another worker, the Franco-American surgeon Alexis Carrel,
had introduced with Prof. H. D. Dakin an antiseptic not formerly
much employed. This was a hypochlorite solution which had
been christened " ensol " or " Dakin's solution." The technique
employed was more important than the antiseptic, and to some
extent justified the views of Wright. It was a continuous drain-
age secured by the use of cans and rubber tubes. The wound was
thus kept flushed and all its discharges were washed away.
This system found many supporters but was attacked by Wright.
Finally a third school dealt with the problem and brought to its
solution the methods of the great German biochemist Paul
Ehrlich. Ehrlich's idea was that a drug possessing a specific
effect on specific forms of protoplasm might be found in connexion
with any bacterium. He proved his case with his own discovery
" salvarsan " or " 606," which possesses a special destructive
power where the spirochaetes of syphilis are concerned.
In the case of the bacterial poisons of wounds another sub-
stance, flavine, was brought forward. This preparation belonged
to the same group as salvarsan; it was used in the first instance
by Prof. C. H. Browning. Very good reports of its efficacy were
received. But again Wright and his followers attacked it on the
ground that it failed of its object, the destruction of bacteria,
and interfered with the physiological processes of nature.
It canno't be said that any permanent settlement of this dis-
pute has as yet been reached, but it does seem clear that the
foundations of Wright's work physiological study will be
hard to shake. Indeed he has here an advantage over all his
critics, the nature of which they did not seem at first to realize.
Vaccine Methods. To Wright indeed belongs the credit of
having brought the laboratory to the bedside. He saw that no
method can succeed unless it is based on practice. Practice in
this sense means physiological principle. It was recognition of
this fact which inspired his antiseptic studies. Further, though
this has not been sufficiently appreciated, it was recognition
of it which enabled him and those who worked with him to bring
the anti-typhoid vaccination to the high pitch of perfection it
had reached when war broke out.
Typhoid. Of the single facts of medical history during the war
period the success of this anti-typhoid vaccination is certainly
the most conspicuous. Such a success was indeed undreamed
of, for of all the enemies of the soldier typhoid fever ranked first.
A study of earlier campaigns reveals the fact that this scourge
usually swept away large proportions of the armies engaged in
European warfare, and in some cases the casualties by bacilli
chiefly typhoid stood to the casualties by bullets in the pro-
portion of 80 to 20. Thanks largely to the preventive inoculation
against typhoid this condition of affairs was reversed in the
World War, the proportion being gun-shot wounds (including
all forms made by all manner of missiles) 80 and disease 20.
The credit for this result is due largely to Sir Almroth Wright
and Sir Wm. Leishman, who devoted endless trouble to the work
of perfecting this brilliant application of bacteriological and
physiological principles to preventive medicine.
Tetanus. Not less striking, though less dramatic, was the
success achieved in the prevention of tetanus or lockjaw. This
dreaded disease began to manifest itself almost at the beginning
of the campaign. Before the battle of the Marne was fought it
was relatively prevalent and was causing great consternation, for
it was recognized that the intensively cultivated soil of Europe
was impregnated with tetanus bacilli, and that thus every wound
was dangerous. Moreover, up till this time the treatment of
tetanus had proved singularly ineffective, so much so indeed
that the patient was regarded as doomed.
As the tetanus bacillus presents many features in common
with the diphtheria bacillus, and as the antidiphtheria serum
had proved a very great success, it was thought that a serum
prepared in the same manner might solve the tetanus problem.
This hope had not been realized in practice at the time of the
outbreak of war. Nevertheless, there was some reason to think
that, though the serum failed when given after the disease had
declared itself, it might not fail if administered at the time of
actual wounding.
Tetanus, as is well known, takes several days to incubate.
In consequence, there is available a period in which measures
for its suppression can be carried out. This fact was the basis
of the antitetanus inoculation which was begun experimentally
in 1914. From the outset the experiment succeeded beyond the
expectation of those who had planned it. Tetanus became a rare
disease, thanks to the fact that every wound, no matter how
trivial, was regarded as a possible source of danger. It was an
order that as soon as a soldier got even a scratch of the skin
he must report to his medical officer. A prophylactic dose of
serum was then administered.
At a late period the War Office set up a Tetanus Committee
under the chairmanship of Sir David Bruce. This committee
investigated cases of so-called " delayed " tetanus, and also
those cases in which tetanus made its appearance at long periods
after the initial wounding when surgical measures had been car-
ried out on the wound. The view which was formed was that
the bacilli in such cases were walled in and rendered innocuous;
but manipulations of the wound were apt to break down the
walls and so release the toxins.
Shell Shock. Meanwhile the circumstances of war were
directing attention to a series of new disease conditions which the
peace-time physician had not encountered in so severe a form.
Chief perhaps among these was the nervous disturbance caused
by high explosive shells. At first a number of wild statements
were made and believed, but presently, and thanks in no small
measure to the common sense of Sir Frederick Mott and other
distinguished neurologists, some light on the darkness was ob-
tained. Mott pointed out that among the large group of cases
classed as shell-shock patients there were a number who had
suffered actual physical injury of the brain as a result of ex-
plosives. If these people died, punctiform haemorrhages were
found in the brain substance.
These cases were not psychopathic, they were organic lesions
cases of injury. After elimination of this group there remained a
large group of individuals, considerable numbers of whom had
not received any injury. These cases were often very severe, but
they differed in no material respect from the neurasthenics and
victims of functional neuroses well known in civil life. The ques-
tion was asked why these patients should break down whereas
other men could be severely wounded and yet show no sign of
nervous disturbance.
Various answers were given to this question, and probably all
of them contained a germ of truth. Thus it was pointed out
that hereditary influences played a part in some of the cases.
The men came from mentally unstable families; they themselves
had only just managed to support the conditions of ordinary life.
The conditions of life in the trenches broke them down. Again,
many of these patients were clearly the victims of chronic in-
fections such as rheumatism, which exercise an irritant effect
on the nervous system. Thus the men were more easily stimu-
lated than in normal cases, and so more easily fell victim to the
excessive stimulation of war.
Thus new recognition was given to relationship existing be-
tween disease and temperament, between the nervous system and
the functional activity of the body. It was seen with a clearness
not before achieved that the mental case may be the case
of disease, slight, unrecognized, yet perpetually active. The
treatment of these cases occupied a large number of distinguished
workers. Little by little a process was evolved whereby disease
elements were eliminated so far as possible before mental con-
ditions as such were pronounced upon. Thus the patient's
general health was made the subject of careful study, while at
the same time his mind was being dealt with.
Psycho-analysis. The purely mental aspect of the subject
forms one of the fascinating chapters of modern medicine.
Never before was so vast a material presented to scientific work-
ers. This material, too, came at an hour when a great upheaval in
mental medicine was in process. The writings of Sigmund Freud
of Vienna had just begun to find adherents among British psy-
chiatrists. They were the subject of hot dispute; but the first
wave of incredulity was spending its force. Thus Freud's methods
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