MEDICAL SERVICE, ARMY

an army medical service (service de sante, fr.; sanitdtsdienst, gm.; servizio sani- turio, it.; eisei rimmu, jap.) is an indispensable technical branch of the military organisation. on its efliciency the man-power of an army toa great extent depends. its duties include the care of sick and wounded, the prevention of disease and the preservation of health, the medical examination of recruits, the invaliding of men unfit for further service, the supply of medical and surgical material, the administration of military hospitals and the com- mand, education and training of a personnel for all these pur- poses. in time of war the collection, evacuation and distribution of battle casualties and the strategical and tactical employment of a variety of medical units for these duties are additional func- tions of an army medical service. administration —the army medical service of the british forces is administered by a director-general in the adjutant- general's branch of the war office, with a staff for personnel and mobilisation services, for preparation of statistical reports and consideration of professional questions, and for the supply of medical and surgical material, together with two new directorates of hygiene and pathology which were instituted after the world war in consequence of the lessons of the war and of the scientific advances in the domain of medical research. the director- general also administers the nursing services and the army dental corps, the former through a matron-in-chicf and the latter through an inspector of dental services at the war office. he is represented in commands at home and overseas by deputy directors and assistant directors with deputy assistant directors for hygiene and pathology. a similar form of administration exists in other armies. in the united states the surgeon-general controls not only the medical, dental, nursing and a new corps, the sanitary corps, but also the veterinary corps. advisory boards.—these are composed of military and civil members and are associated with the british army medical ad- ministration. they meet from time to time at the war office for consideration of general professional policy, questions of hygiene and of pathological research, nursing services and the co-opera- tion of voluntary aid in war. personnel.—the estimated peace establishment of the royal army medical corps in 1926 was 584 officers and 3,579 other ranks. they serve in all stations at home and overseas where there are british troops, including india. their work there is supplemented by assistant-surgeons of the indian medical dept., formerly the indian subordinate medical department, and by natives of an indian hospital corps, formerly the army 856 hospital corps and army bearer corps, who with soldiers trained for hospital duties from combatant regiments formed the sub- ordinate staff of british military hospitals in india before the war. a separate body of officers, the indian medical service and sub-assistant-surgeons of the indian medical dept. served until the world war with indian regiments and in regimental hospt- tals under much the same conditions as the british regimental medical services of earlier days. since the world war, station hospitals for indian troops have been instituted. istm division | 2n° division | 38° division go00o 0000 caco ]9000 g000 o0n0c}]0000 09000 0000 ambulance transport. regt! stretcher ees fhs shas ish sse fe44 f444 /ftte $444 +444] boarers. oo oe ok xk ne a es field amb. stretcher ‘de ef wil & ails of bf bearers. field amd. transport. (amb.wagons end cars.) light railways. cores & divisionat area | army area > ambulance trains. improvised ambulonce trains. motor ambulance convoy. ambulance barges. lj “wy <q q a) 2 a | <q ls & i z © i q = z pe = = 170 q & oo tal = ma hospital ships ar --*l ine of evacuation. > line of supply. +4 railwoy. + regt! aid post. © adv. dressing st" main dressing st? awolking wd? dressing st" @ adv. depot med. stores. ® motor amb. convoy. [ej genera! hospitol. casualty clearing stn. © mobile laboratory. qsstotionary hospital. @bose depot med. stores aconvalescent depot. 0000 brigade of four battalions. fic. 1.—diagram of the organisation of medical services, from a corps front of three divisions in an army to a sea base. (from ‘‘history of the great war" [medical services], vol. rr. by permission of the controller, h.m. stationery office, london.) the army dental corps, with an establishment of 71 dentists, is estimated to provide one dentist for every 600 recruits or for every 1,500 troops ina command. (see dentistry.) queen alexandra’s imperial military nursing service (q.a. i.m.n.s.) has an establishment of 270 nurses and the queen alexandra’s military families nursing service (q.a.m.f.n.s.) an establishment of or nurses. they serve in the larger military and families hospitals at home and overseas, except india. territorial army royal army medical corps.—the personnel is organised in peace to provide a regimental service, one field ambulance for each division of the territorial army, eight cas- medical service, army ualty clearing stations, three general hospitals and eight sanitary sections. these are field service units and form a cadre for the training of the r.a.m.c. (t.a.). previous to the world war the territorial force had three field ambulances, one casualty clear- ing station and one sanitary section for each division, together with 23 general hospitals. the reduction therefore in territorial army r.a.m.c. units since the war has been considerable. military hospitals reserve-—an establishment of 2,000 other ranks is organised to provide trained personnel to staff military hospitals in england on the outbreak of war when the regular royal army medical corps personnel is withdrawn, and to furnish reinforcements for an expeditionary force. service.—the number of medical officers (1924) was 930, of dentists 155, of nurses 675 and of veterinary officers 124. in continental armies with conscript service the fixed establish- ments for medical services cannot be computed for purpose of comparison on the same basis as those of the british and ameri- can voluntary armies. training.—oflicers of the r.a.m.c. attend preliminary and post-graduate courses at the royal army medical college, and military training with the men at the r.a.m.c. depet at alder- shot, where there is also an army school of hygiene. in america, an army medical centre was opened in 1923, at takoma park, near washington, district of columbia. it consists of schools for the training of the medical, dental, nursing and veterinary corps. there is also a medical field service school at carlisle, pennsylvania, and a school of aviation medicine at new york. in italy, there is an army medical school at florence, and in france, at lyons, in addition to the post-graduate school at the val-de-grace, for student candidates. military hospitals —in the british army, military hospitals and small depet hospitals are established in all commands. in america, there are garrison hospitals and eight large general hospitals, similar to some of the larger military hospitals in england. in continental armies there are also garrison hos- pitals, but in france, military sections of the civil hospitals take their place to a great extent. army medical stores —in some continental armies most of the medical and surgical material is or was prepared in army medical laboratories and factories. in great britain and america it is distributed from army medical stores, that for the british army being at woolwich. war organisatiotn.