UPON MY RETURN from service at the American Ambulance in 1915 the Society of Clinical Surgery met in Cleveland. The major theme of the meeting was Acidosis.
For several years in association with Dr. M. L. Menten, Dr. W. B. Rogers, Dr. B. I. Harrison and Dr. W. J. Crozier, I had been engaged in a research on the hydrogen-ion concentration of the blood---the H-ion index being a measure of the acidity of the blood---in normal and in pathologic states.
Among the many clarifying results that these studies presented was the observation that the hydrogen-ion concentration of the blood steadily increased during anesthesia and at the exact time that all the buffer substances in the blood were overcome and the blood became acid, death inevitably occurred. This finding disclosed a fundamental fact in the living---it disclosed that protoplasm ceases to function when it becomes preponderantly acid or preponderantly alkaline. In other words when the nucleus and the cytoplasm of a cell no longer takes a differential stain, the energy of the cell is lost and the cell breaks down. According to the cytologic findings arising out of this long research, the maintenance of the acid-alkali balance between the nucleus and the cytoplasm of the cells---the electrical potential---is essential to life and furnishes the immediate driving energy of the living process itself. Its reduction to zero or equilibrium is death.
Clearly I needed a new approach.
The months of 1916 followed each other in an uneasy hubbub of activity and frustration. While the final organization of the Lakeside Unit was delayed by slowness in the collection of funds, W. B. Saunders Company published The Kinetic System, the last of the three volumes that recorded my studies on phylogenetic association, and I continued to receive letters about The Origin and Nature of the Emotions which they published in 1915. One letter was from Vilhelm Magnus who wrote from Norway, "It is the most interesting and original book I have read for a long time, and I think it has a wide application for the understanding of many nervous diseases . . . . I often wonder here in Norway how very seldom our patients fear operations ---if that is the cause, shock is very seldom seen." This comment supported my observation that in the North individuals and, I believed, animals also are not so adrenalized as in the warmer climates.
During the summer the death of John Murphy was a great personal grief to surgeons all over America. When Murphy died a great light went out.
Throughout this summer I tried to forget my sense of impending war in work on the hospital Unit, a driving practice, and a new research and many administrative duties. Finally, by the middle of July, I was able to send the muster roll to Colonel Kean, for transmission to the Surgeon General. We had hoped that as the Civilian Base Hospital originated in Cleveland, our Unit might be designated No. 1, but because of delay in raising funds it was No. 4.
Since it was obvious that the practicability of the organization and equipment of the fifty base hospitals made up from the personnel of civilian hospitals could be determined only by an actual experimental mobilization, the National Committee on Red Cross Medical Service, at its meeting in Detroit June sixteenth, passed a resolution requesting the American Red Cross to mobilize one of the units in Philadelphia on October 28, the time the American College of Surgeons was to meet in that city. The Presbyterian Unit, of which Dr. George Brewer was director, was asked to mobilize, but three weeks before the time appointed, the Trustees were unwilling to spare their personnel, whereupon Colonel Kean wired me from the Surgeon General's Office, asking if he could get our unit for mobilization. The same afternoon, Franklin Martin and Newton Baker, the Secretary of War, telephoned. I assured both of them that we would be ready.
In less than three weeks from that time sixteen medical officers, twenty-five nurses, twenty-five of the administrative personnel and five of the civilian personnel, all in uniform, were entrained for Philadelphia.
The place of encampment was a beautiful plateau in Fairmount Park where housing was furnished by tentage from the Philadelphia depot of the government. The camp had already been erected by a detachment of the United States Medical Department under the command of Major Harold W. Jones, M.C.U.S.A. The equipment had been brought from the Red Cross depot at the Bush Terminal, Brooklyn and, although it was far from complete, on the afternoon of the day of our arrival, October twenty-seventh, we were putting through fictitious cases of wounded soldiers and making full records.
The idea of this trial-and-error mobilization was a good one as it disclosed defects, particularly in the operating-room equipment. Experienced Army, Navy and Red Cross officials as well as leading surgeons critically inspected this base hospital. Suggestions and comments were elicited, correlated, discussed, discarded or adopted.
This led to the establishment of a Committee on Standardization of Medical and Surgical Supplies and Equipment. Harvey Cushing, John Finney, Will Mayo, George Brewer and I went to Washington and checked the surgical instruments available in the Surgeon General's Office where we found in old rosewood chests many queer instruments of which we did not even know the use. One set was wrapped in a newspaper dated July IX, 1898, and carrying in large headlines, "Battle of Santiago."
In accordance with our reports, medical preparation for war was speeded. To a letter from Franklin Martin who was then on the Advisory Committee of the Council of National Defense, asking for five suggestions of practical value for preparedness, I answered:
"1) Lay in a stock of gauze, cotton, instruments, etc., etc., etc., sufficient for six months of a major war.
2), 3), 4), 5) Do it now."
---which shows the impelling feeling I had that America could not avoid war.
As a consequence of all our efforts, General Gorgas came to the war wholly prepared.
We all knew that it was only a question of a few months at best until we would be in the war and it was hard to go about our usual work. At Christmas, Grace and I took the children for a sailing cruise among the Florida Keys and invited Ed and Mabel Lower and Mrs. Lyman to join us. We anchored near Trestle No. 2 and from the entrance to the fishing field spanned by forty symmetrical white arches of the railroad, sailed out to the haunts of the sharks and barracuda. Here the struggle was as fierce as trench warfare. Roaming this entire field, the shark was supreme, but on the free reefs, in the pools, on the shore, in the air, the most fierce and destructive animal, I thought, and the most bloodthirsty, the most cruel, the most savage, the most feared of all animals, was man, the builder of Trestle No. 2.
Of this holiday I have one vivid memory, frightening even now. Barney was nine years old and was almost uncontrollable in his excitement over fishing. I can see him now in his blue linen suit, big hat and dark glasses, standing in a small motor boat behind me, his spear poised to cast at a sand shark.
As the boat turned he lost his balance and fell overboard in deep water and came up on the other side of the boat-hat and glasses still on. Reaching far out I grasped him with a hook by the collar and hauled him in---choking and dripping.
Gathering all my philosophy I asked, "Well, what did you see down there?" "I saw a candle burning," he replied. "Then at least," I said, "you have proved that it is not dark when you swim under water, but light." I was so anxious that not a "footprint of fear" be left in the mind of that child.
After I had returned to the United States in 1915, I was one among a small group of surgeons who called upon the Secretary of War to suggest the formation of a civilian committee to co-operate with the regular Army in working out clinical organization and clinical problems, in case the United States should enter the war. When the Research Division of the National Academy of Science was organized, I had been assigned the investigation of the cause of death from air concussion due to high explosives, so, early in 1917, through Secretary Baker and Mr. Schwab, I arranged to conduct air concussion experiments at the Sandy Hook Proving Grounds or at the Bethlehem Steelworks.
My theme was that neurasthenia as a consequence of war, represents a facilitated path of action, and as a consequence there is abnormal expenditure of energy. From my observations of shell shock I had learned that after the detonation of a high explosive shell there is a diminution of the many functions of the brain, such as loss of memory, loss of consciousness, and loss of power of speech, hearing, sight, taste, smell, or dissociation of personality. There may be paresthesia and anesthesia. Nearly all of the functions of the body may be interfered with in shell shock. In the study of it in the English line it had been found that if a long ether or chloroform anesthesia is given, many cases of shell shock may be cured. It had been found also that if a patient having shell shock suffers a heavy physical injury, he may be cured. Faradic electricity given massively, painfully, even cruelly, may cure. The theory on which I based the plans for the shell shock research was that the loss of function in the various parts of the central nervous system was due to a physical interference with the facilitated paths of action---a disconnection or crossing of circuits between the processes in the past and those in the present. Therefore, an overwhelming injury or impulse might connect and renew the old facilitated paths of action. I had seen uncontrollable shell shock cases suddenly recover from a hard fall, out of bed.
