Paris, April 17th

I AM HERE to attend the Interallied Surgical Conference. Among the conclusions adopted by the Conference (England, Belgium, France, Italy, Japan and Portugal) relative to the treatment of war wounds was the following:

Under the heading of traumatic shock: Local anesthesia combined with general anesthesia by means of nitrous oxide is the best. Next to this ether appears to be the least harmful.

And under amputations: In the case of serious shock the use of nitrous oxide and oxygen is desirable. Ether is the next best anesthetic.

It's coming!

At No. 9 I am organizing a mobile unit to be made up from our personnel, the object being to work as near as possible to the line to see if immediate operation will save more soldiers with peritoneal wounds.

General Hospital No. 9, April 19th

Not since I left home have I laughed so heartily as I did today when I heard that the galley proof of the Notes on Military Surgery has crossed the seas again. Apparently it cannot get itself either published or unpublished. The poor little book has a burr under its tail and the burr is the third chapter which has caused all the row in the Medical Department of the Army, although the organization over here is made in accordance with that burr. Undoubtedly the publication of the book as a war manual will be prevented--- the official copy which was sent to Edward Martin for final approval, by signature, seems to be lost anyway---but I don't mind since it has helped to do away with the old reactionary C.O.'s and win for the American soldier a real advantage in the care he will get. The book first went to the Council of Defense where it was requested as a war manual; then to the Surgeon General who approved it; then to me in London to put through the British censor; then back to the States where it had a second hearing before the regular Army officers who advocated alterations; then to the U.S. General Staff at Washington; and at last, after much discussion, it was sent to the G.H.Q. of the A.E.F. for the General Staff to consider. Meanwhile, the publisher is frantic.

However, the Army medical organization that has finally come through is essentially the same, almost to a dot, as that which was worked out at the meetings in Chicago and Washington by Franklin Martin, Will Mayo, Ned Martin and me last October---a slow, but real triumph in which I cannot but feel a personal satisfaction in a good cause, because before America entered the war, Brewer, Finney and I had been appointed a Committee of Standardization to study the methods of handling the wounded in the British Armies and suggest recommendations for a medical organization for our own Army, as well as methods of treatment.

War came to our country with such swiftness that the trip could not be authorized, but when our unit landed in Liverpool I was ordered to the Interallied Congress where the British and French requested that I visit their Fronts with an idea of criticizing methods and suggesting new ones. This gave me a rare opportunity to study organization.

Edward Martin, head of the Editorial Committee of the Council of National Defense, and Franklin Martin, cognizant of this, requested that our overseas group of consultants work out a standardized method for the treatment of the wounded and a plan for medical organization. They then asked me to put this, plan in the form of a report and I was ordered to return to America with it. The plan was approved and signed by the medical consultants in France, therefore when I went to America in October I represented the consensus of opinion of the Medical Corps of the Expeditionary Forces. While I was in the United States, Gorgas urged me to take the Headquarters job. If ever I had vision it was when I declined it and suggested that by temperament I believed that Finney was best suited among the oversea consultants to meet its requirements.

After my return to Europe I proceeded to the Medical Headquarters of the Consultants at Chaumont where I saw Finney. He seemed quite contented and happy in his new position, greeted me cordially and told me that all of the positions in the American Army and Field and Base Hospitals had been filled.

After an awkward pause he asked what I would like to do. To his obvious surprise I suggested the formation of a department of clinical research to study the problems, the principles, and the practice of war surgery and that I would like to take the position of Director and would like Jack Yates, who was Finney's brother-in-law, to be my associate. This was granted and to my great satisfaction this liaison of surgery and research has proved of great value.

May 10, 1918, Rouen

Think of it! Transfusion is now such a routine procedure that today's order of the day carries a recommendation from the D.D.M.S. that the C.O. of each hospital give a donor of blood for transfusion a certificate granting leave for the day.

The first transfusions in this war were given at the American Ambulance during the service of our Lakeside Unit in 1914. The first transfusions in our overseas service were given by our teams at C.C.S. No. 57. The first transfusion in a base hospital was given at No. 9 to a Tommy, an American giving his blood. It was not so many years ago that I transfused Miller---in the middle of the night in that dim, gaslit St. Alexis Hospital!

No. 9, May 16th

Ed is leaving today. The thought that he is soon to see my family has penetrated my protective armor, quite completely. But some day will be my day.

No. 9, B.E.F., May 27th

I am still boning up like a schoolboy on physics. So many advances have been made and there are so many problems, that I feared I might be out of step. Physics, biochemistry and physical chemistry have been of much benefit to me, and physiologies of very little help. This means that medicine must be put on another basis and that practical problems can be based now directly upon physics and chemistry.

No. 9, May 31st to June 2nd

On my way to Langres for a lecture at Colonel Bailey Ashford's wonderful Army Medical school I spent a night on the train which was about five hours late on account of the big battle at Soissons and Reims. During luncheon a gentleman stepped into the room and inquired if Major Crile were there. He was my old friend, George Adee, of New York, one of the typhoid patients whom I rescued from behind the enemy lines in Porto Rico in 1898. I returned that night by train to Paris and was eight hours late. As we came into the outskirts of the city, we ran into a Big Bertha attack, and our train---like an ostrich---backed up far enough to get its luminous head underneath a bridge so the Germans couldn't see it. The barrage---thousands of shells bursting in the air---was the most wonderful thing I have ever seen.

Paris, June 7th

It is June again and war---and Grace's and my June seventh. I attended an interesting service at Rouen on Decoration Day and heard a remarkable address by the Bishop of Verdun. It seemed an extraordinary circumstance that in that wonderful setting, amidst the realism of the present protest and struggle against the Hun, the British officers ---and the French bishop should with pomp and pageant commemorate the day when other British officers and other French clergy assembled together here at Rouen, to try and to find guilty Joan of Arc and to sentence her to be burned. We also burned "witches" and not so long ago. There may yet be some hope for the Hun. France, England and we have seemingly crawled out of the cave into the sun. I trust we may ever remain there.

June 10th

This morning I went by Saint-Valery to Étaples where the enemy threw down flares that lighted up the area, then machine-gunned the patients and personnel. Medical officers, nurses and patients were killed and wounded to about six hundred.

