were applied to many cases of shell shock and their value put to immediate test.
These psychic methods were founded on recognition of a mental field operating below consciousness and charged with various " repressions." A repression is a desire which for one reason or another cannot be fulfilled and so is forgotten. It does not again enter consciousness; but it nevertheless remains active and unsatisfied, and under various disguises attaches itself to desires which are permitted to become conscious and greatly intensifies those. Thus the patient shows abnormal reactions to certain stimuli and evinces abnormal likes and hatreds which cannot be explained in terms of his evident circumstances. This man has an unbalanced mental outlook, and, given circumstances such as warfare, will evince symptoms of nervous breakdown. The method of treatment suggested by Freud was to analyze his mental state, discover the repressed wish, and bring it into consciousness. Once the patient knows it and realizes it, it is said to lose its power over him.
The method is called psycho-analysis, and in some hands has yielded important results. It is now being widely practised. Unhappily, while in some directions perversely applied by Freud himself, it lends itself also to the uses of unqualified persons and also of mere charlatans. On this account it has to some extent fallen into evil repute. That it is, when properly applied, a great contribution to the study of the mind is nevertheless evident. Its application to shell shock did much to convince the medical profession of the necessity of seeing its work as a whole and not in little bits. It also helped to convince physicians of the importance of the " imponderabilia " in every case.
Mental Hygiene. It had another effect not less far-reaching. There sprang into being a body of physicians who declared that mental effects of warfare could be prevented to a great extent if a kind of mental hygiene was instituted for the soldier. So far as possible the causes operating to lower his physical and mental vitality must be found and removed. Well-being must become a study. Effects of this theory were the rest camps, the con- valescent depots, the insistence on games, on baths, on lectures, on medical supervision. Other effects included the care taken to show the soldier that if he fell ill or if he was wounded every sort of effort would be made for his safety and comfort. Thus while the enemy on the one hand was doing all in his power to break the soldier's moral, physicians of the new school were steadily and tirelessly building it up. In a large view of this work we are entitled to include every one of the schemes which had as their object the comfort of the soldiers we are entitled also to include such appliances as steel helmets and gas masks. These were more than defensive armaments; they were expres- sions of preventive medicine as applied to the human mind in time of great stress.
That the success which attended these labours has left an indelible impression on modern medicine goes without saying. Circumstances and environment are now receiving a measure of attention never before accorded to them. The demand for play- ing-fields for the nation's youth, for swimming-baths, for holiday camps, is a part of this campaign. So is the interest which all doctors are exhibiting in food values, in housing, in ventilation, in industrial welfare. Indeed, the science of industrial welfare is largely a war product.
Welfare Work. This science has made an immense progress in the last few years. Employers of labour have been aroused to the fact that their human machinery is as important, is indeed more important, than their working plant. In consequence, physicians have been called in to act as expert advisers to many great industrial undertakings. Attempts are being made to select suitable candidates for the vacancies in industrial life, and it is becoming a working maxim that to employ unfit persons is both unjust and uneconomic. The study of what is called "welfare" is progressing, and money is being laid out on good ventilation, on rest-rooms, on workers' canteens, on bathing facilities and other amenities. All this expenditure is found to return a profit both to employer and employed.
Moreover, the study of industrial fatigue has shown that it is in
the highest degree wasteful to keep men at work after they have become exhausted. Thus, shorter hours of labour have been instituted on medical advice and have increased instead of low- ered output. The method known as motion study has helped to eliminate wasteful movement in particular operations and so has added to the profit of them while reducing their cost. Further investigations have been carried out into the circumstances of what are known as " lost workers," i.e. persons who learn a trade only to leave it, and into those of industrial misfits.
The effects, too, of environment on industry have been studied from a new angle. The whole science of ventilation has been reviewed and restated. Thanks to the work of Dr. Leonard Hill, it is now accepted that ventilation is no mere question of cubic feet of air but is a large and difficult problem involving a study of air movement, humidity and temperature. Stimulation of the skin by moving currents of air is of as great or greater importance as the amount of oxygen available. Moreover, the drying quality of the air depends on its movements, and so the degree of evapo- ration of sweat on which cooling of the body largely depends. In this work Dr. Hill has employed an instrument of his own, known as the kata-thermometer, a thermometer the bulb of which is enclosed in a glove finger and kept moist. It records rate of temperature-loss in any given room. It is significant that changes in ventilation effected on the advice of Dr. Hill have resulted in a marked increase of output.
Another vastly important series of observations of this kind are those of Dr. John Scott Haldane of Oxford on dust phthisis. He has conclusively demonstrated that silica dust is the real agent of destruction. Coal dust is actually beneficial. Why this should be so is not known, but it would seem that the coal dust excites responses in the body which result in a cleansing of the lungs; silica or rock dust, on the other hand, excites no such response, and the gritty particles in consequence tear the lung tissue and prepare a nidus for the tubercle bacillus. An outcome of the work is the clever method of sprinkling coal dust in rock- dust mines. By this means the rock dust is rendered harmless.
The mining industry has further benefited by the work of Dr. Thomas Lister Llewelyn, who has traced miners' nystagmus or blindness to its cause bad lighting. He has placed this subject on a sure foundation and made it possible to say that if certain changes in lighting are introduced this most costly and disabling disease will be abolished. (See INDUSTRIAL MEDICINE.)
Orthopaedic Surgery. The immense strides recorded in this branch of medicine are paralleled by the brilliant advances in another. (See ORTHOPAEDIC SURGERY.) If the war influenced industrial medicine only indirectly, it actually revolutionized orthopaedic surgery. This study had rather languished in England owing to the relatively small number of cripples. In America, where infantile paralysis is rife, it had advanced farther. English practice, however, was well represented at the Liverpool school, at the head of which was Sir Robert Jones. The War Office called on Sir Robert Jones, and he became the organizer of a rest sal- vage corps, the duty of which was to mend the broken soldier. The subject soon divided itself up into branches; there was the work for the limbless at Roehampton, from which has come the modern light artificial leg. This appliance almost, if not com- pletely, restores lost function; it is a permanent boon to human- ity. Again, there was the astounding development of so-called " plastic " surgery, the result of which has been to render any disfigurement capable of great improvement if not of complete cure. The treatment of severe fractures, too, and especially frac- tures of the thigh was studied as a new problem and undertaken on new lines. These results are now a permanent gain to surgery.
General orthopaedics evolved from a method to a science. The study of muscle groups and their antagonistic action led to the formulation of new ideas and so to the application of new lines of treatment. Every case was considered on its merits and regarded as a separate problem; yet it was found that the same general laws could be applied to all. We are perhaps entitled to include in this progress the surgery of the heart, which was undertaken on a large scale in the war. As a result a remarkable diminution in death-rate from heart wounds was achieved both
