon the fibrinous coating on its surface, and in part, perhaps, on the lack of efficient respiratory movement on the injured side. In one case there was evidence of the presence of stomach contents in the haemothorax fluid. Signs and Symptoms of Haemothorax. Dyspnoea, although often at first urgent, diminishes rapidly, and even when the quantity of fluid in the chest is large—that is, over three pints—it is not usually a marked feature after the first three days. It is, however, greatly increased by exertion and movement, and hence many patients on arrival at a base hospital after a long journey often have considerable dyspnoea and distress for twenty-four hours. Moderate pyrexia is usually present, and it may rise to 103° F.; but the pulse is not much accelerated, and is usually under 100, and the patient does not have much distress unless cough is severe, frequent, and painful. The continued presence of high fever, pain, distress, rapid pulse, and furred tongue should always suggest the possibility of the haemothorax being infected, and a sample of the fluid should be removed with an exploring syringe without delay in order to determine this point by bacteriological methods. Jaundice is an important sign, as, if marked, it is a characteristic sign of infection, and more especially infection with anaerobic bacilli. In simple sterile haemothorax only a slight icteric tinge is present in the conjunctiva, but in anaerobic infections a deep yellow jaundice involving the skin generally develops, often with great rapidity. Such a jaundice is often misinterpreted as indicating a wound of the liver, especially when the wound is in the lower chest, but jaundice is quite exceptional in liver wounds, whereas it is a very characteristic sign of infected wounds, and especially of anaerobic infections. It may also, of course, be seen in the course of streptococcal infections. The physical signs produced by haemothorax present considerable variety and often are very difficult to interpret. They are much more complex than those usually regarded as characteristic of simple pleural effusion. One outstanding sign, easily demonstrated by percussion and confirmed by x-ray examination, is that the diaphragm on the affected side is much higher than normal. The high level of the diaphragm is most easily demonstrated in left-sided haemothorax, since then the tympanitic percussion note due to the stomach resonance is readily obtained high up in the axilla, and also in the antero-lateral region of the chest. In some instances this tympanitic stomach resonance may reach so high a level as to merge into the area of skodaic resonance in the infraclavicular region above the level of the fluid, and unless care is taken a mistaken diagnosis of pneumothorax may readily be made. X-ray examination often reveals that the diaphragm is not only high but also immobile. The skodaic resonance obtained in the upper chest above the level of the fluid is usually much more marked and much more extensive in its distribution than that present in ordinary pleural effusion, and not infrequently extends beyond the middle line, and this fact again is liable to lead to confusion of the condition with pneumothorax. The distribution of the skodaic resonance is confirmed by the observations on the morbid anatomy, as these show that the upper portions of the lung, especially anteriorly, are greatly over-distended and emphysematous, and that quite frequently the upper lobe is so over-distended as to extend well beyond the mid-sternal line. The high level of the diaphragm, notwithstanding the presence of a large amount of fluid in the chest, and the 96 BRITISH MEDICINE IN THE WAR, 1914-17. very extensive and marked skodaic phenomena are two striking features of haemothorax and are in contrast to what obtains in simple pleural effusion. Over the area occupied by the fluid, blowing tubular, or even cavernous, breath sounds are frequently heard on auscultation. They are not only more marked than those occasionally heard over pleural effusions, but they are also heard over a much larger area, instead of being limited, as in pleural effusion, to a small area in the vicinity of the angle of the scapula. Bronchophony and oegophony are also well marked and very definite; pectoriloquy is by no means rare. The physical signs thus often present a more or less clear resemblance to those usually regarded as characteristic of pneumonic consolidation, and it is not surprising that in a considerable number of cases where haemothorax is present, the erroneous diagnosis of so-called traumatic pneumonia is made. The signs described above are not present in all cases ; in some the signs are similar to those found in cases of pleural effusion—that is, dullness, weakness, or absence of vocal fremitus, and weak or absence of breath sounds. Further, a case may present at an early period of its course the first set of signs with well-marked tubular breathing, and later on, with an increase in the amount of fluid, the second set with weak or absent breath sounds. This is more especially observed in infected cases where a rapid and considerable increase of the effusion may occur. In others where, result of the presence of anaerobes, gas is formed, a cracked-pot percussion note may be elicited often over a localized area where previously the percussion note had been dull. In these cases a bell sound mayor may not be obtained, but the percussion note is quite characteristic. Collapse of the Lung. In ordinary pleural effusion the chest on the affected side is usually obviously enlarged, and the respiratory movements are diminished in amplitude; this is also true of some cases of haemothorax, more especially when the amount of fluid present is very large—that is, four to five pints. In a considerable number of cases, however, a very different condition is present, inasmuch as the chest is flattened and retracted on the side of the effusion, and the movements are so much diminished that the affected side is practically immobile. This retraction and immobility of the side may be present not only when the amount of fluid is small, but also in many cases where there is a moderate collection of fluid, approximately two pints in amount, but it does not occur in association with the largest collections. It is remarkable that in cases where retraction and flattening are quite marked, the apex beat may be displaced, as in ordinary pleural effusion, towards the opposite and unaffected side. This retraction of the injured side is a remarkable and common phenomenon in cases of haemothorax, and it seems to be a fact of the same order as the high level of the diaphragm already noted. Sometimes it is only seen in the first few days after the wound, and then, with an increase in the amount of the effusion in infected cases, it is replaced by bulging of the usual type. Well marked tubular or even cavernous breathing is heard on auscultation in those cases where marked retraction is present, together with bronchophony and pectoriloquy. The retraction of the injured side, the immobility of the chest and the high level of the diaphragm, would all seem to be due to extensive collapse of the lung or of the lower lobe of the lung, a collapse that is out of proportion to the amount of fluid present in the pleura, and is really very probably a collapse that is more or less independent of the presence of the fluid, and has some other mode of origin. It may well be that this collapse is a constant phenomenon in cases of gunshot injury of the chest, but that when a large haemothorax coexists its presence is naturally attributed to the mere effusion and its real nature is only obvious where it is clearly out of proportion to the effusion. Thus cases of massive collapse of the lung on the side of the injury have been observed by Bradford and Elliott where the amount of the effusion was so small as not to need aspiration, and where the signs cleared up and the lung re-expanded after a short interval. There are, however, other tacts that may be adduced in support of the view that the collapse is more or less independent of the effusion. Thus it may occur on the opposite side of the chest to that injured, and not only is this the case, but it is probably of quite frequent occurrence, only the physical signs produced are erroneously attributed to the presence of contralateral pneumonia when contralateral collapse is really the condition present. The main distinguishing feature between the physical signs of pneumonia and those of massive collapse is the position of the heart's apex beat ; in pneumonia there is no appreciable displacement, whereas in massive collapse the apex beat is displaced towards the collapsed lung. In an ordinary haemothorax affecting one side it may be impossible to determine clinically whether physical signs on the opposite side are due to pneumonia or collapse, since if the apex beat is found displaced, the displacement will necessarily be attributed to the presence of the fluid on the injured side. In such cases the diagnosis of contralateral collapse is largely an inference based on the absence of the clinical picture of pneumonia and on the rapidity with which the signs clear up, but in any given case there may be much doubt unless the diagnosis is confirmed by autopsy. Contralateral collapse, however, has been observed in cases of wounds implicating the chest wall only, where . physical examinations confirmed by x-ray observations showed that there was no lesion of the pleural cavity on the wounded side, the injury being a contour wound. Nevertheless, in such cases very extensive massive collapse has been present on the side opposite to that wounded and where there has been no retained missile or other foreign body. In some instances the massive collapse has involved the whole of the left lung and the displacement of the apex beat into the left axilla has been very marked. Such patients do not present the clinical picture of pneumonia, although the physical signs in the affected lung are very similar, and the patients' general condition of comparative well-being, together with the absence of high fever, rusty sputum, etc., shows at once that they are not suffering from pneumonia. Further, contralateral collapse has been observed both during operation on the chest and also on autopsy. In one instance an exploratory operation was performed on a case of contralateral collapse under the impression that the physical signs indicated the presence of an intrapulmonary abscess. Although the mechanism producing collapse of the lung on the side of the injury and on the opposite side is obscure and cannot be discussed here fully, the presence of this collapse is probably the explanation of the curious and characteristic physical signs so often present in haemothorax, such as the high level of the diaphragm and the frequent presence of tubular breathing, bronchophony, and pectoriloquy over the area of the pleura where fluid is present. This collapse of the lung must be regarded, therefore, as one of the leading, if not the leading, phenomenon of gunshot injuries of the chest. There is some evidence to suggest that it occurs early, soon after the infliction of the wound, as when cases are seen within a few hours of being wounded few physical signs beyond immobility and deficient air entry on the side of the injury can be detected. Such cases seen again twenty-four hours later may then show the ordinary signs of a haemothorax, but in their earlier phase the signs are often quite insignificant in comparison with the urgency of symptoms, such as distress and dyspnoea. Displacement of the heart's apex beat is a valuable sign in haemothorax; sometimes it is of a simple character and similar to that seen in pleural effusion—that is, displaced to a varying degree away from the side of the haemothorax. In others the displacement is mainly dependent upon the presence of contralateral collapse, and, as mentioned above, in some of these cases, there is no pleural lesion—that is, no fluid, air, or gas in the pleura on the side of the injury—such cases may be misinterpreted unless care be taken in the examination. The displacement present in any given case may undergo an increase or a diminution. An increase in displacement is usually due to the haemothorax being really infected, and an increase in the exudation or gas formation has taken place in the interval between the two clinical observations. A decrease in the degree of cardiac displacement in recent cases of haemothorax and occurring during the first week after the date of wounding is also not infrequent, and is often more difficult of explanation. It is commonly attributed to absorption of some of the bloody exudate; this, however, is highly improbable, since absorption from the pleura in these cases is extraordinarily slow and certainly does not occur to any appreciable extent in the early days after the wound. The return of the heart may GUNSHOT INJUEIES OF THE CHEST. 97

be due to an alteration in the distribution of the haemo-thorax fluid dependent on increasing collapse of the lung on the side of the lesion, or else it may be due to disappearance of contralateral collapse. The degree of displacement of the heart in any given case is therefore a very uncertain guide of the size of a haemothorax. Diagnosis. The main problem in diagnosis is the determination whether a haemothorax is infected or not, and this often presents difficulties, since a haemothorax that at first runs an apparently sterile course may be infected later, owing to the spread of infection either from the wound track or from some localized infection round a retained foreign body. In some of these cases of delayed infection, and more especially in those with anaerobic infection, the symptoms may develop with much rapidity, and be of such a character as to suggest the occurrence of secondary haemorrhage, where no haemorrhage has taken place. Rapid pulse, pallor, sweating, and collapse are not uncommon symptoms of a rapidly spreading anaerobic infection. Microscopic and bacteriological examination of the fluid withdrawn from the chest will generally determine absolutely the presence or absence of infection, provided care be taken to repeat the exploration and too much stress is not laid on the negative result obtained at the first puncture. It is often necessary to explore the chest at different levels. Cases are seen occasionally where the symptoms, and especially the character and duration of the pyrexia, suggest that infection is present, yet no bacteriological confirmation is obtained even with repeated paracentesis. Such cases may get well with no special treatment after running a prolonged course of several weeks' duration. Their explanation is difficult, but it may be that the pyrexia in such cases is dependent upon the inflammatory process in the wound track, and more especially in that in the lung, and that the layer of fibrin coating the pleural surfaces prevents the infection reaching the pleural fluid. Care must always be taken in considering the diagnostic significance of pyrexia that it is not due to some associated complication, such as purulent bronchitis, contralateral pleurisy, pneumonia, or pericarditis, although all such complications are much more liable to occur in infected than in sterile haemothorax. The rarity of pulmonary inflammation in the compressed lung on the side of the haemothorax should always suggest, if symptoms are urgent, that infection of the fluid is present rather than pneumonia, although the physical signs may be such as to render diagnosis difficult. In all such cases there should be no delay in making an exploratory puncture, as it is essential for the successful treatment of infected haemothorax that the cases should be recognized as early as possible. Treatment. In sterile haemothorax, if the amount of the bloody effusion is small, there is no need for any special active treatment; such cases do well, although their progress may sometimes be slow. If the effusion is at all large in amount—that is, the dullness reaching above the angle of the scapula—the fluid should be removed by aspiration about the end of the first week after the wound. In a few cases earlier aspiration may be required to relieve distress arising mechanically from the amount of fluid present. Aspiration with oxygen replacement is better than simple aspiration, since by this method, with suitable local anaesthetics, the operation can be carried out without discomfort to the patient and without any of the symptoms that so commonly occur in ordinary aspiration, and not infrequently prevent by their urgency the completion of the procedure. Further, with oxygen replacement practically all the fluid present in the chest can be removed at one sitting ; this is rarely feasible with ordinary aspiration, where the development of such symptoms as a sense of constriction, distress, cough, etc., occurs before all the fluid has been removed. These unpleasant symptoms develop as a consequence of a too sudden change in the intrapleural pressure resulting from the rapid removal of fluid, together with incomplete adjustment owing to incomplete expansion of the lung. Different patients vary considerably in the degree of their tolerance of pleural pressure changes, and these are necessarily much influenced by the degree and rapidity with which the lung re expands. With an oxygen replacement apparatus a measured quantity of oxygen at any desired pressure can be introduced, and thus violent and sudden changes in the intrapleural pressure are avoided. For practical purposes it is not necessary to measure accurately the intrapleural pressure; it is sufficient to regulate the introduction of oxygen by the presence or absence of symptoms. The aspiration of the fluid should be temporarily stopped when distress or a sense of constriction is first noticed by the patient; if the symptoms do-not subside at once, a small quantity of oxygen from the oxygen replacement apparatus (Parry Morgan or other) should be allowed to flow into the pleural cavity. Then with the relief of all distress, a further quantity of the fluid can be aspirated and the process continued until the operation is completed. The patient is left at the end of the aspiration with a small quantity of oxygen in the pleura—for example, 200 to 500 c.cm. at a pressure considerably less than the pressure of the haemothorax, but still appreciably above the normal pleural pressure. The oxygen is gradually absorbed in the course of the following, week, but it is remarkable that many days are required for the pleura to absorb even small quantities of gas, and this slow absorption is probably due to the coating of the parietal and visceral pleura with fibrin, as it is in remarkable contrast to the rapid absorption of air that is known to occur after opening the normal pleura. Free drainage is required in all cases of infected haemothorax, and it is of the utmost importance that this should be provided as early as possible, as the organization of the deposit of lymph on the visceral pleura produces a great impediment to the rapid expansion of the lung after the removal of the fluid, and this organization proceeds rapidly in cases where delay in operating takes place. Removal of the infected fluid by free drainage is, however, not. sufficient treatment in all cases ; the inflammation in the pleural sac and the septic clots must be treated by the local application of some efficient antiseptic, applied either by periodical washing out of the cavity or else by the instillation method and the Carrel-Dakin technique that is now so much used. If the cavity is treated by washing; out, care must be taken to avoid raising the intrapleural pressure. Septic clots, often of considerable size, can be removed with success by this method. Recently the Carrel-Dakin technique has been applied with success to-cases of infected haemothorax, and a few cases have already been so successfully treated that the operation wound required for the excision of the rib has been closed by secondary suture before the evacuation of the patient-to England. Two difficulties are met with in practice in cases, of haemothorax. In one group of cases, although the pyrexia and the patient's general condition suggests the presence of infection, bacteriological examination does not confirm this. In another series of cases organisms are detected in the fluid, but there is little or no pyrexia, and the patient does not seem to be very ill. It is probable that some of the cases falling into this second group recover after simple aspiration, but their convalescence is-often very slow, and certainly in some instances such cases develop serious and even urgent symptoms. For these reasons it is advisable to excise a portion of rib and procure free drainage in all cases of haemothorax where the bacteriological examination reveals the presence of pathogenic organisms, even if the clinical condition of the patient is not such as to suggest infection. As regards the first group, the position is more difficult, but it is probably wiser to delay opening the pleura until proof of infection in the fluid is obtained, as the pyrexia and even the other-symptoms may have some other origin ; it is a serious matter to open a sterile haemothorax in view of the possibility of secondary infection. Care must be taken in selecting the site for excision of a portion of rib to provide really efficient drainage, and the fact that the diaphragm is abnormally high in these cases must be borne in mind, as otherwise the opening will be made too low down. In some instances the wound of entry or exit communicates more or less directly with the pleural cavity and fluid in variable quantity drains from it; this drainage is rarely satisfactory or sufficient, and such cases require a counter opening in a suitable situation to really drain the effusion. RefeRences. 1 Bradford and Elliott: British Journal of Surgery, vol. iii, No. IP,. 1915. 2 Journal of the R.A.M.C, vol. xxvii, No. 5, p. 525. CHAPTER XI. TROPICAL MEDICINE AND HYGIENE. BY Sir PATRICK MANSON, G.C.M.G., F.R.S., Late Medical AdviseD to the Colonial Office. It has long been recognized that a number of diseases are peculiar to, if not confined to, warm climates. Many hypotheses in explanation of this circumstance have been advanced, but it is only of late years—only since we have been able to recognize the germ causes of many of these diseases, or the media by or in which they are conveyed— that it has become possible to arrive at the true explanation. Almost without exception, tropical diseases— that is to say, those diseases which require for their successful propagation a warm climate—are caused either by a protozoal organism or by a helminth, which, in their turn, in order to pass from one vertebrate host to another, demand either an animal vector peculiar to warm climates, or require a warm medium in which to qualify for such passage. Hence, although tropical disease once acquired can run its usual course even if the person remove to a cold or even frigid climate, that person cannot spread the disease there, nor, under natural conditions, can the disease be acquired there. On the other hand, bacterial diseases may be acquired and spread in any climate, as the germs in their passage from one human host to another do not necessarily demand any special animal intermediary, nor are they destroyed in their passage by ordinary temperatures. In the following summary relating to British contributions to tropical medicine bacterial diseases are therefore not considered. It is true such bacterial diseases as leprosy, cholera, and plague are often referred to as tropical diseases, but a little consideration—a little investigation into their history and geographical range—will show that they have no more claim to be considered tropical diseases than have tuberculosis or syphilis. Malaria. Although a number of contributions of considerable importance in tropical pathology had been made by British as well as by other investigators prior to 1880 there can be no question that it was the discovery by Laveran of the malarial parasite, in the November of that year, that has led to the recent rapid and remarkable development in tropical medicine. It was some time before the value of Laveran's discovery was recognized, or the nature of the organism concerned and the significance of its various phases determined. Golgi made an important advance in these respects by working out the morphological features of the tertian and quartan parasites, and of what is now known as the schizogony or asexual phase. Further advances in our knowledge of this part of the life-cycle of the malarial parasites were also made by other Italian observers; but here, for the time being, progress ceased. It may therefore be said that, except as providing an invaluable guide in diagnosis and treatment, Laveran's discovery for more than a decade remained barren. It gave no clue to prevention; it did not tell us in what way malarial infection was acquired, nor did it explain its peculiar geographical and topical distribution and limitation. As the development towards sexual maturity—a biological necessity for the malaria parasite as for all animal parasites—had never been traced in the human body, it follows that to effect this necessary development escape from the human body is essential. Neither Laveran nor Golgi's observations had filled in this important gap in the life-history of the parasite. Golgi, it is true, had made out the significance of certain phases of the parasite as seen in the circulation; he showed in what way the invading organism multiplied after it had obtained entrance into the human body, but neither he, nor any of his co-workers, had grasped the significance of certain additional phases also represented in the blood, and more especially manifested on the microscope slip—that is to say, in blood after its removal from the human body. Perhaps the most striking feature in connexion with the malarial parasite as observed under the microscope is the ″so-called "flagellated body." This squirming, wriggling, many-armed organism had long been a puzzle to the naturalist as well as to the pathologist. Some got over the difficulties of its explanation by pronouncing it to be a moribund or effete form of the parasite in its death agony. It had been observed that this flagellated body shows itself only in blood that had been for some time on the microscope slip—that is to say, after the parasite had been removed from the human body. It had never been seen in quite newly-drawn blood. Its development had been witnessed over and over again from certain intra-corpuscular forms of the parasite, but only after tbe blood containing these forms had been in the field of the microscope for a considerable period. This fact of the flagellated body coming into existence as such only when the parasite from which it was evolved had left the human body suggested to the writer that its function lay outside the human body, and, if so, that it was the early extracorporeal phase of the parasite and, if we may use the expression, designed for its passage from one human host to another. But, assuming that such was the case, it remained to explain how an organism, which while still in the body was invariably included in a red blood cell, could spontaneously and by its own efforts escape from the human body. Such a feat on the part of a passive organism was inexplicable. I was driven to the conclusion that if this phase of the malarial parasite were really the first stage in its development outside the human body some extraneous agency must act as liberator. The question then came to be what this extraneous agency might be. Many years before the writer had shown that in the case of another blood parasite—Filaria bancrofti (the Filaria sanguinis liominis of Lewis)—the mosquito acted as a liberating and also as a fostering agent. Impressed by the close parallelism, as regards their respective physical conditions and necessities, between the malaria parasite and the filaria—the one being imprisoned in a blood corpuscle and powerless to escape, the other, the sheath-included and equally helpless filaria—as well as their respective biological necessities, he thought that the same, or a similar liberating agency might be operative in both instances. An additional circumstance pointing to such a hypothesis was that both parasites are limited in geographical range to warm climates. On these considerations it was concluded that as the mosquito had been proved to be the liberating agent in the case of the filaria, it might be, and probably was, the liberating agent in the case of the malarial parasite, and therefore that the first phase of the malarial parasite outside the human body had to be passed in this insect. I formulated this hypothesis in the British Medical Journal of December 8th, 1894. Unfortunately, circumstances made it impossible for me to follow up the fate of the flagellated body in the mosquito, but Sir Ronald Boss, who was then in England, was so impressed with the probability of my hypothesis being correct, that on his return to India in 1895 he set to work to endeavour to establish it. After many years of intense application and in the face of many difficulties, he succeeded in tracing the malarial parasite into the stomach wall of certain " dapple-winged " (Anopheles) mosquitos. In consequence of difficulties in procuring material and suitable human subjects for observation and experiment, he transferred his attention to a malaria-like parasite (proteosoma) of birds. In these he succeeded in tracing the development of the parasite in the stomach wall of Culex mosquitos, and thence into the salivary glands and saliva of the insects, and by experiment showed that such insects were capable of conveying the infection to hitherto immune birds. Ross's observations were quickly confirmed by Daniels, Christophers and Stephens, Grassi, and many others. Grassi recognized Boss's "dapple-winged" mosquito as belonging to the anophe-lines, and showed conclusively that certain members of this family of mosquitos were efficient transmitters of malaria. Ross had not ascertained what exactly (98) TROPICAL MEDICINE AND HYGIENE. 99 happened to the malarial parasite immediately after ingestion by the mosquito, and while still in the lumen of the insect's stomach, which enabled it to pass into the tissues of the stomach wall. An American observer— Macallum—filled in this gap. He showed that the flagellated body of halteridium, another malaria-like parasite of birds, was the male parasite, that the flagella it produced functioned as spermatozoa, that when they broke away in the blood in the stomach of the mosquito they entered a female parasite, inducing therein a development that eventuated, while the female was still in the stomach of the insect, in the formation of that " travelling vermicule," which penetrated the stomach wall and therein entered on the development Ross had so successfully traced. Thus was completed the history of the life-cycle of the malarial parasite outside the human body, confirming the mosquito-malaria hypothesis. Although the work of Laveran and Ross was accepted by those best competent to judge, and although the direction in which its principal application should be made was ″evident to all well-informed tropical sanitarians, the public was by no means convinced of its reliability or of the importance of the mosquito as a diffusing agent of malaria. Experiments on human beings had succeeded in the hands of the Italians in demonstrating that a mosquito fed upon a malarial patient could, after an interval of ten to twelve days, convey malaria to hitherto immune individuals, but the public did not appreciate this, and moreover, as the experiments had been conducted in malarious countries there was always a possibility that some unsuspected fallacy associated with locality had crept in, seeing that other influences which might include the true malaria influence were possibly operative. Accordingly, the British Colonial Office, believing in and recognizing the importance of the discoveries as bearing on the health and prosperity of tropical countries, devised an experiment designed to convert the public to the mosquito-malaria theory and to facilitate in this way practical measures based on that theory. In 1900 it sent to the Roman Campagna an expedition consisting of Drs. Sambon and Low, of the London School of Tropical Medicine (who were subsequently joined by an artist), with instructions to live in a mosquito-protected hut located in a highly malarious district of that highly malarious region during the most malarious season of the year, protected at night only, and by wire gauze covering only, from mosquito attack. Although the people about them were heavily affected with malaria these observers, relying solely on mosquito protection, remained in perfect health. At the same time mosquitos infected in Rome with malarial parasites were sent to London by the same observers, and were there fed on two Englishmen who had never been exposed to malarial influences, or been in malarious countries, with the result that both these men contracted malarial fever and showed malarial parasites in abundance in their blood. This ″crucial experiment was accepted by the most sceptical as ″conclusive proof of the mosquito-malaria theory. It was long before Laveran's discovery was appreciated in England, but it made way by degrees, and its significance and importance became thoroughly apprehended by a few. It may be said that it led more or less directly to the establishment, at the instance of the late Mr. Joseph Chamberlain, of our schools of tropical medicine, wherein large numbers of post-graduate students destined for service in tropical countries were taught haematology and the study of the blood parasites generally. These students, well taught in blood examination with high powers of the microscope, were, as a result of this training, not only more efficient practitioners but before long were instrumental in discovering other pathogenic organisms of importance in tropical pathology. Some of these discoveries may be referred to. Trypanosomiasis. Forde, a former student of the London School of Tropical Medicine, found in the blood of an Englishman living in the Gambia and suffering from an irregular fever an organism the nature of which he failed to recognize. He showed it to Dutton, an emissary of the Liverpool School of Tropical Medicine, who recognized it to be a trypanosome, and named it Trypanosoma gambiense. Sir David Bruce, Nabarro, and many others definitely linked up the trypanosome of Forde and Dutton with sleeping sickness as cause and effect. The parasite having been discovered and its association with sleeping sickness confirmed, it became a matter of importance to ascertain in what way the infection was conveyed. Just as happened in the case of the malarial parasite, some antecedent observations led to the clearing up of this point. Many years before Forde and Dutton's discovery Lewis described a similar organism {Trypanosoma lewisi) as a frequent parasite in the blood of the rat. Apparently this parasite of the rat was non-pathogenic. Not long afterwards Evans found a similar parasite in the blood of equines, bovines, and other domestic animals, in association with, and as the undoubted cause of, the deadly disease known in India as "surra." In 1894 Sir David Bruce investigated in Zululand the disease known in South Africa as " fly disease," an epizootic extensively prevalent among and fatal to domestic animals in South Africa and other parts of that continent, and therefore of great economic importance. He very soon found a trypanosome {Trypanosoma brucei) in the blood of the stricken animals and also in the wild game of the infected districts, and confirmed the popular belief that the disease was conveyed by the bite of the tsetse fly —Glossina morsitans—one of several species belonging to a genus of biting flies peculiar to Africa. In the light of this antecedent knowledge it was not long before Bruce and his colleagues in Uganda were able definitely to link up sleeping sickness and its parasite with another species of tsetse fly, Glossina palpalis, very prevalent in the afflicted sleeping sickness areas. Observations on the topical distribution of the fly and of sleeping sickness confirmed the conclusions arrived at by experiment on the lower animals—some of which were found to be susceptible to the infection, and to be harbourers of the parasite even under natural conditions. Bruce at first supposed that the fly transferred the trypanosome directly and in a mechanical way on its blood-fouled proboscis from the infected to the uninfected, just as the lancet inoculates the vaccine virus; but a German (Kleine) showed that although such might be the case in a small proportion of instances, and for a short time—twenty-four hours—after the fly had bitten, in the majority of cases the parasite was conveyed only after it had undergone developmental changes in the fly—changes which require some eighteen days to complete, and which eventuate in a proportion of flies becoming permanently infective. Miss Muriel Robertson, who had previously made important contributions in the morphology and life-history of the trypanosomes of some of the lower animals, confirmed Kleine's observations, and also considerably expanded them by showing that it was only during a particular period in the recurring cyclical multiplication of the trypanosome in the circulation of the vertebrate host that it could be efficiently conveyed- to its intermediary the tsetse fly. Further, this talented protozoologist traced the development of the parasite in this insect through its various phases in its passage from the alimentary canal to the salivary glands and thence to the vertebrate. Concurrently with investigations into the life-history of the trypanosome others were directed to ascertaining the topical distribution and bionomics of Glossina palpalis, notably by Hodges and Bagshawe. For some time it was believed that man was subject to only one of the considerable number of trypanosomes now known to affect the vertebrates, but recent discoveries have shown that he is subject to invasion by at least two other members of the group equally, if not more, dangerous —namely, Trypanosoma cruzi, an American species which so far has not been studied specially by British observers, and Trypanosoma rhodesiense. The discovery of this latter trypanosome we owe to Stephens and Fantham. It appears to be confined to Rhodesia, particularly, but not entirely, to the north of the Zambesi. Morphologically it resembles Trypanosoma brucei, if it be not identical with that trypanosome, and like Trypanosoma brucei is transmitted, as shown by Kinghorn and Yorke and others, by Glossina morsitans. Much attention has been given by British workers to the symptomatology and morbid anatomy of sleeping sickness. As regards the latter, the most important observations are those of Mott, who has shown that the nervous symptoms of the disease are the result of an extensive small-cell infiltration of the perivascular connective tissue of the brain, very similar to that occurring in general paralysis of the insane. 1OO BRITISH MEDICINE IN THE WAR, 1914-17. Tick Fever. Vandyke Carter was the first to describe a spirochaete in association with the relapsing fever of India, a spirochaete possibly identical with the Spirochaeta recurrentis of Obermeyer. According to Mackie, it is transmitted in India by the louse. Livingstone and Sir John Kirk had called attention many years ago to a fever prevalent in particular parts of Portuguese East Africa (notably Tete on the Zambesi) which was attributed locally to the bite of the carrapata, a tick having bug-like habits. It was reserved for Milne and Ross in Uganda and Dutton and Todd on the Congo to show that this African carrapata disease is a relapsing fever, and that it is caused by a spirochaete—Spirochaeta duttoni—which, in its turn, is transmitted from man to man by the bite of the tick Ornithodorus moubata ; and, further, that it can be transmitted not only by the tick originally infected but also by the progeny of that particular tick. At first there was some doubt as to whether or not the new spirochaete was identical with that of Obermeyer, but well marked differences in their respective pathological and clinical effects on man, as well as the experimental work of Kinghorn and Breini, showed that, although morphologically similar, they were specifically distinct. The life-history of the spirochaete in the vertebrate host has been worked out to some extent, particularly by Breini, of the Liverpool School of Tropical Medicine, and in the tick by Sir William Leishman, R.A.M.C. According to Breini, the parasites, when they disappear from the blood at the crisis of the characteristic recurring febrile paroxysms, are taken up and destroyed for the most part by the phagocytes ; a proportion, however, enter certain cells wherein they coil up and, ultimately, after breaking up into a number of granules, escape as such from the cell and develop in the blood into the spirochaetes which, on maturing, give rise to the succeeding paroxysm of fever. As regards the spirochaetes in the tick, Leishman found that on entering the stomach they also break up into minute granules, which pass into the cells of the Malpighian tubes, and thence into the eggs of the tick, and also into its excreta. Thus the parasite has double opportunity of survival, either in the next generation of ticks or by passing out in the excreta of the tick and so obtaining access to a human or other vertebrate host through contamination of the wound it inflicts when the tick next proceeds to feed. Balfour has made some very interesting observations on the process of granule formation and discharge in the case of a similar spirochaete in Sudanese fowls, which tend to throw light on what occurs in Spirochaeta duttoni, both in the tick and in the human body. Yaws. Soon after the discovery of the spirochaete of syphilis by Schaudinn, Castellsni, then of the Ceylon Medical Service, described a similar though different organism, Spirochaeta pertenuis (v. pallidula) as the germ cause of yaws. His observations have been confirmed and are now generally accepted. The same observer described another species of spirochaete, Spirochaeta bronchialis, as the cause of a form of chronic bronchitis occurring in Ceylon, and probably in Africa. Leishmaniasis. Medical men in India and elsewhere have long been familiar with a form of chronic irregular fever associated with great enlargement of the spleen and liver, it is a deadly disease. In parts of India—Assam, for example— where it is especially prevalent and is called kala-azar, it is a serious matter, having swept away a large part of the population of some districts, and is, or was, spreading steadily as an epidemic over a large part of the Brahmaputra valley. The disease was generally relegated to the malarial group, although some observers, being struck with the absence in this febrile splenomegaly of the three pathognomonic marks of malaria —namely, tertian or quartan periodicity, amenability to treatment with quinine, and the presence of the malarial parasite or its product, haemozoin, in the blood—refused to acknowledge its malarial nature. Several commissions sent by the Government in India to ascertain the exact nature of the disease completely failed to establish its etiology. Some of us thought that kala-azar might possibly be due to some parasite similar to the trypanosome, at that time recently discovered in association with a chronic irregular fever and sleeping sickness. Sir AVilliam Leishman in 1902, and again in 1903, almost simultaneously with Donovan, found in the spleen, in cases of Indian febrile splenomegaly, a minute oval body possessing two nuclear masses, one spherical or oval and relatively of considerable size, the other linear or bacilliform and very minute. Extended investigations have shown that these oval bodies are present in the spleen, liver, bone marrow, and elsewhere in every case of kala-azar, and that they are characteristic and the cause of this deadly disease, which, as we now know, is by no means confined to India. Attempts at cultivation on bacteriological lines, that is to say in warm media, were unsuccessful. Later, however (in 1904), Sir Leonard Rogers ascertained that if these Leishman - Donovan bodies, as they came to be called, were kept at ordinary tropical atmospheric temperatures, about 22° Centigrade, in a sodium citrate solution, they underwent a remarkable development, first multiplying by division and later on developing into flagellated herpetomonas forms. This discovery indicated that the parasite is capable of living outside the human body, it may be in some cold-blooded animal, such as an insect or other intermediary. From, the point of view of prevention, it is extremely important that the life-history of Leishmania donovani be completed. In endeavouring to attain this desirable end workers must not allow themselves to be too much obsessed by the fact that in the similar parasites of malaria, of trypanosomiasis, of spirochaetosis, as well as those of yellow fever and of dengue, an arthropod intermediary is essential in their life-history. Possibly Leishmania requires such a vector and intermediary; analogy certainly suggests this, but suggestion is not proof. The recent, and to my mind very important, observations of Laveran and Fantham and Porter have shown that similar flagellated organisms—proper to insects, etc.—can be transmitted both by inoculation and by the mouth to warm-blooded vertebrates and nourish in them, such transmission being by no means in every instance a biological necessity for these parasites. It is true that Patton has succeeded in tracing the development of Leislimania donovani up to a point in the bed-bug, but so far his observations have not been accepted as conclusive that the bug is the transmitter or a necessary agent in the life-history of Leishmania. Not long after the discovery of the Leishman-Donovan body in kala-azar similar parasites were found by Wright in Oriental sore, of which troublesome form of ulceration they are undoubtedly the germ cause. Still more recently similar bodies have been found in a variety of other ulcerative affections in tropical America and, by Chris-topherson, in the Sudan, one of them, Espundia, being a very grave disease indeed. Yellow Fever and Dengue. There arc two fevers peculiar to warm climates which, though differing very much as regards gravity, have in some respects, both etiologically and clinically, many features in common. I refer to yellow fever and dengue. (1) Their respective germs exist in the blood and are ultramicroscopic; (2) their germs are conveyed to man by the same species of mosquito, Stegomyia calopus ; (3) one attack confers absolute or relative immunity; (4) in both there is a primary fever and generally a secondary fever ; (5) in both there is marked flushing of the skin, violent headache, general aching, and a rapidly attained high temperature which is generally associated with a relatively slow pulse; the duration of the primary fever—three, four, or five days—is about the same in both. These etiological and clinical features held in common suggest some kind of relationship as regards the respective germs. Carlos Finlay of Havana was the first to endeavour to prove experimentally that yellow fever was conveyed by mosquito bite, and he distinctly indicated Stegomyia calopus as the species concerned. His experiments were neither numerous nor convincing, and the subject was dropped till the American commissioners—Reed, Carroll, Agramonte, and Lazear—took the matter up and definitely established the fact that yellow fever is transmitted by the bite of Stegomyia calopus and, in nature, by no other means. The practical application of this discovery, in Havana and on the Panama Canal by Gorgas and his colleagues, and by others elsewhere in tropical America, has led to what must be regarded as one of the greatest triumphs of preventive medicine, whether in the tropics or TROPICAL MEDICINE AND HYGIENE. IOI elsewhere. Any claim for a share in this important achievement that might be advanced for British workers can be at most only an indirect one. Fortunately the deadly yellow fever has hitherto been confined to tropical America and West Africa, extending to Western Europe and parts of America only at long intervals and only during the hot months of the year, and even then only in circumscribed epidemics. Not so dengue ; it occurs in extensive epidemics throughout the entire tropical and subtropical belts, where in certain places it is more or less endemic. Why yellow fever has not a similar distribution is hard to explain, seeing that both diseases are conveyed by the same Stegoniyia mosquito. It is only quite recently (1916) that Stegoniyia has been proved to be a vector of dengue. For this important piece of information we are indebted to three Australian physicians— Burton Cleland, Bradley, and McDonald. It is true that previous workers had blamed the mosquito as the vector of the germ of dengue—notably Graham in Syria in 1903, and, later, Ashburn and Craig in Manila, but in neither case were the experiments satisfactory, and it would appear now that the mosquito which they blamed— namely, Culex fatigans—is not the only transmitter, if it be a transmitter at all. The Australian physicians referred to, although they failed with Cidex fatigans, succeeded in communicating dengue, under conditions which completely excluded every possible source of fallacy, by infected Stegomyia calojnis. Pappataci Feveu. Pappataci fever—an ephemeral fever of approximately three days' duration and regarded sometimes in tropical countries as a fever of acclimatization—has long been known to tropical practitioners. Shortly before the part played as vector by Phlebotomus papatasii was known the clinical characters and specific nature of this fever were described and recognized by James in India and McCarrison in Chitral. Subsequently Birt confirmed the discoveries of Doerr, Franz, and Taussig as regards the part played by Pldebotomus, and British naturalists have worked out in a great measure the bionomics of that insect. Undifferentiated Fevers of the Tropics. There can be little doubt that in addition to the foregoing there are other fevers of a specific nature peculiar to the tropics, whose germ causes and vectors have hitherto escaped detection. Many attempts have been made by British observers, particularly Crombie and Leonard Rogers, to classify these fevers on a clinical basis, but until the germs or their vectors have been recognized, any arrangement of this nature can be regarded only as a temporary one. Helminthiases. Trematodes. Of late years many additions have been made to the list of trematodes invading tropical mankind, as well as to our knowledge of the pathological effects and life-histories of the more important of them. For much of this we are indebted to British investigators. I may cite the new West African fluke, Watsonius watsoni, discovered by Dr. Watson in 1904, and since found to be not uncommon in certain parts of Nigeria ; Gastrodiscus hominis, discovered by Lewis and McConnell in India in 1876; Echinostoma malayanum, by Drs. Macaulay and Stanton in 1911 in the Malay States; Clonorchis sinensis, by McConnell, in 1874; Opisthorchis noverca, by Lewis and Cunningham, in 1872 ; Fasciolopsis buskii, by Busk, in 1843 ; Paragonimus westermanii, for the first time in man, by Ringer in Formosa in 1880, its ova having been recognized previously and independently by Baelz and the writer as a characteristic feature in the sputum of patients suffering from a somewhat serious form of endemic haemoptysis occurring in Japan, Korea, Formosa, and the Philippines. Schistosomiasis. These discoveries, though interesting to the helminth-ologist, are of comparatively small importance to the pathologist, especially if compared with the most recent discoveries in connexion with that peculiar family of trematodes, the Schistosomidae, including Schistosoma haematobium (Bilharzia), Schistosoma mansoni, and Schistosoma japonicum. Since Bilharz, in Egypt, in 1851, discovered the parasite which bears his name it has been ascertained that this trematode is widely distributed throughout the African continent, the adjacent islands, and in parts of Asia ; that in many districts it is very prevalent—for example, Lower Egypt, where it affects one third and in some places even 90 per cent, of the fellaheen population; that it is the cause of grave and even fatal disease; and that it has a decidedly deteriorating influence on the general health and therefore on the economic condition of the seriously affected area. Its pathological effect has been fairly exhaustively studied of late years, especially by Madden, Milton, Sandwith, and others, and the morphology of the adult worm and its ova determined, but the important matter of its life-history and the channels by which it enters the human body were until quite recently (1916) either quite unknown or at most mere matters of speculation. Dr. Leiper of the London School of Tropical Medicine, by a series of brilliant observations and successful experiments, has now completely filled in this hiatus in our knowledge, and has thereby placed in the hands of the sanitarians a sure guide in developing methods for the prevention of a disease which hitherto has proved the despair of the therapeutist. The history of Leiper's discoveries is interesting, not only as regards the subject they concern more particularly, but also as once more showing how what at the time appears to be a discovery with relatively small bearings may, sooner or later, lead to others of vastly greater importance. A chronic and very fatal disease characterized by enlargement of the liver and spleen, blood and slime in the stools, anaemia, and ultimately ascites, had been recognized for a considerable time as endemic in certain parts of Japan and China. Subsequently the ova of a trematode were found to be a feature in the stools and organs of such cases. Still more recently Katsurada found in the liver of cats from one of the endemic areas numerous schistosomes containing eggs identical to all appearances with those found in the faeces of the human subjects of this disease ; and still later, 1905, Catto found the same parasite and eggs in the organs of a Chinaman who died in Singapore. The disease is now known as Katayama's disease. Japanese observers have found that its parasite, Schistosoma japonicum, can be communicated to cats simply by immersing them in the water of certain rice fields in the endemic area. It was not essential that the water should be swallowed; simple immersion of part of the body of the cat sufficed. Myari succeeded in infecting animals from a mollusc common in these rice fields. He traced the development of the trematode in the mollusc and concluded that man acquired infection by working in the rice field, a conclusion supported by the experience of Europeans in China, principally sportsmen devoted to snipe shooting, who, it is to be presumed, had acquired the disease in wading through rice fields or swamps. Leiper, impressed by these observations and recognizing their possible bearing on bilharzia disease of Egypt, applied for and obtained permission and facilities from the London School of Tropical Medicine to proceed to the Far East to familiarize himself with and to test Myari's conclusions. The latter, somewhat modified, he confirmed. Returning to England, he placed the matter before the War Office authorities, who, recognizing the importance of bilharzia disease to the large body of troops assembled in Egypt, and acting in concert with the Medical Research Committee, commissioned Leiper to proceed at once to that country to study locally the etiology of bilharziasis and to suggest measures for its prevention and for the protection of the troops. In a very short time Leiper, assisted by Drs. J. G. Thomson and Cockin, ascertained that on emerging from the terminal-spined egg, opportunity serving, the miracidium of Schistosoma haematobium enters the liver of a fresh-water mollusc, a species of Bullinus {dybotvshi), very common in the irrigation canals of Egypt, and transforms into a sporocyst and daughter sporocysts, wherein vast numbers of cercariae develop. The cercariae ultimately escape into the water, penetrate—opportunity offering—the skin of man or other vertebrate, and, dropping their tails in the passage, find their way into the liver of the vertebrate host, wherein, after six to ten weeks, they attain sexual maturity, becoming adult trematodes, which, passing into the veins of the bladder, produce the characteristic terminal-spined eggs which escape in the urine. During these investigations Leiper was able to settle another and much disputed point in connexion with 102

BRITISH MEDICINE IN THE WAR, 1914-17. bilharziasis. It had long been recognized that there are two types of bilharzia ova, one terminal-spined and passed principally in the urine and only occasionally in the faeces ; the other lateral-spined and, practically, found exclusively in the faeces. Both types of ovum were generally attributed to the same species of trematode, the difference in the position of the spine being variously explained. In 1903 the writer, in examining the faeces of an Englishman from the West Indies, encountered numerous lateral-spined ova. Seeing that the patient had never visited Africa or any other region where bilharziasis was known to be endemic, that the urine contained no terminal-spined ova, and that, although thousands of examinations of the urine must have been made in the West Indies, bilharzia ova had never been reported from that part of the world, he suggested that the schistosoma producing these lateral-spined ova must belong to a species other than that producing terminal-spined ova. Sambon, adding many additional reasons, concurred in this view and paid me the compliment of naming the new species Schistosoma mansoni. Looss, who considered that this trematode did not require an intermediary, refused to accept the species. Leiper, however, in the course of the investigations just referred to, found that the miracidium of the lateral-spined ova enters a species of snail, Planorbis boissyi, quite distinct from the Bullinus favoured by the terminal-spined ova, and that on reaching the vertebrate host developed into a sexually mature schistosoma anatomically quite distinct from that resulting from infection from the miracidium of the terminal-spined ovum. Thus Schistosoma haematobium produces only the terminal-spined ova, and Schistosoma mansoni only lateral spined ova, and are distinct species. Quite recently many cases of lateral-spined bilharziasis have been reported from the West Indies and Brazil, but never a case of terminal-spined bilharziasis, so that now there can be no question as to the validity of the new species Schistosoma mansoni. In further confirmation of this conclusion Lutz has found that a Planorbis is its intermediary host also in Brazil. Dracontiasis. Although the anatomical features of the adult guinea-worm and of its larva had been ascertained, little was known of the life-history of this formidable parasite until Fedschenko discovered in 1870—a discovery subsequently confirmed by the writer—that the larva on being passed into water enters the body of a fresh-water cyclops, wherein it undergoes extensive developmental changes. In 1907 Leiper was sent by the London School of Tropical Medicine to West Africa to endeavour to ascertain in what way the parasite after leaving cyclops returns to man. He found that if the infected crustacean were immersed in a weak (0.22 per cent.) solution of hydrochloric acid (in imitation of gastric juice) the cyclops was immediately killed, whilst the included parasites, on the contrary, were stimulated to great activity, and bored their way through the integument of the cyclops. This experiment, he conjectured, indicated the route likely to be followed by the guinea-worm in nature. As confirmatory experiment on man was out of the question, Leiper administered infected cyclops to a monkey, and had the satisfaction, on the death of the monkey several months later in England, of finding three female and two male guinea-worms in an advanced state of development in its tissues. From this we may conclude that the infection is acquired by man from cyclops-infested drinking water fouled by guinea-worm carriers. Efficient preventive measures are clearly indicated by this new knowledge. Ascaris lumbricoides. It has been generally accepted that the experiments of Davaine, Grassi, and other Continental workers had proved that the larvae in the ripe eggs of ascaris were hatched out in the human intestinal canal, and therein immediately proceeded to sexual maturity. Quite recently, however, the experimental work of Stewart tends to show that the life-history of this very common parasite may be not quite so simple. Sambon already had pointed out that the papilla or beak, a conspicuous feature in the larval ascaris, indicated that the little organism at an early stage of its existence bores its way into the tissues. Stewart has now shown that if ripe ascaris eggs are fed to a mouse many of the larvae liberated in the intestinal canal pass to the lungs, and, if the dose of eggs is large, may even induce fatal pneumonia. The complete bearing" as regards man—the normal host of Ascaris lumbricoides —of this observation is not quite apparent, but it certainly goes a long way to prove Sambon's view that, before attaining sexual maturity, the parasite must enter the tissues of its human host. Filariasis. In 1872 Timothy Lewis, in India, ascertained that the larval filaria discovered by Demarquay and Wucherer in pathological fluids was normally a parasite of the circulation. He called it Filaria sanguinis hominis. In 1876 Bancroft, in Australia, discovered the parental worm, Filaria bancrofti. Subsequently, in 1878, the writer ascertained that a Culex mosquito served as its intermediary host, abstracting the microfilaria from the blood and providing it with an opportunity for undergoing important developmental changes, during which it increases in size from a microscopic object to one just visible to the naked eye, and possessing an alimentary canal as well as remarkable powers of locomotion. In 1900 Low at the London School of Tropical Medicine, and subsequently James in India, made the important discovery that at this stage of development the larval worm passes into the labium of the mosquito's proboscis, and gets back into man direct, the old idea of the mosquito dying on the water and the embryos escaping into this medium and so reaching man, being thereby, if not absolutely disproved, rendered improbable. Noe, Grassi, and Fulleborn in the case of the allied parasite (Filaria immitis) of the dog, and Bahr in the case of the human parasite, have shown the exact mechanism of how this takes place. Finally, the metamorphosed embryos arrive at the lymphatics, where development is completed and the new generation of embryo filariae born. When working in China at the life-history of the filaria I stumbled on the phenomenon known as " filarial periodicity." The microfilariae, I found, under normal circumstances come into the general circulation in the evening, increase in number till midnight, and gradually disappear towards morning, being almost entirely absent from the peripheral circulation during the day, when, as I subsequently ascertained, they lie up in the lungs and greater blood vessels. Stephen Mackenzie showed that by inverting the habits of the human host as regards the times of sleep this periodicity was correspondingly inverted, the filariae then coming into the peripheral circulation during the day and disappearing from it at night. For many years it was believed that this type of periodicity was observed by Filaria bancrofti embryos in all countries and climates. It certainly applies in most instances to China, India, Africa, and America, but we now know that it does not hold good for the islands of the Pacific—islands in which filariasis is particularly prevalent. Thorpe was the first to notice this, and later Lynch and others, especially Bahr, confirmed his observation in Fiji and elsewhere. A larval filaria described by Ashburn and Craig in the Philippines in 1906 under the name of Filaria philip-pinensis has recently been proved to be only an example of F. bancrofti, adults from such cases being indistinguishable from the latter. Further, Leiper, after careful study, has failed to find any anatomical differences between the adult worms from Fiji and those from Asia and elsewhere. It seems to the writer that Bahr may have supplied the explanation of the discrepancy as regards periodicity between the ordinary and the Pacific microfilaria. This observer has shown that although in Fiji, as elsewhere, the night-feeding Culex fatigans is an efficient intermediary for the filaria, it is not the usual or most efficient intermediary in that group of islands. In Fiji the day-feeding mosquito, Stegomyia pseudo-scutellaris, is not only a very common insect but in respect of efficiency as an intermediary for the filaria is ahead of Culex fatigans, and he concludes that the filaria has partially adapted its habits to those of its favourite intermediary in the Pacific, just as it has adapted itself to the habits of Culex fatigans and other nocturnal mosquitos, its favourite intermediaries in Asia, Africa, and America. It may be suggested that the explanation might lie in some peculiarity of climate or other circumstance peculiar to Fiji and the Pacific islands generally ; but the same writer has shown that the microfilaria of coolies imported from India, who, presumably, had brought their parasites with them from their native country, retained the TROPICAL MEDICINE AND HYGIENE. 103 nocturnal periodicity habit even after years of residence in Fiji, whilst Indians born in Fiji acquired the non-periodic filaria only. The point, however, is not settled, as Culex fatigans does exist and can carry the filaria in Fiji. Although in many instances the filaria appears to be non-pathogenic, nevertheless, seeing that it is apt in a considerable proportion of instances to give rise to serious disease, especially elephantiasis, and that it occurs in a large proportion (5 to 75 per cent.) of the inhabitants of many tropical countries, it is a very important element in tropical pathology. Many British workers have studied the pathological bearings of this parasite, and have definitely linked it up as the cause of lymphangitis, of chyluria, varicose groin and axillary glands, lymph scrotum, chylocele, various forms of lymphangiectasis and of tropical elephantiasis, and also of fatal septicaemia supervening on suppuration in abdominal and other seats of lymphatic varix. Of interest are the observations of Wise in Demarara, and Bahr in Fiji, on the cretified remains of effete filariae in the lymphatic glands and elsewhere. Other Microfilariae. As opportunity presented itself the writer made systematic examination of the blood of the natives of many different tropical countries, and in this way was enabled, to discover the blood-haunting larval filariae of three additional and specifically distinct nematodes, namely, Filaria loa, Filaria perstans, and Filaria demarquayi. The embryos of Filaria (loa), the eye worm of tropical West Africa and its hinterland, and the cause of the peculiar condition known as " Calabar swellings," so common in Europeans in those regions, and so often mistaken for erythema nodosum, resemble very closely those of Filaria bancrofti. It differs, however, from the latter in minute anatomical details, and also in observing an exactly opposite periodicity, entering the general circulation during the day and disappearing from it at night. This circumstance led the writer to suggest that its liberating and intermediary host must be a biting fly of corresponding habit, and as the mangrove fly, Chrysops diniidiata, was very common and very active during the day in the endemic districts, he suggested that it might be the intermediary host, and therefore responsible for the spread of the parasite. This suggestion has been proved to be correct by Leiper, whose observations have been confirmed quite recently by Kleine in the Cameroons. Acanthocheilonema perstans. The larval form of this parasite was found in 1891 in the blood of a Congo negro suffering from sleeping sickness, and subsequently found in many cases of that disease. I concluded that it might be the cause of this condition, but Low and others have shown that this is not so. We now know that it is a very common parasite in West Africa, on the Congo, in Uganda, in British Guiana, and probably elsewhere in the tropics. Daniels was the first to find the adult worm in aboriginal Indians of British Guiana. Filaria, demarquayi. The larvae of this species I found in the blood of the Caribs of St. Vincent, West Indies, and subsequently in aboriginals of British Guiana and possibly of New Guinea. Low has shown that it occurs also in others of the West Indian Islands—Dominica, Trinidad, and St. Kitts. He experimented with many insects to determine the intermediate host, but failed to find it. The adult form was discovered and described by Daniels in 1898. Whether the two last-mentioned nematodes produce any serious pathological effects has not been absolutely determined. It is unlikely that they do so. Sprue. Sprue is one of the more important diseases of the tropics, particularly as regards Europeans, among whom, especially among the older residents, it is a very common, very intractable, and very deadly disease. It is only of late years that its characters, symptoms, and diagnosis have come to be generally recognized, mainly through the writings of Fayrer, Thin, myself, Carnegie Brown, Begg, Castellani, and Bahr. The histopathology of the disease has been well worked out by British pathologists. There has been much speculation about the assumed specific cause—bacteria, hyphomycetes, and even helminths having been at different times incriminated; so far nothing definite in this respect has been arrived at. We are there- fore still at a loss to indicate a scientific prophylaxis of a disease which amounts to a positive curse in such places as Ceylon, the Malay States, parts of India, of China, and of many other tropical countries. The Dysenteries. It is only of late years that anything approaching to a scientific conception has been attained of what is indicated by the term " dysentery." Formerly the word was taken to indicate one definite and distinct disease, but nowadays we must regard it as indicating several forms of colitis brought about by a number of specifically distinct disease germs. Thus we have protozoal dysenteries attributable to such germs as the Entamoeba histolytica, the malarial parasite, leishmania, and Balantidium coli; helminthic dysenteries resulting from invasion of the walls of the colon by Schistosoma japonicxim and Schistosoma mansoni ; bacterial dysenteries produced by the several members of the Bacillus dysenteriae group, and probably of other bacteria. Although most of the original discoveries which have enabled us to arrive at this classification of the dysenteries are to be attributed to workers other than British, some of them maybe fairly assigned to our fellow-countrymen, especially those having a bearing on the prevention of these diseases, such as the elucidation of the part played by dysentery carriers and their treatment. Beri-beri. How many etiologically distinct forms of tropical multiple peripheral neuritis are included under the term " beri-beri " it is at present difficult to say ; probably there are several. If we confine the term to that form, of endemic multiple peripheral neuritis occurring in the Malay archipelago, China, and Japan, evidence is rapidly accumulating that, if it be not the only and sole cause of the disease, a dietary deficient in the vitamines essential for healthy nutrition has much to do with it. Although the initial observations which have led to this conclusion are to be credited to a Dutch physician— Eijkman—much has been done by British workers in narrowing the field for observation and in giving precision to conclusions. The observations of Eijkman on beri-beri in the Dutch East Indies distinctly indicated that in some way or other the disease was associated with a particular kind of prepared rice. Later Braddon insisted on this; and although his explanation of the modus operandi of the rice factor was not the right one, yet his insistence led to careful and fruitful investigation and experiment by Fraser and Stanton under Government auspices. The last named observers have distinctly shown that a leading element, if not the only element, in the causation of beri-beri, at all events in the Malay States, is absence (owing to excessive milling) of the pericarp and germ of the rice which constitutes the staple food of the Chinese, Indian, and Japanese coolie. And, further, they have shown that the administration of the millings of the decorticated and highly polished rice can arrest the development of a threatened attack of beri-beri, and, if it is not too far advanced, cure the disease. These observations on man are supported by experiment on the lower animals, especially on fowls, in which, as Eijkman and many others have shown, a diet exclusively of the incriminated forms of rice induces a polyneuritis closely resembling, if not identical with, that of beri-beri. The conclusions of Fraser and Stanton have been substantiated by many independent observers in the Philippines, in Japan, and elsewhere, and action based on these conclusions has had most happy results in prisons, asylums, hospitals, and other public institutions, as well as on native labour in plantation and mining camps. Mott, Halliburton, Durham, and Hamilton Wright have made important contributions to the pathology and anatomy of this disease. Skin Diseases. Mycetoma.—Since Vandyke Carter, in 1859, demonstrated the mycotic nature of the melanoid and ochroid forms of what is variously termed Madura foot, fungus disease of India, and mycetoma, considerable attention has been given to this and allied diseases by British and French pathologists, notably in Britain by H. J. Carter, Kanthack, Boyce, Hewlett, Adami, Kirkpatrick,. and many others. Owing to the labour of these observers, it is now known that mycetoma occurs in many tropical countries besides India, and in a variety of forms, and that the germs are introduced through wounds in the skin. 104 BRITISH MEDICINE IN THE WAR, 1914-17. Ulcerating granuloma of the pudenda was first described in India by McLeod, and in 1896 by Conyers and Daniels in British Guiana, and subsequently by other British workers in Africa, Australia, and elsewhere. Donovan called attention to certain coccoid parasites included singly, or more usually in groups, in the large mononuclear cells obtained by scraping the surface of the characteristic ulcers. Intravenous injections of antimony have lately been used with good effect in the treatment of this disease by workers in Brazil, and Low and Newham have recently published the details of a case in England cured by this method. The systematic study of the tropical dermatomycoses had been neglected until recent year's, and until the adoption of Sabouraud's methods by Castellani and Chalmers had brought about a certain amount of order into this little understood department of tropical dermatology. Other British workers have from time to time contributed to the advancement of the subject, and I may mention Turner and Sir William MacGregor. The tropical practitioner is no longer satisfied with a comprehensive diagnosis of the mycotic skin diseases by the expression "dhobie itch." He now recognizes that there is a great variety of hyphomycetic skin disease both in the native and in Europeans; he distinguishes between erythrasma, tinea cruris, tinea imbricata, pityriasis versicolor, and so forth, and he knows now that these are only a few of the many forms of hyphomycetic skin disease fostered by the heat and moisture of tropical climates and contact with tropical animals. Vomiting Sickness of Jamaica.—For many years it has been known that a peculiar disease, called " vomiting sickness," occurs from time to time in certain districts in the island of Jamaica. It is an extremely fatal disease, the mortality being anything from 80 to 90 per cent. It occurs particularly in children, although sucklings are exempt. Naturally its etiology has been the subject of much speculation and several commissions have attempted to clear this up. Some have regarded it as a manifestation of yellow fever, others of malaria, but it has been reserved to Dr. H. Harold Scott, Government bacteriologist, Jamaica, to solve the mystery. He has found that the so-called disease is produced by poison liberated in some mysterious way in immature or damaged ackees, the fruit of Blighia sapida (a tree very common in Jamaica) and much used by the negroes of that island. Shortly after the consumption of damaged fruit, especially of the soup prepared from the damaged fruit, vomiting sets in; presently this subsides, to bo followed three or four hours later by a recurrence and a rapid superveution of convulsions, coma, and death. The average duration of the illness is little over twelve hours. Dr. Scott has proved that certain animals are susceptible to the poison and show post mortem a remarkable fatty degeneration of the liver and other tissues, a condition which is also a notable feature in fatal cases of vomiting sickness in man. Treatment of Tropical Diseases. Many recent advances in our knowledge of the germ causes of tropical diseases and in our diagnostic methods have led to a more accurate application of certain drugs long recognized as efficacious in particular types of dysentery, and to the introduction of new drugs and methods of treatment in other diseases. I can allude to a few only of these drugs, and such as are justly attributable to British workers. The value of atoxyl in the treatment of trypanosomiasis was first indicated by Thomas, then of the Liverpool School of Tropical Medicine, and the use of salts of antimony in the same disease by Plimmer and Thomson of the Lister Institute. Sir Leonard Rogers, following up Vedder's work on emetine, introduced this drug to be given hypodermically as a substitute for ipecacuanha in the treatment of amoebic dysentery and amoebic hepatitis. It has recently been demonstrated that this method does not, in many instances, sterilize the individual of his amoebae, and that many of these cases become chronic carriers. Quite recently, Dale, Low, and Dobell have used a new compound, emetine bismuth iodide, by the mouth in such cases, and have found its sterilizing effect on the amoebae to be much greater than that of emetine given by hypodermic injection. It is quite likely, therefore, that the oral administration will supplant the hypodermic method in the treatment of the disease in the future. Donovan and other British physicians have proposed radiotherapy in the treatment of granuloma of the pudenda, and many British practitioners in Africa and the West Indies have demonstrated the value of the intravenous injection of salvarsan and other arsenicals in tick fever and yaws. INDIA AND MEDICAL PROGRESS. R. McCARRISON, M.D., D.Sc, F.R.C.P., Major I.M.S., Laureate Academy of Medicine, Paris. To what extent has India contributed to the advancement of medical science ? In providing an answer to this question it is necessary to indicate that Western medicine, even at the present day, is represented in India by only about 1,000 British medical men, the major part of whom form the Indian Medical Service. One thousand British doctors in a land of over 300 million people! In a land where plague, pestilence, and famine are the crude problems of everyday life. In a land where tropical heat and torrential rains sap the vitality of the strongest frame and the resolve of the strongest will. In a land where strange diseases lurk in unsuspected places and death comes in a moment to even the most watchful. To the teeming millions of such a land this small service has, since the earliest days of the East India Company, brought the benefits of Western medical science, carried into its waste places and most desolate outposts the standard of medical progress, and evolved sanitary order out of pestilent chaos. It has established medical schools and training colleges, and has brought into being an army of Indian-born and Indian-taught medical men. It has provided the professorial staff for the medical colleges, and has taught as well as practised the science and art of medicine and surgery. It has instituted a sanitary service, and has laid the foundations on which the science of tropical sanitation is built. It has established hospitals and dispensaries in every city and town in every district from Ceylon to the Pamirs, and has made it possible for twenty-eight and a half millions of India's people to receive the benefits of Western medical and surgical treatment in a single year. It has organized medical research and established research institutions where problems peculiar to India are studied by competent experts recruited from its own ranks. It has founded Pasteur Institutes for the treatment of rabies and the manufacture on a large scale of prophylactic vaccines and serums. It has ministered to the needs of India's army in peace, and tended to the sick and wounded in her frequent campaigns. It has organized the jail system of India, and taught her convicts trades. It has established tropical schools of medicine in Calcutta and Bombay, which bid fair to hold premier rank amongst such institutions in the world. All this the Indian Medical Service has done in the ordinary discharge of its duty, and what more? Our knowledge of the natural sciences—botany, zoology, and geology—has been enriched by its aid. It has sifted from amongst the mass of tropical fevers a number of definite disease entities, described their etiology and symptomatology, and elucidated their cause or their mode of spread. It has made important contributions to our knowledge of other diseases of more universal distribution, discovered the means of cure of some of the tropics' most deadly maladies; and, finally, it has made striking additions to forensic medicine and to the art of surgery. It is with these, since they represent additions to the sum total of medical knowledge, that it is necessary to deal, emphasizing the fact, however, that they have been made during the performance of a task which in itself was colossal. Let us consider, then, these contributions of India to the medical knowledge of the world. INDIA AND MEDICAL PROGRESS. Fig. 1.