Zbe ÜBoston flfoebícal anb Suroícal Journal

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ADDRESS Students' Text Book of Hygiène. By W. James Wilson, M.D.. 208 D. M.D. 209 Paokt and Elliott C. Oxford Medical Publications. By M. Macdonald, Sir James Paoet's Disease. By Cutler, Albert P. Mathews. 209 M.D., Boston. 187 Physiological Chemistry. By ORIGINAL ARTICLES EDITORIALS for State Legislation. 210 A Sketch of the Organization for the Care and National Suggestions Traits* Statistics. 211 PORTAT10N OF THE SlCK AND WOUNDED IN THE BRITISH EX- University Registration Psychological Study of Criminalb at the Massachusetts PEDITIONARY Forces in France. By Itogcr I. Lee, M.D*, 211 Boston. 192 State Prison. Massachusetts Milk Legislation. 212 The Occurrence op the Wabsermann Reaction among Hos- 212 pital 1'atiknth. By Albert A. Hornor, M.D., Boato». 104 Medical Notes. Treatment of Central Nervous System Syphilis. By I. OBITUARY Boston. 195 Chandler Walker, M.D., GeoHoe Howard Malcolm Howe, M.D. 217 THERAPEUTIC AND PREVENTIVE MEDICINE CORRESPONDENCE The Treatment op Syphilis. By C. Morton Smith, M.D., Thomas F. M.D. 221 108 Surgeon of the "Mayflower." Harrington, Boston. op Influenza. D. Spear, M.D. 221 The Source Edmund 222 MEDICAL PROGRESS A Reminiscencp. of Dr. White. liobcrt A. tides. M.D. Acknowledgment From the Front. Allan Récent PnociiiEss in NEunoi.ociY. By John Jcnks Thomas, A Gracious 222 M.D., Boston (Continued). 203 Perry, IA. Col. BOOK REVIEWS MISCELLANY for Dr. Cheever. 217 as a William Allen M.D. 207 Memorial Resolutions Syphilis Modern Problem. By Puscy, in the United States. 218 Mothcrcraft. By Sanili Cornstock. 207 Improvino Cancer Statistics 210 The Practical Series. 208 United States Death Rates in 1014.,. Medicine Examinationb. 220 Sixteenth Annual Report of the State Board of Insanity of Benefit of Physical 222 the Commonwealth of Massachusetts. 208 Notices, Recent Deaths, Etc.

care to students and a fine example to any who model their lives thereafter. To clear up what may confuse some of you, I will merely recall that there are two diseases SIR JAMES PAGET AND PAGET'S called Paget's disease. In 1874 Paget read a ' ' Areo- DISEASE.* short report on Disease of the Mammary la Preceding Cancer of the Mammary Gland." BY Elliott C. Cutler, M.D., Boston. At the present time, cancer of the breast, begin- ning about the areola, usually as an intensely I. PAGET'S DISEASE. is known red, raw, finely granular skin lesion, as Paeet's disease. My claim to talk on os- Paget's disease of bone, In disease of bone, called by mm does not rest with interest I Paget's it any exceptional may teitis deformans, we are more interested, and as a medical in this for liave, man, affection, is in relation to this disease that Paget's name it does not seem to within the realms be of pos- is most often recalled. His original communica- that the treatment this dis- sibility successful of tion I have here; it came out in 1876, when he ease shall come through surgical efforts. But, ' ' A Form was years old, and is entitled as to all students of with suffi- sixty-two medicine imbued of Chronic Inflammation of the Bones." Now cient and the values of a historical in curiosity this disease forms a definite clinical picture diseases which are named background, appeal its outward and it occurs to me that, so in aspects after their discoverers, this instance, be- like Addison's disease, Parkinson's disease and the I was led to a the cause of name, study of disease, it was the external manifes- man and times. The was a Hodgkin's his effort thousand tations of the disorder that attracted Paget's times repaid, for James Paget is one of the curiosity and observation and made him study men in modern medicine. I great say modern, further a group of cases so evidently unusual. for he lived the years when anesthesia through Even now there must be many unrecognized dis- was discovered and had as Pas- see contemporaries ease entities amongst us which we may even teur and Lister. but doubtless their outward mani- And to talk on I have full because frequently, Paget right, festations are obscure and vary so greatly that lie was, a much of first, great surgeon, though even our best observers fail to detect them. his greatness was obtained because of his scien- himself called this bony disorder a rare tific and his Paget efforts, his teaching, literary gifts. disease of bone and it still remains such, though I found his life stimulating and in the tremendously some 200 cases have been reported litera- and it constitutes an ideal interesting, indeed ture. Since out the characteris- whose will be of vast benefit to all medical Paget pointed study tics wbich we shall discuss, studies of the past *Read at the meeting of the historical section of the Harvard have re- Medical Society on Jan. 4, 1916. literature and old museum specimens

