HoUinger Corp. pH8.5 D 628 .L8 Copy 1 On the Battle-Scarred Fields of France. A Physician's Impressions of the Medical Services of Both the French and German Armies. By Adolfo Luria, Ph.D., M.D., 920 Independence Boulevard, Chicago, Ii,i,. Reprinted from Medical Council 420 Walnut Street, Philadelphia, Pa. Sept., Oct., Nov., 1918 Gift Author ^ V On the Battle-Scarred Fields of France. A Physician's Impressions of the Medical Services of Both the French and German Armies. THESE LINES are just impressions; they are not intended to be raised to the dignity of a complete account of the status of the medico- surgical and sanitary organization of the belliger- ents. Eather are they the findings of a student, who was willing to learn, by keeping his mouth shut and his eyes and ears open to all that was to be seen and heard, near and around him. in those memorable days of the latter part of 1914, when it was his privilege to be in the war zone. It is by the mistakes of yesterday that we learn how to do better today and, still better on the morrow. With this fact well grounded in my mind, and feeling as every red-blooded American has felt long since, that sooner or later our own fair land would be drawn into the vortex of the maelstrom that engulfs Europe, by a force over which we had no control; this fact, I say, decided me then and there to see as much as I was permitted to see, and to assimilate as much as I could assimilate for the purpose, that, should ever the time arrive, I might be able to narrate my experiences thus garnered for the use and benefit of the Service of our own Army. When the fate of two nations is hanging in the balance on the point of the sword, one can readily conceive why the movements of a stranger must, of necessity, be limited. The best of credentials under those conditions count for naught. You simply have to look pleasant, smile and be grateful for ever so tiny a glimpse you are permitted^f what is going on behind the curtain; hence, what I shall relate is only fragmentary of what I have seen at the time and places of my visits; but I shall relate facts, pure and simple, such as I possess them. For this very same reason I shall refrain from commenting on the French or the Grerman serv- ices. Suffice it to say, that they are different — must be different — ^by the very essence and nature of things ; and, what is more, by reason of the dif- ferent conditions under which these two services were and are still operating, their status is not a fixed one but is one that is subject to change from day to day, from hour to hour, according to the pressure and exigencies of the fortunes of war! under which the contending forces operate. Hence,!, conditions were different at different posts of the same units, and often similar or nearly alike in the posts of contending armies. War is not a re- specter of fixed rules and well-balanced, sedate orders. It strikes with fulminating rapidity at everything, here, there, everywhere. C'est la guerre! Et a la guerre, comme a la guerre, Voila tout! The Sadden Tide of Invasion With the force of a steam-roller Germany first invaded little Belgiinn, then overran, in those criti- cal days of August, 1914, northern France. Hun- dreds and hundreds of kilometers she occupied by force of arms — away from her own borders. She was then, as she is now, with both heels in enemy's land, knocking at the capital's door and stretching forth her mailed fist to grab some more vital points, some more important cities. Tet, with a stout heart and an indomitable will nat to be conquered. France fought and fights yet. valiant- ly, courageously, heroically, so as to compel the admiration of even her hereditary foe. In her medi- co-military service, France had then, as she has now, a decided advantage. She could then, as she can now, rely on the good-will of her home towns, her cities, big and small, wherein to mobilize and distribute to best advantage her mobile military medical and sanitary service. But not so with Germany; she, the invader, was and is in this re- spect at a disadvantage. She was compelled to create, to equip and to provide for, new hospital units in enemy territory, a territory naturally hos- tile to her forces, a territory often destroyed by enemy and friend alike, according to the tragic exigencies of the war. And what was the result? German Method I With an uncanny, methodical effort she over- came the obstacles and solved thus her sanitary problems; and, while France could call and did call into her service her city halls, her public buildings, her hotels, and transformed these into establishments for the care of her wounded and ill, listributing them in proximity to the firing lines, ipportioning her units in a methodical manner, ^hanks to the innate patriotism of the French na- tion, such units sprang into existence like mush- rooms, over night, while private homes threw open their portals to welcome the defenders of France, each and every citizen vying with each other to outdo themselves in deeds of patriotism, nothing of the kind happened to Germany. She was com- pelled to rely wholly and solely on her own mili- tary-sanitary organization and the resources of her own Eed Cross body, hence she was by force of necessity compelled to create new and great hospi- tal units, so that there should emerge, as it did emerge, a nucleus, with a kind of centralization power, for the better care and surveillance of her stricken and wounded. The question now arises : how did she do it ? Well, first of all, she brought from Germany into the invaded and occupied territory large barracks. Those barracks constituted the nuclei spoken of above. These she managed to dispose near to and around industrial centers. There she seized the immense factories that dotted these regions, con- verted then into hospitals, and when such a fac- tory was entirely or partially wrecked, she took it upon herself to rebuild or to repair the damage. The wounded that could stand a protracted trans- port were transferred to her own soil. There, too, as in France, her people opened their doors to the wounded and maimed to give them the best of care. Recuperating places sprang into existence, maintained either by private means or by the Government. Thus the President of the Reich- stag turned over his palace for the use and com- fort of the womided. But the ideal places for such purposes, as I found them extant in Nizza, Mar- seilles, Lyons, Dijon and Paris, I have foimd no- where within the German lines, and I have visited a good many of them — before Rheims, Verdun, St. Quentin as well as at Valenciennes and Brussels. The Sanitary Services With reference to the structural organization of the sanitary services of the two parties, all I have to say is, that they are made up almost on iden- tical lines. Thus, the French Poste de secours finds its equivalent in the German Truppen Ver- iandplatz; the French Hospital de Campagne is the German Feld-Lazzarett; the Hospital d'Eiapes is the German Etappen Lazzarett, while the Hos- pital de reserve finds its counterpart in the Re- serve und Vereins-Lazzarett. In the