—a regimental medical service, field ambulances, casualty clearing stations, general hospitals, con- valescent depets, advanced and base depdets of medical stores, motor ambulance convoys, ambulance trains, hospital ships, sanitary sections and squads, and mobile hygiene, bacteriological, x-ray and dental laboratories come into being for service with a british expeditionary force on the outbreak of war; there are equivalent units in other armies under different names and organisation. to complete their personnel on mobilisation the medical and nursing reserves are called up. for this purpose there is a regular reserve of r.a.m.c. retired officers and men liable to be recalled to service, a supplementary reserve of officers, a home hospital reserve of the st. john ambulance brigade, the territorial army r.a.m.c. and the voluntary aid detachments (under t. a. county assn.) of the british red cross society, the st. john and the st. andrew ambulance associations. there are also important reserves of the q.a.i.m. n.s. and the territorial army nursing service. but in a great war, practically the whole of the country’s medical resources may be enrolled within the limits of age. in the world war, the peace establishment of the r.a.m.c. thus expanded to 15,000 officers and 120,000 ranks; while in the u.s.a. the medical service ex- panded to 30,591 officers and 264,181 other ranks. a similar vast expansion occurred in nursing personnel and in the number of medical units. military hospital beds, for example, reached a total of 637,746 for the british forces and 353,887 for those of the united states. the various units are distributed in the war zone, from front to base, in divisional, corps, army and lines of communication, areas of command, according to the nature of the functions medical service, naval for which they are organised. the regimental medical service consists of an officer and four men of the r.a.m.c. with 16 men of the regiment as stretcher bearers and nine as sanitary detach- ment. in battle, a regimental aid post (poste de secours, fr.; truppenverband plaiz, gm.; posto di medicazione, it.), to which they collect the wounded, is established. each division has three field ambulances (the equivalent of the medical regiment of a u.s.a. division, the groupe sanitaire divistonnaire of the french, and the sanifatsbatialion of the german organisations). a field ambulance is composed of a headquarters and two companics, each company consisting of a bearer and a tent division, repre- senting the bearer company and the field hospital respectively of the time of the south african war and previous equivalent units of the continental army divisions. with a cavalry division there is an organised field ambulance for each cavalry brigade. w orking of the systems.—in battle, the tent division opens an advanced dressing station at a point to which its wheeled am- bulance transport can be brought, and a main dressing station further back. the bearer company removes the wounded from the regimental aid posts to the advanced dressing station, and the transport brings them from there to the main dressing sta- tion. the motor ambulance convoys (section sanitaire auto, fr.), composed of 50 motor ambulance cars each and with one convoy to each corps, bring the wounded from the main dressing stations to the casualty clearing stations (evacuation hospital, u.s.a.; hepital d’evacuation, fr.; kriegslazarett, gm.) which are estab- lished in the proportion of one to each division, at or near rail- ways and at the head of the lines of communication. from there, when fit to travel, the sick and wounded are taken in ambulance trains to the general hospitals, which are units of 1,000 or less beds placed at sea bases or other convenient centres. hospital ships transfer the patients to home ports, whence they are dis- tributed to hospitals throughout the country. such is the normal system of collection, evacuation and dis- tribution of sick and wounded in a war zone. it is liable to modification according to circumstances and the nature of the terrain, especially as regards methods of transport by road, rail, river, canal or air. it worked well in the world war, where the test was severe. during the battles of the somme, for exam- ple, the british field ambulances collected 316,073 wounded between july 1 and nov. 30 1916, including 26,675 in the first 24 hours; 304,285 were transferred to the base hospitals, and on one day, july 6, 10,112 arrived in hospital ships at south- ampton and dover. the mobile laboratories and advanced depots of medical stores are usually placed with or near the casualty clearing stations. for sanitary duties a sanitary section, of 25 men, is allotted to each division and base, and sanitary squads of five men each to small posts, such as railheads. their influence and that of medical research had remarkable results during the world war in preventing disease. enteric and typhus fever, the scourge of armies in past wars, became negligible quantities in the british and american forces, and fatal gangrene of wounds and trench fever, for long a cause of much inefficiency, were brought under control. indeed, the two outstanding features of the army medical service of the present day are its power of controlling disease and its power of systematically, rapidly and eflectually bringing battle casualties under life-saving surgical and hospital treatment. in this beneficent work it is assisted by voluntary aid organisa- tions. amongst all civilised nations there are national red cross societies (sce rep cross) organised as auxiliaries of their army medical services in time of war. they are of special value in distributing voluntary gifts and comforts, such as are not sup- plied through official sources, to the various hospitals in the home territory and in the war zone, in organising auxiliary hospitals and in various other activities. those recognised by their governments, together with the whole of the personnel and units of the medical services of armies, are protected and become the recipients of special privileges under the geneva convention of 1906, should they fall into the power of the enemy during war. (w. g. ma.) 857 medical service, naval.