The Boston Medical and Surgical Journal as published by The New England Journal of Medicine. Downloaded from nejm.org at SAN DIEGO (UCSD) on July 8, 2016. For personal use only. No other uses without permission. From the NEJM Archive. Copyright © 2010 Massachusetts Medical Society. vealed many unrecognized cases. Jonathan row cavity, in the new spaces left by the de- Hutchinsoii himself claimed to have found a struction of the old cortex and also on the sur- typical example in a mummy's skull from face of the bones. The new bone at first is Egypt. Yet, that it is still a rare disease is lacking in bone salts, and Paget himself found shown by the fact that of 285,000 out-patient (hat phosporus, calcium and magnesium were cases at the Massachusetts General Hospital, in less than normal in affected areas. Thus the the years 1903 to 1915, only 7 cases are recorded structure, though thickened up and larger, is as definite examples of this disorder. less strong and gives way before the weight of Now, as I have suggested, the clinical picture the body, producing in the spine and lower ex- is pretty definite except in the cases where a tremities the characteristic deformities. single bone is affected. These cases are ex- (Lantern slides were then shown, illustrat- tremely rare and the diagnosis rests entirely ing by photographs of patients and x-rays of with the x-ray findings. It is essentially a separate bones from different localities, all the chronic disease of bone occurring in middle Ol- typical characteristics of the disease. In addi- íate life and usually unattended by any symp- tion the plates from Paget's original case were tom other than those of skeletal changes, except reproduced and finally two portraits of Paget for grumbling rheumatic pains in the parts af- and an engraving of St. Bartholomew's Hos- fected. Paget himself paints the picture pital, made in 1844, were shown.) clearly as follows: "The disease begins in middle age or later, is very slow in progress, II. SIR JAMES PAGET. may continue for many years without influence James was born in on the and other Paget Yarmouth, Eng- general health, may give no in 1814 and died in London in 1899. trouble than those which are due to the land, changes These 85 were filled to of shape, size and direction of the diseased bones. years overflowing always with incessant and it seems Even when the skull is and activities, indeed, hugely thickened, to that a man could work so all its bones altered in remarkable, me, exceedingly structure, and so hard and survive to such the mind remains unaffected. The disease af- continuously yet a old It is for those of fects most the bones of the lower ripe age. interesting frequently long who are connected with the medicine of extremities and the and is you skull, usually symmet- Boston to recall that it was in 1810 rical. The bones that Warren enlarge and soften, and those and Jackson started the foundation of the Massa- bearing weight yield and become unnaturally curved chusetts General Hospital, which received its and misshapen. The spine, whether by first in 1821. to the weight of the skull, patient yielding overgrown Stephen the was a brewer and or by change in its own sink Paget, father, structures, may ship owner, refined, and seem to shorten with increased dor- prosperous, temperate, pub- greatly and generous. The mother was a sal and lumbar the become lie-spirited curves; pelvis may splendid woman of better social Paget wide ; the neck of the femora become position. may nearly of lier father as a real who left but the however speaks gentleman horizontal, limbs, misshapen, as a only the gout, of which he himself remain and fit to the legacy strong support trunk." inherited a most troublesome share. She was a in his first he em- Further, describing case, handsome, strong-willed woman, best remem- phasizes strongly the postural defects. "The bered for her intense love of her children, but shape and habitual posture of the patient were also for her great industry and skill in writing, thus made strange and His head was peculiar. needlework, and painting. Such then were his advanced and lowered so that the neck was parents and boasts he. was well born ! very and the when he held his Paget short, chin, head It was a large family, 17 children in all, nine at ease, was more than an inch lower than the growing to full age, of whom James was the top of the sternum. The narrow short, chest seventh. All were well gifted, two artists widened into a much shorter and being suddenly of considerable skill, and one an entomologist broader abdomen, and the pelvis was wide and of note. low. The arms appeared unnaturally long, and Paget speaks of his schooling as being fair. It though the shoulders were very high, the hands took place in a small boys' scbool in Yarmouth, hung down by the thighs and in front of them. where he states they progressed in mathematics Altogether, the attitude in standing looked to the quadratic equation and to unknown strangely in contrast with the large head and depths in Homer and Zenophon after Caesar, handsome features." Sallust