The doctor in war

Front matter

THE DOCTOR

WOODS HUTCHINSON

RECEIVED

Preface

Believing that the doctor and the sanitarian would play an important and by no means discreditable part in this World War, after offering my services to friends on the British A rmy Medical Staff, only to find that they could not accept any one, save on the terms of taking the oath of allegiance and losing American citizenship, I decided to attempt to visit and study the medical arrangements on the Western Fronts.

As I had more than half anticipated, I found there the finest and most triumphant demonstration of what modern science can do for the protection of the health and life of an army or a nation ever given in history, equaling if not surpassing the hitherto unrivaled victory of the forces which save life on the Panama Canal.

Thanks to the personal kindness of the Secretary of War, Mr. Baker, and of my friend Colonel Roosevelt, together with the courtesy of my medical colleagues, I secured letters of introduction and papers which made me successful beyond my expectations in securing permission to see almost everything of any value or interest from a medical and public health point of view, from the Base Hospitals up to the Aid Posts in the front-line trenches and from the munition works and Training-Camps to the Hospital Ships and the British Fleet.

I was gone practically a year, from January 15 to December 24, IQ17, and spent about three months in England, going and returning, visiting the Base Hospitals, the Training-Camps, the munition factories, and the re-fitting establishments for the blind and the crippled, winding up with a vi PREFACE

•week's visit to the British Fleet and its Hospital Ships, Ambulance Trains, and Naval Hospitals.

Then I was granted a special permit to visit the medical arrangements of the British Army in France and spent nearly three weeks on the Front tracing the course of the wounded from the front-line trenches through the Dressing- Stations, the Casualty Clearing-Stations, or Field Hospitals, back to the great Base Hospitals, including the huge group Hospital-Camp of 35,000 beds at Etaples, where the Harvard Units are.

The English authorities passed me through to Paris, where I spent nearly six months making frequent trips out to the Hospitals and trenches of the French Front, to Soissons, to Carrel's Hospital at Compilgne, Chateau-Thierry, the "pays reconquis," the Chemin des Dames, Rheims (twice), the Argonne, Saint- Menehould, Verdun, Alsace; in the intervals visiting the great Paris hospitals, and schools for re-education of the crippled, munition works, sanatoria for tuberculosis, homes for the refugees, and finally spending four days with the Red Cross among the " rapatries " at Evian.

Early in A ugust I went to the Italian Front, visiting eight or ten of the big War Hospitals in Rome en route, and had a fascinating four weeks on the Isonzo, while the big Italian offensive was under way, which opened so hopefully and ended only a couple of weeks after I left in such a distressing temporary backset. Some of the best hospitals and service for the care of the wounded that I saw anywhere were in Italy, and I formed a very high opinion of the Italian A rmy and its organization and fighting morale.

Back to Paris in September, where I tried to enlist in our A rmy Medical Reserve Corps, but found I was too old! —

PREFACE vii

to my huge disgust; out to our American Zone in France along the foothills of the Vosges, for ten days with our boys in their billets; thence back through the British lines, to visit all our American Hospital Units which were serving in English Hospitals, nine in all, through to London to deliver the Chadwick Lectures on War Hygiene at the Royal Society of Medicine, and complete my visits to the War Hospitals and munition works; and so on home.

It is the first war where the doctor has been given a free hand, and he has responded by almost wiping out disease, making the death-rate from it in the camps lower than that at home, saving ninety per cent of the wounded and sending eighty per cent of them back to the firing-line within forty days! and making the death-rate from all causes in this most horrid- sounding and appalling of wars the lowest on record, barely three per cent per annum, and for the past two years under two per cent.

As a consequence he has become such a valuable part of the fighting force that he has lost all his former immunities. He and his insignia, the Red Cross, as well as his stretcher-bearers and his wounded, are eagerly fired upon by the Huns, who count one doctor worth five hundred soldiers and one stretcher-bearer the equivalent of ten combatants and issue orders to their snipers and machine-gunners accordingly.

He lives under fire, sleeps underground, operates in a gas-mask, and if captured is sent to a prison-camp like a line officer, in flat defiance of all the rules of civilized warfare. He is even contemplating bearing arms to defend himself and his wounded. Blessings (?) on the Hun! 1 !

The courtesies shown me on every hand wherever I went were so constant, so gracious, and so innumerable that it seems almost invidious to mention individual names. If there viii PREFACE

are to be found anywhere a body of more kindly, courteous, and considerate men than both the Medical and Line A rmy officers of the English, French, and Italian commands, it would be difficult for me to imagine them. I must have been an awful nuisance to them sometimes with my requests for visits and information in the hurry and strain of open war, but they never allowed me to see it, and my opinion of war as a school of manners is of the very highest.