At Camiers we stopped to see the Chicago Unit where we met Colonel Cabot and Fred Besley, then we left for Boulogne where the Harvard Unit is stationed. I spent the night with Harvey Cushing who took me to the ancient citadel above the city where hundred-year-old trees grow on the ramparts. Under the citadel are vast sealed caverns in which prisoners were once entombed alive. In these caves every night a thousand or more women, children and tottering old men lie on the ground like so many animals.

No. 9, June 30th

We have been making a group research at this Base on transfusion of blood, and Tom Shupe has written an excellent report. Up to June of this year, 320 transfusions have been done by our Unit, 268 at C.C.S.'s. The majority of those done at C.C.S.'s were on men sent to the Resuscitation Ward and represent all manner and degree of shock, hemorrhage, collapse and severity of battle casualties.

Grouping was done in fifty-two of the 268 cases that were transfused at the clearing stations. Unmatched or ungrouped blood was used in 216 cases without symptoms of any consequence, immediate or late attributable to blood incompatibility.

No. 9, July 4th

The French with their usual grace have made their Bastille Day coincide with our Fourth; in fact they have taken over the Fourth bodily, including the modest field day sports that Major Vieder of the St. Louis Unit had planned with us. To our astonishment, not to mention embarrassment, they have made a formal state and military function of it, complete with generals, admirals, civil and state functionaries in brilliant regalia and French troops of honor.

Having just returned to the Base, I strolled down to see what was going on and arrived at the entrance to the athletic field to be told that, as the American generals and colonels had failed to arrive, I, as ranking officer, would have to lead this gold-braid military procession. It was then within two minutes of time for the gates to open.

"Very well, we're off," I said, and down the broad, flag-decked avenue we gravely marched, past saluting officers and bugling squads of honor, then, just as slowly and gravely we mounted the stairs carpeted with crimson to the crimson-covered seats of honor in the grandstand where rank had been measured and names placed in advance. With utter gravity we seated ourselves. To lead a procession of all nations in a foreign land, among an alien people who were at home in their brier patch, was a rather stiff offhand job. This, however, was easy as compared with three long hours of French pantomime. The Belgian general was the only one who spoke English.

In the bleachers were perhaps ten to fifteen thousand spectators, French, British, Singalese, Scots, South Africans, Australians, Canadians, Belgians, Italians and Americans. A band of Scottish bagpipers marched back and forth in the middle of the field to the delight of the women. Our American brass band had not yet arrived, but just as the gates were closing and everyone had given it up, we heard a drum in the distance and in a moment the American boys, begrimed and dusty, fresh from the front, their automatics hanging from their belts, swung through the gate, led by a tall swaggering Yank. Straight for the gold braid sector of the grandstand they paraded, while the entire arena reverberated with such cocksure martial music that the Americans went wild.

Then the coin was tossed and the great American game of baseball was begun. It was just there, when I thought I had passed the rapids, that I dropped my molasses jug, for the grizzled French general who spoke no word of English asked me to explain all the points of baseball. On the one or two times that I have attended a baseball game in Cleveland with a visiting foreigner, my explanations have been such that the matter was taken out of my hands by a neighboring fan. This, at last, was my day. I had the opportunity to explain a game the intricacies of which I did not understand, to a polite dignitary, in a language I could not speak. He bowed and smiled as I finished each sentence, which might as well have been a quotation from Alice in Wonderland, and I smiled and bowed back.

In the evening the French general appeared in red breeches, more gold braid and carried an enormous sword. By this time an American general had appeared on the scene but at dinner they sat side by side in dignified silence. After dinner we marched over to the theater which was packed, the seating being according to a precedent that, no doubt, went back to the time when Caesar visited here and found the three parts of Gaul. It was difficult to arrange for the Archbishop as he was not on good terms with the State and he did not have military rank. This almost cost us another year of way, but it was smoothed out by efficient Major Vieder.

When the curtain went up the four ranking Allied generals were on the platform. The veteran, fire-eating French senior general spoke first, and whenever he rattled his sword at the close of a period, the Americans applauded. The British general spoke most appropriately; he left the impression that the original Fourth of July was arranged by harmonious collaboration between the British and the Americans.

Langres, July 15th

A group of combat engineers came in to hear my lecture on Shock this week. At the close the Chief Engineer, Colonel Paul Bond, who is writing a textbook on tactics, said, "What you have talked about today we are trying to do to the enemy. Your object is to prevent shock; ours, to induce it. The information you have given in your lecture has great tactical value. If you would take the biological side and we, the mechanical side, I think you could give us valuable assistance in planning offensive warfare."

Of course I was interested. Colonel Bond cautioned me that if I joined them in their research I could no longer be protected by the Geneva Convention, but victory is all that interests me.

What, then, is the problem? If fear and worry interferes with sleep, and sleep is essential to life, then the problem is how can we cause fear and worry and lack of sleep to the enemy. So I wrote "Fear and Worry and Loss of Sleep as a Means of Making a Diffuse Offensive," in which I suggested to Colonel Bond that fear and loss of sleep are more injurious to the enemy than wounds from direct hits. Aviation seemed to me the ideal weapon for wholesale production of fatigue and inefficiency. Bombing which is of value in proportion to the amount of the vitally necessary restoration of sleep it prevents, would seem most profitable between twelve and two at night. This is the period of heaviest sleep, and once thoroughly disturbed, the restorative value of the remainder of the night will be relatively light. The compulsion of the loss of sleep is made possible only by instilling fear. Fear is instilled only by actual damage in loss of life and destruction of property. Therefore, a campaign of bombing should be planned in such a way that it will produce the greatest possible fear.

The two factors that will instill the greatest amount of fear are demonstrated destructive power coupled with absolute uncertainty. It would be best in a campaign to choose a conspicuous city and out of the blue, lay waste to it to the utmost degree. This will establish the fact by which not anxiety, nor worry, but genuine, intense fear is generated. But it is extremely difficult to prevent an able and analytic adversary from catching glimpses of the mental habit and philosophy of the attack. Should he "catch the step" of the attack, much of the power to compel fear and loss of sleep would be lost.

Therefore, in order that the campaign should be clearly and always one of a series of surprises, I suggested that it would seem advisable to set up a system, for a period of time and for the achievement of a certain set of objectives, that is wholly independent of intellectual processes. This could be accomplished by drawing by lot the names of the cities to be reduced by bombing or those in which the inhabitants are to be reduced to fear by the expectancy of bombing. Such a plan would remove all data from which the enemy could draw conclusions and would maintain the element of chance which is essential.