and Euclid ! Anyway he made the best The pathology is characteristic and borne oui of his opportunities and early distinguished himself in the by the x-ray findings. It consists in a destruc- by being head-boy school for his tion and absorption of the bony tissue in the last two years there. At 16 he was this school and it was part affected ; and cells attaclc through phagocytes giant determined he should be allowed to enter the the bone, which disappears with confluence oi navy. Indeed, his father had already written a the Haversian systems and trabeculation of cor- letter to a friend, asking for a commission, when tical but. at the same time substance; prolifera- thinking better of it, he kept the letter over tion goes on, new bone is laid down in the mar night and destroyed it the next morning. There

The Boston Medical and Surgical Journal as published by The New England Journal of Medicine. Downloaded from nejm.org at SAN DIEGO (UCSD) on July 8, 2016. For personal use only. No other uses without permission. From the NEJM Archive. Copyright © 2010 Massachusetts Medical Society. was much turmoil and inward struggle for at the height of his fame and his talks were the young Paget, but what a lucky bit of suffering great mainstay in the school. He was an im- it was ! pressive speaker, knew his subject well and got perfect attention. From Stanley, the anato- Apprenticeship. 1830-1834. mist, Paget got much, and in after life he speaks So it was determined he should become a sur- of learning from him the value of dull, careful geon, and at 16 he was apprenticed to Mr. painstaking work. Paget himself became a beau- Charles Costerton, the active and energetic local tiful dissector and was always at work on this practitioner. Here he was to assist for four subject. The museum of the hospital was well and a half years and then be allowed to go to rounded and equipped and a constant source of London to study. Paget at once set himself to enjoyment to the boy. He read a great deal ; in- work with great enthusiasm and energy. He deed he never seemed to sleep, and during the kept the office, the accounts, learned to put up evenings of his first year taught himself Ger- medicines, the dispensing of drugs and care in man. This gave him much repute, for but one minor surgery, lie writes of the time spent in other student knew this language and but few this work as too long, but his interest was un- of the staif. The result was that older men, flagging, lie saw much work of our out-patient clinicians, and even his teachers brought him class type and speaks of varicose ulcers as being foreign publications for translation and thus he useful for bandaging, and the experiences in in- came into contact with many more medical peo- juries, minor sicknesses, etc., quite valuable. He ple with whom acquaintanceship was valuabe. studied hard at books, taught himself French It was during this year that he made the discov- and learned considerable anatomy. ery of the parasite "Trichinella spiralis." For During all these years he was a keen student years in the dissecting rooms the small white of botany, in which he early displayed great in- flecks had been noted in the muscles of subjects, terest. He was always walking about but Paget's curiosity and thirst for exact truth and collecting observing, and indeed an old lady of Yar- led him on, even tó borrowing the use of a mi- mouth wrote, "that young Paget walks about croscope, then indeed a rarity. It was then that the country too much to be a student of medi- he observed the parasite, encysted in its capsule, cine." His thirst for knowledge in the things made drawings and called the attention of others be was interested in was unquenchable, and he to his finding. One of his instructors, Owens, speaks of digesting fully a book on botany of 36 borrowed the drawings and reported the dis- volumes, which he found in his father's library. covery, giving Paget full credit. At the end of The result of this botanizing was the joint pub- this first year he graduated first in all four sub- lication with his brother Charles of a book en- jects and thus through his industry, ability and titled, "The Natural History of Yarmouth." success was already a marked student. This came out in 1834 when he was only 20 Of the vacation at the end of his first term years of age and remains even because of he " I do not remember the occupation of its today, writes, thoroughness and accuracy, a distinct au- the vacation time," but doubtless it was well thority on the local flora. It won him the taken up with work of some kind, for he never nition of recog- Sir William Hooker, then the greatest rested or let his interest slacken. During the botanist in England and a celebrated scientist. second year he was more in the hospital and In looking backward from the prospective of his about the wards, seeing and studying actual -whole the life, value of this training in botany cases, much as our clinical clerks do