armies of both nations the soldier is fur- nished with a small sterilized emergency package, so disposed that the lightly wounded may apply it to himself without incurring any danger. The Ger- man package is smaller and more compact than the French one; it is easier to handle, and it is en- closed in a little pocketbook hung obliquely over the left side of the jacket, from where it can be reached, extracted and opened by either hand, while the French carry in addition to these emer- gency packets some vials filled with the tincture of' iodine, with a view that the wounded himself may, even before medical help can reach him, disinfect his wounds, provided he is wounded only very lightly. Heiney and Fritzi must forego this vial, because it has been found that Heiney is rather given over to the idea of "the more, the better," and his indiscriminate and lavish use of the tinc- ture had caused him some startling and unpleasant after-efi^ects. Hence, he must await his regimental doctor's service, either in the trenches themselves or at the Truppen-V erhandplatz, and where a med- ical officer is not available, some medical nurse is surely" there to attend to his first-aid needs. The wounded are gathered together into the Ti-uppen- Verhandplatz; those able to march go there on foot, or they are brought in by litter-bearers. The wound- ed may or may not have received first medical aid by that time; but at the Truppen-Verhandplatz more appropriate attention is given to the nature of the wound and the adequate and appropriate handling of the case proper. Here the most urgent cases come first; thus, those that have been gassed or nearly asphyxiated, are quickly resuscitated; collapse, severe hemorrhages are immediately over- come by proper measures; fractures are coapted, dislocations reduced, and the injured limb immo- bilized. Limbs that cannot be saved are here, if possible, amputated, and every wounded man is guarded against tetanus by the injection of anti- tetanic serum. When the V erhandplatz is too busy, those that can march go then to the nearest Haupt-V erhand- platz., or they are taken there by litter-bearers; or they may even go to the nearest Feld-Lazzarett. For those who cannot be removed or cannot come out from the trenches, because such an attempt would be too perilous an undertaking by reason of the enemy's fire — for those then, wherever it is possible, the regimental officers must step in and take care of them ; but, more often, owing to the peril that attends their bringing in, these poor wounded must remain just where they are until late at night, or perhaps they must await a more propitious moment to be taken up and brought in. Terrible Bailie Conditiona I have witnessed cases, and I have it from the lips of the wounded themselves, that often many of them had lain in the path of the raging battle for four or even five agonizing days without any aid whatsoever. Late at night I have often seen the Sanitary Corps come out and go directly to- ward the trenches and the battle lines; a long line they form of sanitary vehicles; these were drawn by horses because of the impassability of the roads and the impracticability for the use of automo- biles, for, besides the light projected by the auto- mobile reflectors, the noise produced by the motor readily attracts the attention of the enemy and constitutes the main drawback to their use. Hence, autos are used only when and where the roads are in good condition between the Eaupt- verhandplatz and the Feldlazzarett, or where their line of communication is, even in the daytime, safe from the enemy's fire. Location of Units The Sanitary Section takes its place near to but yet at a safe distance from and behind the firing line. It is somewhat farther in the rear than the Tinippen-Verhandplatz, protected as much as it is possible to protect it from the artillery of the enemy; this is, with respect to the care of the wounded, the most important post of the entire sanitary service, simply because these first treat- ments are often the treatments that are the decid- ing factors of the fate of the wounded. Especially is this true of present-day warfare methods. Erom there the wounded are rapidly removed to a sur- gical post, where, with adequate means, instru- ments, and under the special care of trained mas- ters in combating diseases, many a grave surgical complication that otherwise would have manifested itself, is thus forestalled. One of these German sanitary sections I visited was located near a wood, half buried in the ground to facilitate its heating up. The roof was, as it is, as a rule, in such oases, covered with green branches of pine, birch or other trees. These branches are their camouflage, serving for the pur- pose of hiding their existence from the ever-vigi- lant eyes of the enemy aeroplanes. All the barracks that belong to such a section can be put up within two hours and taken down in less than one hour's time. They have operating rooms for septic as well as operating rooms for aseptic cases, and also disinfecting rooms, etc. The service of each unit is constituted by the personnel of nine officers. Three of these are surgeons, four medics, one is an oculist, one a chaplain, and a number of nurses, and it can accommodate two hundred wounded. The Typical German Soldier The German soldier combines his industry with an instinct of organization; therefore, the moment he enters a section he sets himself to the self-im- posed task of bettering his condition by making his quarters more comfortable by adding to it, despite the fact that he is well aware that he might have to relinquish his hold on his quarters any moment to the Franzman. Thus, I saw that, in addition to the regulation barracks in a little wood, hardly 6 km. from the firing line, ever so many more additions made with the wood that the forest offers. Some served for additional sick wards, one was used as a chapel, others were for the officers' club rooms, while still others served as extensions to the kitchens. There were also spacious stables, large enough to accommodate from SO to 100 horses, and garages for the housing of the autos used by that sanitary unit. There was enough space there to accommodate with comfort 200 wounded, besides its staff members and personnel of the infirmary service. There were also kennels for the housing of wolf-dogs. These dogs were trained to explore the battlefield and even to ven- ture into "No Man's Land," to search, find and assist in the bringing in of many a wounded sol- dier; and let me record it here, to their everlasting credit, these intelligent animals performed deeds that were simply stupendous. Hans "Kept the Pig in the Corner" In the same unit there was also space staked off for the fattening of swine; they were fed on all the table refuse, and they, in turn, furnished Heiny in due time with some dainty morsels of ham and other porcine delicacies. The rooms were equipped with instruments and sterilization apparatus, such as one would expect to encounter in a first-class, modem hospital, ready to cope with any major operation. Makeshift Bedding Beside