There are even now fairly good and simple criteria for estimating the reserve power of troops, so methods of sampling enemy troops as well as our own for reliable evidence of their reserve power should be developed. For instance, if 100 represents the normal power of electrochemical energy, we could take one group of muscles, like the respiratory, and see how high the soldier can raise a column of mercury by respiratory force, and how long he can sustain a column of it at a given height. This would tell roughly how much reserve the brain cells that operate this sector of the body have.

Another method, the electrical, is now in the process of development. It may possibly prove that observations now in progress may show a relationship between the conductance of tissue and the reserve power. The respiratory calorimeter also would give an indication whether or not the organism has been changed in such a manner as to show either an increase or a decrease in metabolism or a more or less permanent change.

No. 9, July 31st

The real offensive began on the fifteenth when the Germans made their long-expected attack. The counterattack was made by Foch on the eighteenth.

The hospitals did not expect this attack and in some cases were not prepared.

Why? Because this attack had to be kept secret. Not even Pershing knew. Pershing trusted Foch and secrecy of that attack was essential to its success. Evacuation of hospitals would have given away the secret.

But it was on July fifteenth that a new America was born. Château-Thierry was its birthplace. The "easy-going," "good-natured," "soft-hearted" Americans proved that they could fight and die as in the Revolution and the Civil War.

No. 9, August 2nd

I am extremely busy working on standardization of surgical methods for the A.E.F. and on research in the hospitals and laboratories and writing. I live like a schoolboy, working most of the day in the room in which I sleep.

We have five monkeys, twenty rabbits, ten guinea pigs, nine mice, a hundred and nine chickens, twelve ducks, four geese and a pool chuckfull of gold fish; all waiting for our research experiments. The equipment came several days ago and we are expecting the research group daily.

Latest orders are that as a field officer I must wear spurs at all times, whether on boots or shoes. This will finish me; I can't as yet remember to wear my Sam Brown belt.

No. 9, August 27th

Frank Bunts came today to be C.O. in the place of Ed who has returned to the United States. Frank will make a good C.O. I am more delighted than I can express to have him here, for I have missed Ed sorely. What a remarkable record Bunts, Crile and Lower have had all these years. We have been rivals in everything, yet could differ in opinion about anything and through all the vicissitudes of personal, financial and professional relations we have been able to think and act as a unit.

Paris, September 5th

I lectured today before the Sanitary School at Langres. Captain Boothby, who had been with the Mayo Clinic in research, pleased me by asking if he might join my research group. He is in agreement with our viewpoints on exhaustion.

Colonel Bond told me that the notes I sent to him on how to make a diffuse offensive he considered so important that he had passed them on to the Air Service.

Private Sanger tells me we have driven ten thousand miles since I took this job. Some of my recent trips with Sanger at the wheel have skirted high adventure. While returning in the dark to Paris the other night, he hit a cow with the wheel of the Ford, breaking the car's frame, severing the radiator hose and losing all the water. We were ten miles from anywhere. Sanger started on repairs and I took our collapsible bucket to search for water. I must have been gone over three hours as it was not easy to walk and keep water in that bucket.

When I reached Sanger at last, I set the bucket down in front of the car. It was still dark and he had not finished his repairs. When all was ready to put in the water, I jumped up and in my eagerness to be helpful, tripped over the bucket and spilled every drop of water. It took us two days to reach Paris and it was only a hundred and thirty miles.

Paris, September 6th

The Research meeting in Paris was held yesterday and today. One day was given over to my program, "Surgery in Battle Areas."

To send out a group of questions on a subject and then hold a conference over the answers, was a new idea to everyone. The house was packed and every one was enthusiastic over the idea and the results, so I was delighted.

This will be known as the "Panel Method" and I believe will prove to be a most efficient means for covering knowledge of various methods in a given field.

Paris, September 8th

My tryouts in the Moribund Wards at Rémy Siding have resulted in the allocation of a group of British and French surgeons to study methods in our Army. This decision was the first step in the organization of the Division of Clinical Research in the Interallied Line, of which I am the head.

Formerly the Research meetings consisted of speeches and long discussions but there is no longer time for that; we must get our information quickly and disseminate it. Conclusions and bald facts are what we want. The catechism or panel method seemed to me the most direct; a question-and-answer meeting to cover a vital subject. Instead of having guests address the meeting I arranged this week to have two or three able men, who know their subject, catechized. The catechism will then be published in small pamphlets entitled "War Medicine." It is as simple as that. And why not? Such Chief Consultants as Cushing in neurosurgery, Goldthwaite in orthopedics, Blair, of St. Louis, in plastic surgery, are so authoritative that when they make a recommendation, Finney, in whom final authority rests, will always approve.

Over and over again, I, as head of Clinical Research, have gone up and down the Interallied line, observing, recommending, picking up a group where there seems to be an unnecessarily high mortality rate, changing this or that method of handling, until they get better results. This group of consultants is singularly open to suggestion, proposals or recommendations of any sort. Their purpose is to try out, on a large scale. If a new method of sustaining a fracture is called to our attention and the method seems more feasible than one already employed, I ask a unit to try it out, and we then compare their results with those of other units. It is research on a colossal scale. The methods of years can be overthrown in a night. We have no fixed ideas.

The great contributions coming out of these researches en masse are:

1. The defense of the patient's own tissues in infections is the real defense. Strengthen that by clearing away the debris and do not allow secretions to pool. The English call this excision-revision.

2. Don't sew a wound tightly; that causes anemia.

3. The value of Dakin's solution is only the value of drainage, for, although the solution dissolves the culture medium, it also handicaps the defense of the tissue to rid itself of the infection. Normal living tissue can defend itself if there is a drainage and if the wound is clean. We used to be afraid to close a "strep" infection, for instance. Now if we play the defense of the patient and not the defense of the germ, we can close anything.

In playing the defense of the patient, nothing is so useful as blood transfusion which has become so obvious a method in treating not only infection but also shock and hemorrhage that blood is being gathered from the wounded and stored at the casualty clearing stations. Although citrated blood was used in large amounts in the forward areas as early as September 1916, it was at C.C.S. No. 36 that my old friend, Dr. A. L. Lockwood of Toronto first made blood banks in advance of the needs. This, I believe, is the first attempt to store blood.