—in great britain the royal naval medical service is administered by the medical director- general, an officer selected from the list of surgeon rear-admirals. he is responsible to the board of admiralty for the efficiency of his department. the work of the medical department includes questions regarding the personnel of the naval medical service, the supply of surgical instruments, drugs, medical material, etc., assessments arising from invalidings and claims for compensa- tion, the hygiene and sanitation of ships, hospitals and estab- lishments, preparation of estimates for the medical vote, nursing and sick-berth reserve forces and publication of the medical statistics of the navy. conditions of service—the medical director-general superin- tends all professional and administrative details of naval medical establishments and the practice of medical officers. candidates for cadetships and for commissions in the navy are physically examined at his department. he also nominates the appoint- ments of all naval medical officers which are submitted to the board for confirmation. the existing ranks date from rg19, and are: on entry, surgeon lieutenant; after six years’ satisfactory service, surgeon lieutenant-commander; after six years’ service in the latter rank, surgeon-commander, providing the neces- sary promotion examination has been passed; the senior ranks of surgeon captain and surgeon rear-admiral are reached by selection. | | until the outbreak of the war candidates were entered by competitive examination, but, owing to the lack of applicants since the war, these examinations have not yet been resumed, and for the time being officers are entered for temporary service, engaging for three years with the option of turning over to the permanent service 1f considered suitable. officers senior to the rank of surgeon-commander do not normally serve afloat, but are employed in hospitals and depets. conditions of service, etc., are published in the official monthly navy list. all ships, except the smallest, carry medical officers, larger ones carrying two. in view of the fact that ships are frequently on isolated service, the medical officer, in addition to his ordi- nary medical and surgical duties, has to fulfil the function of medical officer of health, and consequently has to advise his commanding officer on all questions relating to the protection of the health of the crew, and suggest any measures considered necessary for this purpose. he must acquaint himself with the conditions of health prevailing at the ports the ship is likely to visit, and veto the introduction into the ship of any water or food likely to carry disease. it is his duty to instruct the ship’s company in “ first aid ” and personal hygiene, with special reference to venereal diseases and the evils resulting from the abuse of alcohol. in fleets and squadrons the hygienic responsi- bilities are, as far as is compatible with efficiency, relegated to the senior medical oflicer of the flagship, who 1s designated the fleet or squadron medical officer as the case may be. this arrangement does not, of course, absolve individual medical officers from responsibilities concerning their own ships. the royal naval dental service was inaugurated in 1920, and is supervised by a dental officer of commander’s rank attached to the staff of the medical director-general. the sick-berth nursing staff, instituted in 1884, has a complement of 1,100 highly trained men who carry out their duties both ashore and afloat. equipment and hospitals —the special accommodation which is allocated for the sick in all ships is termed the “ sick bay.” these places, in spite of the fact that all serious cases are, for their own comfort, transferred to hospital on the earhest con- venient occasion, are specially equipped for the comfort of patients and for all medical and surgical contingencics. the larger ships have special operating rooms. also, for the greater safely of the wounded in action, spaces are reserved in the most protected part of the ship. these are known as “ medical distributing stations.’’ the nursing on board is carried out by the sick bay staff. the naval hospitals are: haslar, chatham, plymouth, portland, south queensferry, at home; and malta, iiong-kong, the cape, bermuda, wei-hai-wei, abroad. in addition, there is a naval mental hospital at great yarmouth. 858 all these hospitals conform in every way to the most modern requirements of medicine, surgery and hygiene. auxiliary services:—these include the medical officers of the royal naval volunteer reserve, queen alexandra’s royal naval nursing service reserve and the royal auxiliary sick- berth reserve. the personnel of these services is called up for periodical training and would be mobilised on the outbreak of war. eas foreign navies.—the organisation in the principal foreign navies is similar to the british. medical officers of the french navy—instead of being selected from candidates qualified in the ordinary way, as is the practice in the british, italian and japanese navies—are professionally educated at special naval medical colleges, and subsequently hold purely professional titles of rank. italian naval medical officers, in common with other non-executive officers of that navy, hold military in contradis- tinction to naval rank. the medical organisation in the japanese navy is almost identical with the british. the werld war.—at the outbreak of the war the naval med- ical service was expanded by mobilisation of its retired, emer- gency and royal naval volunteer reserve officers. later, a large number of temporary surgeons were entered for gen- eral service, and also medical students were taken in for service in destroyers under the title of surgeon probationers. queen alexandra’s naval nursing service was more than trebled by the mobilisation of the reserve sisters and the sick- berth staff, supplemented by the naval auxiliary sick-berth reserve. except under abnormal climatic conditions, and during epi- demics of influenza, the health of the navy during the war was remarkably good. this satisfactory state of aflairs can be attributed to:— (a) the careful supervision of the personnel by the medical officers and the strict quarantine precautions enforced. (b) the care exercised concerning food, water and victualling arrangements, both in ships and establishments. (c) preventive inoculation against enteric fever. (d) the comparative isolation of the fleets lessening the chance of venereal infection and abuse of alcohol. (e) lectures given to the men on personal hygiene. (f) measures taken to lessen the monotony of ship life in war time. casualties.