The research was outlined and the plans made when on April twenty-eighth, twenty-two days after war was declared, like a bolt from the blue, I received a telegram from General Gorgas asking me to wire the earliest possible date our Unit could be mobilized for duty abroad. Colonel Kean telegraphed that he hoped we could be ready within ten days, to which I replied: "Mobilization order received. Base Hospital Number Four is ready to move within desired time."
This message had hardly left my office before the historic order which initiated the first mobilization of any United States contingent for overseas service was in preparation.
Base Hospital #4
Office of the Director
April 28, 1917Order #1
Instructions have been received this day from Washington, ordering the immediate mobilization of Base Hospital #4 for service abroad. You are accordingly requested to report in the amphitheater in Lakeside Hospital, Monday, April 30, at 12:00 o'clock for further information.
G. W. CRILE, Director
Base Hospital #4
A copy of this order was mailed by special delivery to each enrolled officer and the directors of departments were ordered to proceed with the immediate organization of their departments, while I left for Washington to secure more explicit information.
The research I left in the hands of Grace who became executive secretary of the staff that was composed of Dr. R. E. Mosiman and Dr. J. B. Austin of Western Reserve Medical School for the cytologic studies, Mr. Robert Milner of the Research Department of Agriculture for studies in metabolism, and Mr. G. E. Obear of Case School of Applied Science as physicist. They were to carry out a research in shell shock that I had outlined and report to me in France.
Events moved rapidly. On May third, Major H. L. Gilchrist of the Army Medical Corps arrived in Cleveland and took command. He had been on his way to duty on the Texas border when he was assigned by telegram to Cleveland so he had no overcoat and could not get one in Ohio. Neither did the Quartermaster Department in Ohio have a sufficient supply of uniforms or overcoats for the unit. Grace who was going to New York and had volunteered to shop for us, left knowing the chest, waist and head measure of most of the staff. On her list of necessary items were nine overcoats, fourteen belts, half a dozen uniforms, blouses, breeches, army blankets, underwear, bathrobes and army hats as then no one wore caps.
No Army, Navy or wholesale store in New York could furnish all of that quota, so Grace boldly telephoned to the Quartermaster Department and told her story. She was referred to Major I. M. McArthur, to whom she frankly stated that she was making her request without authority and that all she had as identification was her calling card.
Major McArthur replied that he knew Major Gilchrist had been detached on his way to Texas to report in Cleveland, that Base Hospital No. 4 had been ordered overseas, and that supplies were low throughout the country. He could not vouch for her but he would recommend to the authorities at Governor's Island that they accommodate her. Armed with a gracious note from him, she went to Governor's Island and staggered out of the building with her entire quota. Then she bought and packed two trunks and left that night for Cleveland where she unpacked on the platform of the Pennsylvania Station and distributed her supplies.
At three o'clock on the afternoon of May 6, eight days after the receipt of the first orders for mobilization, the entire personnel of Base Hospital No. 4 entrained in Cleveland for New York, the train running under military orders on cleared tracks to Jersey City where we were transferred by ferry to Cunard Dock No. 54 and boarded the nameless Orduna in battle gray, carrying a gun astern. General Gorgas, representing Secretary Baker, and Major Noble, M.C.U.S.A. came up from Washington to see us off and in addresses to the officers, the enlisted men and the nurses, emphasized the great political significance of this expedition, since it represented the inauguration of a departure from the tradition of the United States and opened a new page in our history. We had the honor of being, the first American contingent of the U.S. Army to serve in the First World War.
It was of no small significance that on this eve of departure, all British and American flags within the range of vision were at halfmast. It was Lusitania Day!
The next morning, May the eighth, we sailed. The second day out on H.M.S. Orduna, our military training began; the officers and enlisted men assembled in the Second Class dining room to hear the Articles of War read by Major Gilchrist. I had not heard them since the Spanish-American War, and my opinion of them remained that it would be impossible to spend a day in active service without being liable to punishment by death. The bugle, fife-and-drum corps practiced steadily and soon the men were able to play some part of the same tune at the same time. Major Gilchrist thoroughly drilled the medical officers and all over the deck resounded the calls of "right face" and "about face." Major Lower reported without his puttees and was ordered to put them on.
We were nine days out before we had our first U-boat scare. The day started dull, foggy and rainy, with a high wind. In the morning everyone dressed for torpedoing, and the lifeboats were checked anew. From the captain to the deck hands the kinetic drive was intense. The sea was running so high that no lifeboat could survive, but, on the other hand, when the sea is high the chances of torpedoing are correspondingly small. Cotton bales, boxes, debris, went floating by as reminders of recent U-boat activities, like the telltale bones and feathers about a fox's den.
At about eleven-thirty the captain, who never left the bridge day or night, came down to the lounge and asked me to bring Major Gilchrist with me to his chartroom. He seemed to be under a heavy strain and his face wore an extraordinary expression, strong worry alternating with pleasure. He dismissed all of his assistants with the exception of his first officer, then opened his wireless book, snapped shut the code, put it aside and showed us the following message in British code but German spark: "State your position at twelve o'clock and give your course and speed."
Feeling that this was a ruse of the Germans like the one which is supposed to have sunk the Lusitania, the captain wired back: "Who are you and what do you want?" Out of the fog came the reply: "U.S. Destroyer Wadsworth." Opening the official Navy register, he indicated to us that the name "Wadsworth" did not appear in the U.S. Navy list.
This then, was the dilemma: if it were a German ruse, and the captain gave a correct answer, the result would be fatal; if it were not a ruse but our convoy, and he gave no answer, he would miss the convoy. Neither Gilchrist nor I was certain that there was a destroyer Wadsworth so we went down and asked our men. Dr. Twigg of Annapolis replied, "Yes, there's a Wadsworth. Lieutenant George White, Jr., a friend of mine, is her paymaster." The captain then wired: "What is the name of your paymaster?" and out of the mist came the word: "White."
At four o'clock, the hour of the rendezvous, predetermined before we left New York, we saw a tiny speck on the distant horizon. A strong glass showed it to be a ship heading across our bow. Was she friend or foe. No sooner was the ship identified as "a destroyer with four funnels"; as "flying the American flag"; and finally as "the Wadsworth" than the entire unit disappeared to appear a few minutes later in uniform.
All day and all night the Wadsworth zigzagged, traversing the field just ahead of the Orduna like a bird dog hunting quail.
The next morning, May eighteenth, we arrived at Liverpool and sighted a fierce-looking officer strolling up and down the pier. He proved to be Hugh Cabot of Boston who had come over in 1916 to serve with the Harvard Unit in the British Hospital No. 22 at Camiers.
Unfortunately I was immediately detached by cable from the War Department and ordered to report to the American Embassy and then proceed to Paris as U.S. Representative to attend the second session of the Interallied Surgical Congress. I had barely time to catch the first train for London where I presented myself to the American Ambassador who furnished me with a passport diplomatique---a wonderful instrument---and consigned to my care a woman who was going to Paris.
I also called on General Sir Alfred Keogh, the D.G.A.M.S., or Director General of the Medical Services in the British War Office, to whom I stated that we were entirely at their disposal but that we were there for work, to do what we could in every way to further our mutual interests. General Keogh inquired as to the kind of assignment I thought would be best and added incidentally that Colonel Hugh Cabot who was very much concerned about the great difference between civil surgery and military surgery, thought it would take three months before our Unit could be prepared to take over active service in a hospital. I replied that my Unit had had three months' experience at the American Ambulance in the early part of 1915 in a two-hundred-bed service, so military surgery was not new to us, and that in my opinion if the Unit should be broken up and scattered for training as Colonel Cabot suggested, our splendid esprit de corps would be lost. I assured General Keogh that I personally would be responsible for the work of the Unit and suggested that the best results would be obtained by our going at once to France, as had been explicitly arranged through the British Mission, where we could take over an active hospital under the guidance and instruction of the existing staff. General Keogh then assigned us to B.E.F., No. 9, at Rouen.