But I do feel under special and peculiar obligations, for invaluable and most helpful courteous permissions and assistance, to Sir Alfred Keogh, Director-General of the Royal Army Medical Corps, and to Colonel Horrocks and Major Smales of his staff in England; to General W. G. MacPherson, of the Medical G.H.Q. in France, and Sir George Makins, Consulting Surgeon to the British Armies in France; to Lord Northcliffe and Sir George Riddell, for the splendid opportunities afforded me of visiting the medical arrangements of the British Army both in the Training- Camps and in France; also to Mr. Sidney Walton, of the Ministry of Munitions, and to Colonel John Buchan and Mr. St. John Hutchinson, of the Foreign Office, for most courteous and valued assistance and permission to visit the British Fleet and the great English munition works.

My warmest acknowledgments are also due to our Ambassador in Paris, Mr. William G. Sharp, not only for most helpful official assistance, but for unfailing and constant personal kindness; to M. Justin Godard, Sous-Secretaire of War for Sanitary and Medical Affairs, and to Surgeon-General Tuffier, of the French Army Medical Corps, for permission and most kindly assistance and facilities in visiting the various Sectors of the French Front.

For my Italian visit and the most liberal facilities af-

PREFACE

IX forded me on the Isonzo and Trentino Fronts, I owe my most cordial and grateful thanks to the Italian Ambassador in Paris, Marchese Selva di Reggio, and to the Comando Supremo at Udine.

Many of the chapters of the book have previously appeared in magazine and syndicate articles, and I wish to acknowledge my indebtedness to the Editors of the " Saturday Evening Post," the " Metropolitan Magazine," the Star Publishing Company, "Harper's Magazine," " Pearson s Magazine" {London), and the "Daily Mail" {London).

Contents

I. The Triumph of the Doctor i

II. The Real Perils of War 21

III. Feeding a Million Men 51

II

ROM the earliest dawn of consciousness the three most dreaded perils of the race have ever been war, pestilence, and famine. And the greatest of these is war. Every age has echoed the sobbing chant of the Litany: "From battle and murder, and from sudden death, Good Lord, deliver us."

The march of civilization has been one long, bitter fight against this devil's trinity, and up to about a century ago with indifferent success. Then the harnessing of steam and the birth of science began to make man the master of the elements and the gods, instead of their football; and within fifty years more headway was made against these three Furies than in fifty centuries before. During the next halfcentury — the past fifty years — this has been simply multiplied by five.

Famine was the first of the hereditary curses to go down and be swept off the earth. This does not sound remarkable to us now, because we have forgotten that bitter starvation and death by hunger were once parts of the regular process of the seasons. Famine occurred every winter among savages, every three to five years among semi-civilized peoples, and, on an average, about every fifteen years among the most highly civilized nations, until about seventy-five years ago.

It was the deliberate and carefully considered statement of one of the greatest English economists, sixty years ago, that four fifths of the people of Great Britain never in all their lives had had as much as they could eat, and never were comfortably warm from November to April. Now famine — thanks to our steam-won conquest of empires of virgin soil — is a thing unheard of and incredible among civilized races. The last flickering horror of it in western Europe was the year of the potato blight in Ireland, and, in eastern Europe, the year of the corn mildew in Russia; though like the rest of the dead and half-forgotten plagues of the past, famine has again " resurrected " to play a part in this war and has actually claimed more people in Poland, Russia, Armenia, and Serbia than the sword or the shell.

The next to weaken and give ground was the plague of the pestilence. That winning campaign is such recent history as to be within the memory of all; indeed, many of us have borne or are still bearing a musket in the ranks. The victory is more than half- won already ; and the end — the sweeping away of all infectious disease and the bringing of two thirds of all deaths under two great causes, accident and old age — is in sight.

What have we accomplished against the last great enemy of humanity — war? From some points of view, painfully little. If we look at the so-called leaders of civilization piling up armament on armament ; loading war taxes on the backs of the peasant and the laborer until they groan beneath the burden; matching regiment against regiment and dreadnought against dreadnought in insane rivalry, which has finally burst the bounds of civilization and is deluging Europe with blood, we are ready to cry in despair that our boasted progress has been but milling in a circle, and to echo Browning's despairing apostrophe to the Prince of Peace : —

" Whose sad face on the cross sees only this, After the passion of a thousand years."

Plunged at a moment's warning, by the mad vanity and insensate jealousy of a few hereditary leaders, into what bids fair to be the bloodiest war of all history, it hardly looks as though we could boast ourselves of any real superiority over the Huron- Iroquois Confederacy or the age of Attila and Jenghiz Khan.