now-a-days. cannot be overestimated. In the first place it At the same time his interest in the Post-mortem -was self taught and next it made him an accu- continued and he was at all odd mo- rate room busy observer. It gave him a scientifically in- ments with dissections. His knowledge of ana- quisitive him the value of mind, taught going was excessive already. At the end of this to books for reference and and tomy knowledge bj he was first in all subjects studied the success of the effort hin term again published brought success with his classmates was very pop- into contact and with scientific and his friendship really for his abilities and industry were well men and gave him a taste for the exposition ol ular, bis work. known and recognized. He himself writes that in those years he must have had a "great facility Hospital Pupilage. 1834-1836. for cramming," for in his examination in medi- In 1834, when 20 years old, he went to Lon- cal jurisprudence, he afterwards found he had don and entered the medical school of St. Bar- almost verbally whole from tholomew's This had been for quoted paragraphs Hospital. many a on this he had read the book subject just previous years greatest of the London Schools and the this he its of the Aberne- to examination. During year passed through great surgeons past, and accurate Percival Pott and others had become for the College of Surgeons, his thy, espe- of is cially noted in its surgery. At the time Paget and comprehensive knowledge anatomy entered, the interest in the school and in teach- shown by the fact that when in this examina- ing had somewhat fallen away and disorder was tion he was asked to tell abouth the fifth nerve, beginning to prevail in the staff and school. But he gave a full description of the otic ganglion, Lawrence, then the surgeon to the hospital, was a then little known subject.

The Boston Medical and Surgical Journal as published by The New England Journal of Medicine. Downloaded from nejm.org at SAN DIEGO (UCSD) on July 8, 2016. For personal use only. No other uses without permission. From the NEJM Archive. Copyright © 2010 Massachusetts Medical Society. Wailing Time. 1836-1843. a general anatomy which was refused. It was And now at 22 he was ready to sur- a bitter disappointment but he consoled himself practice the he gery. The question at once arose of where to with thought that had learned much in pre- go. Two choices were open, local country prac- paring it. From now on papers followed in tice or to stay on in London and to hope, with rapid succession. In reviewing a summary of time, for a position on the hospital staff. Of his publications, I counted 147 publications of course he chose the latter, despite the difficulties, books, addresses and reports and there were and there were many obstacles, primary of many others. In 1842, came a paper on "The which was his absolute lack of funds. His father Chief Results Obtained by the Use of the Micro- and And was to send him ten pounds a month when pos- scope in Anatomy Physiology." al- was a the sible, but as the latter had already entered on ways he great pleader for microscope. the years when his business failed, this It was one of the most valuable inheritances steadily from his was a most precarious source of support. How- botanical education. ever, the die was cast and Paget had hopes that These seven years of waiting were ones of by tutoring, journal work and a rare case he the most confined, unremitting labors. He kept could eke along. Curiously enough, he very soon terribly late hours, was a tremendous reader, an became engaged to be married, of which he writes, enthusiastic student and became an admirable "it is not to be pretended that wisdom, discre- teacher. Of patients he had very few, his re- tion, forethought or any method of sound judg- ceipts for these seven years from patients being ment had anything to do with it, ' ' adding, how? 94 pounds, something less than $500. Think what on ever, later, "this indiscretion was the happiest dull years the surface they appear to be, event of my life." his ful- and yet they were unquestionably the most fruit- Certainly marriage, he him- filled eight years later, was a very happy one. ful of all, for in these years trained Following his graduation from the school, self. He became the most widely read medical seven hard years passed before any promo- man of his time and his knowledge of French, by him tion came, years of unremitting, colorless work. German, Italian and Dutch put in touch But with all the drudgery and hours of with all the scientific work going on. He, there- disap- of pointment, there were bright moments, and the fore, was more up to date than any his con- vast amount of knowledge acquired and work temporaries and admirably suited for whatever done was the basis for his future the future might bring. unquestionably I with his great success. These seven years are best called think these years, coupled wonder- ful start and his interest and