Dr. Robinson of the Harvard Unit also has made a splendid contribution by working out a plan whereby blood can be grouped, withdrawn and kept sterile so that any time within ten days it is available for transfusion.

Not long ago a new unit came overseas. I received word by telephone that something was wrong as they were having an abnormal number of infections. A consultant investigated and found that four or five of the men were sewing the wounds so tightly that they were causing an anemia, thereby breaking down the defense of the tissues and giving the bacteria a chance to spread. We showed them our method and within twenty-four hours better results were reported.

But the dissemination of medical knowledge is made possible only by medical journals which, more than any other factor, are responsible for the professional growth of medical men after graduation from medical school. Medical journals, like our daily bread and the air we breathe, can best be appreciated when we have none. In France there are none, and the professional stagnation has become so marked that General Ireland cabled for one of America's most talented and successful editors, Seale Harris, to become the Secretary of the Research Society of the American Red Cross and the editor of War Medicine, the editorials of which I write anonymously. I was able to have this medical journal published and paid for through Mr. George Perkins and Dr. Alexander Lambert, and sent by the American Red Cross to every surgeon in the line. This is the only way of unifying methods of procedure for the American surgeons.

 

Mobile Unit No. 5, Ravine les Placys, September 25th

WE ARE NEAR Rampont, eight miles from Verdun, where our Mobile Unit has taken over an old French advance post. We are the farthest forward hospital in this offensive---five miles behind the line---in a ravine among wooded hills. The hospital is dirty, the site beautiful, the morale high, the roar of the guns weirdly attractive.

On the eve of this Argonne offensive all of us, and I in particular as head of the Sector of Surgical Research, are under great tension because G.H.Q. has issued an order for a procedure new to this war and it is based on our research at No. 9. Following the Fifth Army defeat when No. 9 suddenly became a front-area hospital filled with the seriously wounded as well as the lightly wounded that were usually sent to the Base, we organized at once to push the lightly wounded on. It worked. I telegraphed Bowlby to come and see. He was amazed to find that we could classify so early the cases that could take neglect for a few days and those that could not.

At that time there was a tendency to operate as soon as possible all cases of perforation of the lungs or through-and-through wounds. This showed that they could be left alone, that they could travel, and that nature itself gave a healing process. In other words, this great push showed that many of these injuries during the first hours were safer on a train than in the hands of a surgeon.

Bowlby was so impressed with these findings during the March offensive that he took the results to the next meeting in Paris and as a result a recommendation was sent to General Pershing that at the next large battle sixty-five per cent of the wounds be sent back to the Base and only the thirty-five per cent that could not travel be kept in the front area. This was so sound that it was partly tried out at St. Mihiel, but for the Battle of the Argonne it is an order.

Mobile Hospital No. 5, Ravine les Placys, September 26th

Since our hospital holds the post of honor as the most advanced in this offensive, we are not allowed to put up an inch of canvas and have to conceal or camouflage every item that is brought in. Our camions are covered with leaves, our huts are hidden in the edges of the forest, and we are not to appear in the open lest the hawk fly over us.

Rain, rain; mud, rats! The mud is unbelievable. The whole ravine is a marsh. We can only get about on duckboards, and even so, I wish I had hip boots. The nurses wear boots. Often it is a question which of them shall have precedence, the rat or the nurse, and many a nurse yields the duckboard to the rat.

My own little shack, just large enough to turn in, is on the hillside. I make my bed, fetch water and run my own bailiwick.

Mobile Hospital No. 5, October 13th

This morning as a result of yesterday's warning about the great offensive, we were expecting a large intake of wounded so our men were asked to sleep all night to be prepared for a long turn. I arranged to take my table for abdomens. The expected barrage in the night began but ended abruptly. The morning was dead quiet; not a patient came. Seeing a chance to go to Colonel Garcia's for a conference, I walked over to Headquarters and, as I reached the building, was met by several officers who said, "The war is over." They gave me a copy of the telegram signed by Solf, State Secretary of the Berlin Foreign Office. At first I didn't believe it could be authentic, but coming from headquarters it must be right. I returned to Mobile 5 and read the message to a group, then Rogers had a number of copies made and read them aloud in each ward. I attended these readings and noted the effect on the wounded men and the nurses. Everyone laughed, some applauded and some were almost shocked. It was an interesting study in reactions.

The great highway that we see from our ravine has been deserted by day, and by night swarming with machines of war groping in the dark, but tonight the headlights of the vast stream of war traffic dazzle us. As I look out of my little window, it is as if moles had turned into fireflies. Thousands of men are peeping out of darkness into light, thousands of them are cautiously raising their heads above the ground and thousands are to remain in the ground. On this resurrection day, man may come out into the light and learn not to skulk, not to look overhead, not to seek shelter or wonder who will bring food by day. But many thousands, though they walk in the light, will remain in darkness. Thousands will not walk but shamble, thousands will remain a part of France---a cross, a wooden enclosure, perhaps a wreath or a flower.

Mobile Hospital No. 5, October 14th

This morning our troops went over. The war goes on. Off with the peace! Roads are all but impassable; automobiles are mired everywhere; wreckage is on every side. Guns are booming; miles of convoys, ammunition and food are going up; trains of wounded are coming down. The Argonne forest is sprouting wooden crosses.

Mobile Hospital No. 5, October 17th

Everything is overflowing with patients. Our divisions are being shot up; the wards are full of machine gun wounds. There is rain, mud, "flu" and pneumonia. Some hospitals are overcrowded, some are not even working. Evacuation 114 has no medical officer but hundreds of pneumonias and no one to look after them. A few days ago Major Draper asked me to see the situation with him. Every sort of infectious case was there, packed in as close as sardines with no protection. An ophthalmologist was in charge of these hundreds of cases of desperate pneumonias that are dying by the score. Thayer was told of it and said, "We must send up a laboratory man at once and have the cases grouped!" Binnie, Roger Lee and Vaughan, Consultants of the Third Corps, all feel the same about the lack of organization of surgery. There is no consultant for No. 10 Evacuation or for any of the mobile or evacuation hospitals.