When we come to look at the actual facts and conditions of war, however, the manner in which it is waged and the circumstances under which its grim purposes are carried out, we find considerable ground for encouragement. War, of course, is, and in the nature of it always will be, exactly what General

Sherman called it; but even the cheerful pastime of slaughtering our fellow men has in the most recent wars been carried on with smaller loss of life and less suffering and hardship, both to the actual combatants and to the non-combatants in whose territories the war has been waged.

It has taken a smaller percentage of dead and wounded to decide the fate of a battle. The actual losses in battle have grown steadily less in each successive century, and the total death-rate of the most recent wars has been barely a fifth of what it was a century ago. The average death-rate of the first three great wars of the past century — the Napoleonic, the Mexican, and the Crimean — was 12.5 per cent a year; that of the last three wars — the Spanish-American, the Boer, and the Russo-Japanese — was 4.8 per cent; that of the present so far is about 3 per cent.

How has this unexpected change and remarkable improvement been brought about? At first sight the fact itself will probably be called sharply in question and seem almost incredible. The burden of the song of the modern advocates of peace is that owing to the fiendishly ingenious improvements which have been made by science in our implements of slaughter — dynamite shells, rifles that kill at ten times the old range, cannon that hurl a ton at a shot, Maxims and Nordenfelts that pour bullets like a stream from a fire hose — war has become so horribly deadly, so cataclysmic in its destructiveness, that human spirit and flesh and blood can no longer endure it.

Here we go at it since 1914, however, as coolly and recklessly, though not quite so cheerfully and lightheartedly, as they did in 141 9. The reason is that the same brain which invented these killing-machines has to some extent devised means for neutralizing or evading their deadly effects. A battle may be fought to-day with high-velocity bullets, the latest field artillery, lyddite or cordite shells, dynamite mines, and pom-pom machine guns capable of mowing their way through the trunk of a tree, and decided with less than half the loss of life that it cost in the days of the arrow, the javelin, and the spear, or in those of the flintlock and the sabre.

That this striking decrease in the fatality of war has actually occurred is as abundantly attested as any fact of history ; for, since the time when anything approaching accurate records have been kept of battle losses, each century has shown a steady and constant lowering of the number killed and wounded in proportion to the forces engaged. But the history of the battles now being fought has still to be written.

In the days of Agincourt, for instance, when the issue was decided by showers of arrows at fifty paces, or by sword, spear, and battle-axe, breast to breast and hand to hand, the average loss in killed and wounded was anywhere from fifteen to thirty per cent of the forces engaged; in fact, in those days the soldier who came out of a seriously disputed battle between anything like equal forces without some kind of wound was looked on with considerable suspicion as to his courage or his fidelity. ^

After the introduction of gunpowder, — which, paradoxical as it may seem, has been one of the great life-saving forces of history; first, by deciding battles at long range; second, by breaking up and wiping out of existence the baron's castle and the walled and fortified town; and third, by making civilization permanent, eternally superior to savage attack, Goth, Vandal, or Hun, — though much larger armies were brought into the field and campaigns conducted on a far more extensive scale, the actual percentage of losses fell distinctly.

By the time the Napoleonic wars were reached the death-rate in war from all causes had fallen to about one hundred and twenty-five per thousand a year, or about twelve per cent. In our own Civil War it fell to ten per cent. The Sedan campaign cost the German army only eight per cent of its three quarters of a million men; while our Spanish- American War and England's Boer War reached the low-water mark, with barely three and four per cent of loss respectively.

As to the cause of this gratifying reduction in war fatalities, several influences have been at work. One of the most obvious has been that the invention of gunpowder and the improvement of rifles and artillery, with such enormous increase in their range of death-dealing, has steadily forced more and more of the fighting to be carried on at long range.

The net result of this has been that not nearly so many men are actually hit as in the days of old point-blank firing by platoons; that as a battle becomes a long-range duel, directed by field-glasses, heliographs, and telephones, its fate is decided more and more by maneuvers such as surrounding a force or cutting it off from its base than by actual sacrifice of life or by weight of numbers in a bayonet charge. That both these influences are at work and have operated in this direction is unanimously admitted by all military experts and supported by convincing proof.

In the first place, the weight in lead or shells which has to be fired from rifles or cannon in order to kill a single soldier has markedly increased within the last fifty years. The old saying used to be that every bullet had its billet. Then, twenty or thirty years ago, this was changed to the statement that for every man killed his own weight of lead or iron in the shape of bullets or shells had been fired. In the last official slaughter but one — the Balkan War — a Belgian surgeon, Dr. Laurent, who served with the Bulgarian army, calculated the actual expenditure of ammunition compared with the number of Turks killed, and found that there were one hundred and ten rifle balls and ninety shells and shrapnel fired for each dead Moslem. While in this present war it is estimated to take nearly two tons of shells and explosives to kill one enemy soldier.