General Keogh stated that as a result of a large experience he had concluded that while all men wish to do their part in war, most of them are glad to avoid service at some stage by being found medically unfit. Therefore, the advent of the specialist, the ophthalmologist, the dental surgeon, has enormously increased the claims for disability. After the nerve specialist came, the men soon found that they could not sleep, noises startled them, their nerves were shattered. As soon as the ophthalmologist came, they found they had faulty accommodation, disturbed night vision, diplopia, etc. The dentist with his intensive suggestion upset the men's teeth. General Keogh found that by putting everything up to the regimental surgeon first and keeping the specialist for purely consulting work, he was sacrificing a smaller good for a larger one.
I left for France with the feeling that all would go well with our Unit and that in London it would have official recognition by the King. Paris was greatly changed; by comparison the streets were quite animated. At the American Ambulance I found the same commanding officers and the same group of men acting as officers of the day. Dr. du Bouchet was in charge, Dr. Gros was there, earnest and fine as ever, and so were the same group of ambulances. The only change was the gardens which had been improved.
The Interallied Conference over, I called upon Ambassador Sharp whom I had known for years, for authority to go to Rouen to meet the Unit. Mr. Sharp said there was no U.S. Army Headquarters in France at that moment. I was the U.S. Army! I visited the French Headquarters where, after puzzling over the situation, they advised me to try the British Headquarters. In spite of the fact that it was a British unit to which I was going, they had no authority to issue a military permit to a United States officer.
Very well I thought, I will establish the precedent, so writing out my own orders to proceed to Rouen, I requested passage. Instead of objections, the agent smiled, issued the ticket, escorted me to a compartment, unlocked it, asked my choice of seats, bowed, locked the door and left.
On the train and upon my arrival in Rouen, French officers saluted me with overwhelming graciousness. It was evident that a great welcome awaited the U.S. Army.
That same evening I visited our station, General Hospital No. 9, B.E.F., which was, they told me, one of the best hospitals in France. It had 1,540 beds, 1,240 regularly, with a crisis expansion of 300.
The next evening at six o'clock the Australia steamed up to the wharf to the music of a British military band. It was a stirring sight to see our own officers, nurses and enlisted men with the American flag flying over them, and to hear their lusty American cheers. The Unit disembarked in military fashion and with drums and fifes blaring, marched through the streets of Rouen amidst throngs of French and English people cheering lustily "Vive les Américains!"
Everyone in the Unit spoke with the greatest appreciation of the sincere welcome that had been accorded them in England.
The enlisted men and some of the officers had remained in Blackpool. The others had proceeded to London where, on the morning of May the twenty-third, the nurses and the civilian personnel were received by Queen Alexandra at Marlborough House, and in the afternoon the Unit was officially welcomed at Buckingham Palace by the King and Queen-the King stating: "It is with the utmost pleasure and satisfaction that the Queen and I welcome you today. We greet you as the first detachment of the American Army, which has landed on our shores since your great republic resolved to join the world struggle for the ideals of civilization. We deeply appreciate this prompt and generous response to our great needs. It is characteristic of the humanity and chivalry which have ever been evinced by the American nation that the first assistance rendered to the Allies is in connection with the profession of healing and the work of mercy."
At No. 9 we cut down a great pine from the beautiful forest of Rouen and, for the first time officially raised Old Glory in this European war, flying her beside the Union Jack and the Red Cross flag.
The next day, May twenty-eight, we began to take over the service. At last we were in the war.
IT WAS A great surprise to me that no plans whatever had been made for the use of transfusion in the English or French armies. Immediately alter we had settled into General Hospital No. 9, I sent for transfusion cannulae, but as submarine warfare interfered with their delivery, I found a glass blower and designed a cannula which was turned out in quantity by Gentile in Paris under the name "No. 17," the number of the casualty clearing station at Rémy Siding. Here Ed Lower and I introduced the use of blood transfusion in the British line where it became so obvious a method for the prevention and treatment of shock and for compensating hemorrhage, that before the end of the war blood was gathered from the wounded and stored at the casualty clearing stations.
In order to standardize treatment so far as possible, I proposed that in No. 9 we conduct a clinical research on the various methods in vogue in the British and French services. To that end we gave a thorough and impartial trial of Carrel-Dakin, eusol, B.I.P., salt pack and our own home method of Dakin plus electric light, in two wards each. For compound fractures we tried out Blake's system, the Thomas splint and other methods; for infected joints, the Rankin method of marsupialization, incision and drainage and extensive lavage; for exhaustion we used analgesia, blood transfusion, dietetic and hygiene treatment as for tuberculosis. The criteria were to be: first, the clinical course; second, the labor and cost.
Notes from my diary jotted at odd moments during these days of tremendous tension, are an irregular but firsthand record of our Unit. I begin with the end of May 1917.
General Hospital No. 9, B.E.F., May 30th
General Woodhouse called here to enquire whether or not we had a nitrous oxide manufacturing plant in France, stating that there had been a sudden awakening of interest in nitrous oxide in the British service and there were many more demands than could be supplied in England. He suggested that I be ordered up the lines to investigate the conditions at the casualty clearing stations at the Front in the Second and Fifth Armies to see if I could formulate better methods of handling patients. As I had been asked by Gorgas to make a study of Army organization, this gave me an unusual opportunity.
General Hospital, No. 9, B.E.F., June 6th
Left Rouen at 8 this morning in a Maxwell car on a perfect June day for the C.C.S.---casualty clearing station at Rémy Siding. Normandy is exquisitely lovely. Passed through Neufchâtel and Abbeville where I reported to the D.M.S. Lines of Communication. General Woodhouse was absent, and I was received by Colonel George H. Barefoot, Chief Aid. The following points are gained:
1. Anesthetics not satisfactory. All much interested in nitrous oxide.
2. The problem of shock and exhaustion unsolved.
3. It would be better to make lines of standardization and control include a sector, as I propose. Britain will adopt American Base Hospital organization after the war.
An automobile was furnished us for our trip to Hazebrouck. I noted the French cutting trench timber, thinning great forests by cutting every second tree. All this is fuel, and for war.
Dined with General Porter and Sir Anthony Bowlby. Conversation ran as follows:
1. Health of troops remarkable---3 per 1,000 sick.
2. Great problems are lice, scabies and laundry. Soldiers given clean clothes and hot bath every ten days. All soldiers are lousy. Trenches and dugouts are infested. Practically all soldiers have scabies. Scabies causes itching, abrasions and loss of sleep. Abrasions lead to infections. Lice carry disease. A Dublin entomologist is Louse Specialist for the Second Army. He is in command of lice! The Second Army uses Belgian refugees for washing and mending. Trench mud and water lead to trench feet, trench nephritis, rheumatism. In the early period of the war, men were always up to their waists in mud. Now all men in the trenches must have their feet anointed with oil. This is a matter of parade. Albuminuria is a strange disease and appears in all armies; it was first noted in the Civil War. Sometimes it comes on so acutely that it causes death in a day or two.
Sir Anthony Bowlby reported as follows:
Carrel-Dakin method superior to others.
Wright not good; causes unhealthy granulations.
B.I.P. good.
Eusol good.
Good horse sense in revision of primary wounds necessary.
Thomas' splint absolutely good for upper as well as lower extremities.
Good results of closure of joints is a surprise.
Ether and chloroform as anesthetics bad.
N2O good. Sir Anthony keen to have nitrous oxide plant installed in France.
Flavin prevents infection but does not clear the wound of bacteria. With Flavin there is no pain, no heat, no redness, no swelling, no pus, but strangely, no healing.