There are head hospitals, chest hospitals, hospitals for lightly wounded, seriously wounded, gas, psychiatry, and this in spite of all the work put on organization by our civilian group. Surgeons who have had no experience with such cases are sent to hospitals for the heavily wounded, and experienced surgeons are sent to care for the lightly wounded. Nothing seems to have been learned from the long years of experience of our Allies, the British and the French.

I have been operating on twelve-hour shifts here. One hundred and twenty cases are waiting for operation this morning. In one night I had sixty deaths.

Rain, rain; mud, blood; blood, death! All day, all night we hear the incessant tramp of troops---troops going in, wounded coming back.

Even in our dreams we hear it.. If it ceases for a few hours it is so insistent in our conditioned brains that the incessant rhythmic tramp continues.

Autumn in the beautiful Argonne! Rolling hills, green meadows, shepherd dogs, sheep, lazy cows, brown oak leaves, yellow linwood, red gum, gray and velvety beeches, the rocks and the ground brilliantly blotched with blood-all color blending with the dying and the dead! The trees show their color because the sun grows colder; man shows his color because passion grows warmer!

Headquarters Neufchâteau, October 18th

I returned today to Headquarters and pointed out to Finney the chaos in his organization and the handicap of his clinical colleagues.

Bill Fisher agrees with Harvey Cushing and the rest of us. I am now going down over the area of distribution of patients in this push---88,000 is the price up to date, and only a few miles gained.

Dijon, October 21st

I am sampling the stream of wounded. This is the way our consultant group serves, and it is in the front area and in the front hospitals in which judgment against old methods and fixed ideas is made.

It is clinical research on a colossal scale and is yielding fundamental facts and results.

The country through which we travelled today is vineyard country with marvelous coloring, purple and yellow fields in alternate patches; the purple sensuous in its intensity. Sometimes as we turned unexpectedly around a bend in a winding valley, the landscape was so startlingly brilliant that I wanted to shout with delight. It reminded me of our rides through the autumn woods at home.

At last I have a wonderful souvenir of the war for the children. They will love it, at the Knob, at the Shooting Club, and at the House on the Hill. Everyone who has seen it wants it. It was captured in an enemy dugout. It is a wonderful Belgian police puppy, one month old.

Paris, October 22nd

The Ford could not be repaired at Neufchâteau. I had orders to attend the Interallied Congress in Paris, the program of the next meeting of the Research Society was in my charge, my manuscripts were there, and I wanted to see how the work was going in Rouen so I planned to go by train, but Sanger turned up with the news that the car could limp to Paris. We lunched quickly and limped the 210 miles.

Up to today the Argonne Battle has cost us over 110,000 wounded and yet no one regards this with more personal concern than he does the fallen leaves. Everyone is technically occupied; everyone has been prepared to hear of losses, and the world seems to have reached the stage that the student surgeon reaches after he has mastered all the sentiment, the problems of the individual, and sees only the technical problem, only the case. As surgery becomes technical, war becomes professionally interesting but loses its drama; hence it will soon end. War must be dramatic to continue. Now the surgical problem is how to get the men back into the line. We must see that the lightly wounded get quick and good attention so they may return quickly into the line and be wounded again.

The dead are the trouble. They arrive dead in ambulances, often without a mark of identification. They die all the time in the wards, sometimes in singles, sometimes in groups. Evacuation of a dead man means digging a hole in the rocky ground; evacuating a live man means a short carry by stretcher.

We have no padre so we have to do it all ourselves. On the third day we did not have a single grave ahead, no reserve stock, when twenty German prisoners were found. They dug well, seemed to take an interest in their task and were both prodigal and expectant in the reserve supply of graves that they prepared.

Rouen, October 24th

I brought my puppy, that I have named "Captive," all the way to Rouen and left him here. Captive is half wolf in nature and was brought up by the Huns in a dugout, so his manners are those of a puppy who is bounding in health and has associated with Huns. I brought him from the Argonne to Neufchâteau in my car and there gave him over to our housekeeper with a five-franc note. The next morning she returned the puppy, saying that neither money nor anything else could induce her to keep him. He had chased the cat, worried the rabbit, chewed her rug and dress, and otherwise showed no manners. In turn he insulted our quarters, barked all night, bit everyone's legs, so nothing remained but evacuation.

The next day I resolved to take Captive with me to Paris in my Ford. He was not quiet one moment, he chewed my puttees, my clothes, and when confined, howled. We stayed over night at Provins where he worried the house dog and committed atrocities. I healed the wounds of the hotel by money and we moved off to Paris where I bribed a porter to keep him all night.

On the return trip to Rouen I carried Captive in a basket on one arm and on the other my satchel packed with six huge and heavy shells. On the train I put him on my seat, the basket neatly covered with straw, and went to get a paper but when I returned Cap had turned the basket onto the floor, scattered the straw all over the car, and was chasing a French woman down the corridor, hanging onto her dress and trying to bite her ankle. After paying for the woman's ruined stockings I put him back into the basket and tied down the lid until he howled and I had to take him out and keep him in the seat with me. This necessitated my buying a London Times. When I spread it on the seat, he chewed the paper, then he chewed my clothes, then atrocities, and at last, alas, I could not go to the dining car for my dinner. But he shows me great affection.

At Rouen my hands were full with the six heavy shells and Captive. I found an ambulance going out to No. 9 and when we finally arrived I turned him over to Jack Kilmurray, who looks after me and my possessions. I mean to take Captive home if I can.

Toul, October 31st

Last night I was in Toul and spent the night with Jack Yates and Hans Zinsser. The latter said he would give any amount of money for a fifteen-minute conversation in good English with any woman who washed behind her ears!

When I returned tonight to Mobile 5, all was serene. A masquerade dancing party was in progress. An old colonel from Boston was sitting on a bench, watching. He had a wonderful, high-powered, purring staff car and told me that he often saw nurses walking and offered to pick them up, as he felt sorry for their loneliness. He evidently had forgotten the flight of years and did not realize that to so practical a woman as a nurse, youth on the front seat of a rattling truck appeals more than age in a staff limousine.

This reminds me that recently two nurses were picked up by a young staff officer driving a limousine and taken to Souilly. While he was attending to his errand they were left alone. When an old colonel from across the street started toward them, they were terrified as they were without identification cards or orders. The colonel came right up to the window of the car, looked them straight in the eye and said, "Talk to me!" Poor lonely old colonel!