—as compared with land warfare, the number of men killed outright in action was striking, and this, combined with the numbers of deaths from immersion, made the ratio of killed to wounded far higher in the navy than in the army. for instance, at jutland, out of 6,688 casualties there were 6,o14 either killed or drowned. the higher proportion of fatal wounds was due to the conditions of modern warfare—explosion of large shells in closed compartments. in comparison with the wounds in the trenches, where the clothing and skin were ingrained with filth, wounds in the navy were less disposed to become septic. burns formed a high proportion of the casual- ties, and were chielly caused by the ignition of our own cordite or from the momentary flash of a high explosive shell in a confined space. a considerable number of casualties arose from gas poisoning, caused by the explosion of shells, the most lethal factor in these cases being nitric oxide gas. (g. l. b.) united states —in 1926 the medical corps of the u.s. navy consisted of 38 medical directors, 4 of which had the rank of rear-admiral and 34 of captain; 66 medical inspectors with the rank of commander; 320 surgeons, with the rank of lieutenant- commander; 217 past assistant surgeons, with the rank of heu- tenant; and 147 assistant surgeons, with the rank of lieutenant (j.g.). the dental corps consisted of 66 dentists, with the rank of commander; 71 past assistant dental surgeons, with the rank of licutenant; and 22 assistant dental surgeons, with the rank of lieutenant (j-g.). the medical and dental officers are admitted to the corps after passing satisfactory examinations and as vacancies occur. above the rank of lieutenant-commander promotion to each grade is by selection and examination. all medical officers re- ceiving their appointment to assistant surgeon are given a medicine, general course at the naval medical school in washington, after grad- uation from which they reccive their assignments to different posts of duty, either on board ships, at naval hospitals as in- ternists or at other naval bases. the health and hygiene of the navy personnel are entrusted tothe medical and dental officers of this branch of the service. fully equipped hospital ships with an efficient personnel and skilled medical officers, including specialists, accompany all large flects. the hospital corps consists of pharmacists, pharmacist mates, first, second and third class, and hospital apprentices, as well as a corps of trained female nurses who serve on special hospital ships and in hospitals ashore. the enlisted men in the hospital corps are given special training and instruction at the various pharmacist and pharmacist mate schools throughout the country. during the world war those members of the hospital corps who had enlisted or had been drafted into it were put through a special course of training in civilian hospitals. the naval medical reserve is com- posed of officers taken from civilian life and from among ex-naval medical officers. they reccive a certain amount of training each year, are examined annually, and are promoted according to prece- dence, as in the regular service. they are ready to be called upon in any emergency. the surgical instruments, medicines and dressings are all sup- plied, in great part, from the navy medical supply depot in brooklyn, new york, and from the medical supply depots in mare island, california, and canacao, philippine islands. the en- tire naval medical corps is under the direct supervision of the surgeon-general of the u.s. navy, who is appointed by the presi- dent for this duty, for a term of four years, after which he may be reappointed. this duty carries with it the rank of rear- admiral. 3,093 commissioned officers of the medical corps of the u.s. navy served in the world war, together with 24,587 enlisted men in the hospital corps. ee or be medicine, general.—since 1910 the progress of medicine has been much influenced by the four years of the war, which, while interfering with steady research, brought with it urgent problems, caused diseases previously rare or unrecognised to become matters of common knowledge, and produced epidemics on an enormous scale, thereby calling forth much investigation and new knowledge. influence of the world war.—trench fever and a special form of kidney affection, called trench nephritis, were practically new diseases; and the serious condition of epidemic (lethargic) en- cephalitis (g.v.), though it may have existed previously, for the first time became common and was recognised during the war. certain industrial forms of poisoning, namely of trinitrotoluene among munition workers, and of tetrachlorethane among aero- plane makers, were temporarily in evidence, and an impetus was given to research into the conditions modifying efficient per- formance of labour. deficient dict caused scurvy, especially in ‘iraq, and other “ deficiency discases ’’ came into evidence, es- pecially in central europe. cerebrospinal (‘‘ spotted ’’) fever became for the first time epidemic in great britain (see spinal meningitis); as a result of the depressing conditions and the lowered bodily resistance, influenza (g.v.) became pandemic all over the world in 1918-9; and a fatal form of infective heart disease (endocarditis lenta) became much more frequent in dis- charged soldiers. a form of infective jaundice (spirochaetosis icterohaemorrhagica), formerly known as weil’s disease, became prevalent in flanders, and its true nature, namely, an infection with an animal microbe, akin to that of yellow fever (q.v.) (lep- lospira icicrotdes), was found in europe to be identical with that described in japanin 1914. paratyphoid fevers (see infectious fevers) a and b, though of course known before, became much more familiar during and after the war, and it may be noted that the distinction between the forms of enteric fever known as typhoid and paratyphoid was not recognised in the boer war (1899-1902), when the disease exacted a relatively heavier toll than in the world war, when the troops were eventually exten- sively protected by t.a.b. vaccination. dysentery (g.v.), as in past wars, became prominent, as did malaria (q.v.) in the eastern areas of the campaign. the influence of a sanitary corps in the prevention of disease among the allied armies was a noticeable feature (see medical service, army). much progress has also been made in the prevention of tropical diseases (see thera- peutics and tropical medicine). medicine, general mental diseases.—the war provided a tremendous field for the observation of the mental perturbations commonly desig- nated as “ shell shock,” due to the psychical effects of long-con- tinued bombardment, mental strain and anxiety, repression or the active forgetting of terrifying experiences, and of fear. inci- dentally it gave an opportunity for testing the opinion of the more advanced followers of sigmund freud of vienna, who, on the assumption that the sexual instinct is stronger than those of self-preservation and of the herd, have increasingly tended to refer mental symptons akin to those of shell shock to the conflict resulting when some sexual experience had, in obedience to the conventional influences, been repressed and thus removed out of the zone of consciousness. the value of freud’s contribution to morbid psychology (see psycho-analysis) in the conception of mental conflict resulting from the active forgetting or repres- sion of unpleasant experiences is undoubted, but to refer them mainly to sexual causes was shown by war experience to be too narrow a view, and the treatment by psycho-analysis and inter- pretation of dreams, and the patient’s “ associations ” aroused much opposition. on the other hand curative measures on psy- cho-therapeutic lines, such as sympathetic analysis, re-education and occupational therapy, met with success and approval (see psychiatry, psychoses, psychotherapy). orthopaedic surgery (q.v.).