They are beginning to open the chest and remove foreign bodies and close without drainage.
After removal of a foreign body a curious contralateral collapse of the lung is noted, e.g., a wound of the left lung is followed by collapse of the right lung for some days.
No bone plating is done.
Gas gangrene is not completely solved.
Rémy Siding, C.C.S. No. 1, June 7th
Here at Rémy Siding, just north of Poperinghe, there is a group of four C.C.S.'s---casualty clearing stations---located along a railway track eight miles from the Front. About once in ten days long-range guns put shells in here.
Breakfasted this morning with a water specialist. He reported no typhoid, no dysentery, no water-borne diseases. Pipes were run into Hill 60 within four hours after it was taken at the Battle of Messines Ridge. Tanks were put up the next day, and from them pure chlorinated water flowed down over the plain to the troops.
Colonel Gordon-Watson, Consultant of the Second Army, has a field hospital two or three miles from the Front, equipped with wooden furniture, galvanized receptacles, scrub brushes, simple lights. This hospital cared for 1,052 bed cases yesterday by stacking patients three high, two abreast, six to each tier. Kitchen made of petrol tins. They save grease by screening dish water and filtering out fat which is sent to the Base, made into nitroglycerine and sent back to kill the Boches.
At an advance dressing station just behind the crest of a hill commanding the fighting line I saw oxygen warmed, then passed through brandy and inhaled through a nasal tube as a means of restoring gassed patients. The men improved---the major in charge said sometimes they became quite jolly under the treatment. The gas was administered in an open tent with oxygen tubes along the middle, from which other tubes ran off to care for gassed cases by the wholesale.
In the late evening I returned to C.C.S. 17 where night shifts were working in a three-table operating room. Groups of wounded are lying on stretchers in the dimly lit anteroom, another group in a dark hall---twenty-three in all. They are moaning. Guns are booming.
Watched excision-revision of heavy penetrating wound of hip. Ball penetrated through ilium---not found. A young boy was brought in on a stretcher and laid on the floor. Waiting! Ten minutes later an anesthetic was administered to the lad still on the floor. Everything moves quietly, smoothly. The field is protected only around a small operative zone; simple precautions but well done. Basins are sterilized by burning spirits in them---like a plum pudding!
A penetrating wound is brought in: shattered bones cutting off femoral artery of left leg and a shattered right tibia. Tourniquet has been on for past eight hours. Patient pulseless, dying; 1/2 gr. Morphine administered then sent to moratorium ward---a dark tent where men are allowed to complete their exitus without disturbing other patients. I would have transfused him.
To the boom of cannon I returned to Canadian No. 3. In a moratorium ward were four patients, two of them Germans. One Briton was gurgling on toward dissolution with the respiratory tract full of blood from a penetrating wound. A German in a dark corner was repeating two words over and over. He was shading into mild delirium, with fading pulse and cold hand from gas gangrene. The two words that he spoke with each sighing respiration, with dry tongue and parchmentlike lips, were "Mutter! Schwester!" I walked out of this dimly lighted room leaving these two antagonists to finish together, untended, because this station at the twentieth hour has taken in 1,650 wounded, long rows of them, waiting on the floor with blood trickling and dressings swollen tight.
C.CS. 17---June 8th
Saw Harvey Cushing at New Zealand Stationary Hospital taking head cases and working with the infinite precision and exquisite technic of his civilian surgery. Unhappily battle conditions cannot adjust themselves to such precision. It is the line, not the man, that must be cared for.
Bowlby was embarrassed and came to me. Such exactitude and finesse were too "time-consuming and were causing congestion." What should he do? I suggested that he leave Harvey alone with his group as it was worth while to have so perfect a technician as Harvey serve as a model, then organize other groups about him to care for the waves of battle. Bowlby had not thought of that and he so arranged.
C.C.S. 17, June 9th
After luncheon at Canadian No. 3, I met Sir Arthur Sloggett, the overseas Director General, General Porter and Colonel Gordon-Watson. In twenty-four hours, 14,100 patients were evacuated from nine casualty clearing stations. The bed capacity in a C.C.S. is five per cent of the fighting strength. These stations cleared their capacity and a half in that period.
In the anteroom are four German wounded. I spoke to one who said the bombardment was awful. There are four British lying with them waiting to be operated upon. Opposing sides lie together and groan, while the cannon of both sides boom together. Opposition in fight, consonance in their wounds. The cannon are head on, the wounded are parallel!
Battle of Messines Ridge, June 11th
Colonel Chicada Wilson, Colonel Gordon-Watson, Major Brown and I, in gas masks and metal helmets, set out for a tour of inspection of the advance Front. As we came near the line the country was increasingly torn up. The fields have more and more the appearance of vast construction gangs; countless numbers of trucks, mules, convoys. There is but little movement excepting road building on a large scale. Activity along these lines comes at night---concealment during the day.
As we reached the front-line trenches one striking fact impressed us: while all the battleground was as devoid of any living thing as the sand on the beach, "No Man's Land" was green, and small flowers were blooming in the grass. After crossing the soft grass we found such complete destruction of the enemy's trenches that we could follow the line with difficulty.
Passing on farther, we saw the Peckham Crater---600 feet across and 90, deep---all ground as full of crater holes as a nutmeg grater. We climbed up and down and around and among the craters on our way to the highest point of the Wytschaete Ridge where there, was a crater 800 feet in diameter and as deep as sand rolling back can make it. This crater occupied the entire crest of the hill and brought us to the highest point of the entire ridge. From here we could see Ypres, Armentières and Lille and many villages. We could see the present front line 2,500 yards ahead. I asked Colonel Watson where Messines was.
"It is within a stone's throw---that is its location."
There was no Messines; it had disappeared with the grass and the hedges.
During this time English batteries several hundred yards, behind, on the lower ground, were firing steadily, small guns and great guns, singles and in salvos, the shells passing noisily over our heads. The German shells were falling at the crossroads where Wytschaete and Messines had been, while beautiful shrapnel was bursting with pure white puffs of smoke over the rear of the British lines and in front of us.
As we drove back through the maze of this vast mechanism of force ---a mechanism more than ten miles deep and a hundred, long; a mechanism which includes within it the iron, steel, copper, lead, aluminum, the oils and petrol, the nitrates and glycerine, the hides of animals, the fleeces of sheep, timber, the special elements of the solid earth and of the atmosphere, the grain, fruit, flesh, the cotton and hemp, all that sustains and clothes man; all that maintains the health of man and all the things that give him the power to produce maiming, exhaustion and death---things from every field and forest and mine---things created through the labors of millions of men, women, children---materials and labor drawn from every quarter of the globe by a great, rich and powerful empire---all assembled in this widely woven machine that occupies the roads and the fields, that occupies the earth below and the sky above, that stabs and tears, that bleeds and shocks, that poisons with gases, that terrifies and kills---what a compliment to pay the few simple German peasants who lie beneath the rubbish!
C.C.S. 17, June 13th. The Moratorium Ward
My mind has been focussed so many years on salvaging the handicapped by various means of resuscitation that I cannot reconcile myself to the plan of placing the seriously wounded in the moratorium ward until the wave of battle is over. It should be called the "Resuscitation Ward" and be in charge of a team skilled in methods of resuscitation. In order to ascertain myself whether help is possible in these cases of serious gas poisoning for which no remedy is known, I asked permission of General Bowlby to serve in this ward. The padre was my assistant.
Sea water being practically identical with the fluids of the body, Hoover and I thought that if diluted and given as an intravenous infusion, owing to its many constituents such as calcium, phosphorous, sodium, etc., it might like vitamins supply body defects.