Paris, November 11

MY BIRTHDAY AND Der Tag. Among the many birthdays that I have celebrated this one has two unique features: Germany capitulated and I have been made a colonel.

Immediately I set off for Paris. At Headquarters in Neufchâteau there were rumors; Chaumont was swimming in them. There was not a flag, not a sign in any village, yet the hour approached. I ran into Colonel Salmon and Colonel Boggs half an hour out of Bar-sur-Aube and we agreed to lunch together. As we rolled along toward the town it began to seem as if the war were continuing but as we entered it, the mayor was reading the proclamation of the armistice. Just as the bells began to peel the announcement of the end of the war, Salmon pinned on my eagles.

After luncheon we set out on a triumphal tour to Paris. Villages, country folk on the highway, the dancing, singing populace of larger cities like Troyes, acclaimed the American uniform. Cheerless, unilluminated faces were animated at last. These moving masses charged my car. Garlands, bunting, flags, flowers, all were strewn lavishly upon my limping Ford with its Roman chariot wheels and its top through which I could identify many of the constellations, giving it the appearance of a chariot of victory.

When we reached Paris there was no Place de la Concorde, it was hidden under the rejoicing multitudes. In front of the monument to the lost, but now returning provinces, Alsace and Lorraine, a French woman with a beautiful voice vibrant with emotion was singing the "Marseillaise." We were carried with the crowd over the Place de la Concorde, up the Rue Royale, the Boulevard des Capucines to the Place de l'Opéra. Tens of thousands of men, women and children moved along like gusts of wind over a wheatfield, laughing, singing, never boisterous. They encircled us, danced about us, kissed us.

Étretat, November 14th

I set out this morning on a tour of inspection of Base Hospitals in B.E.F. Tomorrow to Paris, to wind up the professional work of the A.E.F.

Paris, November 18th

Today I attended the meeting of the Interallied Conference at Val-de-Grace. There were delegates from France, Britain, the United States, Italy, Serbia, and Belgium. Japanese members sat together alone in an inconspicuous place, quiet as two mice. They reminded me of spider monkeys holding onto each other in an uncertain environment.

I lunched with the clever and skillful Tuffier, Harvey Cushing, General Makins, General Wallace and Alexis Carrel for the purpose of either organizing a permanent Interallied Council or terminating the Interallied Surgical Conference. We concluded to defer immediate organization for six months.

The Research Committee Meeting

For some years Yandell Henderson, Professor of Physiology at Yale, has held the acapnia theory of shock and has advocated inhalation of carbon dioxide, as treatment.

Walter Cannon, Professor of Physiology at Harvard, has recommended the infusion of gum acacia solution and sodium bicarbonate intravenously as treatment of shock during the war.

Porter of Harvard has supported Cannon; and Bayliss, Professor of Physiology at Oxford, has proposed the infusion of gum acacia and other admixtures in the treatment of shock.

My conception of the cause of shock is pathologic physiology. I interpret shock to be an overstimulation of the key organs of the energy system, viz., the brain, the liver and the adrenal cortex and the treatment we recommend is morphine, warmth, blood transfusion, rest and negativity.

Thus in my endeavor to aid the wounded soldier, I have found myself precipitated into the same problem that I glimpsed so long ago. Strange that the quest started then, should still be my quest!

The first day of the meeting of the Research Society was given over to the discussion of shock; the British Physiologic Committee on Shock, as well as the American Physiologic Committee on Shock were represented by such talent as Sir Walter Fletcher, Professor Barcroft, Professor Cannon and others. As the net result of four years of research on shock these two groups had produced but one idea, viz., the use of gum acacia infusion in the treatment of shock.

The physiologists opened the discussion, advocating gum acacia. They sang its hymn of praise.

Then came the turn of the practical surgeons from the Argonne fight who in the crucible of experience had tried out gum acacia and condemned it. They sang its swan song. Exit gum!

November 24th

Bowlby, Makins, Wallace, Finney, Fisher and I set out in two British staff cars for a tour of the Front. We lunched at Château-Thierry which is beginning to be repaired. Children play hide and seek in the shell holes. I could not help thinking how commonplace and dull war had become, how jaded and faded! The dead, who are they? The wounded, the sick, the captured, the lost ground, the victory, the defeat, what are they? Uniforms, guns, explosives, planes, bombing, the odor of marching troops, move no one, but what a thrilling thing is a quiet fireside!

Toul, November 25th

Tonight at Toul, in my headquarters, formerly a stable, we reminisced and told stories. Bowlby told us that in Armentières near the large cavalry depot and veterinary hospital there was a shallow ravine, into which vast quantities of manure and dead mules and horses were thrown.

The taking away of all sources of heat and light was one of the heaviest blows that France suffered. In the midst of this famine of warmth and illumination a Tommy tossed the stub of a cigarette into this manure pile. To his astonishment a blaze flickered. Investigation showed that everywhere the manure burned.

Chemists and scientists were consulted, a pipe was sunk and for six months a good quality of illuminating gas warmed water, cooked food and lighted the way of the living mules. Thus in turn each mule served as torchbearer and comforter to those still carrying on.

Paris, December 23rd

Thank God my final report is in---both to the Medical Department and to the Research Society.

December 25th

Early this morning my brother-in-law, Hal Sherman, and I set out for a tour, with Harry Sanger at the wheel.

We spent Christmas Day in the Vosges and that night at the base of the mountain, for Christmas dinner Hal and I had horse meat.

December 28th

Fred Murphy and I have engaged passage for home on a French liner. As there are laws against importing French dogs into the United States and, furthermore, no dogs can be taken on a U.S. transport, we are paying our own passages as well as those of our dogs on the Rochambeau. I have our train tickets for Bordeaux, cabin tickets on the Rochambeau and a cable from Grace saying an import license has been granted. The end of the trail seems to be in sight for Cap and me.

For some time Cap has been living in style at the Continental Hotel taking a daily stroll on the Boulevards and learning French manners. But not without adventures! One day when I arrived at the hotel, the concierge threw up his hands, crying, "le chien, le chien!" I thought Cap must be sick, dead or lost; but no, the concierge took me down to the basement and showed me a woman's trunk with one side entirely chewed away. Cap is expensive but he was glad to see me.