in his "waiting time" and they are necessary years training botany, for all who would rise to such heights. Of these gave him the basis for all that came after ; for in he learned and years, Paget writes very haphazardly. He was botany the value of careful cor- for a He tried rect observation, and in school, the advantages waiting hospital appointment. of his hand at everything; teaching, museum dull, laborious study. In the seven years of he added a fund of work, had a very rare case, but mostly it was waiting knowledge that made reading and abstracting and translating for him the most resourceful and scientific medical man in for the next journals. There was one trip to Paris from which England thirty years. he returned a bit broadened and with a wider Promotion. 1843-1851. for and but range thought study, he was not Finally in 1843, when he was 29 years old he much stimulated. He learned Italian Dutch and was elected to fill the new chair in physiology so more work as to get and better positions on and was made Lecturer in Physiology. For this the various staffs for which he journal labored. position he was suited and there was Ho wrote for the the admirably Penny Cyclopedia and Bio- no contender for the position. His lectures were graphical Dictionary. And he kept very long a great success. He had read everything and and late hours. had tested out most that he had read. He After spoke a few years he became curator of the well, his lectures were well attended and per- museum, where his time was taken up with ar- listened to. The best of his was and fectly pupils ranging sorting specimens, drawings, dissec- Kirkes, a clear headed industrious boy, who etc. It was a for tions, good apprenticeship the shortly afterwards published a "Text Book on position of Demonstrator of Anatomy, which Physiology" which consisted practically of his; came later, and also, it led to his writing the notes of Paget's lectures. And indeed Paget "Pathological Catalogue of the College of Sur- became a really gifted speaker and gained much geons Museum." this way. This notoriety all kept him from practice but he "had Soon after he was given this appointment, St. to live." Bartholomew's established the collegiate system, In 1839, he had typhus. Later in the same Paget's efforts. Quarters were he chiefly through year was made Demonstrator of Pathological taken in which many of the pupils came and in hospital Anatomy 1841, Demonstrator of Ana- to live and Paget was made regent of the col- tomy. He was very popular with the students lege. This rapidly proved most successful, for and his vast amount of reading kept him so well boys studied medicine very young in those days informed of the most modern ideas in medicine and thoughtful parents at once saw the advan- that he talked easily on all subjects. He wrote tage of having their sons live in a college under-

The Boston Medical and Surgical Journal as published by The New England Journal of Medicine. Downloaded from nejm.org at SAN DIEGO (UCSD) on July 8, 2016. For personal use only. No other uses without permission. From the NEJM Archive. Copyright © 2010 Massachusetts Medical Society. the guidance of some older and more thoughtful | Lieut.-Surgeon to Her Majesty and the Princess spirit. The fact that almost all the prizes in the of Wales brought him a great reputation as well school were taken by those boys residing in the as a baronetcy. He acquired an immense con- dormitory or college building shows that the bet- sulting practice, which he speaks of as the most ter class went thither and also that Paget's in- interesting because it brings "the largest num- fluence was indeed a stimulating one. He mar- ber of interesting cases, the least work, the great- ried shortly after this and for eight years lived est responsibility, the most agreeable associations in the college dormitory. His life now became and the best position and relation with one's much fuller and more happy but there was no brethren in the profession." He was very popu- remission or let down in his work. The cares lar with both the profession and patients, but of the college, the school and his lectures took always considered the former as by far the more all his time. He gave up his journal work. valuable and important. Soon promotion and new offices came First In time he succeeded to the Surgeoncy and the the assistant surgeoncy to the hospital and then position of Lecturer on Surgery in the Hospital. Professor of Surgery and Anatomy to the Col- He was constantly overworked and run down, lege of Surgeons. He now completed his cata- averaging 16 hours at work a day, year in and logue of the hospital museum and also the path- year out. As a result there was some sickness, ological catalogue of the College of Surgeons, at including six attacks of pneumonia between 1851 which latter work he writes he was at work and 1870, of which, he writes, "had they been "every day for seven years." In 1843, he was cared for would have made