the reglementary ambulance bedstead, there were others to be seen of quite a different pattern. Here, too, the practical proclivities of the German mind came to the service for a good purpose. The reason for it was as follows : their march, in its initiatory phase, was executed with great rapidity; it was because of the able Fabian strategy of Joffre, beyond their own expectations, hence, in such an onslaught, and they being the aggressors, it was natural that their casualties should, as they did, pile up to a degree they never expected it to attain. Therefore, not being pre- pared for such an emergency, they were short of beds; but the commissariate carried foodstuffs well packed in wooden cases. These cases they utilized, and thus with this rough material they built 8,000 beds, roughly made to be sure, but quite comfort- able and provided with straw mattresses where hair mattresses were not to be had. Operating at Night Inasmuch as the wounded were all brought to the Haupt-Y erhandplatz or the Feld-Lazzarett in the dead of the night, it follows that the opera- tions were performed, for the most part, at night. Hardly had the ambulances arrived at their desti- nation when the work to operate was started. The operating rooms wei'e lighted either by gas or by alcohol lamps. Everything worked clip-clap in the first and best of shape, under the most rigorous ob- servance of aseptic methods, each of the operators a specialist in his line of work, with assistants trained to interpret a motion, to anticipate a move, and to know beforehand the desire of their mas- ters. Under such conditions it is not to be won- dered at that even the most difficult operations were fruitful of splendid results. Especially is this true when we remember how much depeiids on a correct operative measure, how much it influences the outcome of a major operation performed either on the head or in the abdominal cavity. In the latter case we know that the prognosis is by far a better one if we are able to operate within twelve hours after the woimd has been sustained; this, plus adequate preparations in an adapted locality, and provided with the best of surgical means handled by competent operators, who have all the time at their disposition to do first-class work, nothing more ideal could be desired; and all these conditions were, in 1914, prevalent in most of the German sanitary campaign units. Deferred Surgery But to every obverse of a medal there is the re- verse side of it, and so it was with their cases, just as there is a shadow to every light. Not all of the units presented such a roseate hue as described above. There were cases, naturally, which for ob- vious reasons could not be operated upon within the ideal time limit of twelve hoiirs; and there were cases for which neither the surromidings, nor the means, nor the surgeons best fitted to cope with all the intricacies of a fine technic that the gravity of the case required were at hand; then, of course, they had to rely on the vis medicatrix na- turae of the individual and hope for the best. Fearful Sigliis The spectacle of thousands and thousands of bits of humanity, shot to pieces in all sorts of shapes and forms, is not a cheery one; and going from bed to bed, visiting and ministering to them, eas- ing their pain and cooling their aching brows, re- quires a stout heart and a particular heroic nature of its own. Glory to the doctors of any race who, with a self-abnegation second to none devote the best that there is in them, so that pain may be assuaged and a life may be saved! They should do this un- selfishly, indiscriminatingly, be the issue the life of a friend or that of a foe. Before the majesty of suffering all enmity should cease, and the charity and the divine brotherhood of men come into its own and reign supreme. Oft I have asked myself the question : "What is the hardest thing to contend with among the Golgothas of sorrow and pain?" and I frankly ad- mit that I cannot say with precision what it is. I saw some terrible cases of disfigurement and I met some horrible poison cases, but the most piti- ful cases, to my mind, were the shell-shock cases. In one of the sections I had occasion to inspect a few laparotomy cases which had been operated upon early, and consequently all were now on the high road to recovery. In all these case? the wounds were caused by small firearms. What sur- prised me somewhat was the fact that neither within the German nor within the French line miits did I come across a case wherein the Murphy button had been used. The fear that I expressed in another paper, some twenty years ago, that the indiscriminate use of it in supra-public sections is fraught with dangers, that often the sigmoid flex- ure would be found so narrow as to obstruct its passage through it, was vindicated at the front. French and German surgeons alike told me that in their hands it did not act so brilliantly as we saw it work in the hands of our late lamented John B. Murphy. TAe First Dressing Station In some of the first dressing stations, both in France and Germany, I saw some dangerous scalp wounds that had received inunediate and adequate attention. All causative factors of compression had been removed and the wounds aseptically treated, with the best of results. However, not all serious eases could "be treated there, because de- spite the fact that there was a more than ample ambulance service, with a great number of autos at their disposition to take care of the wounded, by fetching them from the Paste de secours or the Truppen-V erhandplatz to the Hospital de Cha/m- pagne or the Feld-Lazzarett, yet the evacuation sta- tions were nearly always full to an overflowing and hence, not all that were there could be at- tended in an adequate maimer. Many of the cases therefore I witnessed myself were taken from the front directly, either to the Hospital de Campagne or to the Hospital d'Etape. All they were given was some kind of a first dressing or medication; and then they were sent on their way where better care and attention could be given them. Each wounded carried, tacked on his jacket, a little note that gave in a general way a history of the case, the nature of the wound or malady, and what medication or treatment were already administered. When, however, after a serious engagement, or after a big battle had been fought, the number of wounded brought in reached into staggering ciphers, then, and only then, were the activities of the surgeons wholly, and solely limited to the most urgent eases, either of the seriously wounded or the gravely ill ones; while the others were ex- pedited with the greatest dispatch toward the ter- ritorial hospitals, where they were evenly dis- tributed and properly taken care of; but, under no circumstances was one put on his journey if there was the slightest doubt in the mind of the attend- ing physician or surgeon that such a journey might aggravate the case or imperil the life of a patient. Immense Casaalties If we pause for a moment and reflect that after the battle at the Marne was fought and won, the casualty list of the French showed the