Case 1: G.S.W. (gun shot wound) Penetrating. Pulseless. Unconscious fifteen hours after injury. 4:10 P.M. began intravenous infusions 1.3. sea water diluted with sterile water. Pulse picked up. Patient opposite died. Nine more threatening to "go out." No patients elevated. Nothing systematic. Pulse improving. 4:19 P.M., pulse 108, respiration slowed, sweating diminishing.
Case 2: At 4:20, a delirious patient with fractured skull and broken thigh got up behind me on all fours, including splintered leg, and rolled off the cot. At 4:35, case 1 quietly sleeping. Pulse 96.
Case 3: Dying, groaning, pulseless, G.S.W. thigh and abdomen. At 4:30, sea infusion began. (Gramophone in next ward loudly playing ragtime.) 4:35, slight flicker in pulse. Patient becoming wild. Patient in distant corner shot through larynx, suffocating. Leave No. 3 to insert tracheotomy tube and give artificial respiration to larynx case. 4:37 P.M., No. 3 pulled needle out of vein in struggling. Inserted needle in opposite arm and resumed infusion. 4:50, Padre who held delirious No. 2 on floor, left me to attend dying man in ward 132. A thud. No. 2 sat up and fell back on floor, displacing bandage. He is bleeding. (Gramophone screeching Sousa's March.) Began sea water infusion on No. 2, groaning, pulseless, cold. Tracheotomy case gurgling. Everybody---orderlies, Sisters, doctors, patients who come---more or less unconscious of all about them. Show no interest. Might as well be on a walk in the country.
Case 4: Patient with rosettes about a beautiful head of a woman tattooed on each thigh. Shell tore away tattooed head on left thigh. Left arm off. Feeble pulse. Amputation made just above tattooed lady, leaving a few roses on anterior flaps. Silk gut through a rose.
Case 1: 5:10 P.M., pulse that was excellent, now fading. Skin dry. (German plane going over hospital, heavy anti-aircraft firing, machine gun action, huge munitions dump a thousand yards below us. Gramophone playing "I Love a Lassie." Blue-eyed Irishman just stopped and asked if I wasn't Irish. "Ye-e-es," said I.) 5:21, tracheotomy case dead. Bearers taking him out. More quiet now.
Case 1: 6:06. Improved. Sleeping or anesthetized by sea water?
Case 3: Slowly going out.
Case 5: Multiple shell wounds. Knocked unconscious. Lay in No Man's Land for four days. Shell hole full of water. Drank it. Tried to get out but slipped back each time. Came in with great hunger and thirst, and wounds full of maggots. (Note: Curiously, wounds with maggots never have gas gangrene. Would maggot juice be a remedy for gas gangrene, I wonder.)
Case 3: Dead 6:30 P.M.
Case 1: Seemingly unconscious but wakened on being spoken to. Pulse better.
Case 2: Delirious head case dead 6:39. 6:46 P.M. But seven out of today's intake of thirty-three remain. Some went to operating room, some to morgue. Those left are not yet ready for either. The ward Sister said, "I'll have a bit of a stroll." Padre is writing letters to the relatives of the dead.
With a small group of enthusiastic surgeons I am going into a conference to plan a new campaign against this war exhaustion and gas poisoning. Out of the wreckage of today we have picked up one hope---the sea water man who improved. We will continue the sea water infusion tomorrow to see if by this means we can prepare cases for operation.
The Padre, a fine, young, Oxford, Church of England parson who has been helping in the ward all day, was just telling me that he thought the Church would come out of the war more tolerant of differences in religious opinion, when Major Bindloss of Harrow and Captain Thatcher of London appeared and asked me to go for a walk. First I visited my sea water case and found him fine and entirely rational.
C.C.S. 17, June 17th
Sea water case doing well. He was smoking a cigarette. Left in ambulance for Hazebrouck. After luncheon Colonel Cuthbert Wallace and I visited the St. Omer Shell Shock Hospital No. 4 where there are eight hundred cases, with Major Jones in charge. I followed several cases with Major Jones.
Case 4: No pain is elicited when arm is pinched. Patient behaves like our resurrected dogs. Stoops forward, cannot speak. Face earnest, with no sign of emotion or intelligence. Major Jones asks his name. No reply. Do you belong to the Second? A jerky respiratory animal sound. What battalion? The First? a wheezing inarticulate "no." The Second? Third? until finally the Tenth excited him and with a trembling forefinger he pointed to 10 on the board.
For half an hour Major Jones struggled to teach him to say "a." He whispered the letter, he shouted it. No change of expression. Then the major put a laryngoscope down the man's throat. No cough---no laryngeal reflex.
While annoying the larynx, the major had the patient cough out violently "a, e, i, o, u," pounding him on the back and encouraging him. Slowly but gradually the blocked action patterns were reopened. Slowly the man's idiotic face began to clear, yet all the time he was dodging shells. It was impossible to fix his attention.
While we were visiting the wards, anti-aircraft guns opened up. The thousand or more shell shocked cases jumped as if an electric current had been passed through the camp. Many ran. for shelter, some to the house, some under the verandahs, some crept under their beds, others pulled the bedclothes over their heads. Officers as well as men made this reaction. Some cried, some shook, all were worse. What an illuminating but cruel experiment.
Shell Shock Day, June 17th
Major Jones told me today the best cure for shell-shocked patients is to release them from all war associations and to endeavor to recapture former associations. Put a barber back to being a barber, a carpenter to carpentering. Although adaptation of living things has been studied extensively in relation to environment, to survival and procreation, these studies have been largely as to form, texture and color. Here these studies are being extended to the inner physicochemical processes, to psychical processes, to gross behavior processes and to disease.
Students of normal biology rarely include abnormal processes, such as disease, in their investigations; students of disease usually fail to include a study of normal biology in their investigations. I feel quite certain that the study of shell shock in this war. will lead to further interpretations of normal and pathologic adaptations.
Out of the Messines Battle, Major Jones tells me, 5 per cent of the total wounded were shell-shocked. With him I went about the tents, seeing hundreds of acute cases. Some were only weak, some stammering, some mute, many deaf, some with hands and feet sweating, some with blue nails, others with diarrhea or constipation, many with tremors. Many showed the peculiar face of fever, the earnest face of preoccupation, of light anesthesia, of sleepiness, moderate asphyxia, slight pain, but none showed a sign of emotion or a gleam of intelligence. In short, they exhibited an adverse state of the kinetic system. On closer examination the faces showed that the muscles of expression, which reflect relaxation, were waiting for impulses from the brain, but the action patterns in the brain whose activation awakens the muscles of expression, were completely dispossessed of their path of action and were possessed by the major pattern of war. The facial muscles, therefore, could not be marshalled into a smile, they could not be moulded into a feeling of well being.
The mechanism of any soldier in the midst of battle becomes highly activated, that is, the brain, the special senses, the adrenal-sympathetic system, and the thyroid gland---while the digestive system and the procreative system are completely inhibited. In most instances this intense activation passes, especially after a long sleep, as in the long retreat of the Marne. But after every battle a certain percentage of the participants, instead of recovering the normal equilibrium of their protoplasm, show a prolongation of the battle phenomena over weeks, months, even years. These phenomena are characterized by high nervous tension, fine tremors, sweating, palpitation, tachycardia, indigestion, tired facies, irritability, instability, and sometimes an increase in the size and vascularity of the thyroid gland. In other words, a picture of hyperthyroidism which must be the result of increased activity of the adrenal-sympathetic system, or hyperkineticism which is a state of pathologic physiology.
Here we have a human being modified by a battle, the components of this modification being essentially a continued pathologic stimulation of the brain-adrenal-thyroid-sympathetic system.
Now the adrenal glands could not have heard the shells, nor did they see the enemy; nor did the sex organs hear the shells nor see the enemy; nor did the salivary glands, nor the muscles of the intestines, nor the pancreas, nor the digestive glands. Yet the whole organism of the soldier, his glands, his structures, his mechanisms, were in a physiologic sense divided, one group being stimulated and the other, inhibited.