hard work almost one of the original 300 Fellows of the College of impossible." To me, as I have said before, one Surgeons. His lectures there, as Professor of of the most extraordinary things is that Paget Anatomy and Surgery, formed the basis of his did live to be 85. In 1871, when 67 years old, book, "Lectures on Pathology," published' in he poisoned himself during a post-mortem exam- 1853. In 1861, he became a Fellow of the Royal ination. After an illness of three months, which Society. Again, in a lecture on "Recent Prog- doubtless was greatly prolonged because of this ress in Anatomy," he emphasizes the great past overwork, he resigned his hospital ap- strides due to the use of the microscope,—"The pointments to his great regret. He says of him- microscope must be used before we can approach self, "I was very heavily overworked, was 67, the knowledge of one of those truths for want liable to trouble in my lungs, and not unlikely of which we are still constantly practicing in to break down in such rush and haste as I some- doubt." times lived in." He continued in private prac- In 1851, he resigned the wardenship of the tice for some years still and worked even harder college, moved into a new home and began to than ever, fearing lest people should think him practice medicine. During this second period of about to retire. seven years, his so-called academic years, Paget. Now throughout all these years ran his con- had worked almost without intermission, usually stant gifts to medical knowledge. He was a till 1 a.m. Lectures, school administration, pub- most prolific contributor, and the numbers of lications and writings left no time for anything lectures he gave and meetings of societies he at- else. It is remarkable that he could have kept tended is extraordinary. lie belonged to most up the pace. of the medical and scientific societies of Great Private Practice. 1851. Britain, the Continent, and America. (Among them the Massachusetts Medical He was now 37 and his life as a and Society). Paget great was on all sorts of boards and committees and successful surgeon began. For those of very held many active and honorary offices. There who are as students or internes, de- you already, were few vacations and he cared little for sirous of into and chaf- sports getting private practice or animals. at the years, there is much philoso- ing passing He had numerous of them of in these fourteen years of Sir James Paget. friends, many phy wide Gladstone, Ten- /Vnd none of you can afford to miss the opportu- repute. Newman, Ruskin, nities to study them well. nyson, Lowell, Tynsdale, Oliver Wendell Holmes, Pasteur and Darwin were among his If up to now his work had been hard and lluxley, intimate and what a it it be said there was no diminuí ion acquaintances, group laborious, may was ! in the hours at work in the to come. He years In and was at Besides a 1895, Lady Paget died, from this time always working top-speed. he seemed fail. But he his tremendously active practice there were lectures, to fought old age offices in multitudes of societies, public positions, with good spirits, and up to his last year, when the Bible was his constant source of he publications and duties end on end. His success reading, in is well shown by his income. This kept at his medical readings, studies and the practice analysis of his work and cases. rose to 700 pounds a year, then gradu- past Finally, rapidly while at a children's at his to exceed 10,000 $50,000), party son's home ally pounds, (over Christmas he and ' till at 64, he gave up his hospital appointment Day, 1899, caught cold within a week succumbed to and active operating, from which time it de- broncho-pneumonia. creased. He had the very best practice in Lon- It had been a remarkable life, very full, very don and his attendance on the Royal Family as active and satisfactory and led him in his old

The Boston Medical and Surgical Journal as published by The New England Journal of Medicine. Downloaded from nejm.org at SAN DIEGO (UCSD) on July 8, 2016. For personal use only. No other uses without permission. From the NEJM Archive. Copyright © 2010 Massachusetts Medical Society. age to a position from which he could with real Every disabled soldier is sent to the dressing sta- satisfaction look back on the fruits of his labors. tion, and if his condition is at all serious is kept A close study of it reveals much of interest to under observation over night. Here begins the all, but particularly to those of the profession preliminary sorting of cases. A fair number interested in something above ordinary success. of minor ailments may return to the trenches. It is a revelation of the advantages of connect- All the others are promptly transported, evac- ing scientific learning with the practice of medi- uated it is called, in ambulances which are sum- cine, and a model of many of man's best quali- moned by telephone. We saw in the trenches them- ties, and highest ideals. selves a stellate