stupendous figure of 1 12,000 wounded alone, and that during the twelve days that followed the beginning of the hostilities at Ypres, 100,000 wounded German sol- diers were sent forth from the distributing sta- tion of Brussels toward Germany, then one will easily comprehend the why, as well as the where, of all surgical preparations, no matter on what a vast scale of preparedness undertaken, had, of ne- cessity, to remain inadequate. ISTot even the well- organized German sanitary service could cope with it, despite the fact that they were evenly distrib- uted and magnificently equipped all along the terri- tory of the war zone. From Attigny to Vouziers, to Rethel, to St. Quentin and from Caudrey to Valenciennes and Brussels, their sanitary units were marvels of efficiency and order. Wherever and whenever it was feasible railroad branch lines were established that ran into and connected with the big trunk or main lines, wholely and solely devoted to the service of the wounded, who, over these lines were sent back to Germany to be treated there at the various hospitals adapted for their needs. Rethel, at the time of my visit, was only 10 Ian. distant from the firing line. The place bore all the evidences of the terrible havoc war had played there. Bombarded first by the Germans, precious little left whole of it, it was again bombarded by the French, who finished by destroying the little that had escaped the German destruction. San Francisco, after the terrible earthquake, I am sure must have looked like a well-kept garden in com- parison with the sight Rethel offered, and yet in this place of desolation the Germans dug them- selves in like moles, and I well recollect now of what once was a fine factory, but then was merely a fragment of a ruin, which the Germans suc- ceeded in rebuilding and converting into a mili- tary hospital with a capacity of 1,650 beds; besides, this factory-hospital was fully equipped with the best and latest radiographic machinei-y, with well- ventilated, spacious operating rooms, disinfecting and sterilization compartments, such as one would expect to find in a first-class hospital in New York or Chicago. Isolation Hospitals In and around the nearby villages, with the hospital as a central unit, thirty-five or more bar- racks were built aroimd, which, in their turn had a capacity of 2,700 beds. These barracks were, for the most part, used for observation and isola- tion of infectious diseases, notably typhus fever and small-po.x. The sections were divided into three groups; in the first group the very severe cases were kept under constant attendance, in the second group the convalescent found lodgment, while in the third group the quarantined ones were kept under constant observation. All sick mem- bers of that unit had to pass through all these three groups, and they were not discharged from the third until their feces, which were examined weekly, had riot shown for three consecutive exam-, inations that, as far as specific organisms are concerned, the findings were absolutely negative. This proved the cases to be immune, and only after such negative tests were they discharged as cured. These barracks were for the most part erected in some forlorn, uninviting, barren place, where, as a rule, the mire was kneedeep, yet the conva- lescent Germans succeeded in transforming these desolate places into splendid garden spots. The military authorities encouraged it, and even of- fered premiums and prizes for the best kept or most beautifully laid out garden spot; and all this was going on while the big cannons roared and the shrapnels whizzed and shrieked their song of death all around. In these barracks as well as in other units I found the most modern hygenic principles applied and translated into practice. The feces were all collected and disinfected with chloride of lime, everything was cleanly washed and sterilized, from the covering of beddings, bed sheets, etc., to the drinking water, wine, eating stuff, utensils and so on. Everything had to pass through the hands of capable inspectors. To each sanitary unit there was attached a bio- logical cabinet. The hospital sections were all lighted by electricity. Where the electrical plant was out of order, or was wanting, there was at some little distance a place where the electrical ^ energy was generated. Even in places which, prior to the war, never Ichew of the existence of such a thing as electricity, under the exigencies and stress of the war, electric service was there. Even the trenches were so supplied, and there the force sei-ved a double purpose, to wit, for lighting as well as for heating purposes. Everywhere I found established sections for full baths, sitz-baths and douches. In a little village near the firing line, where the roof had to be rt- constructed, I found such a balenaria. At the time of my visit there some Prussian and Saxon sol- diers, who just had come out from the trenches, were taking the baths. First, they changed clothes ; then were examined and assigned to a bathing sec- tion. One section was set apart as the Entlaus- ungs-Stelle, to rid them of vermin and scabies. This section was fully and adequately equipped, in addition, with special and sterilization apparatus. Radiography Attached to every surgical section there was a radiographic cabinet. Outside of these fixed cabi- nets there were maintained radiographic cnbinets on either auto trucks or on trucks draAvn by hiirses, ready to lie used here, there, everywliere, wlieve tlie urgency of the case required their presence. I saw many of these apparatuses in the field hospitals as well as in the territorial ones, and I saw some am- •bulatory ones at the great military units. Sani- tary authorities prefer the fixed ones to those ol the ambulatory type, because the loading and un- loading always entailed a loss of time: besides the transportation in itself from one i^laee to another involved the danger of getting them out of order. It seemed to me that Germany was compelled to erect, create and establish medico-surgical units, despite all difficulties tliat were in her way and in the very nearest vicinity of the firing lines, in a territory over which constantly the storm of raging battles centered; and all these units wei-e amply provided with adequate means to be in shape to cope with all sorts of conditions and emergencies that arose out of these battles. The territorial hospitals were reserved to look after the care of the convalescent, or to handle the after-treatment of all traumatic cases. Besides these there were instituted reclaiming stations to make the maimed ones, as far as science permitted, capable to reas- simie their physical functions by means of artificial apparatus, etc. However, after a big sanguinary battle, when the number of wounded assumed staggering propor- tions, then, and only then, was it that those who did not require immediately urgent treatment, were directed at once toward Germany, and in this ef- fort they were helped by the wonderful net system of railroads they had devised especially for that purpose. Among the French centers it was my