—orthopaedic surgery also made great advances as the result of the numerous cases of injury during the war, and remedial gymnastics and exercises have thus been of great use in furthering recovery in such cases. preventive medicine (q.v.).—the prolongation of life and dim- inution of infant mortality in great britain have both improved by about 50% in the last half century, and in the united states of america the average age at death has advanced from 4o in 1855 to 58 years at the present time. this has coincided with improved conditions of hygiene and environment, and has stim- ulated active measures in the prevention of disease—the ideal of medicine. the establishment in tg1g of the ministry of health in great britain was a far-seeing advance for the im- provement of the national health and the prevention of disease (see therapeutics). in america regular periodic examination of healthy, or supposedly healthy, persons has been begun, and the statistical experience of life-assurance companies has already proved that this practice exerts a beneficial effect on the mor- tality of those adopting this course. the prevention of disease has been greatly assisted by the rockefeller foundation in new york, which has undertaken a world-wide campaign with this object on very broad lines through its international health board, its division of medical education and its china medi- cal board. in 1913 the rockefeller sanitary commission, founded in 1909 for the eradication of hookworm disease (q.v.), was incorporated as the international health commission (called the international health board after 1916) of the then recently established rockefeller foundation, and since then has carried out campaigns against yellow fever (g.v.) in south amer- ica, which have practically exterminated it and incidentally led to noguchi’s discovery of the cause (leptospira tcicroides) of the disease, against malaria (¢.v.) and tuberculosis (g.v.) (see also therapeutics). in connection with the national insurance act (1orr) the medical research committee (now council) was created, and research workers have been financed and an enormous impetus given to the advancement of medicine and so to the diminution of disease. industrial health.—~the special conditions bearing on health in factories and industries, particularly the dangerous trades, have attracted specialised attention, particularly in america, where a school of industrial medicine has been instituted in connection with harvard university. insanity. —the prevention of insanity by early treatment in psychiatric clinics, usually attached to general hospitals and often part of the neurological department, has been an important step in the prevention of mental disorder (see psychiatry). it is connected with the social service and after-care movements. in 1908 the american council of mental hygiene was founded, in ror8 a similar council was started in canada, in 1920 the 859 french league of mental hygiene was inaugurated and in 1922 the british national council for mental hygiene was estab- lished. this is evidence of the awakening interest in health of the public at large since the war, as is also shown by the society for the prevention of venereal disease, the league of health and the british empire cancer campaign. comparative medicine —the increase of experimental research has been followed by the study of comparative medicine and pathology, whereby human and veterinary medicine may mu- tually help and benefit each other; an institute for research in the pathology of animal diseases and a professorship were es- tablished at cambridge in 1923, and the study of experimental epidemics has been undertaken in laboratories at the rockefeller institute, new york, and at manchester. statistical methods.—biological, anthropological and _ statis- tical methods are now being more formally utilised in medicine than in the past, and exact measurements and skilled calcula- tions are being employed. an individual’s constitution, or “‘ the aggregate of hereditary characters, influenced more or less by environment, which determines his reaction to the stress of environment ”’ (g. draper), was present to the mind of hip- pocrates and others, but the rise of bacteriology diverted atten- tion from the internal to the external factors of disease. anthro- pological measurements, formerly used for the recognition of the racial characters of mankind, have now been applied by draper of new york to patients suffering from certain diseases, and the data thus obtained analysed by biometrical experts. applied physiology—applied physiology was extensively developed and utilised during the war, for example in aviation, the transfusion treatment of surgical shock and haemorrhage, and the relief of gassing, and has advantageously been continued since on other lines, such as ventilation, the effects of sunlight and ultra-violet rays on bacteria, infections, general health and rickets (see public health). following on the established value of open-air treatment of tuberculosis and other infections, the beneficial influence on bodily resistance induced by sunlight (heliotherapy) and ultra-violet rays has been utilised. helio- therapy (g.v.), practised for 20 years at leysin by rollier in sur- gical tuberculosis, has been adopted in great britain. sunlight prevents and cures rickets, and its relation to the anti-rachitic vitamin d is an addition to knowledge, possibly of potential importance in connection with other ‘deficiency diseases.” ultra-violet rays act on a complex alcohol, cholesterol, present widely in the body and also in the skin, so as to confer on it the anti-rachitic action of the vitamin; they also raise the amount of calcium, iron, iodine and phosphorus in the blood, increase its bactericidal power and accelerate the healing of wounds. the tungsten-arc and mercuric-vapour arc lamps are employed to provide artificial ultra-violet rays. diathermy or the application of a special form of intensive heat has been employed in cancer, pneumonia and other infections (see electrotherapy). biochemistry.