arrangement of trenches and dug- outs which was designed as a sort of hospital bay in the actual trenches. We were told that this had never been used and probably never would be used, because in any severe action sufficient to justify the use of this hospital bay, the chance of a shell exploding in the ramifications of this A SKETCH OF THE ORGANIZATION FOR arrangement and killing everybody in it was too In THE CARE AND TRANSPORTATION OF great. times of severe action patients are laid on stretchers in IN THE merely and placed a pro- THE SICK AND WOUNDED tected spot to await their removal. From the BRITISH EXPEDITIONARY FORCES IN advanced dressing stations patients are removed FRANCE. either to a field ambulance or to the casualty clearing stations, nearly always the latter. BY Roger I. Lee, M.D., Boston. A field ambulance is usually situated about five miles back of the front line and may be well The following little sketch must in no sense compared in appearance to a gypsy encampment. be regarded as authoritative. It includes only The several that we saw were all the same. They what came under my own eyes in a recent trip to were located usually on the border of a little France as a member of the Harvard Unit. This wood. Only the actually necessary tents were unit took complete medical and surgical charge in place. The three or four tents for the officers of a British Base Hospital and was a part of the were up, and perhaps a large tent or two for organized Medical Department of the British patients. In case of pressure a considerable Government. For a little over six weeks I par- number of tents could be erected at short notice. ticipated in the activities of the unit in a so- Since five miles is within easy shelling distance, called British Base Hospital, No. 22 General every attempt was made not to suggest to scout- Hospital at Camiers, Northern France, and was ing aeroplanes the presence of a military en- able to see the intimate details of the workings campment. The field ambulances draw their base of a hospital. At the end of my stay there patients mainly from the reserves who are bil- I was fortunate enough to be permitted to visit a letted in the nearby houses and villages. Pa- number of the casualty clearing stations, field tients who were not seriously sick or wounded ambulances and advance dressing stations near may be sent here for further observation or and at the front. treatment from the advanced dressing stations. For descriptive purposes it is easier to follow Only a relatively small proportion of an army is the course of patients from the firing line to the actually in the trenches at any one time. The rear. At the front itself one finds the so-called artillerymen, the reserves, the men resting after advanced dressing stations. The nature of these their stay in the trenches and the large number depends entirely on the configuration of the of men furnishing supplies, ammunition, etc., ground and the personal ideas of the medical and form a large majority. The field ambulance military officers of the regiment. The advanced cares for this group. Tn the field ambulances dressing station that I saw reminded one of a there was no set operating room, but in case of rabbit's hole in the side of a hill. It was a dark emergency operations could be done. Cases re- dug-out made of the roughest possible material, maining over two or three days were evacuated an oblong space with room for 12 stretchers on to one of the casualty clearing stations by ambu- the floor. A rough wooden table and a very few lance. simple instruments completed the equipment. The casualty clearing station is the most in- The personnel consisted of two doctors and two teresting unit of this whole organization. That orderlies. Wounded cases were usually seen on is situated usually ten or fifteen miles back of the field and merely brought there as a place to the front lines and consequently out of the usual rest before they were transported. One was told range of shells. In the casualty clearing sta- that little or no surgery was attempted here. tions one finds nurses. This is the nearest to the One must remember that outside of a big action front they arc allowed to go. We saw two fairly the usual activity of an advanced dressing station typical casualty clearing stations. One was in is very like the accident ward in a large hospital an old military prison and the other was in tents Soldiers come with fever, scabies, middle ears, in the open. A casualty clearing station usually skin trouble, sprained ankles as well as the accommodates 600 to 800. The reason for this wounds incident to desultory artillery fire. number is that it is the usual complement of a

The Boston Medical and Surgical Journal as published by The New England Journal of Medicine. Downloaded from nejm.org at SAN DIEGO (UCSD) on July 8, 2016. For personal use only. No other uses without permission. From the NEJM Archive. Copyright © 2010 Massachusetts Medical Society.