good for- ture to visit, Creil and Amiens stand out in bold relief. Amiens is one of the most important hospital centers of the French army. At the time of my visit, it was some 20 odd kilometers distant from the firing lines, with which the city was intimately connected by a very efficient automobile service that radiated in all directions. I visited there various hospitals. Some units were located in public build- ings, others were in the civic hospitals of the city. One of the .units there belonged to the 14th Divi- sion of the Ninth Army Corps, ably supervised by Prof. Ambroise Monprofit of Angers. The wounded were brought into Amiens either by automobiles, or by vehicles drawn by horses. They arrived either directly from the trenches or from some Paste de Secours. They all were landed under the vast roofing of the railway station. Each and every one had his identification schedule pinned on him. This schedule gave in a general way a sum- mary of the nature of the wound or illness of the patient. There at the station they were re-examined, and each and every one assigned to one of three distinct classes. To the first belonged all those who needed but little treatment, at best only a few days of rest to recuperate their strength, and these after a short period were promptly returned to the front. To the second were assigiied all those ill and wounded who needed a protracted course of treatment. These were sent home to their territorial and departmental hospitals. To the third and last class were assigned all seriously ill and wounded who needed urgent at- tention. Often these cases were treated right at the station, but wherever and whenever practicable it was pre- ferred to send them to the hospital units of Amiens itself. As soon, however, as they were in condition to travel, they were sent from there to a more dis- tant hospital. Evacaation Hospitals. At the evacuation hospital of Amiens, located at the railway stations, I saw 300 beds constantly kept in readiness to receive patients. I found there oper- ating rooms, as well as a perfectly maintained emergency service, ready to minister and to take care of the most urgent cases. At one time I wit- nessed the arrival of 30 autos, full of wounded. I saw each one re-examined and assigned to his proper class. I saw them placed on a sanitary train of third-class carriages, taking these heroes of France back to their home departnients to recuperate. All went on with an order and precision worthy of the highest encomiums and traditions of the French Army. I heard no voice raised in protest, nor did I hear any one complaining; they suffered in silence and with dignity — these noble sons of a truly great nation. Hospital Trains. The trains, I was told, could each acconimodate 600 wounded. They differed from the German troop trains in that no medical officer went along with them. Only the nurses went with them, and they saw to it that nothing was wanting. However, in cases of need, a medical officer was always in at- tendance or could be easily found at any of the principal stations these wounded and ill had to pass through on their long journey. Those cases who by reason of the voyage became aggravated were promptly removed from the train and taken to the hospital unit of that place. By direction of the Central Command of Paris that has supervision of such cases, the wounded and ill were sent from the evacuation hospitals to the various departmental and national hospitals, and distributed among these ; according to the beds, each unit had at its disposition. The sanitary train of- ficials were beforehand apprized by wire of the precise time of the arrivals of such trains. These wires went also to the officers of the departmental headquarters, who were charged to see to it that the correct division and distribution of the wounded should be made. Being informed daily of the train movements, tliese officials were, therefore, beforehand in a posi- tion to take the necessary and appropriate steps to distribute the new arrivals between the territorial hospitals that were best adapted for the handling of the cases, according to the nature of the disease or the degree or severity of the wound of the in- dividual. Central Territoritil Hospitals. In France, by virtue of the proximity of the fir- ing lines, the main central territorial hospital units are located at Paris, Lyons and Dijon. But, where pure air and ideal climatic conditions are sought as adjuvants to treatment, then Nimes, Menton, Cannes and all the beautiful Riviera towns easily win the palm ; hence southward, toward the land of sunshine, great numbers of the wounded are directed. By reason of what is stated above, the French service had not, and did not, need nearly as many sanitary units as the German service was required to maintain, nor were the Freiich units at the front so lavishly equipped as the Germans simply because the French had, and still have, ample facilities to fall back on their home units. I have seen patients with scalp wounds exhibiting all the symptoms of compression coming directly from the front, arriving at terri- torial hospitals, having traveled probably for a few days, only to undergo treatments there. I saw compound and comminuted fracture cases, under the same conditions, who had received only a pri- mary dressing. Changing Methods as War Changes. Such a sanitary service was, up to the present war and for all intents and purposes, an adequate one, simply because the lesions produced by the fire- arms of former wars always pursued a benign and favorable course ; hence it was good surgical practice to send the wounded, after they had received either an emergency or primary dressing, to some better equipped hospital. But this war is an entirely dif- ferent proposition; and this fact the French were the first to recognize. Hence their front service today is by a far cry a better one than the one 1 saw nearly four years ago. Today their front serv- ice is second to none, and those who have charge of the service are the master minds of the medico- surgical world of France — and that means some- thing. Now what are the causes that producea such a change? Well, they are manifold indeed! Fore- most, however, among them all is the fact that the small firearms had to give way to grenades ,and shrapnel and cannon of gross calibre. Translated into traumatic results, this means that wounds pro- duced by such weapons tell a more sweeping and disastrous tale. And while as late as the Italo-Turkish-Tripolitan war, or to come still nearer home the last two Bal- kan wars, the number of wounded hit by balls from rifles still amounted to nearly 85-90%, while those produced by cannon or other gross caliber arms amounted only to 10%, at best to 15%; today the reverse marks more nearly the truth. Character of Woands, I saw more wounds produced by cannon than due to rifle shots. True, the reason may lie in the fact that the rifle wounds heal quicker, hence there was less opportunity for their observation by a mere casual visitor than by a regular attendant. As a matter of fact, I saw many soldiers who had been