The other most important change, due to the new methods of fighting since the use of gunpowder and long-range weapons, was that in the old days, when battles were decided by hand-to-hand fighting, the victors were literally right on top of the vanquished the moment the tide turned and the retreat began; and only superior fleetness of foot or length of wind could save a very large percentage of the beaten troops from slaughter, maiming, or slavery.

By far the most important and influential factor, however, in denaturing and taking the curse off war has been the advance in medical science. This may seem, at first sight, an extraordinary if not extravagant statement; for even the most enthusiastic champion of medicine will admit that, with all our progress, we have never been able to raise the dead, or do much to restore the man who has had his head taken off by a cannon ball or been blown to pieces by a shell. Doctors may cure diseases, but they cannot do much to remedy sudden death.

This incredulity, however, is simply due to a misunderstanding of the facts. Naturally enough, since the main business of war is the slaughtering or disabling of the enemy, we have taken it for granted that the chief risk of warfare is that of death in battle. As a matter of fact, battle is one of the least of the perils of war; for until within the last forty or fifty years the loss in battle and by wounds has never been more than a fifth as great as the loss resulting from disease. In Napoleon's Peninsular campaigns, for instance, of four hundred and sixty thousand men lost, only sixty thousand fell in battle — that is to say, in bloody war disease caused from five to twenty-five times as many deaths as the sword or the bullet. And the real horror of war is fever. The whimsical paradox holds that, by cold figures, soldiers are safer on the battle-field than in camp, though not in proportion to the time spent there.

Four fifths of the slaughter in war has in the past been due to disease, and at least ninety per cent of that disease is preventable; in fact, it has already been prevented in one epoch-making modern instance — among the Japanese in the Russo-Japanese War, where the death-rate from disease was barely two per cent. Improvements and progress since then have put us in a position to cut in two even that low rate and reduce it to one per cent a year, or the same as that of a similar body of men engaged in peaceful occupations.

Even the direct and necessary fatality from deaths in battle and from wounds has been tremendously reduced by medical science. Though those who are killed outright, or are so terribly torn and mangled that they die from shock or hemorrhage within a few hours, are, alas! beyond our skill, these constitute barely half of the total deaths from battle; in fact, when we first begin to study the figures we get the gruesome impression that war is becoming deadlier, because a so much larger percentage of the lost are killed outright or die on the field.

In an earlier day the proportion used to run: five thousand killed in battle; seven, ten, or twelve thousand died of wounds. About fifty years ago the proportions became about even. In our Civil War the deaths on the battle-fields forged ahead — namely, sixty-seven thousand, while only forty- three thousand died of wounds. In the Franco-Prussian War, on the German side seventeen thousand were killed outright and eleven thousand died of wounds ; while in the Russo-Japanese War forty-seven thousand Japanese fell in battle and only eleven thousand died of wounds, making the proportions over four to one. In the first Balkan War the figures ran thirty thousand to twelve thousand.

The briefest hospital experience will explain this paradox. There are as many wounded in proportion to the killed outright as before ; only, instead of from twenty to fifty per cent of the wounded dying from their wounds, as in the old days of hospital gangrene, tetanus, and erysipelas, in these days of antiseptic surgery, from ninety to ninety-five per cent of the wounded recover.

To put it briefly, judging from the statistics of recent warfare the chances of the modern soldier's being killed in battle in a year's campaign have been reduced to about one in thirty; his chances of dying of wounds received in battle to about one in sixty; his chances of dying of disease to less than one in a hundred. How this compares with an earlier day may be illustrated by one concrete average instance : In the Russo-Turkish War of 1828, out of an army of one hundred and fifteen thousand Russians who crossed the border, not more than fifteen thousand ever returned to Russia, after serving in only two campaigns.

One of the interesting by-products, as the chemists say, of this transformation of warfare is the striking diminution in suffering, agony, and discomfort of those who actually become food for powder.

It is, of course, obvious that those who are killed instantly on the field of battle mercifully suffer no pain; and consequently the, larger the percentage of such deaths in the total number of fatalities the less the actual agony and suffering endured. The old prayer to be delivered from sudden death had it wrong. It is from every point of view the best form of death there is — though we are not anxious to have Gabriel call us any earlier than necessary.