To me it is perfectly clear that it is the sympathetic nervous system and the parasympathetic nervous system that inhibit one gland and excite another, inhibit one muscle and excite others. Therefore, this organism that is pathologically divided into groups of inhibitions and of stimulations, might be corrected by dividing the sympathetic nerves emerging from the adrenal glands.
HARVEY CUSHING was billeted in town, I out in a meadow which I preferred to a room---a meadow by a brook, in a forest near the airdrome of St. Omer where the nightingales sang me to sleep. My striker was a nice, blond Lancashire boy, fifteen years old, his voice just changing. I asked how he came to be in uniform, and he said they were not demanding birth certificates when he enlisted.
Colonel Stephens, attached to the Research Committee, picked me up in the morning and took me to Boulogne where I met Colonel T. R. Elliott, Chairman of the Committee. Elliott at once wanted to know what I was doing in research. This is the Elliott who did the great work in adrenal function---one of Britain's best men.
I spent the night with Sir Almroth Wright who occupies a great suite in a beautiful old French château filled with trophies and luxuries.
Gen. Hospital 9, B.E.F., June 22nd
Have just returned from an extended tour of inspection in the Second and Fifth Armies. General Bowlby said the British and French had been at it so long they were all "stale" and he thought a fresh mind would observe mistakes and suggest methods. The trip has led to the establishment of a Resuscitation instead of a Moratorium Ward and the formation of Resuscitation Teams properly equipped to administer nitrous oxide and give transfusions. -
I believe I have a clue to shell shock. Exhaustion I think is the problem. The answer I feel should be found in further work on metabolism, in measurements of electric conductivity and potential, and in histologic changes.
The British have a wonderful organization. We are learning much from them, particularly in the care of fractures. Orthopedics is being born.
General Hospital, No. 9, June 25th
Cases of gas gangrene are beginning to come in. It kills as many soldiers as the bayonet. It develops only on devitalized tissue. It can be mastered only by so perfect a system of transport, so mobile a surgical organization and such ample operating facilities that within the first twenty-four hours every injured man may have the tissue of his injury completely excised. In other words the specific for gas gangrene is gasoline and executive ability.
June 29th
I have made arrangements with Mr. James Perkins, head of the Red Cross, for the construction of a nitrous oxide plant in Paris. When we came over we brought with us a considerable supply and apparatus for administering it. The French and the English recognize in it the anesthetic of choice, and now wounded soldiers come into the hospital and ask that they be given the new anesthetic.
General Hospital No. 9. June 20-July 10th
Major Stewart, Captain Douglas and Captain Lance of the Royal Engineers have been conducting a research on high explosives. Knowing that I have been conducting one in shell shock, they presented to me their problem: why in dugouts made to safeguard the lives of soldiers during heavy bombardment, are the lives of some spared and others destroyed with no visible signs of injury?
My researches in blood pressure and the discussion on air concussion that I had heard at the Sorbonne at once recurred to my mind, and I offered the negative or vacuum phase of the air wave as an explanation. The suggestion met with immediate response from the Engineers who stated that if the deaths were caused by the negative or vacuum phase of the air wave, they believed the dugouts could be so changed as to make them safe. I suggested that they arrange to collaborate with me in a research. Through the Mayor of Rouen I was able to obtain stray dogs. We placed these at different positions in the dugouts and found that those in certain locations were always killed while those in other locations were not. It was evident that the air wave as it entered caromed like a billiard ball, killing those dogs with which it came in contact.
The cause of these deaths I felt was concussion. Unlike shock, it had nothing to do with the nervous system. During the negative phase of the concussion wave the expansion of gas in the blood vessels ruptured millions of capillaries in the walls of the lungs, the blood escaping into the tissue, and into and filling the air vesicles, causing death from asphyxia, amounting to drowning in one's own blood.
We then made a series of experiments in the open field and in various types of dugouts, saps, pillboxes, observation shelters, machine gun nests, shell holes and trenches to test their protective value against the air wave of high explosives. The first test was crucial. We placed animals, dogs, rabbits, rats, birds, guinea pigs, toads, grasshoppers, around the margin of the field in which an enormous amount of explosives was to be set off. Although a hole twenty to thirty feet deep was torn in the ground the animals were unharmed.
If the passing of the positive wave over animals could not kill, then I knew that the deaths in dugouts must be due to some type of wave interference as there had been no reports of such deaths in the open.
We then placed a dog in a gunny sack at the bottom of a Russian sap. The firing of a torpedo at the mouth of the sap killed the dog. Autopsy showed the dog to be full of blood. Countless blood vessels in the lungs were ruptured. As I thought, the negative phase had killed him.
Next we placed dogs in various parts of a dugout the exact replica of the British and German dugouts used for troops. All of the dogs that were placed in the dead ends of the various chambers were killed by the negative wave as it rebounded from the dead end. The others were uninjured. Over and over we tested this. Over, and over with mathematical exactness death came to those that occupied certain positions.
Therefore, in the standardized thinness, hence fragility, of the walls of the blood vessels of the lung we had a biologic test of the value of various defenses against the effect of the air concussion of high explosives. This became a reliable means of not only testing safety but also of calculating accurately how much explosive will kill the enemy in a given type and size of dugout. A study of the German dugout showed that it was ideally made for the purpose of killing as it presented all the physical arrangements that we had found most efficient in killing dogs. This suggested making the final test in the standard dugout used by the British. In this research, we were not only able to discover the cause of death in air concussion from high explosives, but also to suggest so altering the dugouts as to prevent death by air concussion.
The new model of dugout projected by the Royal Engineers and our research group has been adopted as the standard type of dugout throughout the Allied line. Thus was biology made a useful adjunct to the applied physics of war.
The question as to whether or not carbon monoxide (CO.) played any part in the death in the dugouts suggested that we try CO. poisoning. Many years ago Lenhart and I did a research in illuminating gas poisoning and found that when an animal is gassed with carbon monoxide, the carbon forms a chemical union with the hemoglobin in the blood, depriving it of the power of carrying oxygen. Therefore, in the treatment of carbon monoxide poisoning, the administration of oxygen is almost specific. When oxygen is not available or in cases in which symptoms are not cleared by the administration of oxygen, we found we could restore patients by bleeding them, then transfusing them. I applied that here. It worked beautifully and will be adopted in the line.
I was also conducting a research in which the endeavor was to combat the effects of phosgene and mustard gas poisoning by the use of various treatments, such as intravenous infusions of soda bicarbonate solution and the use of soda bicarbonate directly into the larynx and into the lungs to neutralize the acidity which was thought to be the fatal factor and to determine what effect the loss of sleep had on animals subjected to high explosives and infection.
Captain Lambert, one of the most brilliant minds I have met in the British service, is consulting chemist on gas at General Headquarters. It was he who invented the gas respirator. He came to see our work and stated that phosgene produces a delayed poisoning, the patient going into a state of exhaustion. Death, he said, occurs sometimes from heart failure, sometimes with loss of memory, sometimes through pneumonia, but not through nephritis. No course of treatment is known. I suggested that the actual lesion might be interference with internal respiration or the oxidation function of the cells of the brain, liver and adrenal glands and that if so, forcing oxygen into the plasma of the blood under pressure might tide the patient over until hypertonic solutions with sodium bicarbonate could be tried. Although this was a new hypothesis, he felt it a reasonable one and promised to collaborate in furnishing the materials.