wounded twice or thrice, and who had returned to the trenches after only a few days of illness. In this instance I refer to rifle wounds produced b,y small caliber projectiles thrown from a great dis- tance, whose vital force is quite irrelevant. But there is a diff'erent tale to tell in the ease of wounds produced by the selfsame arm and projectile thrown out at a sho7-t distance, whose disruptive force in consequence is an enormous one. Under such latter conditions, wounds thus produced assume quite a grave aspect indeed, simply because the explosive character produces in the organs hit extensive, de- structive lesions, often tearing everything to pieces — similar to the destruction produced by a bomb. Especially is this true of organs tEat contain liquids, such as the heart, containing blood; or semi-solids, such as the cranium, containing the cerebral mass; while in the liver or muscular system it produces lacerations having but a small entrance, but in which the wound becomes larger and larger and more conical in shape as it nears the exit of the projectile. Another aggravating factor that has often been observed is the fact that, not infrequently, the pro- jectile in its trajectory, and before reaching and hitting its victim, encounters in its course some hard impediment that flattens it — and in this con- dition it ricochetes or rebounds, hitting the soldier in this rebound. Wounds thus produced are of ne-. cessity irregular in shape and by far more lacerative and destructive in character than are the wounds due to other projectles. Inasmuch, as nowadays battles are often fought out with the opposing trenches at a short distance from each other, such mishaps are of quite common occurrence. When these experiences, at the beginning of x,ne war, were quite new and their causative factoi still was un- known, it led to the most acrimonious accusations, hurled by the contending armies at each other, of being guilty of uncivilized warfare by the use of dum-dum bullets. This much for wounds produced by rifles. Shell WoanJs. Now, how about the wounds inflicted by artillery ? Here, too, even in a greater degree, present warfare has produced new and terrible types of lesions, un- known before in seriousness and destructiveness. They are particularly due, first of all, to the more extensive use of cannon of gross calibre, as well as to the great state of art and perfection inherent in these monster weapons; hence the requisite greater efficiency in markmanship has evolved a de- structive potentiality never heard nor dreamed of before, so that, nearly every shot fired carries de- struction with the maximum of telling force. Not a little credit for this precision is due to the eyes of the army — the bird-man in his aeroplane — who with the greatest precision maps out and signals the enemy's exact position. I have noticed but little difference in the effects produced in wounds due either to the French gren- ade or to the big German projectiles. The French grenade, such as are projected by the 75 cm. cannon, scatters itself into infinitesimal pieces as soon as it bursts, increasing thereby to a manifold degree the lesive power of the projectile, yet it inflicts but a small wound; the German projectiles burst into large fragments, hence, they produce a far larger wound. Be this, however, as the case may be, the one luminous fact remains, that owing to the greater number of cannon used in this conflict, the number of shell wounds by far surpasses those produced by rifles, and consequently the irregular fragments of the grenades or shrapnels are productive of very serious lacerations. Aside from this fact, there is another element inherent to the gross caliber weapons in that the wounds so produced are often complicated by the danger lurking in infection from pieces of clothing Or other septic materials carried by them into the wounds, while rifle wounds cause more clearly de- fined and less dangerous lesions. Another ominous factor of the grenade is its property of bursting on the ground and scattering around clouds of earth- works, stones and dirt, each of which increases the danger of infection. Such complications were observed at the begin- ning of hostilities and they found their expression in the great number of cases that developed tetanus or gangrene. However, nowadays, judging from the reports, such cases are happily of rare occur- rence, thanks to the energetic prophylactic measures instituted. True, some inevitable suppurative cases are still manifest, but better results are gained day by day, and soon these will pass into history as things that have been, but are not now, to be dreaded. Conservative Surgery. Out of evil there always arises some good, some blessing to mankind; and thiis out of the turmoil and strife of this gigantic world war conservative surgery came to the fore and into its own. ~No-w no longer are amputations made needlessly, but wher- ever and whenever possible, a limb is saved. Hence, we may well be filled with professional pride at the achievements of our profession at the front. How were these remarkable results brought about ? Simple enough ! They are due to the great in- fluence civilian physicians and surgeons have brought to bear on the professional medical corps of the armies and navies of the contending forces. This commingling of the two great branches of the profession, the civil and the military, in one homo- genous body, was productive of an efficiency never heard of before. I saw within the German lines, working as su- perior military officers, the greatest luminaries of the medico-surgical world of Germany; thus I saw Peyer at Eethal, Garre at Vouzier, Angerer, Schem- mel and Neumann at St. Quentin, while Bier di- vided his time between the front and his clinic at Berlin. France, on the other hand, can boast of the services of Tuffier, one of the greatest living clinicians. He has the rank of a general, and I saw him supervise the surgical field organization. Be- sides him, there were at the front such eminent men as Faure, Cuneo, Proust, Schwartz and Lecine, While Baudet was at the head of the Italian hos- pital for the wounded in Paris, while Quenu, Del- bert, Monclaire, Thierry, eminent French surgeons, each a master mind, directed somewhere in France some important territorial hospital. The Civil UospHab. In every city in France, as well as in Germany, the civil hospitals are given over to the care of the wounded; everywhere the military cases take prece- dence over the civil ones, and where such a course was feasible the latter were mixed up with the former. Special care and attention is given to the various specialties. Thus, each unit had an oph- thalmological, an aural, a genito-urinary, as well as orthopedic departments, and last but not least a department for brain and nervous diseases. At the head of each department an authority of national or even international fame, was placed. The city of Valenciennes had completed an im- posing building that was to serve for school pur- poses. It was just to be inaugurated when the Ger- mans took possession of tlra city. They