In the second place, the greater part of the pain and suffering and agony produced by wounds comes not at the time of their infliction, or within six or eight hours thereafter, but when they begin to fester and suppurate and inflame. This we used to call, in our innocence, the process of healing; now we know it to be the onset of infection.

It is difficult to make any one who has not had actual experience, either as a surgeon or as a patient, believe it; but it is, nevertheless, a merciful fact that the severest and most serious injuries or wounds often cause astonishingly little pain at the time of their infliction. A broken leg or a broken arm, for instance, eight times out of ten causes little or no pain. Thousands of cases are on record where a man has had his leg broken in a railroad wreck, or runaway accident, or factory smash, and has never known that it was broken until he tried to move it or to walk on it. The same is true of bullet wounds. Many a soldier in a bayonet charge has suddenly plunged headlong, feeling as though one leg had gone numb, or supposing he had tripped or stumbled; and when he tried to rise has found the bone shattered by a bullet.

On the other hand, many wounds, not at all dangerous to life or even temporarily disabling, are agonizingly painful simply because the injury has been just severe enough to tear or graze or lacerate the nerves, but not sufficiently crushing or stunning to numb and paralyze them. This is not, by any means, to say that to be wounded in battle is a trifling and painless amusement; but only that a considerable percentage — from fifty to seventy would not be too large an estimate — of the more serious wounds, and a still higher percentage of the mortal ones, are attended with comparatively little serious or agonizing pain.

In war, as in the sick-room, the ability to feel acute pain is a sign of life and resisting power; and so long as our patients are actually afraid they are going to die, or are making audible complaint of their sufferings, we seldom feel uneasy about the outcome. It is when they begin to lose interest in whether they are going to get better or not, or lie wide-eyed, without uttering a word or making a sound, that we feel the situation is serious. Either disease or wounds that are serious enough to prove fatal or to put life seriously in peril carry, for the most part, — most mercifully, — their own anaesthetics with them, by either crushing or poisoning the nerve-trunks until they are unable to report pain.

Should a bullet or bayonet wound prove fatal, the nerves never recover consciousness, so to speak; but in those of lighter character, from which the patient is able to rally as soon as strength and consciousness begin to return, the nerve-trunks wake up with the rest of the body, and a period of intense boring or burning pain follows. This, however, can usually be kept fairly within bounds by an opiate and in any severity lasts only until the tissues begin to heal — that is to say, anywhere from six to forty-eight hours.

The time when wounds really begin to hurt is from thirty-six to seventy-two hours after their infliction, when suppuration or inflammation sets in. This swelling and burning and throbbing with a profuse outpouring of matter or pus — pus laudabile, " praiseworthy matter," as it was called — used to be regarded as part of the regular process of healing; but since the days of Lister we have discovered that, instead of being a part of healing, it is a purely mischievous and injurious process due solely to infection with one or the other of the so-called pyogenic or septic germs, usually streptococci or staphylococci. Keep these out of the wound, and inflammation, with its throbbing agony and fever and horrible discharges, will be entirely avoided.

Easily two thirds of the pain and suffering endured by the wounded in war is not due to the wounds themselves or to the process of healing, but to suppuration and infection; and all this has been wiped out by antiseptic surgery. What military hospitals were like in the pre-antiseptic days beggared description, and can hardly be imagined even, let alone believed, at the present day.

Marlborough's surgeon in the famous Blenheim campaign declared that hospitals were the most important cause of death. And a famous French surgeon in 1 74 1 declared that he had known vastly more men to die in the hospitals from lack of care than to lose their lives in combat; and that "hospitals are an unfathomable gulf; the source of their horrors appears to be inexhaustible." Two patients in each bed was the rule and often three or even four. The hospitals were literally breeding-places for disease. The deadly typhus fever used to be known as " hospital fever"; while typhoid, dysentery, erysipelas, and gangrene fairly ran riot in them. Browning's characterization of the mediaeval hospital, as " that good house that helps the poor to die," was painfully accurate.

' Even as late as our Civil War, when the dreaded hospital gangrene once put in an appearance in a ward it was a sentence of death to be sent into that ward with an open wound; and in some instances from forty to sixty per cent of all the inmates actually died. Up to, and, indeed, during, the Napoleonic wars anywhere from twenty to sixty per cent of the wounded died. To-day any army medical service that loses more than five or six per cent of its wounded considers itself disgraced.

The methods by which these wonderful savings of life and suffering have been accomplished, the triumphs of antiseptic surgery, need no description; for they are common knowledge, as well as one of the wonders of the age. The strictest and most scrupulous cleanliness, the boiling of instruments, and cleaning of surgeons' and nurses' hands — these are practiced in every hospital and taught to the rising generation in our schools.