—Anopheles maculipennis, a carrier of malaria in Europe. Fig. 2.—Culex fatigans, the chief carrier of elephantiasis. Fig. 3.—Sitting postures adopted by mosquitos. a, Anopheles ; b, Culex. These figures are reproduced by permission from Mosquitos and Their Relation to Disease (British Museum—Natural History Series, No. 4), price Id. Malaria. The discovery by Ross that the plasmodium of malaria is conveyed to man by anopheline mosquitos (Fig. 1) ranks not only as the greatest of India's medical triumphs, but as one of the greatest discoveries of modern times. As a result of this discovery it is now possible to control the spread of this disease, whereby an inestimable benefit has been conferred upon mankind. Through it a great light was shed upon the mode of spread by suctorial insects of other protozoal diseases, by which light the problems of the propagation of dengue, yellow fever, sleeping sickness, and other diseases of the tropics have reached, or are gradually reaching, solution. Truly Ross's achievement was epoch-making, and laid the foundation on which the science of tropical hygiene is built. By its aid some of the earth's most pestilent places have been made habitable. Witness its triumphs in the Panama Canal zone, in India, in East and West Africa, and in Greece, Italy, and Egypt—triumphs which Ross's discovery alone made possible. Ross, whose services to humanity have received the highest recognition of almost every country in the world, including the award of the Nobel Prize, has been followed in India by others whose researches have brought to light the important truth that different species of anopheles are responsible for the spread of malaria in different localities, as, for example, Noccellia stephensi in Bombay and Pseudo-myzomyia ludlowi in the Andaman Islands. Accurate studies of the habits and breeding places of different species of anopheles have enabled tropical sanitarians to conserve their energies to the destruction of the responsible mosquito in each locality. In the treatment of this disease by quinine the pioneer work of Edward Hare, and in more recent years of MacGilchrist, must not be forgotten—the former, by introducing, in 1847, the practice of giving quinine without waiting for remission, was instrumental in saving many lives and in putting to an end the pernicious, and then universal, system of bleeding in this disease; the latter, by his careful researches on the value of different products of quinine, has added greatly to our knowledge of its treatment and to the treatment of blackwater fever. Kala-azlar. To the patient researches of Donovan, of the Indian Medical Service, the world owes the discovery of the -causal agent of this malady, and the recognition of Leislimania as disease-producing agencies. More recently Patton and Mackie, of the same service, have brought forward experimental and other evidence which goes far towards elucidating many of the complex problems connected with its spread. Younger members of the service have also added greatly to our knowledge of the epidemiology of this deadly malady. Other Tropical Fevers. It was Vandyke Carter who in India worked out the origin and development of the disease known as famine fever, relapsing fever, or spirillum fever; and Mackie who, in more recent years, discovered that Pediculus vestimen-torum was its carrier. To this service is also due the credit of having separated three day fever of Chitral—now known as sandfly fever— and seven-day fever of Calcutta, from amongst the mass of the unclassed fevers of the tropics, and of indicating the sandfly as the probable source of spread of the former malady, an indication which later researches in other countries proved to be fully justified. Plague. It is to India that the world owes its knowledge of the role played by the rat and by the rat-flea (Fig. 4) in the propagation and spread of bubonic plague—discoveries which were placed upon the statute book of medical progress by Liston and Bannerman of the Indian Service and by the Indian Plague Commission. As a result of these Fig. 4.—The rat-flea {Xenopsylla cheopis), a carrier of plague. discoveries, it has been possible to prevent the spread of plague in countries whence it has been carried in ships and merchandise from India. Furthermore, protection is afforded to the individual in plague-stricken countries by the method of prophylactic inoculation with killed cultures of the bacillus—a method which was introduced at Bombay in the year 1897 by Haffkine of the Indian Service. Cholera. It is to India that the world owes a great part of its knowledge of cholera, and the whole of its knowledge of the treatment and mode of spread of this deadly malady. Leonard Rogers, amongst his other monumental contributions to tropical medicine, has, by his hypertonic saline treatment of cholera, robbed it of half its terrors, and reduced its mortality from 70 to 23 per cent. Greig, by demonstrating the cholera vibrio in tht lungs, the liver, and other tissues, as well as in the urine, has within the last few years provided a wealth of information Io6 BRITISH MEDICINE IN THE WAR, 1914-17. in regard to the human factor in its dissemination. He has shown that cholera can no longer be regarded as solely water-borne, and that the human subject is the reservoir and the carrier of its infective agent (Fig. 5). To India also belongs the honour of having perfected, through Haffkine, as early as 1893, a method of anti-choleraic inoculation the protective value of which has proved of the highest value. Dysenteries. For the major part of its knowledge of the treatment of the dysenteries the medical profession of all lands is indebted to India. Buchanan's introduction of the saline treatment of bacillary dysentery provided a weapon of wonderful effect against this form of the disease; and even now that serum-therapy affords a specific means of cure the saline treatment remains such a reliable addition to our armamentarium as can ill afford to be dispensed with. Few discoveries in the field of therapeutics have been of such signal service to mankind as that of the specific action of emetine hydrochloride when administered hypodermically in amoebic dysentery—a discovery for which we are indebted to Leonard Rogers of the Indian Medical Service. The simplicity of this method of treatment and the certainty of its action when properly administered has reduced the mortality of this disease to an enormous extent. It has provided an effective prophylactic measure against the occurrence of those dangeious complications of amoebic infections of the bowel, hepatitis and liver abscess, and an efficient means of their cure, while it has greatly reduced the necessity for operation in amoebic infection of the liver, simplified our operative procedures, and reduced their risk. Rabies. India also, through its British medical men, has added greatly to our knowledge of the Pasteur treatment of rabies, and has improved upon that of Pasteur himself. In one of India's Pasteur Institutes alone as many cases are treated in a single year by these improved methods as in the whole of the rest of the world put together. Fig. 5.—Section of wall of urinary bladder showing the cholera vibrio in the submucosa. The round cells infiltrating the sub-in ucosa are also shown. (Greig ) Leprosy. India has within recent years made notable advances in the treatment of her lepers—advances which hold out the confident hope of the early evolution of a means of cure of this unclean and fatal malady. (Figs. 6 and 7.) Goitre and Cretinism. In the elucidation of the mystery which from the time of Hippocrates has surrounded the origin of these diseases of the thyroid and parathyroid glands, India has, within the last ten years, been able to play a notable part. Research has shown that intestinal organisms are the agencies mainly responsible for their production. (Figs. 8, 9, 10, and 11.) The Natural Sciences. In the field of botanical research the work of Hill and Prain, to mention only two of India's botanists, has added greatly to our knowledge of the flora of the tropics, while Bose, an Indian-born subject, has gained for himself a preeminent place in connexion with his studies of plant physiology. In the domain of zoology the Indian Medical Service has provided such authorities as Day, Alcock, and Wall, who have greatly enriched our knowledge by the study of deep sea fauna and of reptilia, to mention but two fields of their activities. Modern Indian investigators also have done much to classify and describe many new species of malaria-bearing and other mos-quitos; while such geologists as Falconer and MacClel-land have rendered the greatest services in contributing to our knowledge of the earth's crust. Hypnotism. And let it not be forgotten that even before British medical science had given to the world the incalculable blessing of anaesthesia James Esdaile, of the Indian Medical Service, had demonstrated the miraculous utility of mesmeric anaesthesia, under which he performed painlessly hundreds of operations of great gravity. The use of ether and chloroform has overshadowed Esdaile's brilliant discoveries, but these will find their place again in the armamentarium of the scientific physician and surgeon of the future, and their application in the relief of human suffering will go far to extract from the chaff of Christian Science and faith healing the full ears of wheat which lie buried in them. Surgery. Finally, in general surgery the members of the Indian Medical Service and their pupils have conferred such benefits on the people of India as to leave one awestruck at the magnitude of their operative work. No less than 1,050,000 of India's people received the benefits of surgical treatment in a single year. India's surgeons have never departed from the teachings of the father of all modern surgery —Lord Lister; they have continued to recognize the value and the place of antiseptic, as opposed to aseptic methods, in the treatment of surgical conditions in the tropics, where wounds are so subject to soil infection. To them the surgical lessons of the present war have come as no surprise, while they have long recognized and practised the prophylactic use of antitetanic serum in such conditions as compound fractures and other infected wounds. So much so is this the case that deaths from tetanus in Indian hospitals, which were formerly frequent, have been reduced to a minimum. But there are three departments of surgical practice in which Indian surgeons have led the world, and in which their supremacy is indisputable—litholapaxy, ophthalmology, and rhinoplasty. With the perfection of the first for the cure of vesical calculus, the names Fig. 7. The treatment of leprosy by vaccines (Uost). Fig. 6, Before treat ment. Fig. 7, After treatment. INDIA AND MEDICAL PROGRESS. 107