Paris, December 31st

I went to my room early but was awakened as the old year went out. I'm glad it is gone and hope never to think of it again.

And yet the World War has been my outstanding experience. It has given me a new impetus in research. It has given new viewpoints of medicine as a whole and more particularly of surgery and its organization for efficiency. And it, has given me a training in adaptation. Coming from a civilian experience, in which most decisions were my privilege to make, into a world contact, I had to learn that the individual must always adapt. He must take into account not only the facts but almost as important, the personalities concerned. That in itself is a religion! Without it, there can be no co-operation.

Paris, January 8th

Early this morning the concierge came to my room and told me that Captive was dead. In the night he had chewed off his leash and, finding a trunk with a fairly flexible outside, had spent the night gnawing it. He had swallowed a splinter which had penetrated his stomach.

Quite aside from the loss of Captive of whom I had grown fond, was the disappointment to the children. There wasn't a police dog in the kennels of Paris: every available one had been taken by American officers.

On Board the Rochambeau, January 10th

The Rochambeau, a clean French ship, is chock-full. Our own group consists of old friends, who throughout the war have worked closely together: Colonel Fred F. Murphy, Colonel I. F. McKernan, Lieutenant Colonel Eugene Pool, Lieutenant Colonel George Derby, Lieutenant Colonel A. W. Elting, Lieutenant Colonel A. Greenwood, Lieutenant Colonel W. A. Fisher, Lieutenant Colonel Burton Lee---a most congenial group who are more than my match in poker.

On Board the Rochambeau, January 10th

Every morning a Captain Mason Day exercises his beautiful Alsatian shepherd dog, Prince de Sammie du Conti. I covet that dog, but Captain Day is taking Sam home to his wife although he feels dubious about the practicability of keeping a shepherd dog in a New York apartment. I have made friends with Sam and have finally won from the captain a promise that should life with Sam in an apartment prove too difficult, he will let me have the dog. This is the rainbow on my horizon.

THE YEARS PRECEDING the Great War and immediately following it were driving, busy years---long schedules, constant visitors, much out-of-town operating and ever-increasing writing and lecturing.

Fortunately recharging his own batteries was no problem to the Chief. He could sleep anywhere, as this letter to me from Dr. S. L. Ledbetter, of Birmingham---one of his residents---testifies.

"One night about ten o'clock Dr. Crile telephoned me that he had to go to Youngstown to operate and asked me to get an operating team together for a house operation. I was to meet him at the station as quickly as possible where there would be a special train to take us. Within an hour the group were in taxis on the way to the station with a gas machine and instruments. Dr. Crile was at the station sitting upright on a bench, sound asleep. I saw the station master and he told us he would call us when the train was ready. We let Dr. Crile sleep until time to board the train, which was an engine and one day-coach. It was a bitter cold night but the coach was fairly warm. As soon as Dr. Crile sat down he asked if I was going to sleep or stay awake and smoke, and when I replied that I was going to stay awake and smoke he asked me to lend him my overcoat. I covered him up and in ten seconds he was sound asleep and slept all the way to Youngstown.

"When we arrived in Youngstown we waited at the doctor's office, while Dr. Crile went to see the patient. In a little while he returned to tell us that the patient did not require an operation. We then returned to the station to wait for the regular train to Cleveland. Dr. Crile slept sitting up until the train arrived. This time we boarded a Pullman. After the request that I waken him ten minutes before arriving at the 55th Street station in Cleveland again he went to sleep. When I awakened him he asked me to get him a scalpel from the instruments and he shaved himself with that knife and plain soap and cold water. I always spent about thirty minutes every afternoon sharpening his knives for him, as he insisted that they be razor-sharp. I then knew why! He got off the train at the 55th Street station and we went on down to the Union Station and took cabs to the hospital. I undressed as fast as I could, took a shower, put on an operating suit, and was just going to breakfast when the ticker announced that Dr. Crile was in the house. I got no breakfast and we had over eighteen cases that morning. He had had breakfast, a bath, had changed his clothes, and was as fresh as a daisy. I don't suppose he had lost, all told, one hour's sleep the whole night."

No matter how driven the Chief was he never failed to keep in touch with his family through frequent letters, each of which was provocative in the contents and peculiarly significant to the child. From the American Ambulance in 1915 when Barney was seven, he wrote: ----

"The French soldiers wear the same kind of uniform they have worn many years, a blue cap, a short blue jacket, a long blue overcoat, and what do you think? Red trousers!

"The French soldier is brave, obedient, quick. He can march fast and is quite intelligent. He is not as tall as the German soldier but is usually more than a match for him. The Moroccan soldier is an odd-looking chap---dark skin and hair with good features. He wears a divided skirt, or bloomers, that reach just below the knee and a red fez. One of them in my care has been given the Legion of Honor for bravery. He stuck by his battery until everyone was wounded. He then loaded the gun alone, made a hit, scattered the enemy and rescued his wounded comrades. Another soldier I saw today had a broken arm. Guess how it happened! A shell exploded, blew him into the air, and as he fell he broke his arm.

"The artillerymen all lost their caps. How do you suppose that happened? Well while riding their horses, they nodded, and fell asleep. When they awakened almost every soldier had lost his cap!

"The soldiers that come in from the trenches are covered with mud. They wear heavy clothes, woolen socks and high shoes. In their pockets they have all kinds of things---strings, bullets, tobacco, buttons, chocolate, crackers, a knife---and they have many pockets. They have not had a bath for perhaps several months, so they have all sorts of troubles such as vermin. At the hospital their clothes are taken off, they are given a hot bath, and then they are free of their dirt and vermin and their clothes are sterilized. The soldiers usually come into the hospital during the night. The hospital has many ambulances, that meet the trains---some even go to the Front to get the wounded.

"One soldier had a curious experience. His trench was blown up by the enemy. Many were killed and injured. He was buried under the blown-up earth, and was supposed to be killed, so was allowed to remain there as the fight was hot. How do you suppose he got out? The soldier's dog came along and dug him out---and sure enough he was alive. The dog is in the hospital now with his master. I will try to get a picture of the dog for you.

"I very much enjoy your letters and I am glad that you and Tom Grandin and Henry and John Sherman have such good times playing together. Too bad the skating rink melted, but there will be more ice surely. I hope there will be a snow when I return so that you and I can build a snow house together and we all can play hockey."