converted this building into a great neurological institute, with Oppenheim, the great neurologist, at the head of it, while the far-famed French neurologist, Sicard, is at Marseilles at the military hospital of that city. Imbert, professor of clinical surgery of the Univer- sity of Marseilles, is at the head of the surgical de- partment of the same hospital. In Germany, to each sanitary unit belonged a chemical, a bacteriological, as well as a hygenic cab- inet, and each of these were directed by the famous professors, by men of known ability in biological sciences, by virtue of the positions they occupied at the various universities. I believe, from observation, that the harmonious blending of the military surgeons with the celebri- ties from civil life to whom military ranks and emoluments were given commensurate to, and in keeping with, their high civil status, contributed in. no small measure to the splendid results to which the sanitary services of the contending armies of France and Germany may justly point with pride; because from that intimate intercourse and exchange of ideas, there sprung into existence a sanitary organi- zation that was equal to any emergency, ready to cope with any vexing problems that the gravity of the moment had engendered — to the everlasting glory of the armies to which they beloixged, and, as well, a blessing to the thousands and thousands of wounded or ill committed to their care. The Red Cross. Another great factor that contributed to the top notch efiSciency of the sanitary service was the help and the support that the Eed Cross organizations brought to the sanitary services of their respective coimtries. In France, as well as in Germany, they placed their tremendous resources at the disposition of tlie sanitary service of "la patrie" or "the fatherland." They assumed the task of training and educating nurses for the service at the front, and they con- trolled and managed hospitals; they organized and supervised troop trains for the transport of the wounded; they dedicated themselves, in a most un- selfish manner, to the sanitary and hygienic defense of their armies. Right on the heel, at the declaration of war, while the military authorities called all men to their respective colors, the Eed Cross, as well as all other societies that were intimately related or dependent thereon, started out to mobilize a true womanly army, as a complement to and as an auxiliary for the respective fighting armies. And to the glory and everlasting fame of the women of both countries, they did their duty and responded nobly, conscious of the great need their land and nation had for them. Thus, in Germany, the "Schwestern" or sister- hoods, occupy even in peace times a very important position. They have charge of the training of all nurses; they superintend not only governmental and civil hospitals, but they also administered private hospitals. They have organized, managed and solved the great field sanitary and hygienic prob- lems. Wherever there was suffering, the Red Cross sisters were there — ready to do their part, to help heal the wounded, as well as to mitigate the horrors of war. Well trained to a T, efficient in the ex- treme, no wonder, then, that such an organization was a power for good. There is no service, no matter how humble or ever so exalted, ever so devolving the highest skill and rarest acumen, to which these Red Cross Sis- ters everywhere do not lend themselves. Here they attend to the official or the private correspondence of the wounded ; there they keep the registers or act as bookkeepers. This one is the presiding genius of the scullery; the other has a knack for keeping the instruments in trim shape, while still others act as assistants to physicians and surgeons, or as radiographers, as chemists, bacteriologists, mechano- therapeutists, etc., etc. Red Cross Hospitals. The French Red Cross embraces three distinct and autonomous organizations. (a) La Societe Des Secours aux Blesses Mili- taires, (b) La Union Des Dames Francaises, (c) La Union Des Femmes de' France. All these three societies have control in peace time over many schools for nurses and hospitals, among which I'Hospitai, Ecole de la Societe des Secours aux Blesses Militawes a Paris is a model in itself. When war was declared, a great number joined their ranks with an enthusiasm so characteristic of the French nation. Those who in peace time had gone through the regular course prescribed for nurses, and who had passed a satisfactory examination, were, of course, given the first positions available in the Red Cross service, while for the later arrivals shorter courses were provided to make them available for practical service in the shortest possible limit of time. Fortunately for France, there came into exist- ence an intelligent volunteer body of nurses that placed the three societies in the enviable position to be able to furnish in the shortest possible time an adequate force to serve in 1,561 hospitals, with a supervision of 102,579 beds. They totaled over 20,000, sufficient to cope with all cases, even at times when the influx of wounded almost seemed to be an inexhaustible stream. They were there, those noble women of France, those Red Cross nurses — ever alert, ever attentive, ready to do and to give of the best that was in them in the sacred name of patriotism and humanity. Lyons, for instance, had at the time of my visit the stupendous number of 25,000 beds, supervised for the most part by members of the Red Cross ; yet after the battle of the Marne, this number was by a far cry not sufficient. The very large number of wounded that needed aid and attention, the troop trains going and coming, loaded with soldiers, created the necessity to send the hospital trains over the bigger trunk lines to larger and better equipped military centers ; and thus it came to pass, that whilst such centers as Paris, Lyons or Mar- seilles were crowded to over-flowing other smaller centers situated at some branch line and far from the front remained empty. Immense Samber ef Casaalties. Such staggering numbers as stared us in the face were not dreamed of by any of the belligerents, hence the service was caught inadequately prepared ; but there was never a time when any wounded or suffering did not receive due attention and proper consideration — all received the treatment that France owed to her sons and defenders. The French Red Cross ever alert, ever on the qui vive for such emergencies, was there to bridge over any difficulties arising. The sphere of action, as can be readily perceived, was not limited therefore to the hospital service alone; nay, on the contrary, at every railroad sation where hospital trains were passing, aid stations were erected and soon in full swing. Here society ladies rubbed elbows or took tiu-ns with their sisters of the working classes, to look after the welfare and comfort of the wounded and ill ; there they prepared nourishing food and, where permissible, dainty dishes or delicacies, cigarettes, medicines, etc., etc. There they had also rest beds, for those who on account of the gravity of their