C.C.S. 17, July 22nd
The third battle of Ypres is about to begin. My suggestion of sending teams to the casualty clearing stations has been put into execution. Nine ambulances, each with a team made up from one of the Rouen hospitals, set out for Belgium bright and early on a warm, dusty day. The teams from No. 9 were Major Lower, Miss Roche, anesthetist, Miss Grundies so long in charge of surgery at "the office" at home, and Private Harbaugh; Captain Shawan, Lieutenant Eisenbrey, Miss McKee and Private Cushing; Major Hoover, Miss Briggs, Private Steverding and myself. All of us were loaded with nitrous oxide and supplies, plus two days' rations. Hoover and I drew ambulance No. 8 and a cloud of dust all the day. At about 8:30 we swung into Rémy Siding. I was delighted to see old friends again. How quickly a common labor, and perhaps a common danger, cements friendships.
Hoover and I spent a good night on stretchers in an Armstrong hut. The weather was cold and wet. Next morning out of a clear sky, General Haig's Headquarters called me over long distance and asked what I required to make a research team. I replied, "Two anesthetists," and gave the names of those I wanted. All was adjusted immediately by wire, going over the head of D.D.M.S. at Rouen, for which Hoover and I praised God, as this officer had no interest in poison gas research and had blocked our way for a moment.
July 23rd
Hoover and I saw today about one hundred gassed cases. We have lost seven from exhaustion since 1 :00 P.M. We tried out Bayliss solution, Porter's solution, hypertonic saline---no good!
C.C.S. 17, July 25th
General Jacob, commander of the corps that is to attack south of Ypres, called today to inquire about our experiments on explosions in dugouts. I showed him the results of my work on exhaustion and told him of my desire to get unwounded Germans freshly killed in dugouts for autopsy, in order to see what cytologic changes the long, worrying bombardment which we had given them had produced in the cells of their brains, liver and adrenal glands, and also to obtain some Boches that had been killed in dugouts by air concussion to ascertain if their lungs, like those of the dogs, showed air concussion effects.
General Jacob detached two men to look out for specimens but asked that someone familiar with the needs of our research go with them. I offered but the general refused. Eisenbrey begged to go, but I was much troubled to have him undertake it because he had a family.
C.C.S. 17, July 27th
Today Hoover, the Padre and I went to Dunkerque in an ambulance to get sea water for infusion experiments. We had forty-gallon capacity petrol cans which we took through the edge of battered Poperinghe, then around the cutoff down to the long quay by the sea where men were digging bait. We hired several to go out a quarter of a mile in a boat to get fresh sea water. Graceful seaplanes were diving and maneuvering. A number of guard ships lay lazily about the mouth of the harbor. Coast guns were booming heavily. Taking off our boots and stockings we waded out to meet the boat to carry the cans of water to the ambulance. Having loaded, we drove to Dunkerque again and found a hotel but were obliged to go to the French Military Headquarters for permission to purchase something to eat as it was after 2 A.M., time officers should be in their quarters. The next day after lunch we returned to Rémy Siding.
C.C.S. 17, July 30th
Hoover and I have been making post mortems and studying gas poisoning, the new mustard gas as well as the phosgene. These are the most distressing cases we have seen. The Fourth Army has 3,500 casualties, the Fifth, 2,500 from this gas alone. It blistered and burned faces, arms and groins. Eyes were swollen shut. Postmortems showed the pharynx, larynx, trachea and bronchi extensively necrosed. The mucous membrane could be taken out like an inner tube of an automobile tire. Any treatment seemed hopeless. The mortuaries were filled all the time; burials took place at 1 P.M. daily.
Hoover and I finally reached the point where we were prepared to attempt an intracellular resuscitation by first infusing 500 cc. of sea water with five per cent glucose and ten drops of adrenalin, in the hope that it would increase intracellular oxidation; then superimpose blood transfusion and follow by immediate operation. Many surgeons were watching the results.
In addition to the case of exhaustion, I tried an intracellular resuscitation in a case of phosgene poisoning, the gray variety that is usually hopeless. For thirty minutes Miss Roche gave oxygen under pressure with the nitrous oxide apparatus. The patient became pink and conscious, gave an account of his injury, asked for water, then became cyanosed again, unconscious, and returned to oblivion. Oxygen under pressure resuscitated him each time.
We decided that if he lived until morning, we would bleed him. If bleeding did no good, we would put him again under oxygen pressure and give sea water, glucose and adrenalin simultaneously, hoping that the intracellular acidosis would be relieved. Although each time we gave the oxygen pressure he became pink and conscious, his air hunger was not relieved. But after the combined attack on intracellular acidosis, he gradually grew better, the next day he was conscious, required no oxygen and was pink. Hoover found that the physical evidences of pulmonary edema had improved. Colonel Soltau, Colonel Stephens and Sir Anthony Bowlby watched the treatment with great interest. There is no doubt that it was helpful but impossible in a big push---too long and too costly. There seems to be nothing one can do.
This is the eve of the great British effort of the war----the third battle of Ypres---the opening act of the drive to break the German hold on Belgium and France. On all sides there is tense expectation; motorcycle messengers are rushing about; rumors of combined sea, air and land attacks are numerous; surgical teams are arriving daily; every bed is cleared; hospital trains are mobilized; new tentage for emergencies is on hand. Guns boom louder and louder. General Jacob told me that tonight his sector, six thousand yards of the Front will be given eight thousand gas shells; that there is a gun for each seven yards of Front; that the bombardment will be the heaviest in history. The evening is clear; the moon, dim; the roll of the guns, majestic.
As I lay on my bunk reflecting, I found myself comparing in my own mind the achievement of man in this massive man hunt as compared with the most successful effort of other hunting animals. It costs more than one hundred thousand dollars to kill each man. I wondered how much new poison gas the enemy will send over. I know they are receiving one gas shell for every two feet of the front line and that the shell is placed as nearly as possible at the feet of the enemy gunners. I think of our scientific "expedition" and Eisenbrey on his way in the dark to get the specimens the British guns are preparing. What a research this is! A laboratory that costs millions of dollars to create, that is operated by two million men and the best brains of two great nations; all this ingenuity and concentration of force on the preparation of our specimen!
While collaborating with this twentieth century Frankenstein of planetary dimensions at this volcanic inferno, I am also collaborating with a group of surgeons, physicians and pathologists at Rémy Siding; another group at Rouen, including the expert chemists of Great Britain who are conducting the offensive and defensive chemical warfare; and the Royal Engineers, with Miss Rowland as executive secretary. Back home, Professor Dayton C. Miller of Case School, one of our ablest physicists, is finding time in the midst of his own researches to advise the little group that I left in Cleveland.
Tonight when the battle opened, my first cases of intracellular resuscitation were begun: three cases, a phosgene gas; a neglected, hopeless, tallow-candle colored, exposed and wounded soldier; and a dying post operative. All of these widely separated research groups are concentrating on the cause of the impairment and the methods of resuscitation of the Nissl substance of a microscopic human brain cell. Science and medical practice and the Army went over the top on this same day---the anniversary of the war. If only our attack will attain its objective and surgery can make every wounded man who is anatomically operable, physiologically operable! If this succeeds, then intracellular resuscitation will be universally applicable to vast numbers of exhausted from all causes.
After these musings I awakened Major Hoover and my nephew, Dennis Crile. It was 4 A.M. and we walked out in the dawn toward the Front, a front of infinite explosions, infinite human effort, leaving our intracellular attack for a while.
When I returned to C.C.S. 17, I found Eisenbrey stretched out on a cot. His first words were: "I had no idea it was like that." They had been caught in their own barrage and were lucky to get out unharmed. Then he added, "Instead of making observations on soldiers you can make them on me!"
It seems we will have to wait for another opportunity to get our specimens.
C.C.S. 17, August 3rd
The zero hour was 3:50 A.M., July 31st. The stream of wounded began to increase in volume, slowly at first, then rapidly, until the entire Rémy Siding was swamped. By the night of August first, every bed, every aisle, every tent, every inch of floor space was occupied by stretchers---then the rows of stretchers spread out over the lawn, around the huts, flowing out toward the railway. The walking wounded arrived by the hundreds. Whether stretcher cases or walking cases, all showed the usual grave demeanor---the mud colored, gray, shrunken face, the careworn, war-exhausted countenance.