—closely associated with applied physiology, of which it is really a part, biochemistry (q.v.) has developed out of physiological chemistry and has risen rapidly to an authori- tative position. at cambridge the sir wiliam dunn trustees have built and equipped a fine institute and endowed the pro- fessorship held by sir gowland hopkins, who has 40 advanced students carrying out research under his direction. the rocke- feller foundation, new york, has provided similar laboratories at oxford and university college, london. metabolism.—biochemistry is specially concerned with the changes always going on in the body and described by the name metabolism. the basal metabolism means the average minimal chemical changes compatible with life taking place in the body during complete rest and when food is not being digested and absorbed, and corresponds with the minimal heat-production 18 hours after a meal of a mixed dietary—the working expenses, so to speak, of the resting body. this is estimated directly by measuring by respiratory calorimeters the heat evolved, or in- directly, and more easily in practice, by chemical analysis of the respiratory exchange, and has been shown to be remarkably constant in normal conditions. in disease the metabolic rate 860 may be altered; for example, in myxoedema it is lowered and all the vital processes are on a lower plane; whereas in fever and exophthalmic goitre it is accelerated. in the last-named disease the condition of the patient can be judged by the degree of in- crease in the metabolic rate. knowledge of the chemical pro- cesses underlying metabolism is rapidly growing in exactness. vitamins.—the recognition of the accessory food factors or vitamins (q.v.) has opened a new chapter in nutrition and in the causation and prevention of disease. they are present in food in minute quantities, which greatly contrast with their power, and are essential for health, growth, especially of bone and teeth, and in other ways. new knowledge of the effects of their ab- sence and of the (deficiency) diseases thus caused has accumu- lated, but more may be anticipated. the vitamins each have their special actions; one prevents scurvy (anti-scorbutic), others rickets (anti-rachitic or vitamin d), beri-beri or polyneuritis (anti-neuritic), and recently, it would appear, one is essential for normal reproduction, the absence of which, at least in female rats, produces sterility. starvation, partial or complete, and an unbalanced diet entail a corresponding degree of avitaminosis and deficiency disease; war or famine oedema, which resembles the “‘ wet’ form of beri-beri, has been ascribed to a diet largely composed of cereal and deficient in protein food. blood-chemisiry.—from improved technique chemical exam- ination of the blood for non-protein nitrogen (in kidney disease), sugar and gases, cholesterol, calctum, phosphates, chlorides and bilirubin has become a method of clinical laboratory routine and essential for correct diagnosis and treatment. much work has been done on the hydrogen ion concentration of the blood and the conditions of (1) acidosis, or diminution in the alkali reserve of the blood, which occurs in two forms, ketosis, as in diabetes mellitus, and another due to retention of phosphates, as in renal disease, and (2) of alkalosis or alkalaemia in which the alkalinity of the blood is increased, as in forced breathing when carbonic acid gas is removed in unusually large quantities from the lungs. alkalosis has, like a fall in the calcium salts and the poisonous effect of guanidine, been thought to cause a convulsive state— tetany, which forms part of the condition called spasmophilia seen in children. bacteriology (q.v.) has revealed the organism responsible for a number of diseases and so opened the way to specific treatment and the prevention of the infection. in the case of scarlet fever (see infectious fevers), ascribed to haemolytic streptococci, g. f. and g. h. dick have elaborated a test (the dick test), analogous to the schick test in diphtheria, whereby those sus- ceptible to the disease can be detected and so artifictally pro- tected against it by an antitoxin. the recognition of tularaemia (due to a cocco-bacillus), a disease of rodents and transmitted to man by the bite of the horse fly, and of melioidosis also a disease of rodents and due to the bacterium whitmori, in which the exact method of its transmission to man is uncertain, bear on the desirability of the closer correlation of the human with veterinary medicine. invisible viruses or ultra-microscopic or- ganisms, also called filter-passers (see filter-passing microbes), because they are so minute that they pass through the fine pores of a chamberland or other filter, have attracted much attention and many diseases in man and animals are with a fair degree of certainty or probability ascribed to their agency. cancer.—the outstanding discovery of the ultra-microscopic organism of cancer (q.v.), which is active only in the presence of a ‘‘ specific factor,” by w. e. gye and j. e. barnard, opens pos- sibilities of cure and prevention, for which the medical world has been at work for many years. bacteriophage.—d ’herelle described a phenomenon, previously noted by twort in 1915, often known by d’herelle’s name, which he interpreted as the existence of an ultra-microscopic virus which lives as a parasite upon living bacteria and leads to their destruction and solution. the general opinion about the active substance responsible for these changes in bacterial cul- tures, and called by d'herelle the microbe bacteriophage, is that it is not an ultra-microscopic virus, but an enzyme or ferment produced by the undoubted bacteria themselves. medicine, general protozoan infections (see protozoology) are the cause of a number of diseases, such as yellow fever (leptospira icteroides), a form of infective jaundice (spirochaeta tcterohaemorrhagica), rat-bite fever (spirochaeta morsus-muris), and seven-day fever in japan (leptospira hebdomadis), and probably sandfly fever (q.v.) (a leptospira resembling that of yellow fever). thus their prevention and the employment of curative antitoxins has been rendered possible. immunity (q.v.).—after a fever the individual usually becomes immune and protected against another attack, this is acquired immunity; the blood of such a person contains antibodies which antagonise the cause of that disease, and advantage has been taken of this to inject the blood scrum of patients convalescent from measles into persons who have not had the disease so as to render them immune. anaphylaxts.—the reverse of immunity is hypersensitiveness (anaphylaxis, allergy) which is shown by idiosyncrasies and forms the underlying factor in asthma and other diseases spoken of as ‘ toxic idiopathies; ”’ the substances responsible for the symptoms can be detected by skin tests and the appropriate treatment thus employed. protein shock therapy is also em- ployed for asthma and chronic arthritis. the importance of “‘ focal infection” such as dental disease (see dentistry), is now much more fully recognised (see therapeutics). exact studies upon the chemical activities of bacteria now in progress are beginning to throw light on the actions of toxins and the chemical factors involved in immunity reactions. radiology (q.v.).—in radiology there has been a steady advance in the methods of diagnosis and treatment; technique has been elaborated and special methods have been introduced. dyes opaque to x-rays have been employed in various directions; thus lipiodol has been injected into the bronchial tubes to dem- onstrate dilatation of their lumen, into the spinal column to show the position of tumours, and even into the pregnant uterus to detect pregnancy. the condition of the gall bladder and the presence of gall stones can be made evident by organic com- pounds of iodine and bromine (tetra-iodo-phenol-phthalein and tetra-brom-phenol-phthalein), which after being taken by the mouth are excreted in the bile and show up under x-rays (chol- ecystography). injection of air into the peritoneal cavity en- ables a clearer x-ray picture of the abdominal viscera to be obtained. the skiagrams of the jaws, showing the presence or absence of infection of the apices of the teeth and of the skull, showing the condition of the sella turcica, have facilitated the detection of focal sepsis and of pituitary disease respectively. the improvement of technique has made advances tin treatment possible. by intensive x-ray exposures, following the erlangen practice, the remedial therapy of deep-seated malignant growths has been pursued. the radium treatment of cancer in positions where the radium (g.v.) can be brought into close contact with the growth, is now carried out with increasing frequency, and team work in this treatment of cancer of the uterus has been adopted in a number of hospitals. side by side with advances in treatment the effect of x-rays on the tissue cells has been in- vestigated experimentally; the results have a very definite bear- ing on the methods and dosage employed in treatment, for the destructive changes induced in the cells may give rise to grave symptoms and even death. it appears that the action of x-rays may set up secondary ultra-violet radiations in the tissues and so cause severe changes. . diseases of function.—functional disorder and the investi- gation of the early stages of disease, before the physical signs of gross structural changes appear, have attracted increasing atten- tion and are intimately wrapped up with the ideal of medical science, the prevention of disease, proverbially a higher aim than its cure. the first manifestation of disease is commonly disorder of function, which shows itself by symptoms unaccompanied by any structural change. clinical observation was specially di- rected to the detection of the earliest signs of disease by the late sir james mackenzie, who in r9g19 started team work in this direction at the st. andrews institute for clinical research, where laboratory tests were fully utilised as an aid to the careful medicine, analysis of the patient’s symptoms in an intense search for a real understanding of the familiar manifestations of undue fatigue, malaise, shortness of breath on exertion and pain. tests for disorder of function—some physical, as in disorders of the circu- latory and respiratory organs, others chemical, such as exami- nationof the blood and the ability of the organ to excrete coloured dyes, for example, phenol-sulphone-phthalein, as in disease of the kidney and the liver, others psychological, as in nervous dis- order—have recently been much elaborated and multiplied, and bid fair to facilitate more accurate and early diagnosis and treat- ment on scientific lines. psychology (q.v.).—experimental psychology, once regarded as an academic pursuit, has been the means of great economic saving in industry, and the results of research work and tests have led to the introduction of rest pauses and other modifica- tions, with the result of an increased output of work on the one hand and benefit to the worker on the other. the industrial fatigue research board was set up during the war, and the national institute of industrial psychology, established in great britain after the war, ensures continued practical guid- ance for employers and employed (see industrial psychology). endocrinology (q.v.). ductless glands.—the part played by the ductless or endocrine glands in the production of disease has attracted increasing discussion, especially on the questions (1) of the endocrine balance, meaning thereby that when one gland is disordered the equilibrium which normally exists between them as a whole is upset, and (2) of the effects of disease of more than one of these glands—pluriglandular disorder. this last problem has on the one hand, from the difficulty of positive proof, aroused scepticism as to its existence, and on the other hand stimulated exploitation of commercial preparations of combined glandular extracts, the activity of which, as regards some of the constituents, is open to serious doubt. the out- standing advance in the medicinal use of endocrine preparations, and indeed in therapeutics generally, is the introduction of in- sulin (q.v.) for the treatment of diabetes mellitus (q¢.v.) (see ther- apeutics). the use of the endocrine preparations proved to be active is passing out of the qualitative stage into the further one in which they are being so standardised that the proper dose can be ad- ministered; this has been done for insulin, adrenalin, thyroid and parathyroid extracts. the interstitial cells of the testis (“ inter- stitial gland ”’) has attracted much research in connection with its influence on the secondary sex characters and in insanity. experimental ligature of the duct of the testis (vasectomy) in- creases the prominence of the interstitial gland and is followed by rejuvenation (steinach), and with this object the operation has been often performed on men, as has grafting of testes of men or chimpanzees (voronofi) (see rejuvenation). cardiology and circulatory organs.—the work of the late sir james mackenzie and sir thomas lewis has so revolutionised our knowledge of the heart that there is a new cardiology (sce heart, diseases of). by the electrocardiograph, which is specially valuable in showing the condition of the heart muscle, lewis showed that the extreme irregularity of the heart in cardiac failure, called by mackenzie nodal rhythm, is due to auricular fibrillation, a circus movement instead of the normal contrac- tion; it is in this condition that digitalis is of value. by means of the graphic methods the irregularities of the heart have been classified. angina pectoris——cardiac murmurs have been shown not necessarily to be of grave importance, and much work has been done on angina pectoris. the symptoms—status anginosa—of sudden obstruction of the coronary arteries which supply the heart have been defined, and the cause of angina pectoris has been referred to the failure of the heart muscle (mackenzie), and to disease of the first part of the aorta (allbutt); in accordance with the last view operative division or removal of its nerves has been practised and found to relieve the pain, but not otherwise to affect the disease. bullets embedded in the heart-wall have been removed, and a contracted (mitral) valve has been remedied by surgical measures (see heart and lung surgery). general 861 blood-pressure-—the existence of high blood-pressure with- out kidney disease or hyperpiesia (allbutt) has been established, and it has been suggested that table salt and, probably with more reason, guanidine raise, and that hepatic extract lowers blood-pressure. the state of the capillartes—microscopic vessels —their power to contract, and their influence on blood-pressure have been investigated and much new knowledge has been ac- quired. the prevention of rheumatic heart disease and the responsibility of tonsils and other sites of focal infection have received considerable attention both in great britain and in america. bronchoscopy.—in diseases of the lungs the trial of new meth- ods of treatment has gone on, such as specific or chemical rem- — edies, and the production of artificial pneumothorax (q.v.) (see therapeutics). as the presence of adhesions inside the chest interferes with the production of a curative pneumothorax, they have been divided by a cautery, the process being watched through a hollow tube, illuminated by electric light, passed into the chest (jacobaeus’ thoracoscopy). bronchoscopy for the detection and removal of foreign bodies from the air-passages has, in the hands of chevalier jackson, become a fine art; the importance of an early removal of these bodies before they have set up destructive changes in the lungs, which in the past have proved obscurely fatal, has now been fully recognised. in the abdomen a method, laparoscopy or coelioscopy, by which the contents can be seen by an arrangement similar to that of thor- acoscopy, has been employed; but neither of these difficult methods is likely to come into general use. fractional test meals.—the adoption of fractional test meals. as a more exact method of determining the constitution and vari- ations of the constituents of the gastric contents has, thanks to rehfuss, superseded the single examination made one hour after a test meal. absence of hydrochloric acid, a normal constituent of the gastric juice, has been shown to favour the onset of per- nicious anaemia (see anaemia). aspiration of the bile by a duo- denal tube, after oddi’s sphincter, which closes the lower end of the common bile duct, has been relaxed by a spray of magnesium sulphate, enables a microscopical, chemical and bacteriological examination of the bile to be made, and also does good by drain- age in cases of infection and inflammation of the biliary tract. tests for hepatic efficiency —the search for tests to estimate the functional capacity, or the way the liver is doing its work, has been carried on with energy, and a number of tests for the individual functions have been introduced; but no one test for them as a whole is satisfactory, and another difficulty is that the liver, like the heart and-other organs, has a great reserve, so that it can, although much damaged, discharge its functions so well that tests do not reveal any failure of the compensated condi- . tion; this is especially true in chronic disease. by means of a blood test—the hijmans van den bergh reaction—obstructive jaundice can be distinguished from other forms. neurology —the physiology and pathology of the nervous system has steadily progressed; the researches into the factors presiding over equilibrium and posture have yiclded valuable information; disease of what is called the extra-pyramidal system has attracted attention; acute infections of the nervous sys- tem, acute poliomyelitis, encephalitis epidemica (“‘ sleeping sick- ness’) and cerebrospinal fever were more prominent in the conditions of war than before; much valuable scientific research into the method of actions of poisons on the nervous system has been carried out. panel practice —the conditions of medical practice in great britain were profoundly modified by the introduction, as the result of mr. lloyd george’s national insurance act (1911), of the “ panel system,” whereby 15,000,000 insured persons are now looked after by practitioners paid at a yearly rate of a sum which has averaged about ten shillings a year, paid partly by insurance contributions and partly by the state; this enormous undertaking is part of national insurance and is under the con- trol of the ministry of health. no one medical man is now al- lowed to have more than 3,500 persons on his panel. at the time of its initiation the panel system met with great opposition 862 from the medical profession, but this collapsed, and on the whole the system works well, and is certainly an improvement on the old system on clubs. (see health insurance, meepical as- pects. ) diplomas in special s. wbjects—the enormous advances in medicine have made specialism necessary and inevitable, and as evidence of the general recognition of this need diplomas in these special subjects are granted by the universities and licensing bodies. the general medical council in 1922 revised the regu- lations for one of the oldest diplomas, that of public health (d. p.h.), and ordained that two years, instead of one year as for- merly, must elapse from the date of a candidate’s obtaining a registrable qualification in medicine, surgery and midwifery before his admission to part ii. of the examination for diplomas in sanitary science, public health or state medicine. there are diplomas in psychological medicine, in tropical medicine and hygiene, in ophthalmic medicine and surgery and in laryngology and otology, and since the war the universities of cambridge and liverpool have given diplomas in radiology. (see medical education.) group medicine-—the specialisation of medicine and the elaboration of technique prevent any one man from being master of the whole field of medicine, and accordingly there has been a tendency for men to combine in team work or group medicine, especially in america. a group of men expert in their own lines may work together or under a general physician or surgeon who, in consultation with them, correlates the collected evidence and comes to a final decision on the whole matter. these diagnostic ‘clinics, which are exemplified by the mayo clinic, rochester, minn., are commoner in america than in great britain. they should have the advantage, from the paticnt’s point of view, of providing for a fixed inclusive fee all the special examinations that may be necessary at a lower cost than in ordinary practice would be required for such a number of tests. bibliography.— see bibliographies to the articles referred to in the text; also sir t. c. allbutt and sir h. d. rolleston (editors), a system of medicine, 9 vol., various dates. (h. ro. )