cases could not con- tinue their voyage. Germany's Ready-Made War. But in Germany all this was different, owing to her organizatory talent, and above all, the fact that she had for forty-three years prepared herself for the coming struggle — everything had been made in readiness; everything had been foreseen; nothing had been left to chance; nothing was overlooked. Her Red Cross system was German-made, that is to say, patterned after the army and closely knitted wilii it. Hence, the Red Cross on the other side of the Rhine was established on a purely military basis, so that, not only the soldiers, but even the stricken civil population were looked after by them — in war times just the same as in times of peace. Thus von Behr Pinnow organized from among the Red Cross sisterhood, a special training corps of nurses, whose sole raison d' etre was to look after and to take care of the health of the babies in order to stem the frightful mortality among them on the one hand, and to see to it that the future defenders of the fatherland might grow up healthy in body and sane in mind, according to the Hip- pocratic aphorism: "HI ens sana, in corpore sano." French Efhciency. With all this, the spirit of sacrifice, as well as the efficiency, of the French Red Cross is equal in every respect to that of the German organization, only its division into three organizations, each inde- pendent of the other, instead of being welded into a strong homogeneous unit, is to my way of think- ing, rather a drawback, however small I confess. The American Red Cross. I'm rather partial to our American Red Cross organization. It is an organization that is unique — barring none. It rests on a very strong and solid foundation because organized along military, sani- tary lines. The great number of officers, nurses, professional and volunteer, that belong to its rank and file, the close affiliation it keeps up with the army and navy, makes it one of the most formid- able and efficient organizations of its kind in the world. It has the fullest support of the Govern- ment. Our President, as Commander-in-Chief of our Army and Navy, is ex-officio Commander of the Red Cross, and our highest military and naval officers are members of it. The whole machinery of the United States offensive and defensive power stands behind it, and above all it has the unstinted and loyal support of our nation, that is to say, of every true, red-blooded, patriotic American. America Called to Fight. And now that America has been called upon to fight the battles of and for the democracies of the world, the American Red Cross will play in this great world drama, as it has played Tn the past, a part worthy of its best and noblest traditions, which are the traditions of our Army and our Navy. It will do its duty — nobly, efficiently, abreast of the times — conscious that the eyes of humanity look on it as the embodiment of all that for which our flag stands, which is the visible symbolism of true Amer- ican ideals. America to the Front. And now as to the aftermath — after this world war has been fought and won with the aid of our forces — what shall we do with the wounded and maimed American soldiers? When Johnny comes marching home, minus an eye, arm, leg or both, what shall we do with him? Shall we in the first transport of joy at the reunion gush over him, idolize him for his natural life into unproductive idleness? I say, no; a thousand times no, and this with all the earnestness at my command. He has done his duty, faithfully, nobly, so have hundreds and thousands of other Johnnys done, in just the same unselfish, patriotic manner ; and some of them, aye, a great number of them, have paid the supreme sacrifice — slumbering now the eternal slumber of the hero — decked by the sod of a foreign country — so that their own soil may be unmolested and free from the tread of the enemy; so that their own country may live. The Debt of Oar Soldiers. But this country has contracted a debt; it is Johnny's debtor now, as it was Johnny's creditor be- fore, and that debt is not paid — cannot be paid — either by putting him on a back shelf as Uncle Sam's pensioner, or by placing him on the scrap heap for the rest of his life, selling pencils and shoestrings on some corner curbstone — a burden to himself as well as to those who are around him. It is work and service that the American soldier is asking of his fellow American citizens, and not charity ! Work ennobles; charity degrades. A true Ameri- can never degrades himself. Let U$ Follow the Example of France. France, full well recognizing the great service her sons had rendered to her in the hour of distress, and particularly recognizing at its fullest worth the sacrifice of the one who has suffered loss of a limb — France, I say, with all the finer emotions she is capable of forcibly repressed — gulped them down, and looked at the proposition that stared her in the face from the angle of justice and common sense, in a cold scientific way. She wanted to be just to her heroic sons, and to this end she enlisted the cooperation of every citizen, and particularly of every employer. She did not pass the hat around, nor did she ask financial aid of anyone, least of all the employer, to contribute. Nay, just the reverse. The Surgeon General appealed to them not to follow the dictates of their hearts or patriotic impulses to create new and unnecessary vocations, such as watchman, doorman, or information clerk, for the use and benefit of the crippled soldier. On the con- trary, every employer was and is asked to open his factory, his shop, his place of business, to crippled and disabled soldiers. While the Surgeon-General's office assured the employer, that thanks to the re- education and reclaiming forces of the Government, the soldiers will fully be able to earn every cent of their salaries. Let us do the same! Re-edacating the Maimed. Let us re-educate the maimed. Let us show him our true appreciation of his worth and of the service he has rendered to his country, by giving the country an opportunity to put him in a position to earn his own living; only so, and in no other way, can we pay our debt to him ; only so will he not lose his self-respect and ambition; so that, with head erect, into the shops, into the offices and into the professions he may go to take his place at the banquet table of life and to compete with his normal fellowmen as their equal. By careful training in reclaiming him, he will again become self-supporting, a useful and pro- ductive member of the community wherein he lives. Our Red Cross institutions are admirably fitted to reclaim the crippled and the blind. Coddling a disabled soldier is the worst thing that could happen to him, not barring even German bullets. Do not let us fall into the errors we committed after the war between the States. Reclaim the maimed, as fully 80% can be reclaimed. It is not a gift you are bestowing, but paying a debt, a sacred debt. Oar Boys Over There. Our boys Over There will soon be counted by the millions. They went with a will — if needs must be, to die. Thousands will come home cripple