The operating rooms ran day and night, without ceasing. Teams worked steadily for twelve hours on, then twelve hours off, relieving each other like night-and-day shifts. The work in the operating rooms ran smoothly; each turned out a hundred operations a day but did only about one in ten cases that should have been done. There passed through the Rémy Siding group of C.C.S.'s over ten thousand wounded in the first forty-eight hours. I had two hundred deaths in one night in my own service. The seriously wounded piled up so fast that nothing could be done with them, so I told the Sister to administer as near an overdose of morphine as was possible to keep them alive but free from suffering. One soldier, the entire front of his abdomen torn out, didn't like the Moratori Ward because it was "too dark." This boy lived on and on, morphine conserving the flame of life, until we could operate; and he recovered.
My most interesting case was the unobserved slip of an entrance point of a rifle bullet in a fold under the chin. When I examined further, I found that it had torn off the subclavian artery and vein. These I tied. The bullet went down to the spine. Another large ragged fragment of shell had entered at the middle of the thigh and passed up over the artery and vein into the pelvis and abdominal cavity. There was no viscus rupture, but the bladder, intestines and big vessels were all laid bare though not penetrated. Every conceivable thing happened, phosgene gas, another new gas, wagon wheel injury, mule kicks, ragged barbed-wire tears, knife cuts, penetration of every kind of missile, shell shock lunatics.
I operated all day and all night. Our dump ran as high as eighty waiting. At one time we were thirty-six hours behind the list waiting on the stretchers for operation. Many of these acquired gas gangrene while waiting. Each day of delay was marked by the noise of saws in the operating room. Many hands were lost on account of the "gas gangrene of delay."
Fear and worry alone are causing more derangement and impairment in this war than the vast number of lesser injuries. An injury is local and drives only a part of the organism, and when the immediate effect wears off, its influence is past. Fear and worry, on the other hand, not only drive the activating glands and the brain continuously but recur again and again, not even allowing the depolarization of sleep.
After the big storm blew over I made "trouble rounds" to the other stations and was able to go and see the splendid work of Ed and Captain Shawan and their teams. Ed did an extraordinary thing---he performed thirty-nine operations continuously in one stretch on one table with one crew.
One day Colonel Maynard Smith came along and told me in confidence that the enemy had given evidence of withdrawing and asked if in that case one other team and my own would come to a new clearing station to try out abdominals. General Heine, General Sloggett, Colonel Soltau, Colonel Stephens of the British Research Council, and many lesser lights came along to see us work and to consult with us. Finally a commission consisting of Professor Bayliss, Captain Wolf (biochemist on the National Research Council), Sir Anthony Bowlby, Colonel Cuthbert Wallace of the First Army, Colonel Maynard Smith of the Fifth and a group of local men asked for a hearing on exhaustion and restoration. I talked an hour or more, then took them to the wards to see patients treated.
On the next day Sir Anthony returned and asked me to make whatever organization I desired in order to put my viewpoints into operation. I suggested the formation of the night- and day-resuscitation team, Blankenhorn and Miss Briggs for day, Eisenbrey and Steverding for night. I asked also to have Ed's team transferred to No. 17.
C.C.S. 17, August 4th
In collaboration with Lieutenant Orr, anti-gas instructor, Captain Lambert, chemical adviser, and the Royal Engineers who built a special gas chamber for the research, I have been continuing through daily correspondence, an animal research at Rouen on the various types of gas poisoning that are being used here at the Front, in the hope of finding some means of counteracting the terrible effects of these new gases. Meanwhile, Hoover and I are trying out clinically certain suggestions.
During the push Hoover and I had an interesting case of the gray type of gas poisoning. We kept the man alive for seven days and found that he could be made pink by giving oxygen under pressure continuously with the nitrous oxide inhalation machine---and that he could be held there. We made up our minds that by pushing the oxygen across and oxygenating the blood---which we did for thirty minutes---we could put him in a ward as a regular surgical case and give him oxygen. Colonel Soltau and Colonel Stevens saw him. He was absolutely gray, yet we could make him pink as I am, but during this time he never changed the respiratory rate. I thought the man had something more than asphyxia---because in cases of cyanosed children on whom I have operated in civil practice, as soon as the operation is completed, the breathing becomes better.
This patient did not behave in this way; under oxygen he talked, asked for a drink, gave his history. If we stopped the oxygen, inside of three to five minutes he was just where he was before---unconscious ---so we had not solved the problem. We then decided to turn right about and treat him as one would intracellular acidosis; so I took a pint and a half of blood from the vein and injected a pint and a half of sea water plus glucose, drop by drop, with adrenalin, simultaneously, for forty minutes. That was all we could do.
He improved steadily; came out of the asphyxia, became pink and breathed without oxygen, but the respiration remained rapid. After a while respiration became normal, and the lungs cleared. The next day he was partly rational. I talked with him and finally twisted out a smile although it was difficult. Just as we thought he was all right, he began to grow worse. Major Hoover then went over his nervous symptoms and discovered that he had some brain lesion. He died on the seventh day.
The post mortem disclosed multiple hemorrhages in the brain and spinal cord, but we had accomplished something, we had kept him pink until death. The autopsies on other cases revealed that in many of them the gas destroys the mucous membranes of the respiratory tract.
C.C.S. 17, August 17, 1917
Sir Anthony Bowlby was our guest. While chatting at dinner we were mildly attracted by the report of our anti-aircraft guns. They rapidly grew nearer. When we went outside we saw an enemy plane in the sky as dazzling as a huge illuminated bug on the end of a perfect beam of light. Everyone was delighted at the flashes of light all about, above, below, right and left, like twinkling stars convoying this heavenly creature across a wonderfully fair midsummer evening sky.
One circumstance changed this. Just as the plane came over us vertically, our visitor dropped a torpedo---quite by mistake one would suppose---but everyone fled for shelter. As they struck the earth, the huge bombs made a flash and crash. Two! Three! Each came nearer, the fourth being just outside our grounds! Before the fifth crashed, I managed to reach my hut, followed by my striker Gillet, who struck a match and handed me my steel helmet.
We ran for safety, Gillet straight ahead, but I threw myself on the ground, face down. Another crash! Moans! Gillet was fragmented. Still another! Cries for help just beyond!
The lights were out: the night was dark. With flashlights we groped about, carrying the wounded to the operating room or to the ward. German prisoners but thirty yards from my tent and adjoining our huts, heavily injured, were calling for assistance. The tents throughout the camp were wrecked. Flashlights revealed contortions, anatomical confusion, mangled dead and wounded.
Ed and I at once visited the Sisters' quarters and found our nursing and enlisted personnel safe. We assembled teams and started to work. Transfusions, operations, resuscitation, amputations, bombing went on simultaneously. Out of a total of less than five hundred individuals, there were sixty casualties, twenty-four killed and thirty-five wounded.
But it is an ill wind that blows no good and among the dead were nine German prisoners, killed by air concussion, four of whom showed no wounds!
Thus "concussed Germans"---just what I had been moving heaven and earth to get---were blown to my very door, leaving me nothing to do but examine the specimens.
Autopsy showed hemorrhages in the lungs typical of the results of air compression seen in our Rouen research. The injured were in terror. Like shell shock cases they were ashen gray. Many had tremors. All were prostrate. The blood pressure in all was low. They showed a slow pulse and a slow respiration.
C.C.S. 17, August 18th
This morning the Padre asked Major Lower what he did last night when "the disaster was visited upon us" to which Major Lower replied, "I had not time to do anything. What did you do, Padre?" "I lay on my back and put my trust in the One above," the padre answered. "So did I," said Major Lower, "but I was damned near ruined!"