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The Physician in the War.
THE PHYSICIAN IN THE WAR.
559
this
observation of the peace-time sanitarian. During his whole service in France Sir T. ROSE BRADFORD saw no death from acute rheumatism nor any case of rheumatic hyperpyrexia. Acute infective endocarditis, when it occurred, developed, as a rule, on healthy valves, and only rarely LONDON: SATURDAY, SEPTEMBER 11,1920, as an So much incident of gunshot sepsis. for rheumatism. The war also gave Dr. ADOLPHE ABRAHAMS his opportunity of studying lobar in the War. The pneumonia in a large population of recruits UNDOUBTEDLY the surgeon had the time of his at Aldershot. His analysis on p. 543 of the life during the years 1914 to 1919. He then frequency of symptoms and complications has the obtained more operative practice in a few short special value arising from uniform observation, months than would otherwise have fallen to his for the cases all came under his own eye. He lot in a lifetime. He enjoyed skilled cooperation, had, unfortunately, no opportunity of making an with abundant opportunity of mutual help and exhaustive survey of the troops in order to define counsel. In view of the circumstances no leave the relation between constitution and susceptihad to be wrested from relatives for performing bility-he was not even able to obtain, when he biopsies or autopsies. The services of bacterio- wanted them, the figures of the monthly- strength logist, registrar, and statistician were at his in the Command-but he did adduce the striking elbow. Surgeons from all parts of the country and fact that 62 per cent. of his total cases fell sick of from many civilised lands got to know each other pneumonia within 12 days of joining up. And this as friends and professional colleagues, with lasting was before the influenza pandemic began. The total advantage to the fraternity cf surgery. No wonder mortality of his 558 consecutive cases was just surgery made great advances. The time of the physi- under 11 per cent., being markedly less than the cian came later, and never so completely. The war 30 per cent. of the Johns Hopkins Hospital and needed him just as much, but at the outset no one the 17 per cent. of the Middlesex Hospital (1880-89), in authority was clear-sighted enough to see this, both observed on about the same number of cases, although it is now obvious that the early recognition but greatly in excess of the 3’6 per cent. (quoted by of epidemic disease was a matter on which the Osler) among 40,000 picked men in the German lives of thousands and tens of thousands might army. Double pneumonia had a threefold morhang. The official stage appeared complete with the tality-namely 29 per cent. Herpes labialis was in its position as signum bonumtrilogy of surgeon, sanitarian, and bacteriologist, and although the diagnosis of all known and some occurring, indeed, only in 17 per cent. of the whole, unknown infectious diseases was in reality a task but heralding a mortality in these of little for the highest medical ability, it was not until the more than 4 per cent. The seventh day proved to campaign was half over that the consulting phy- be far the most popular day for the crisis, which is sician began to take his due share in affairs on the more credible than Dr. ABRAHAMS’S singular con" field of battle and behind the lines. What this firmation of the old legend that the critical fall share was is attractively portrayed in the first affects the odd day in general. Empyema was Lumleian lecture, which we print on another page. unduly frequent in the Aldershot cases, even before War conditions made the physician’s work the influenzal epidemic which stamped it as a essentially different from that of civil practice. In common and very fatal complication. Dr. ABRAHAMS the first place the opportunities of group study notes the large proportion of cases in which simple were almost boundless. Not only infectious aspiration was sufficient to clear up the effusion. diseases but maladies of all kinds were notified, Over and above the enrichment of the differential and during the latter part of the campaign facilities study of disease afforded by the circumstances of were such that the physician could take his choice war, Sir J. ROSE BRADFORD’S experience gave him of a syndrome which interested him and work it a further opportunity of great interest, that of out in various areas of the vast field of hostilities. comparing the incidence and mortality of disease in In spite of the great relative improvement in the various nations represented among the British hygienic conditions since the Crimean war, of which forces. The actual attack-rate of tuberculosis was the same among English, Canadian, and sanitarians never weary of telling us, and the of Australian small disease during contingents, whilst among the New remarkably proportion the whole campaign, still, as Sir JOHN ROSE Zealanders it was much higher. On the other hand, BRADFORD reminds us, the actual numbers of the resistance to tubercle displayed by the men of sick were far larger than those of wounded. home origin was vastly greater than that of the Interest was not limited to the diseases gene- Maories or of the natives of South Africa and the Indies, men from the Dominions coming rally recognised in association with campaigning. Typhoid, cerebro-spinal fever, trench fever, dysen- intermediately between the two extremes. No tery, and the like, had their special attraction to single instance of chronic or quiescent tubercle clinician and epidemiologist, but an impetus was was found among an extensive series of autopsies also given to the study of such everyday disorders on men of native races, although in over half the as acute rheumatism and lobar pneumonia. Sir total find of pulmonary tuberculosis the lesion J. ROSE BRADFORD remarks on the rarity of acute was quiescent. Racial variations in immunity,
THE
LANCET.
*
Physician
reinstated
much
West
rheumatism in the field. With an unprecedented population of young males and a very large population of young females, exposed, as never before, to the rigours of wet and cold, this immunity would have been astounding had not Sir ARTHUR NEWSHOLME, when medical officer at Brighton, prepared us to associate acute rheumatism with dryness and warm spells of weather. The wartime physician has established beyond a doubt
whatever their explanation may be, are of great interest. Obviously the material for comparison of the infectivity and virulence of disease among men of various races should be available in abundance, and the time should be approaching when analysis and classification of this experience will be available. The Lumleian lectures will make a fitting introduction to this important chapter in the medical history of the war.