After the Chief's return from France in 1915 he received many interesting letters in praise of his book The Origin and Nature of the Emotions. One that he valued in particular was from J. B. Murphy, who wrote:

"I regret that I did not see you while you were in the city Monday, as I wished to speak to you personally of your work, The Origin and Nature of the Emotions.

"I have gone over it very carefully and have been immensely impressed. I would say of the work that it is so far in advance of the times that only a few will live to see the realization of its great import from a practical standpoint, and none, I think, can judge now of the colossal role which this phase of medicine is to play in the future. Every article you write is to me an inspiration and stimulus to further endeavor, but my mental presbyopia is becoming more and more fixed, and I am less capable of keeping up with the profession."

Major George Crile, 1917.

The family, October 1917, Elisabeth, Grace, Barney, Bob, Margaret.

The aftermath of the American Ambulance brought many new administrative problems---which had to be fitted into overcrowded days. Already the Chief was beginning to question whether he ought to build up an even greater organization at home and take the resulting rewards or whether he should take an easier course of research and writing. "If I choose the latter," he wrote, "shall I do as good work because I would not have the incentive presented by clinical problems?"

In a letter to me written in late October 1916 the tension under which he was working and his desire for more leisure time is evident:

"You have been in my thoughts every moment while I have been away. I have been thinking of what you have been to me in every interest that life holds: your companionship, your wonderful part in our work and in our pleasures, in establishing in the children your ideals, in making life complete and without ever giving the slightest cause for any unhappiness to me.

"I fear in recent times in the drive of life I have given a poor return for all you are and have been. I know I have been preoccupied, perhaps thoughtless and irritable. I can account for it only by having been driven to an extreme by work and responsibility. Sometimes I wonder if I have undertaken more than I could carry without becoming on edge. So much was at stake in trying to sustain the scientific position so widely attacked; so much organization in the University; so much concern over working out our real estate into productiveness instead of heavy carrying charges, together with the many other things, some in themselves a big task, but which had to be assumed as extras. On my return from Chicago my train was late, my clinic large, a San Antonio delegation was visiting my clinic. There was no breakfast on the train. As soon as I arrived at the hospital I found several patients had gone badly and my list of operations was sixteen---all heavy ones; I had to meet many appointments made for the office---a cracker and a glass of milk between operations had to suffice for luncheon; a Lakeside staff meeting at four and two absolutely necessary outside visits in the late afternoon in addition to constant interruptions by telephone; and then off to Baltimore without time to say goodby to you, made up yesterday's hectic day and so the days have come and gone.

"These intensive days have done for me what I have never believed could happen to me---and have repeated history. I fear they have made me take for granted everything that the most considerate home could offer without any decent expression of appreciation day after day. I have now concluded that nothing can compensate for such preoccupation. I have always looked forward to the day when I could feel financially secure, and the ambitions in surgery and in science were equally secure, then the stress would lessen and the drive diminish.

"Sometimes I regret I have not taken a more leisurely course but the game has seemed so completely yours and the children's as well as my own that I have plunged on."

Later in July 1917 the Chief wrote to me:

"Over here the greatest encouragement is offered to any scientific work that has a chance of aiding---as I personally know. Being in the seasoned British service is an enormous advantage.

"You will be pleased to know that nitrous oxide and blood transfusion are being enthroned here. It gives me just a little thrill every time I see a resurrection here---and there are many---and I realize that each resuscitation owes its life to a little dingy dirty laboratory in Cleveland---our laboratory at that. We assembled it---we ran it---we paid for it and now many times every day it is all paid back---paid back in the invisible coin of infinite satisfaction. With this coin you and I may establish an invisible bank account to be sure, but an account that defies all bankruptcy----that drawn upon daily yet remains the same---and it will tide us over the less productive days."

During the Chief's return to France, in December 1917, following his visit to America, he sent me the following amusing appreciation:

"I am writing this on the train from Havre to Rouen. Last night I crossed the Channel. I bless you for many things---but among the things of comfort I bless you most for is the rubber life preserver. The mere presence of this rubber man as I contemplated the infernally cold water gave me not only infinite comfort but almost a wish to enter---certainly a wonderful anociation.

"Well, last night in my stateroom on the Channel boat I sat my rubber counterpart on the sofa beside my bed, with his leaden feet snugly side by side on the floor. As he sat there his great mouth yawning, his pocket stuffed with chocolates and whisky, he certainly was a potential comfort. Having gotten him settled, ready to jump into, I fixed in my mind the exact turn around the corner to the stairway up to Deck E-my exit; practiced finding the electric light switch in the dark from my bunk; tested my electric flashlight; went to bed, and what a night it was! A perfect night---the Suez Canal was no more turbulent---but the contemplation and the rehearsal must have done me much spiritual good, for I thought of all the mean things I ever did; I thought of all the unfinished things; I thought of the things I had left undone; of the things I should have done; and that is why I am writing you this prompt letter on the train, to tell you of my appreciation of your wonderful self instead of keeping that appreciation unexpressed."

After the Chief returned to Rouen from his "tour of duty" he found that, although he had refused the position of Chief Consultant of A.E.F. which Gorgas had offered to him and had suggested that it be given to Finney, all positions had been filled by Finney and the Chief's dilemma was how he could be useful to the American Forces. His disillusionment was thus expressed to me:

"I would give any thing---everything---if only you could be with me tonight. I am utterly lonely and you only can make me feel otherwise. I am tired of the war---I want peace---everlasting peace, and I want you.

"My 'tour of duty' at home was no help. In view of my return it was the worst thing that could have happened."

The Chief's method of meeting this disappointment was characteristic. Calmness of mind meant strength. To be in harmony with things about one, a calm attitude of mind was essential. Therefore to endeavor to hold a "passive viewpoint," one "too realistic to be disturbed," became to the Chief a philosophy. Viewing man as a predatory animal, he interpreted, understood, therefore felt no rancor, difficult as readjustments often were. In his effort to reconcile his disappointment he purchased for himself a gold identification bracelet, on one side of which he had engraved his name and on the other "P" to remind him of the need of maintaining a passive viewpoint. When the war was over and the Chief returned he placed the bracelet on my wrist, saying, "Always wear this and remember it stands for our religion."

Then he told me its story.

Reminiscent of the date on which the Chief and I announced our engagement, he wrote: