THE YEAR I broke up the Inquisitive Club was a fruitful one. Not only were our researches showing results, but plans for the enlargement of Lakeside Hospital that had been in the making for a number of years, began to mature. In 1910 Dr. Allen resigned, several years before he had reached the age of sixty, thus terminating the friendly rivalry between us before I wished. This threw on me the whole burden of surgery both in the school and the hospital but it also gave me a freer hand in promoting an idea that had been occupying Edward Cushing and me for a long time.

A fund for an obstetrical pavilion having been given to Lakeside Hospital, an effort was made, in which Edward Cushing and I were especially interested to see how Lakeside could be remodelled. The natural step was to purchase the adjoining Marine Hospital site but the government would not sell. This led to the suggestion of a group plan to include the Babies' Hospital, the Maternity Hospital, Lakeside and the Medical School.

We easily convinced Mr. H. M. Hanna that this was logical, so I arranged with Abraham Flexner of the Carnegie Foundation to present such a scheme to a small group that was interested; and I myself presented to the Trustees of the Lakeside. Hospital, the Medical School and the University, the general plan with sketches of the proposed buildings, and discussed a group-plan policy. Mr. Hanna had borne all expenses.

A little later Mr. Hanna sent me an urgent request to bring the plans to Thomasville, Georgia, as Colonel Payne whom he had interested in them, was planning his will. Armed with the sketches, I went to Thomasville where Mr. Hanna and I had several conferences with Colonel Payne, with the result that the colonel promised to will one million dollars as a bequest to Lakeside Hospital.

All evolved as planned and sufficient land was purchased across the street from Lakeside Hospital. Then came the war. As time passed the residence and business sections of the city so changed that a downtown site became unsuitable.

At one time the Rockefeller plot was considered; at another Dr. Charles Thwing, President of Western Reserve University and I personally held an option over a year on a large acreage at the head of Cedar Hill, extending to Ambler Boulevard in the hope that the entire University might move to that site. Finally out of it all came the purchase of the Ford property and the University group was formulated.

But although all of these projects eventually worked out as Ned Cushing and I had originally dreamed them, he did not live to see them realized. Early the next year, while Grace and I were dining at his home on the eve of his departure for Europe, he was taken ill suddenly. Harvey Cushing came at once but the obstruction could not be removed, and death, during the approach of which Ned was complete master of himself, came a few days later.

Another of the ideas that had developed to a gratifying degree by the year I became head surgeon at Lakeside, was that of the American Society of Clinical Surgery. The simple but dramatic principle of this Society was quickly recognized by Franklin Martin, the enterprising owner and editor of the journal, Surgery Gynecology and Obstetrics, which he had established in 1905. The keen mind of Franklin Martin saw the possibility of applying this principle on a large scale under the auspices of his journal and began to organize a large national group to be named "The Clinical Congress of Surgeons of North America." At its first meeting, held in Chicago in November 1910, thirteen hundred surgeons were present as against the two hundred for whom Martin had hoped. The medical politicians watched the movement with amusement, but practical surgeons welcomed it because it extended to them the advantages of the Society of Clinical Surgery.

The rapid rise in the popularity of these clinical congresses was so great that only four cities were large enough to accommodate them. In other words Franklin Martin formed, as he himself put it, a "North America-wide Super Society of Clinical Surgery."

For many years a small group of us had persistently discussed the advisability of forming in America a counterpart of the Royal College of Surgeons of England. The insistent demand for such an organization came to a focus at the Clinical Congress in New York in 1912, the members of the American Society of Clinical Surgery collaborating with Franklin Martin in the organization of the American College of Surgeons. The American Surgical Association favored the pattern of the Royal College of Surgeons in England---character, examinations, and a great museum---that is to say, the surgical egg was to be "candled," then left to itself to grow and develop. But the American Society of Clinical Surgery and the Clinical Congress of Surgeons of North America favored an organization that would be a combination of both the static and the dynamic. We wanted one that would have the function of a college-postgraduate education, and standardization.

It was evident that the American Surgical Association, although comprising many of the professors in the medical schools, particularly along the Atlantic seaboard, was too exclusive, too immobile, to undertake this new movement, and furthermore, it was unwilling to cooperate. The American Society of Clinical Surgery furnished the pattern, but this group of forty members formed too small a nucleus to develop a great program alone.

During this period the members of the American Society of Clinical Surgery were collaborating with Franklin Martin in his continentwide application of the principles of their society in the recently formed Clinical Congress of Surgeons of North America. Thus the Society of Clinical Surgery furnished the idea, Franklin Martin and his journal furnished the spark, and the American Surgical Association furnished the opposition.

On November 25, 1912, charter was granted by the State of Illinois for the establishment of the American College of Surgeons.

In its organization the College was patterned after our Federal government, and the government of the Dominion of Canada as it recognized states and provinces as units in the organization.

Dr. Franklin Martin was appointed Director General, and a Board of Regents, a Board of Governors, a Credentials Committee for each state and province, and a Central Credentials Committee were established.

The committee which drafted the original bylaws, rules, and regulations consisted of the following: Franklin H. Martin, of Chicago; George Emerson Brewer, of New York; Walter W. Chipman, of Montreal; Frederick J. Cotton, of Boston; George Crile, of Cleveland; John M. T. Finney, of Baltimore; Edward Martin, of Philadelphia; Rudolph Matas, of New Orleans; Charles H. Mayo, of Rochester; Albert J. Ochsner, of Chicago; John B. Murphy, of Chicago; Emmet Rixford, of San Francisco.

At the organization meeting of the American College of Surgeons I suggested a plan that had recently come to my attention as one of the Founders of the Cleveland Museum of Natural History. This was that each life member pledge five hundred dollars to be paid in full or in installments with interest of five per cent annually on the unpaid balance.

This plan was adopted. Thus in one move the College found itself organized and financed.

The effect of an immediate financing was a prompt projection of an organization with headquarters in Washington. After a long discussion as to the merits of Washington and Chicago, the purchase of the final site, land and building, by the profession in Chicago closed the matter.

Since the organizing committee of the American College of Surgeons was formed during the Assembly of the American Congress of Surgery, since Franklin Martin and his journal, Surgery, Gynecology, and Obstetrics, fostered the Assembly of the American Congress of Surgery, since Franklin Martin possessed endless energy and zeal as well as endless enthusiasm and was not involved in private practice or teaching to the extent that other members were, Martin received the unanimous vote for the Clinical Director of the newly organized College.

Both Murphy and I were sounded out as to accepting the presidency, and we expressed the opinion that it would get better co-operation if it were given an Eastern president who would win over the conservatives of the Eastern seaboard. Everyone liked John Finney: he was an able surgeon, a good teacher, and represented Johns Hopkins University, so on May 5, 1913, John M. T. Finney received the honor of being selected the first President of the American College of Surgeons, and the following men received election to the first Board of Regents: George E. Armstrong, of Montreal; George E. Brewer, of New York; Herbert A. Bruce, of Toronto; Frederic J. Cotton, of Boston; George Crile, of Cleveland; John M. T. Finney, of Baltimore; William D. Haggard, of Nashville; Edward Martin, of Philadelphia; Franklin H. Martin, of Chicago; Charles H. Mayo, of Rochester; Robert E. McKechnie, of Vancouver; John B. Murphy, of Chicago; Albert J. Ochsner, of Chicago; Harry M. Sherman, of San Francisco; Charles F. Stokes, of Washington.

Franklin Martin was peculiarly endowed with talents needed to combat the stormy years of organization and of trial and error, as he possessed beside a genius and talent for organization, inexhaustible energy, idealism, and a realistic understanding of the opportunity for a career. I thought at the time and I still think that no other man could have developed such an organization out of an unorganized surgical profession and on a continent-wide basis, in so short a time. In the spirit of an evangelist, Dr. Martin personally visited the principal centers all over the continent asking for and getting as a nucleus the membership of the leading surgical societies. It requires an historic view to evaluate his work properly, but one fact stands out---his character. The group that shared with him the founding of the College and the journal remained with him until his death at the age of seventy-eight.

The month Finney was elected President of the new College it received an impetus from England. In May 1913, Harvey Cushing, Will Mayo, John Murphy and I were informed by the President of the Royal College of Surgeons that the college wished to confer on us honorary fellowships at the International Medical Congress which was to meet in London in August.

This was a great honor, and with the formation of an American College of Surgeons becoming a certainty, Franklin Martin also visited London at this time and an invitation was accorded him to attend.

Promptly at six, when the big second hand reached the sixtieth second, we were ushered into the council chamber of the Royal College of Surgeons, on the walls of which hung the original portraits of Hunter, Cooper, Pott, Abernethy, Sydenham, Lister and others.

At one end of the chamber was a sort of throne occupied by the President. On his right was seated the Vice President; on the left, the Secretary. All wore impressive robes of office.

Along each side were two rows of chairs. On the rows near the wall the members of the Council were seated. In the front rows sat the candidates for admission. These were: Professor von Eiselsberg, of Vienna; Professor Bier, of Berlin; Professor Tuffier, Paris; Professor Monprofit, Paris; Professor Fuchs, Vienna; Professor Block, Copenhagen; Professor Bastianelli, Rome and Dr. J. B. Murphy, Dr. W. J. Mayo, Dr. Harvey Gushing and I. Everyone wore the beautiful academic robe of the College.

Each candidate in turn was escorted to the President and introduced by the Vice President, who in a few words mentioned the reasons for the candidate's qualifications for Honorary Fellowship. Then the President repeating the name of the candidate said, "In the name and by the authority of The Royal College of Surgeons of England, I grant you fellowship therein."

After signing the roll each candidate was handed a diploma.

The ceremony, simple, dignified and impressive was followed by a banquet tendered to the new Fellows by the Council and a visit to the Museum after which Moynihan took me over to the Royal Automobile Club where we discussed problems of medicine late into the night.

Meanwhile Martin zealously collected information about the function of the Royal College and discussed the American project with the President, Sir Rickman Godlee, a nephew of Lord Lister, who accepted an invitation to deliver the dedicatory address at the first Convocation of the new American College of Surgeons to be held in Chicago on November thirteenth, during the fourth annual Clinical Congress.

But what is the American College of Surgeons? What are its aims and objects? How do its activities affect the general public?

The American College of Surgeons ever since its inception has been constantly extending its interests not for the benefit of the surgical profession primarily, but for the general public. The automobile, the airplane, and other methods of transportation as well as the machinery of civilized man has such a wide distribution on the highways, on the farms, and ranches, and in the mines that everyone is in the front line of danger. This means that in the case of accident, as well as in the case of a disease for which a surgical operation is required, it is as necessary to have a good surgeon in the most remote place as it is in Cleveland or New York or San Francisco.

The task of the American College of Surgeons therefore has been to see that there are good surgeons and good hospitals all over the United States and Canada so that wherever there is a human being who requires the service of a surgeon there may be a good surgeon available and a good hospital within easy reach.

But what of the medical schools? Are not good surgeons being graduated every year?

That is true. But experience in practical surgery comes after graduation. It requires from two to six years of actual practical training in a well-equipped hospital before the young graduate can be trusted to take care of surgical patients, and university hospitals do not provide a sufficient number of internships to take care of all who would be surgeons. Therefore much training is acquired in hospitals not connected with leading universities, and which have to be standardized.

After the surgeon has completed his intern training, is his education complete? By no means. In no other profession is a continuing education more essential than in that of medicine. New discoveries in medicine, new alliances with such basic sciences as physics and chemistry, new surgical methods, refinements of technic, the occasional meeting with a rare disease require that the surgeon keep in constant touch with his fellows. The younger surgeons learn from the experience of their elders, the older surgeons avoid the ever-present danger of becoming stale. Therefore in medicine there is constant need of postgraduate education.

To this end the College inaugurated a plan of sectional meetings to give members of the profession throughout the country the opportunity of hearing scientific discussions by surgeons beyond their own territory, to give the public the opportunity of hearing addresses by leaders of the profession and by prominent laymen, and to bring together hospital administrators in each locality for the discussion of problems encountered by them in the standardization program.

The standard for hospitals and for surgeons, will of course, be everchanging, as the minimum standard will rise and fall with the type of young doctor who enters the field; with the state of medical science; with the social attitude toward medicine; and with the work of the medical colleges.

The Founders of the American College of Surgeons were a surgically patriotic group who set an example of willingness to endow themselves in perpetuity by a gift to the permanent fund, to conform to standards and to make the necessary financial sacrifices to carry out the program of standardization.

It is to the credit of all who have been interested in this far-reaching institution that during its existence there has been a transformation in the standards of hospitals and in all ethical standards, as well as an increase in the number of men taking advanced training in surgery, and continent-wide programs for an increase in postgraduate work and in education of the public in many medical problems.

It is one thing to candle the egg but quite another to hatch it and bring up the chick.

FOR SEVERAL YEARS a high Baker electric roadster had served me on my daily rounds. I drove it with the top down and each morning started out with my little Scottie perched on the top. Although "Bonnie Scot" was always shaken off along the route, he never failed to be on hand for the next morning's adventure.

But one day while in a garage for repairs, the car was consumed by fire. This misfortune introduced me to our first automobile--a 1910 Packard touring car---delivered in July 1909. Our Irish coachman knew nothing about "machinery" so I sent him to Detroit to learn to drive and care for this "motor car."

Grace and the children were at the seashore, so when it came time for me to join them, I sent the car East.

After an historic tour of New England with Margaret and Elisabeth, in which I climbed everything from Bunker Hill Monument to the belfry of the Old South Church, Grace and I set out alone for a tour through the White Mountains. Upon arrival at Bretton Woods, I was summoned to the telephone. It was Judge Robert S. Lovett, personal counsel of Mr. E. H. Harriman, asking me to come at once to Arden, New York, on a special train that would be at the station in half an hour, to see Mr. Harriman.

Knowing when we decided not to operate, that he had but a short time to live, Mr. Harriman asked me to stay and visit with him for a few hours. He told me with considerable bitterness details of what he considered Theodore Roosevelt's dishonesty. A week before the election, he said, Roosevelt asked him to come to Washington. Roosevelt was thoroughly frightened by the prospect that New York could not be saved for the Republican Party and urged Harriman to raise as much money as he possibly could to save the national election. Harriman raised $260,000, of which he himself donated $100,000, almost all of which was spent for the purchase of votes in New York City.

Mr. Harriman said that at the time Mr. Roosevelt was profoundly grateful since he believed that this effort changed the election in his favor by over a hundred thousand votes. Later, however, when it was popular for the President to abuse big business, he also abused men of wealth and disloyally named Mr. Harriman as one of the great malefactors. This, Mr. Harriman never forgave. He was emphatic and bitter in his statements to me that Theodore Roosevelt was not honest.

During this visit I had the unique experience of holding Wall Street in the palm of my hand, for I was one of the three or four people who knew the truth about what Wall Street held to be an uncertainty. It so happened that I had invested in Union Pacific and, when it was low, had increased my holdings, realizing that these were my years of personal harvest time and that if I did not make a financial success then, Grace might one day find herself trying to sell short stories or giving afternoon lectures on European Art as Seen in a Tour with Aunt Ella. So every time I accumulated a few thousand dollars, I invested it, telling myself, this will buy so many months of serenity in our old age. Now here I was with the knowledge by which a man could make a fortune, and I couldn't use it to make a cent.

Ed who was always in every game with me wrote that the office was besieged by newspaper men; and added, "One of the questions you probably asked Harriman when you made the diagnosis was how high will Union Pacific go?"

While Grace and I were motoring in the East, the Governor, Grace's father suffered a slight stroke which left him unable to play golf or cast a trout line to his satisfaction, so that motoring and hunting in the duck season were the only forms of amusement that were open to him.

As the American Society of Clinical Surgery was planning to visit England and Scotland in the summer of 1910 and I was President, we decided to ship the car, take the Governor and Grace's brother, Donald, with us and the chauffeur.

When the members of the Society arrived in Oxford they were met by Osier, who was delightful in his recountal of many facts and perhaps fancies, regarding the men who made history in the days when these colleges were built.

I was much interested to see Watson Cheyne at work in King's College Hospital---a musty old building in the slum district of London. Cheyne was a student of Lister and retained Lister's methods. The anesthetic was chloroform. The patient was scrubbed with corrosive and everything was wrung out in carbolic solution. But although Cheyne wore a rubber gown under a wet cotton one, and a face mask, his assistants worked in high rubber aprons above which their colored ties and collars showed. Yet to the surprise of all of us Cheyne had excellent results with his old-fashioned antisepsis.

At Leeds we saw Moynihan, who stands alone in British surgery. He told us he had "picked up quite a few American tricks," but Moynihan was a great showman. He could learn from others and put on a show.

At Newcastle-on-Tyne, after seeing Morrison operate in the Royal Victoria Infirmary, we attended a beautiful dinner at the surgical museum where he pointed out to us many interesting specimens. In his clinic he and his assistants wore rubber boots and kept their instruments in a weak carbolic solution.

The patient, with the exception of the field of operation, was covered with oilskin and sea sponges were used, the number being chalked up on the window, to avoid an oversight. I was particularly impressed by the possibilities of an assistant of Morrison---Grey Turner---a likeable, alert young surgeon, for whom I predicted a career. That evening I gave a lecture on transfusion before the local society.

The Royal Infirmary in Edinburgh has nine hundred beds and six amphitheatres. As all were going at once, it was like a six-ring circus. I was particularly interested to see Alexis Thompson operate upon a sarcoma, but his method of operating under chloroform and not tying the external carotids or doing a block excision surprised me.

Lovable Harold Stiles struck me as an intellectual surgeon. He follows the Lister technic but was a singularly instructive lecturer.

The next summer Stiles visited the United States and accompanied us on a trip west to attend three meetings: the American Surgical Association in Denver, the American Society of Clinical Surgery in San Francisco and the American Medical Society in Los Angeles. As a travelling companion he proved to be a delightfully absent-minded Scotsman, who never knew where he had left his hat, his coat, or, at times, himself. He was intensely interested in everything American. Once when the train made an unexpected stop, Stiles, unknown to anyone, jumped out and climbed a hill to take a photograph. Meanwhile, the train proceeded, leaving him without hat, coat, billfold, or express checks. After a series of telegrams, Dr. Malcolm Harris who was managing every detail of the thirteen specials, planned with the conductor for the transportation of Stiles on a special engine. Until it came he amused himself in a saloon "listening to cowboy America."

While attending a luncheon in San Francisco, Stiles expressed special interest in the great earthquake. Dr. Moffett said to him, "We have them often. Perhaps we can pull one off for you while you are here." He had hardly uttered the words when a tremor was felt. Water spilled, chandeliers rocked and, as the tremor grew in severity, everyone but Stiles jumped to his feet. Stiles alone remained unconcerned. After it was all over and we had returned to the table, damp from spilled water and wine, we asked Stiles if he hadn't felt the vibration.

"Oh, come, you can't hoodwink me like that," he answered. After much assurance that it was a real earthquake, Stiles rose to the laugh, delighted that it was not an artificial shaking of the building arranged by Dr. Moffett.

The following summer (1912) Grace and I took Margaret and Elisabeth, aged eleven and nine, to Europe with us when the American Society of Clinical Surgery visited Germany. The outstanding memories of the trip were Professor Lexer's clinic in Jena, in which we saw brilliant examples of plastic surgery---among them a new face for which Lexer had contrived a mustache, even an imperial from the patient's hair; and Margaret's determination to view the relics of Frederick the Great. Frederick was her hero so she wanted to see the clothes he wore, the chair he died in, the bullet which had it not hit his snuffbox would have killed him, the flute he played, and his favorite greyhound.

Elisabeth, on the other hand, was as enthusiastic over Napoleon as Margaret was over Frederick, so there was a continual argument. The climax was reached when Margaret learned that after the Siege of Berlin, Napoleon and two of his officers visited the grave of Frederick and, although Napoleon commented that if Frederick were alive he would not be there, he demanded that the coffin be opened and took Frederick's sword and carried it to France. Margaret wept; Elisabeth rejoiced.

Then too, there was the moment when Charlie Mayo and I ran afoul of the German police. We were driving from Stuttgart to Tübingen along a road bordered with cherry trees on which luscious black cherries dangled almost within our reach. We ordered the chauffeur to stop and in spite of his protests, began to fill our hats and pockets when suddenly two soldiers came running across the street, shouting "Verboten!" These were the Kaiser's cherries! We were obliged to hand over every cherry to the military police.

There was also the embarrassing "story of Crile's night shirt," as Charlie Mayo was wont to call it and which he never allowed me to forget. Upon arrival in Heidelberg, the men went immediately to Wilms Clinic. In the middle of the morning I was taken ill, with severe pain-so returned to my room. Grace was not there. Nothing had been unpacked but her nightgown was hanging in the closet. Though a fragile-looking affair, trimmed with lace and pink ribbons I put it on and fell asleep, not waking until Charlie Mayo, Ochsner, Murphy and the august Herr Professor Wilms entered my room.

I had utterly forgotten my predicament until Charlie preparing to examine me said, "What damn kind of a nightshirt is this, Crile? Do you always masquerade like this at night?"

In summing up my observations in the clinics of Kümmell in Hamburg; Körte and Bier in Berlin; Payr in Leipzig, Lexer in Jena; von Eiselsberg and Hochenogg in Vienna, von Müller in Munich; Perthes in Tübingen; Hofmeister in Stuttgart; Wilms in Heidelberg; Enderlen in Würzburg and Rehn in Frankfurt---of all the surgeons in Europe, Professor von Eiselsberg trained by my old master was the most outstanding. He worked in every field. Moynihan was without doubt the greatest surgeon of the upper abdomen in England but our own Judd was his equal in technic although he did not possess his showmanship, but neither Moynihan nor Judd surpassed von Eiselsberg.

I thought that on the whole the German hospitals were better organized than were those in any other country. They had an almost military character. All clinics were under a single head. The number of surgical beds ranged from 125 to 600, so energetic, capable men were given real opportunities for work. Experimental work was carried on in connection with clinical work in every hospital.

While it was true that American clinics equalled or possibly excelled the German clinics in the care and consideration given the individual patient, the German clinics excelled in organization and research. The American surgeon was most vitally concerned with the patient immediately in his charge. The German surgeon was working for the welfare of the future patient.

My personal part in the International Medical Congress which met in London the following year, at which time the Honorary Degree of the Royal College of Surgeons was conferred upon a few of us, was complicated by the fact that Grace and I were expecting the arrival of "Bob." I was so disturbed by the thought of leaving her at this time that I stayed in London only long enough to read my paper on Shock, receive my honor, then rush home. The moment the boat docked I telephoned Cleveland and was told by Margaret that the boy had arrived.

"Oh, all right, all right," I gasped and, in my relief, hung up. Five minutes later I collected my wits and called her again to ask how everything was and what Bob looked like.

Soon after my return, unwittingly I was the means of breaking a speed record. I was called in consultation to Toledo and a special train was sent for me. The engineer made the 102 mile-run in eighty-three minutes. Between Elyria Junction and Amherst, the 7.53 miles in three minutes was at the rate of 150.6 miles per hour, and at this speed, they told me, the drivers of the locomotive turned over at the almost impossible rate of 650 revolutions per minute. It was hurricane speed. We took water on the run and it seemed as though we were in the vortex of a water spout.

The automobile which took me to the hospital in which Mr. George W. Bennet, Vice-president of Willys-Overland Company, was dying, was in charge of a police escort and established a record for an automobile run.

I never recall this dramatic ride without being reminded of a ride that Will Mayo and I had together in one of the large cities of the West. Again if anything was of avail, speed was essential.

When we stepped into the automobile we were told by a policeman that orders were all speed laws were to be abolished, a police escort would clear the way and a second limousine would follow in case of need. It was needed and we climbed out through the window of the first wrecked car and were away in the second one before even a crowd gathered.

During these years I seized every spare moment to write. The whole subject of man as an adaptable mechanism was beginning to crystallize in my mind. More and more, phylogeny appeared to be the key that unlocked the mysteries of man's apparently complicated mechanism.

In our studies of the brain cells we had found that injuries inflicted on the brain, the thyroid and the adrenal cells were identical whether the injury was wrought upon the cells by emotion, infection, toxins, muscular exertion, exophthalmic goiter, adrenalin, or strychnine. We knew also that histologic changes occurred in only three organs---the brain, the liver and the adrenal glands, and that the excision of any of these three organs would cause death; but we had found also that with no exception, excitation by fear alone or by adrenalin alone caused the billions of brain cells to exhibit a brilliantly increased intensity of stain, and that so long as there existed a different stainability between the nucleus and the cytoplasm of the brain cells, recovery would take place. We were handicapped, however, because we could make no direct observations within the protoplasm itself when it was responding to the influences that caused excitation, depression and finally, death, so I felt that we had exhausted the physiological, etiological and biochemical methods.

Having carried in my mind ever since my training in histology at Columbia University, the fundamental fact that all living cells, whether plant or animal, require differential stains to define their internal structure, I turned to the study of the nature of the living. Taking into account that life exists only in cells; that all cells possess two parts, the nucleus that takes an acid stain and the cytoplasm that takes an alkaline stain; that these two parts are separated by a semipermeable membrane and that each part suffers a definite change at death, and that not only animal but plant life is incompatible with acidity, I formulated the theory that all living cells are electrical in nature, functioning and hence living only when there exists a difference in potential.

This conception was at first overwhelming to me as it showed that our long research had disclosed only the machine, not the energy. It catapulted my researches from histology into physics, from structure and form into energy.

My new hypothesis held that all living cells are electric batteries and that energy of the living was not an unknowable, mystical force but the energy of the universe-radiant and electric energy.

With this new hypothesis in mind, as I looked back, I could see that the essential quality possessed by the bad risk patient and not shared by the good risk patient was a loss of electric potential in the organs essential to life, as the normal individual is one in whom there is constantly a normal range of electric potential in all of his organs and tissues. From the initial case of William Lyndman, throughout all of our experimental studies, it was evident that oxidation through the power and personality of the man or animal, in health or disease, automatically released the radiant and electric energy which, depending upon its intensity, resulted in work depression, or death.

Thus from a research into the form of cells, I turned to a research into the energy which operates these cells, a winding trail that was to occupy me the rest of my life.

That year I set up a simple laboratory with physical apparatus for measuring electric conductivity, electric capacity and electric potential.

Dr. G. B. Obear of the Case School of Applied Science and Miss Amy F. Rowland who had become my editorial secretary, were associates in this research. We began our observations upon the electric conductivity of tissues and organs of animals that had been through the entire gamut of excitation, depression and death, as in our long series of previous studies.

That summer, when we spent our vacation in Algonquin Park, a virgin forest in Ontario, I had time to write. In a red-blanket wrapper I drifted on the lake and wrote for hours, or sometimes I enlisted the interest of the children in some simple experiments. Then as a matter of real recreation I crossed the lake to an old mill and "turned" potato mashers, wooden hammers, etc. Barney remembers that the first research he ever did with me was our experiments with trout. Each one of the children brought a live fish for our specially constructed pool. I scraped off the slime and scales on one side and put the fish back in the pool after which we all watched their behavior. They could swim only in circles. After we spread butter, lard or heavy oil over the scraped area, they could orient themselves and showed less loss of power. I was trying to determine whether or not the swimming motion of the fish is dependent on preserving insulation between their nerve and muscular mechanism and the water.

While we were occupied with our fish pond, war was declared. Although we were in the heart of the forest where its tendons could not reach, the war was so compelling that each day I sent a guide to the nearest town nine miles away---eighteen miles for a newspaper.

When we returned to Cleveland, it was good to be occupied with the familiar work as though our world were normal, but behind it all was the shadow of the battles in France. I was gathering together the notes on anoci-association, the manuscript of which was published that year by W. B. Saunders Company, and was making a beginning on the manuscript, "The Origin and Nature of the Emotions," which I expected to publish in 1915. Somehow I felt the need of hurrying to get our affairs in order since we seemed to be driven by a force that we did not want to recognize, as though we knew already that the war was ours.

FOR ME, AMERICA entered the First World War when the Germans nearly reached Paris in 1914, and the Honorable Myron T. Herrick decided to remain when other ambassadors left.

The American Colony in Paris wanted to establish an American Military Hospital or Ambulance Américaine, as they called it, similar to the one that the Colony had established in the Franco-Prussian War. Through Dr. du Bouchet of Paris and Dr. E. L. Gros, Ambassador Herrick arranged with the French government to use for this purpose a new high school, the Lycée Pasteur at Neuilly-sur-Seine, in which they received their first wounded late in August. Ambassador Herrick, ex-Ambassador Robert Bacon and Mr. Francis Drake, President of the American Chamber of Commerce in Paris, drove to the battlefields outside of Paris, picked up the wounded in their own cars and brought them to the hospital. But they needed funds to complete and equip the building.

Early in October 1914, Mr. Herrick wrote me that Mr. Drake was on his way to America to raise money for the hospital, and would come to see me for suggestions. Mr. Drake wanted to visit Lakeside and witness operations. He had never seen nitrous oxide-oxygen anesthesia and was so impressed with the ease with which patients went under and came out of it in comparison with the struggles and dreams under ether, that he asked if I would consider service in their new hospital. Great as the temptation was, I replied that I would be of no use without my staff.

That night I went home and told Grace about it. Before the evening was over I had evolved the plan of a university service: if the Lakeside Trustees would raise ten thousand dollars to send over my staff for a three months' service in military surgery, Dr. Lower and I would be willing to finance our own way. I felt sure I could interest three other universities in taking three months' service each, making a year, if Dr. du Bouchet would give space for these American units.

The next morning I approached Mr. Mather, President of Lakeside Hospital, with a written outline of a plan by which Lakeside would undertake to operate one unit of the Paris Hospital and also carry out important research. The principal features were as follows:

While the Board of Lakeside was considering this idea, Mr. Drake worked out with the Medical Board of the American Hospital of Paris, of which Dr. J. A. Blake of New York was a member, a comprehensive plan for American participation. On November twenty-seventh, he wrote,

"The Medical Board of the American Hospital of Paris have asked me to arrange if possible a plan by which our leading medical schools could send over a corps of men to take care of one of our services of one hundred and fifty beds in this hospital for three months at a time, arrangements being made so that the corps from each college should follow each other in succession and without interruption of service. Since you were the first to offer such a corps to this hospital, I am writing you to see if you will not be the leader in this movement.

"The present capacity of the Ambulance is about 450 beds. There are three services, each one containing about 150 beds. We have a small pathological laboratory and one pathologist whose time is almost entirely occupied in autopsy work. We are in need of a competent bacteriologist and a clinical pathologist as well, with the necessary aids. No money has been raised so far for this very desirable extension of our work which, in my opinion, should be carried out by us since we are practically the only ones who have time and men to give to it ....

"We should like to start this plan by January 1st at the latest.

"I should like to have you, if you possibly can, confer with the other colleges. I have thought of Harvard, Pennsylvania, Johns Hopkins and Chicago as being some of the first we should ask. Columbia is so well represented over here by Martin's contingent which we hope will be followed by another headed by Lambert and then again possibly by Brewer, that I do not think we need consider it.

"In regard to financial arrangements, it is hoped that each university will pay the expense of travel and the salaries, if there be any, of its entire corps."

Less than a week after I received this letter from Dr. Blake, Mr. Mather informed me that the Executive Committee had given authority to release such members of my staff as might volunteer for the Paris work, provided suitable substitutes could be found. Whereupon I cabled Dr. du Bouchet, executive head of the Ambulance, that I accepted the proposal for three months, concluding the cablegram with: "Sail Adriatic thirtieth December. Two anesthetists, two operating room nurses, myself and three surgeons, neurologist, clinical pathologist and three for special research. Equipped for nitrous oxide anesthesia. Authorize expenditure of one thousand dollars for needed changes. Hope to bring bacteriologist and to enlist other universities."

In the meantime there was correspondence with Harvey Cushing of Harvard University, with the University of Pennsylvania, with the University of Chicago and with Johns Hopkins. All but Johns Hopkins expressed willingness to take advantage of the opportunity to form a surgical unit on the pattern of the Lakeside Unit and accept service for three months at the American Ambulance.

Believing that the greatest efficiency would result from the service of men with similar training, I selected my group from among my immediate associates and operating-room staff at Lakeside Hospital, with an additional member for special research. The following were the personnel of the Unit: in addition to myself as chief surgeon, Ed Lower, associate surgeon; Dr. Charles W. Stone, neurologist; Drs. Samuel L. Ledbetter, Edward F. Kieger, Leroy B. Sherry, and Lyman F. Huffman, resident staff; Miss Agatha Hodgins and Miss Mabel Littleton, anesthetists; Miss Iva B. Davidson and Miss Ruth J. Roberts, operating nurses; and William B. Crozier and Amy F. Rowland, researchers. This service in France was made possible by the generosity of Mr. Mather who financed the expedition with the exception of the expenses of Ed and me, and a generous contribution from Mr. H. M. Hanna for research.

The Unit sailed on the Adriatic, I on the Lusitania, as I needed a day or so to arrange with the authorities for the transportation of our supplies to France. The passenger list was interesting, rather taciturn but seasoned and with every earmark of a campaign. Everyone was going to Europe in connection with war business, many being presidents of companies. One evening I found myself in conversation with the occupant of the cabin opposite from me, a Russian from Riga. In the middle of our discussion of the war, carried on through our open doors, the steward came to say that a woman in the next cabin requested that we speak a little louder as she was interested and was missing some points. Whereupon we ran a three-cornered discussion. She was a Canadian going over to meet her husband and was especially interested in the optimism of the Russian.

When our boat docked, the purser voluntarily came onto the pier and cleared our baggage without inspection, but he had no luck with the big steel cylinders of nitrous oxide which were marked "Very Inflammable" and were always under suspicion. When the English debarkation officer heard the name of Kieger who was in charge of the tanks, he asked why a man with a name like that should be allowed to enter England with a lot of inflammable gas. He asked Kieger for his birth certificate, but Kieger had never heard of such a thing. Finally the officer was brought to me. After he had listened to a long explanation of our mission and the nitrous oxide, he said, "Well, I don't know you or anything about you, but you look good to me, and I'm going to let you and your gas pass." As we landed we saw the first evidence of war-Hospital Ship No. 6 loaded with two hundred wounded from France.

In London we heard how the docks were stacked with delayed shipments so after interviewing countless people and getting Red Cross labels for everything, I gave Stone and Sherry money and letters and sent them to Southhampton with instructions to push through our supplies to Paris, dead or alive. Then I called on my old friends and found that everyone was in the service. Watson Cheyne was Chief Surgeon of the Navy, one son was an officer in the North Sea Fleet, the other at Ypres, where there was heavy fighting.

In Paris I found a smoothly running hospital in which we had a well-lighted operating room with an experimental laboratory adjoining. As Neuilly was out of the city limits, I had to go to the Prefecture of Police for a taxicab permit. The streets were subdued---no young life. Paris was at the front. At a meeting of the medical staff we arranged to give the Harvard Unit the next service, then Pennsylvania, Chicago, and Johns Hopkins if they should change their minds and become less neutral.

One of Moynihan's characteristic letters was waiting for me, saying that he wanted to bring his assistant one day soon to see our work.

He was acting as Consulting Surgeon to the forces in Rouen and Havre.

By the eleventh of January we were at work. There was news at last from Stone who had found the supplies aboard a transport, so I managed to send a truck for them.

The personnel of the hospital was fascinating and unusual: one of the orderlies in my operating room was a grand opera singer; another, an educated East Indian; another, a member of a well-known banking house. My best orderly was a French count who gave the ward splendid care and mounted in gold for the soldiers all the bullets and shrapnel that we removed. In charge of the sewing room was an able portrait painter.

The hospital was filled with every sort of wound. I interviewed many Tommies who fought through Mons and Charleroi to the Marne. These soldiers said that they had retreated continuously for nine days and nights without making camp, ever pushed by the fresh troops of the enemy. Only a few times were halts allowed, then merely to catch a moment of sleep or rest. Food and water were scarce and irregularly supplied. The men became so exhausted from the fatigue of marching, added to the fatigue from consciousness without restoration by sleep, that they slept while walking. Again and again they wakened each other. When they halted to rest, they fell asleep. They slept in water, on rough ground, when suffering the pangs of hunger, of thirst, and even when severely wounded. They cared not for capture or death if only they could sleep.

Their faces still showed deep lines. They appeared older than their years and they were relaxed, drowsy, taciturn. In some cases the pulse was still rapid and there was a slight rise in temperature.

To me the point of paramount interest in this retreat was the sleep phenomena experienced by these men. Over and over in my researches we had found that animals subjected to the most favorable conditions cannot survive longer than from five to eight days without sleep. In this retreat from Mons to the Marne we had an extraordinary human experiment in which many thousands had little sleep during nine days and, in addition, made forced marches and fought a great battle. How then did these men survive nine days apparently without opportunity to sleep?

The testimony of the soldiers---and I talked to many of them---never varied. It was that everyone at times slept on the march. They passed through villages asleep, yet marching. When sleep deepened and they began to reel, they were awakened by a comrade. With the enemy so close on their heels, no man was safe if he dropped behind for a moment because sleep conquered him. Many soldiers were captured asleep---asleep in water, on rough stones, in brush, or in the middle of the road, as if they had suddenly fallen in death. The artillerymen slept on horseback, as was evidenced by the fact that every man lost his cap.

The complete exhaustion of these men was vividly shown in what Dr. Gros told me. He, with others, went to the Marne battlefield in the only ambulance that was left in Paris. They arrived at Meaux at midnight and found the town in utter darkness. Not a sound in the streets---not a light. The only living things were hundreds of cats. The men called, they shouted, in vain they tried to arouse someone. At last they succeeded in awakening the mayor of whom they asked where they could find the wounded.

"My village is filled with them," he replied. "I will show you."

By the aid of a lamp they felt their way through the streets to a dilapidated schoolhouse. There was not a light, or. a sound. There was the stillness of death. They rapped. There was no response. They rapped louder. Hearing nothing, cautiously they pushed open the door. The building was packed with wounded; over five hundred, with all kinds of wounds. Some were dying, some were dead, but everyone was in deep sleep. Bleeding---yet asleep; limbs shattered---yet asleep; abdomen and chest torn wide open---asleep! They were lying on the hard floor and on bits of straw. Not a groan, not a motion, not a complaint---only sleep!

Surgical aid, the prospect of being taken to a good hospital, the prospect of food and drink and of being removed from the range of the enemy's guns awakened no interest. There was a sleepy indifference to everything. They had reached a stage of unconditional exhaustion and desired only to be left alone.

Dr. Gros and his ambulance corps brought back first the severely wounded with shattered legs and arms and penetrating wounds of the abdomen and chest. They made little or no complaint on being picked up, placed in the ambulances and transported. The only sound they uttered was when the torn flesh which adhered to the floor by dried blood was pulled loose.

When these men goaded by shot and shell for nine days without adequate sleep or food, in constant fear of capture and finally wounded, reached the hospital they slept while their wounds were being dressed. After deep sleep for two or three days during, which they wanted neither food nor drink, they began to be conscious of their surroundings. They asked questions, they had pain, they had discomforts and wants. They had returned from the abysmal oblivion of sleep.

After this one long draught of sleep their sleep became normal with but one exception---the dream of battle. The dream of a soldier is always the same---never a pleasant pastoral dream or one of home, but always of the enemy. It is the charge, the shell, the bayonet! Many men fight on during sleep. Again and again in the face of the great desire to sleep---a desire so great that the dressing of a compound fracture will not be felt, soldiers will spring up with a battle cry and reach for their rifles.

In the hospital wards, battle nightmares are common, and severely wounded men often jump to their feet. An unexpected analogy to this battle nightmare is found in the anesthetic dream. Precisely the same battle nightmare that occurs in sleep, occurs when soldiers are going under or coming out of anesthesia, at which time they often struggle valiantly, for the anesthetic dream, like the sleep dream, relates always to the enemy, usually to a surprise attack.

Here on an enormous scale was a human laboratory in which I was to observe all the methods of excitation, emotion and death that I had employed during twenty years in search of the identity of the energy in protoplasm which is diminished and finally lost in death by physical injury, pain, emotional excitation, infection, hunger and thirst, loss of sleep, hemorrhage, asphyxia, the destruction of organs, anesthetics, cold, and shell concussion. All of these in every degree down to death, the battlefield presented. Here protoplasm struggled against proto-plasm, each individual striving to exhaust and disintegrate the protoplasm of the other. No investigator would dream of subjecting animals without anesthetic to a tithe of the injuries that were inflicted in battle by normal young men upon each other.

BY THE MIDDLE of January our apparatus had arrived and was unpacked so we could begin to operate as at Lakeside; giving blood transfusions by the cannula method and using nitrous oxide for anesthesia. Our first French patient who had had ether before was so amazed at his nitrous oxide experience that he bowed to us and thanked each one separately.

A little later, a French soldier while undergoing anesthesia, broke the stillness of the operating room, transfixing everyone, while in low beautiful tones, with intense feeling he sang the Marseillaise.

At last, after a number of wasted nights, Dr. Crozier, who was a highly trained biochemist, was able to get a sample of blood from a sleeping patient who had lost sensation over a prominent vein in the foot. No change was seen in the H-ion concentration. In this investigation of the hydrogen-ion changes in soldiers in all degrees of "kinetic drive" from infection, emotion, exhaustion and shock, we were able also to secure blood from sleeping soldiers suffering from cross lesions of the spinal cord. No change was seen in the H-ion concentration. Their cross lesion had anociated them. They appeared to be just cold intellects. They showed no restlessness, no anxiety, no emotion. I later found that this apparent separation of the physical from the so-called "spiritual self" was due to the cutting off, by the lesion, of the adrenal sympathetic stimulation. The line of communication was down.

Meanwhile there was opportunity to see a few of my associates. One evening I dined with Dr. and Mrs. Carrel and met Dr. Dakin, the famous English chemist. Carrel was in a gray officer's uniform, he carried a sword and wore in his coat the Legion of Honor.

One day Dr. Gros and I, as a committee from the American Ambulance, called by appointment on the noted French bacteriologist, Professor Pierre Roux, with reference to research work by American pathologists. Roux, the discoverer of diphtheria antitoxin, recipient of the Nobel Prize and one of the foremost scientists of our time, was a remarkable figure, slender, with delicately chiseled and sensitive face that reminded one of Cardinal Manning. He received us graciously and placed at the disposal of a group of American pathologists a large, well-equipped laboratory and the material and service.

At the suggestion of Dr. Weinberg we paid our respects also to Professor Metchnikoff who was one of the distinguished original members of the Pasteur Institute and who shared the honors of the Institute with Roux. In appearance Metchnikoff was the antithesis of Roux; large of stature, long white hair and beard, typical patriarchal Russian features---an impressive personality.

The Pasteur Institute was in the trenches, killed, wounded, invalided or fighting, while the great problem of how to treat their own infected wounds remained unsolved. The brains which might have solved this problem were enriching the fields of Belgium. Could anything be more illogical?

Professor Metchnikoff who had spent years in research on the prolongation of human life through control of the infections of the large intestines, was much interested in that point of the work in my laboratory in which we showed that indole and skatole which constitute the chemical poisons arising from bacteria of the large intestines, cause increased output of adrenalin and histologic changes in the brain, adrenals and liver.

One of the French surgeons who had read my anoci-association monograph had mentioned these facts to the professor, so he set a day for me to meet him at the Institute and requested that I bring the slides and a copy of the book. Professor Weinberg, Dr. Stone and I kept the appointment. The professor read the description of these experiments and examined very closely the photomicrographs, all of which gave him great satisfaction because my results accorded with his theories as to the development of the phenomena of old age and the cause of certain diseases. In fact, our work seemed to supply his missing link.

The red-letter day for our Unit was that on which we demonstrated anoci-association. After receiving many requests we arranged the exposition of our Lakeside "Kultur" according to the programs of the American Society of Clinical Surgery; a morning of operations and laboratory demonstrations followed by fifteen-minute talks in the afternoon. Berkeley Moynihan, Professor Tuffier, the French Field Inspector, Carrel, Sir Almroth Wright, head of the British Scientific Field Service, and I spoke to an audience of over a hundred distinguished guests including Ambassador Sharp, the titles of the addresses being in the order of the names mentioned; Military Surgery from the Viewpoint of a Field Consultant; Practical Problems from the Viewpoint of a Field Inspector; Science Has Perfected the Art of Killing, Why Not That of Saving; Scientific Control in Field Service; The Vivisection of a Nation.

At eight I gave a dinner for eighteen at the Ritz. It was an extraordinary gathering of talent. Among the guests were Dr. Helm, a facile and graceful French writer-in French medical literature what Osier is in English; Professor Weinberg, the head of the bacteriology laboratories of the Pasteur Institute; Professor Dakin, the biochemist of the Rockefeller Institute who has scarcely a rival; Alexis Carrel who along surgical and biological lines had no living superior; Professor Tuffier of brilliant intellect, Bourbon ancestry, and wealth, the foremost French surgeon; Berkeley Moynihan easily the first surgeon of the British Empire; and Sir Almroth Wright who stands alone in preventive medicine. It was Wright's genius more than that of any other that was sustaining the health of the twelve or fifteen million troops on the battlefields of Europe.

A few days after this dinner we decided to test the suggestion of Wright and Moynihan to treat every second case of the healing of infected wounds in sunlight without dressings, the method I employ at Lakeside for treating burns and skin graft. We also followed their advice to treat certain serious infections by immersion in a bath of normal salt solution, and to introduce the new Balkan splint which was born in the battlefield and of the poverty and necessity of the barbarous Balkan War.

This splint consisted of a simple wooden upright at each end of the bed, with a ridgepole resting in the mortice in each of the upright posts. The pole was just high enough to be reached by the patient who could move himself about and afforded a means of suspending a series of slings to support the injured leg or arm in any desired position of elevation or of comfort, while at the same time the upright post at the foot sustained the mechanism for extension. This pole served also as a wardrobe and a hat tree, in fact, the soldiers could almost use it for light housekeeping. It did away with the necessity for splints, bandages and cotton, and the whole thing cost only twenty-three cents. It was so efficient that I decided to adopt it at Lakeside upon my return.

Sir Berkeley and I discussed shell shock and war neurasthenia which was an overwhelming problem. During quiet periods at the front, three-to-one of the cases that were admitted were neurasthenia. During periods of battle, the ratio was increased to eight-to-one.

It seemed to me that in neurasthenia from any cause, the basic symptoms are the same; they differ only in the specific low threshold in each case. The grieving mother has a low threshold to any reference to her child; the threshold of the wrecked banker is low to any reference to banking; that of the soldier suffering from battle neurasthenia, to noise. War neurasthenia, like civil neurasthenia, is gradually acquired, slowly stepped up hyperkineticism. Only rest, change of scene, rationalization, and in some cases operation, I was convinced, could cure it.

Moynihan and I also discussed pseudo-"frostbite," a condition produced by the combination of moderate cold and constricted circulation caused by standing in water in boots and puttees that have shrunk and exert pressure. The foot turns black and resembles gangrene. If kept dry, it will ultimately shed the skin and nails as a deer sheds its antlers, leaving a healthy member behind.

I was pleased when Sir Berkeley asked if he might send his anesthetist to be trained by Miss Hodgins and later the French sent their anesthetists also to be trained. Thus was anoci-association introduced to France and Britain.

Not long after our demonstration of the Lakeside methods I was invited to present my researches before the French Société de Biologie at the Sorbonne. This historic, scientific body is limited to forty members, and a communication by a non-member is made through the intermediary of the member who introduces him. As Professor Weinberg, who was to sponsor me, and I wound our way through the gloomy corridors and worn stairways, we found the Sorbonne as empty as the Pasteur Institute. The walls of the simple, dignified hall that was the meeting place of the Société were hung with portraits and medallions of the lights of science for many generations. The seats of the members were raised in tiers, each tier supporting a desk with a bench. In the rear of the hall, behind a partition, were three rows of benches as straight and hard as the seats of a baseball stand. These were for the invited guests. Here for generations aspiring young scientists had listened breathlessly to the pronouncements of the "Fortunate Forty." No monastery was ever more rigidly severe and simple than this-the Sorbonne---the greatest institution of learning in the world.

I waited in the gallery until at the appointed time Professor Weinberg arose and formally introduced me, after which the President invited me to step down and sit among the mighty. After Professor Weinberg presented in French the summary of my work on the phenomena of exhaustion, we adjourned into a small room where I demonstrated my slides showing cytological changes in the cells of the brain, liver, and adrenal cortex in a soldier of the Marne who had suffered from hunger, thirst and loss of sleep, made a forced march of 180 miles, was wounded, lay for hours waiting for help, and died of exhaustion after reaching the American Ambulance.

When we returned to the audience room, I heard an extraordinary confidential report by the President on the cause of death by the high explosive French shells. The Germans had charged that the French introduced a poison into these shells because they caused death without physical contact; in fact, they charged that a number of soldiers in the immediate vicinity of an explosion had been killed simultaneously although investigations as to the cause of death showed no wounds.

Discussion brought out the fact that death could be caused by the intensity of the explosion---the rarefaction and condensation of the air causing such violent changes in the gaseous tension in the blood as to rupture blood vessels in the central nervous system, thus causing debility or sudden death. The process is somewhat comparable to "bends" in workmen laboring under atmospheric pressure in building tunnels or bridges under water.

This discussion deeply impressed me as it tied in with observations I had made in researches where at autopsy we had found numerous hemorrhages in lungs caused by air pressure experiments, and I determined to do further work on the causes of death from air compression to see if I could clarify this hypothetical question.

However, there was no time to undertake this research at the moment as I was to return to the United States almost immediately. On the evening of February eighth, Ed Lower arrived to relieve me. He had come over on the Lusitania on which I was planning to return, and said she had carried much war material including planes which were unloaded before the passengers were allowed to leave the ship.

The next afternoon I gave myself the pleasure of presenting to Miss Rowland and each of the nurses a pin which I had specially designed to commemorate this trip. In the evening I said good-by to the rest of my group at a dinner arranged in honor of Dr. Lower and my surgical staff.

The next day Dr. Gros and I drove to Dunkerque. Occasionally we passed two-wheeled carts in the fields gathering up the dead, or we saw men with first aid bandages on their arms or heads. But, whether coming or going, standing in groups in villages or in the fields, waiting in trenches or driving convoys, they were silent, serious, emotionless. There appeared to be an atmosphere of the consecration of human life.

In places we saw portions of the great inundation which was an incalculable loss in rich land to the Belgians but which turned back the German drive to the coast. Here a lake, there a canal, everywhere mud. As our eyes swept over this inland sea we could visualize the five thousand German dead waiting to be disclosed by the receding waters, who---faithful even in death---would defend, their fatherland by their decomposing stench.

On reaching the main road over which we had come, we passed a large body of men who were inflating a huge Clement-Bayard dirigible balloon. There was a wave of gun lire, some rather near us. I felt strongly the mystic urge of the great cannon, the urge to go on, to penetrate farther toward the Front, at least to be nearer. I felt something within myself that I did not know existed.

As we passed into Furnes again and turned westward, the guns faded. Thinking about these weary, bedraggled men intently engaged in killing their fellows, amidst cold and rain and mud, infected with vermin, covered with scabs, the stench of their own filthy bodies mingling with that of their decomposing comrades, I pondered on the attraction of the cannon and the difficulty of sticking to one's comfortable task in times of peace; and it suddenly occurred to me that war, not peace, is the normal state of man.

In the hospitals at Dunkerque which was only eighteen miles from the Front, there were said to be twenty thousand beds. During the heavy German drive to the coast an average of live thousand wounded came in every night and had to be distributed. These wounded, lying on the ground, sometimes made a line three miles long. During this time the medical service was so overwhelmed that it could not even give these men as much as a drink of water.

Before we set out for Calais and Boulogne we stopped at the railway station to bid good-by to the American ambulance drivers. Forty or more German prisoners were at work sweeping the streets near the station, their belts emblazoned with "Gott mit uns," which seemed to me to have miscarried.

I lunched with Sir Almroth and at three o'clock left for the boat, where I expected Crozier to meet me. I caught a glimpse of him, then missed him. He was suddenly taken out of the line, escorted to a small room, searched and stripped. Even the inside of his fountain pen was examined.

The streets of London, like those of Paris, were dark and gloomy but not comparable with the impenetrable darkness of Dunkerque.

In the hospitals in London I found that the chiefs were at the front. I did, however, see Sir Arthur Keith, the noted anthropologist, who expressed an interesting viewpoint about the war and the men making it. Keith stated that the roundheads, in contradistinction to the flatheads, were the dominating human type and heretofore the roundhead had always crowded out the longhead type. The advent of the roundhead into Italy was about two thousand years ago.

From Italy he extended into France, Austria, Germany and Russia. The roundhead is the type that has adapted himself to industrial life. Against the roundheads there stand the English and Scandinavian longheads. The best warriors, Keith observed, are the roundheads, and at that time in Europe roundheads were bobbing up and down in the opposing lines of trenches.

From a test of the wiry quality of the hair and the shape of the head that Professor Virchow conducted with the school children of Germany, it was evident that the Germans were largely roundheads. The great representatives of the type at that time were the Prussians, Keith stated and it would seem that whatever may happen, Russia would be the next nation to rise.

After a crossing that was without incident and on which I spent my time writing of the mechanistic view of war we berthed at New York and there on the pier, were Grace, Dr. and Mrs. Will Mayo, Dr. and Mrs. Charles Peck, and Will Luce wigwagging to me. After conferring with members of the American Ambulance Committee and withstanding an onslaught of reporters, I took the train for Cleveland, where I found a noisy welcome from the four children.

The happy, carefree American faces contrasted sharply with the grim ones of Europe. I had not realized how deep an impression the war had made on me until I tried to resume the daily routine at home. It was difficult to shake off the feeling that nothing was worth while. For the first time I understood the depression expressed by Ambassador Herrick on his return: "Having had a glimpse into the crater of a great civilization which is disintegrating, it has followed me like an evil shadow."

It was encouraging, however, to receive occasional letters from France that assured me my work had been of some value. One of these was from Carrel who wrote,

"I have made a few interesting observations about the influence of pain on shock. You will be pleased to know how the facts that we see every day follow your theory. Yesterday a man who was abandoned for twelve hours on the battlefield after he had received a bad wound, was brought to our ambulance in a condition of shock. After a few hours he was in a better condition and the pulse could again be perceived. Then, during the dressing of the wound, a bridge of skin which was half necrotic was severed. It produced a slight pain. Immediately the blood pressure fell and soon the man was dying. A transfusion of blood had to be made. Another man, after a slight pain inflicted during the dressing of a wound, suddenly became insane.

"We follow your advice to give a great deal of morphine to the men who are profoundly infected ......"

Soon after my return I received a letter from Ed Lower in which he said: "We have an interesting case of a bullet lying at the apex of the heart and embedded in its outer covering. Fluoroscopic examination shows that the bullet moves in a rotary manner with each heart beat. While it is causing no discomfort, it may later, so I am going to attempt to remove it. Besides who would want to carry the bullet of his enemy in his heart, the rest of his life?"

This proved to be a rare case in medical history---one of the first, if not the first recorded case of such an operation upon the heart. Under nitrous oxide-oxygen and novocaine the bullet was removed, Dr. Sherry and Dr. Kieger assisting Dr. Lower. I have often heard Eddie Kieger relate the thrill he experienced when holding the beating heart in his hand while Dr. Lower extracted the bullet. After a stormy convalescence this Frenchman made a complete recovery and entered the service again. I have always been proud that this unusual case came to our group.

About this same time Dr. Thwing, President of Western Reserve, asked me to give a lecture at the University on my war experiences. The idea seemed both arduous and distasteful, but Grace suggested that the scattered notes on the mechanistic view of war, which she had found in my bag, would make a good lecture. I had written them only to get the whole thing out of my system but I told her that if she wanted to revise them, we'd see what we could do. These notes, together with parts of my diary, became the lecture, "A Mechanistic View of War and Peace," and the basis of the book by the same title which Macmillan published that year, a little book which achieved a number of printings.

When Ed Lower returned he strengthened my conviction that, sooner or later, the United States would enter the war. We were perturbed because the government in its eagerness to be neutral would permit no Army medical officers to go abroad for observation. So was General Gorgas; he knew that new methods of treatment and organization were being born overnight and he was ignorant of them. After I made my informal address before the American First Aid Conference, in which I advocated well-organized hospital units of men who have trained together, he wrote me the following letter:

WAR DEPARTMENT
OFFICE OF THE SURGEON GENERAL
WASHINGTON

August 25, 1915

DR. GEORGE W. CRILE
Osborn Building
Cleveland, Ohio

Dear Dr. Crile:

Your remarks yesterday with regard to units for active service have made a great impression upon me, and I would like to discuss the matter with you. As a basis of discussion I will outline the following proposition: Suppose war has been declared and the Medical Department is establishing a base hospital at Huntsville, Alabama; you are the chief of the surgical unit. Can you furnish me the names of other members of the unit, doctors, nurses, orderlies, and all concerned? What equipment is necessary, if any, which should go with the unit?

You understand that this letter is written purely with the object of discussion.

With kindest regards, I remain yours,

Very sincerely,

(signed) W. C. GORGAS

To which I replied with an outline as follows:

In the hypothetical case referred to I would propose---were such a plan of reserve units in operation---to have at hand ready for immediate response an associate surgeon who would alternate with me on duty---this associate surgeon to be a man of mature experience and established efficiency; under him would come in sequence the first, second, third, fourth, fifth, sixth, seventh, etc., assistant surgeons to the extent of the number required to meet the size of the hospital at Huntsville; then there would be a corresponding number of anesthetists; a head operating-room nurse, and first, second, third, fourth, etc., assistant operating-room nurses; there would be a supervising nurse, assistant supervising nurse, head nurse, assistant nurses, etc., according to the size of the hospital. There would be a pathologist, and a stenographer who would facilitate the making of proper records; and finally there would be in reserve here for immediate use the required surgical instruments, splints, apparatus, dressings, anesthetics, etc., to cover the needs of the hospital. I do not think it would be practical to supply orderlies because there are so few of them in civilian hospitals.

This, in a general way, would constitute a reserve unit ready for service. It would mean that the chief surgeon from each reserve unit would have filled at all times his quota, together with alternates for the entire personnel.

It would mean, furthermore, that the hospital trustees would have given their consent in advance to the giving over of certain wards to receive military patients. The care of these patients would be in charge of the general service then on duty---that is to say, we would mobilize the hospital as a whole.

It would seem to me that the work of such a unit would be confined strictly to the surgical care of the patients, but administrative work, the control of the wards, transportation, etc., would be entirely in the hands of the regular army service. The surgical care of the patients by this reserve unit at the hospital at Huntsville would be subject to visits by field consultants who would go from hospital to hospital, conferring with the chief of the hospital unit, giving such helpful advice as their wider knowledge and larger experience would enable them to give. The board of field consultants could in this way to a certain extent standardize the surgical care of patients in widely separated hospitals.

Then I added as a postscript:

It has occurred to me that the heads of surgery in the American medical colleges in good standing would form an excellent nucleus from which such reserve organizations may be built. This would on the average give the best men to the service both in personal fitness and with experience in organization-and of no less importance, they would have connections with our best hospitals; they would also have a large corps of qualified assistants and would be well distributed over the land.

The Surgeon General then asked if I would be willing to undertake the organization of such a unit and send him the names and duties of the medical aides so he could find a way of fitting them into the service under the existing laws. He felt that if I could organize one unit and put it through, it would be a model for all the others.

I submitted to the general a skeleton organization of a Base Hospital Unit formed from Lakeside Hospital and enclosed a paper entitled "The Unit Plan of Organization of Medical Reserve Corps of the U.S.A. for Service in Base Hospitals" which I had given before the Clinical Congress of Surgeons in Boston in September. In it I suggested the following personnel for the care of each base hospital of five hundred beds:

Surgeons

One chief surgeon in charge

Five associate surgeons, each in charge of one service of 100 beds

Three assistant surgeons

Anesthetists, 3

Orthopedic surgeon

Pathologist and assistant

Internist

Neurologist

Dentists, 2

Roentgenologists, 2

Stenographers, 2

Nurses, 50

As a result of this correspondence and of the publicity given the plan, the American Red Cross initiated the formation of Base Hospital Units in connection with civilian hospitals throughout the country, under the direction of Colonel Jefferson R. Kean, Medical Corps, U.S. Army, who was assigned to the Red Cross for this purpose.

In March 1916, Lakeside Hospital signed an agreement with the Red Cross in which Lakeside agreed to assemble a trained personnel for a five-hundred-bed Army base hospital and to keep the specified posts of such a personnel filled in accordance with the Surgeon General's specifications. It was agreed also to keep this personnel ready for service at the call of the Red Cross. An appeal for the required funds was issued by the Cuyahoga County Chapter of the Red Cross and the enrollment of personnel proceeded as rapidly as possible.

Thus the formation and service of the Lakeside Unit at the American Ambulance marked the beginning of the "Unit Plan of Organization of the Medical Reserve Corps of the U.S.A. for Service in Base Hospitals," out of which grew the Civilian Base Hospital organization that was developed later by the American Red Cross.

Chapter Thirty
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