.
559
this
observation of the peace-time sanitarian. During his whole service in France Sir T. ROSE BRADFORD saw no death from acute rheumatism nor any case of rheumatic hyperpyrexia. Acute infective endocarditis, when it occurred, developed, as a rule, on healthy valves, and only rarely LONDON: SATURDAY, SEPTEMBER 11,1920, as an So much incident of gunshot sepsis. for rheumatism. The war also gave Dr. ADOLPHE ABRAHAMS his opportunity of studying lobar in the War. The pneumonia in a large population of recruits UNDOUBTEDLY the surgeon had the time of his at Aldershot. His analysis on p. 543 of the life during the years 1914 to 1919. He then frequency of symptoms and complications has the obtained more operative practice in a few short special value arising from uniform observation, months than would otherwise have fallen to his for the cases all came under his own eye. He lot in a lifetime. He enjoyed skilled cooperation, had, unfortunately, no opportunity of making an with abundant opportunity of mutual help and exhaustive survey of the troops in order to define counsel. In view of the circumstances no leave the relation between constitution and susceptihad to be wrested from relatives for performing bility-he was not even able to obtain, when he biopsies or autopsies. The services of bacterio- wanted them, the figures of the monthly- strength logist, registrar, and statistician were at his in the Command-but he did adduce the striking elbow. Surgeons from all parts of the country and fact that 62 per cent. of his total cases fell sick of from many civilised lands got to know each other pneumonia within 12 days of joining up. And this as friends and professional colleagues, with lasting was before the influenza pandemic began. The total advantage to the fraternity cf surgery. No wonder mortality of his 558 consecutive cases was just surgery made great advances. The time of the physi- under 11 per cent., being markedly less than the cian came later, and never so completely. The war 30 per cent. of the Johns Hopkins Hospital and needed him just as much, but at the outset no one the 17 per cent. of the Middlesex Hospital (1880-89), in authority was clear-sighted enough to see this, both observed on about the same number of cases, although it is now obvious that the early recognition but greatly in excess of the 3’6 per cent. (quoted by of epidemic disease was a matter on which the Osler) among 40,000 picked men in the German lives of thousands and tens of thousands might army. Double pneumonia had a threefold morhang. The official stage appeared complete with the tality-namely 29 per cent. Herpes labialis was in its position as signum bonumtrilogy of surgeon, sanitarian, and bacteriologist, and although the diagnosis of all known and some occurring, indeed, only in 17 per cent. of the whole, unknown infectious diseases was in reality a task but heralding a mortality in these of little for the highest medical ability, it was not until the more than 4 per cent. The seventh day proved to campaign was half over that the consulting phy- be far the most popular day for the crisis, which is sician began to take his due share in affairs on the more credible than Dr. ABRAHAMS’S singular con" field of battle and behind the lines. What this firmation of the old legend that the critical fall share was is attractively portrayed in the first affects the odd day in general. Empyema was Lumleian lecture, which we print on another page. unduly frequent in the Aldershot cases, even before War conditions made the physician’s work the influenzal epidemic which stamped it as a essentially different from that of civil practice. In common and very fatal complication. Dr. ABRAHAMS the first place the opportunities of group study notes the large proportion of cases in which simple were almost boundless. Not only infectious aspiration was sufficient to clear up the effusion. diseases but maladies of all kinds were notified, Over and above the enrichment of the differential and during the latter part of the campaign facilities study of disease afforded by the circumstances of were such that the physician could take his choice war, Sir J. ROSE BRADFORD’S experience gave him of a syndrome which interested him and work it a further opportunity of great interest, that of out in various areas of the vast field of hostilities. comparing the incidence and mortality of disease in In spite of the great relative improvement in the various nations represented among the British hygienic conditions since the Crimean war, of which forces. The actual attack-rate of tuberculosis was the same among English, Canadian, and sanitarians never weary of telling us, and the of Australian small disease during contingents, whilst among the New remarkably proportion the whole campaign, still, as Sir JOHN ROSE Zealanders it was much higher. On the other hand, BRADFORD reminds us, the actual numbers of the resistance to tubercle displayed by the men of sick were far larger than those of wounded. home origin was vastly greater than that of the Interest was not limited to the diseases gene- Maories or of the natives of South Africa and the Indies, men from the Dominions coming rally recognised in association with campaigning. Typhoid, cerebro-spinal fever, trench fever, dysen- intermediately between the two extremes. No tery, and the like, had their special attraction to single instance of chronic or quiescent tubercle clinician and epidemiologist, but an impetus was was found among an extensive series of autopsies also given to the study of such everyday disorders on men of native races, although in over half the as acute rheumatism and lobar pneumonia. Sir total find of pulmonary tuberculosis the lesion J. ROSE BRADFORD remarks on the rarity of acute was quiescent. Racial variations in immunity,
THE
LANCET.
*
Physician
reinstated
much
West
rheumatism in the field. With an unprecedented population of young males and a very large population of young females, exposed, as never before, to the rigours of wet and cold, this immunity would have been astounding had not Sir ARTHUR NEWSHOLME, when medical officer at Brighton, prepared us to associate acute rheumatism with dryness and warm spells of weather. The wartime physician has established beyond a doubt
whatever their explanation may be, are of great interest. Obviously the material for comparison of the infectivity and virulence of disease among men of various races should be available in abundance, and the time should be approaching when analysis and classification of this experience will be available. The Lumleian lectures will make a fitting introduction to this important chapter in the medical history of the war.
.