This basework remained, but was subject to some important
modifications as the campaign progressed. One of these was the
tendency to move the operating surgeon nearer and nearer to the
front. It was a recognition of the fact that in war-wounds every
hour of delay prejudices the chances of recovery. A few experi-
ments carried out at first tentatively showed, for example, that
the mortality from abdominal wounds was greatly reduced when
these were operated on within a few hours instead of within a
few days. The success of these experiments led to the develop-
ment of the field hospitals, situated close behind the lines. Thus,
after a wounded man had been brought from the first-aid post
to the casualty clearing-station, he was " sorted out " by a medi-
cal officer, and, if he seemed to require immediate attendance by
an experienced surgeon, was sent direct to the field hospital,
which might adjoin the clearing-station. Cases not so urgently
requiring operation went by ambulance to the railhead and
from there, by train, to the base.
Another modification was found in the introduction of con- valescent camps. Experience showed that if a man was to make a good recovery he must be followed through all the stages of his convalescence. If he was allowed the freedom of the base town he often did himself hurt and always found it a great strain to get ready again for the life of the trenches. If, on the contrary, he was " kept in the machine," taken from hospital to what was a great military camp equipped with every conceivable means of healthful amusement, he recovered much more rapidly and never fell out of the army spirit.
These convalescent camps were therefore established in the near neighbourhood of the base hospitals. They combined sport and pastime with a certain measure of physical culture. Dis- cipline was fully maintained. On coming to the camp a convales- cent man found himself in the company of hundreds of other men all in process of recovering and all making ready for the fighting ahead. He lived in the war atmosphere. He trained for war. At the same time he was able to enjoy many different kinds of entertainments and to play any games he chose. He might also engage in gardening or less strenuous pursuits while strength was returning. At all periods of his stay he was under careful medical scrutiny. The camps relieved the burden on the hospital ships and also on the base hospitals themselves. They prevented an undue loss of fighting material, and, moreover, gave to the active forces the sense of being well cared for in the event of wounding, which is an important moral support.
Yet a third modification was the introduction of special methods of treatment in the field. An illustration is furnished by the camps for cases of soldiers' heart or nervous heart. This condition was investigated at the request of the War Office by a group of specialists in England who declared that it was not heart disease and that it could be benefited by a course of grad- uated exercise. Instructors were therefore obtained and trained in the application of the special exercises and were then sent out to France to work under the direction of highly qualified medical officers. Heart cases of all kinds were forwarded at once from the hospitals to the heart centres. Here they were sorted out into serious and non-serious types. The first class were sent to England forthwith to be discharged from the service as perma- nently-unfit; the second class began at once the course of treat- ment training. By this means an immense relief was afforded to hospital accommodation there were vast numbers of these cases and a large number of useful soldiers were retained in the active force.
In the meanwhile Sir Alfred Keogh inaugurated, in conjunc- tion with the Medical Research Committee, his famous system of team-work research on war diseases. He called to his assist- ance all the best British brains in medicine and he made it easy for any physician or surgeon with an idea to approach him. Very early in the day anti-typhoid vaccination was enforced throughout the whole army and every recruit received his dose of the vaccine as a matter of routine. Then came the Gallipoli campaign and with it the discovery that, while the vaccination protected against the typhoid bacillus, it did not protect against its prototypes, the paratyphoid bacilli A and B. This discovery
was made the basis of an immediate inquiry, and the result was the introduction of a new vaccine giving protection against all the typhoid group of organisms. After this the typhoid fevers steadily declined and became a minor problem.
Another routine which was instituted was the administration to every wounded man, no matter how slight his wound might be, of a dose of anti-tetanic serum. This measure soon made tetanus a negligible factor. Methods of dealing with the infections of wounds also engaged attention and resulted in much greater care being bestowed on the cleansing and treatment of wounds near the front line. Teams of workers were also set to solve the prob- lems of cerebro-spinal meningitis, which broke out severely in various camps, trench fever, trench nephritis, wound shock, gas gangrene, the treatment of fractures and so on.
In almost every instance valuable knowledge was acquired. So perfect had the organization become that it was possible to apply this knowledge forthwith. Thus a better spacing of sleep- ing accommodation reduced the incidence of cerebro-spinal fever, while the preparation of a serum having powers against all the four strains of meningo-cocci present reduced the mortal- ity by some 30 per cent. As soon as it became known how great a part lice were playing in the spread of trench fever a campaign of disinfestation was started. The services of distinguished entomologists were secured, and these were commissioned and sent out to France to examine and report. The result was an added care of the bathing facilities for men behind the lines and a very perfect system of disinfestation of clothing by heat. In this way enormous numbers of lice and nits were disposed of and the incidence of the disease restricted. Sleeping-quarters were also taken under expert care, and blankets and night attire subjected to careful and continuous scrutiny.
The entomologist indeed became a part of army organization and had plenary powers which were undreamed-of in earlier campaigns. Acting in conjunction with the sanitary corps, he stood between the soldier and the deadly pest which threatened him. Large fly-destruction campaigns were inaugurated and every measure calculated to prevent the breeding of flies in or around camps was put into force. The results were exceedingly good, more especially in the East, where flies constituted a serious menace. In the same way, in the Struma valley, pools containing the larvae of mosquitos were drained or treated with paraffin and the troops thus protected against malaria. In Egypt, too, Col. Leiper was set to solve the riddle of that troublesome disease bilharziosis, and was so successful in his quest that within three months he had located the intermediate host of the parasite, a water snail, and suggested means for its destruction.
Indeed, the organization of preventive medicine in the war was as good in every way as the organization of curative meas- ures. The sanitary corps developed to a state of efficiency which has probably never been equalled. Methods of chlorination of water were brought to high perfection, so that if the men obeyed the instructions issued to them and most of them did all danger from imbibing contaminations was eliminated. Cholera threatened, but it never became serious; even dysentery, though it claimed enormous numbers of victims at GallipoH and else- where, was brought under a great measure of control. Nor was food inspection less successful. The army ate well throughout the whole war; it ate safely, thanks to the unremitting vigilance of this most capable body of officers and men.
An organization of this kind was ever ready to seize on and apply new methods. Thus the use of steel helmets was early suggested by surgeons in France and was finally enforced by the demands of the R.A.M.C. These helmets represent a very good example of preventive surgery, since head wounds, before they were introduced, had claimed great numbers of victims. The reduction in the number of those wounds after the helmets were obtained was a complete justification of everything urged in their favour. The small cuts and scratches, the scalp wounds, the bruises, which before had killed many useful soldiers, be- came things of the past.
Nor was the work accomplished in connexion with poison-gas less triumphantly successful. It is difficult to realize the immense
