nation at war, a mobilization as vital to success as the science of the generals and the valor of the men on the line, and that will assuredly be a factor of dominating importance in any war to come. In other words, whenever a great nation goes to war, not only must it put into the field and there maintain enormous armies, whose effectives are numbered by millions, but the energies of the people at home must be wholly concentrated upon the supply of those armies in the field. The expression "the nation in arms" has taken on a new and significant meaning.

The most important of the supplies just mentioned, in a purely military point of view, is that of munitions. For side by side with other improvements has gone the evolution of artillery. Foreshadowed in the Balkan wars, it is accepted as a principle that an army must be accompanied not only and merely by the classic field piece of small calibre, but also by large-calibred pieces, effective not only against troops, but against positions as well, and not only against positions taken as the fortune of war may dictate, but against positions, i.e., fortresses, or their future substitutes, carefully prepared in time of peace. For the evolution of artillery has caused fortresses as such to lose their value: Liége, Namur, Maubeuge, Antwerp proved of no account, and if Verdun held out, it was not because of its strength as a fortress, but simply because it had become a sector in a long line, like that of Ypres or Arras. It has been made abundantly clear by the war that cities, capitals, fortresses and provinces will be taken in vain, so long as the enemy army remains unbeaten.

When two armies are besieging each the other, and resting on impassable flanks, only frontal attacks are possible: this has produced a strength of trench that can be overcome only by the intensest long-continued artillery fire using high-explosive shell, an expense of ammunition made possible only by mobilization of industries. Under these conditions, "lines" have become literally areas of trenches, one line behind the other, joined by communications. The capture of a first line may be a success of no value. In the defense of these entrenched lines, the machine-gun has played during the European War, and will play in the future, in field-, as well as in positionfighting, a part of the first importance. Mining and counter-mining, heretofore used only in sieges of regular fortresses, will have peculiar weight when two entrenched armies face each other over a long front impossible to flank. And these armies will normally live, move and have their being under the ground.

A feature of trench warfare in the World War was the occasional but deliberate use of asphyxiating gases and burning liquids. Whether in the future this violation not only of The Hague Convention but of fundamental humanity will be endured only experience can tell but there is every reason to believe that asphyxiating gases have come to stay. The end of the war saw them used in cloud form, and in projectiles (projection and artillery projectile proper). That is, the gas projectile had won its right in open warfare, and had become as much a necessity as the shrapnel itself.

The greatest advance in the military art proper has resulted from the application of

in

aeronautics, the great contribution of the 20th century. First shown to be practicable by the Wright brothers, aviation, neglected America, was at once seriously taken up by the French and converted to military use. The rest of the world (the United States and Great Britain excepted) soon followed suit. The aeroplane has been without influence on strategy, but has profoundly affected tactics. It has made surprise well-nigh impossible and dissipated the fog of war. Thanks to its assistance a commanding general now sees the enemy, and what is more sees him almost at once. Hence combinations of troops, movements, concentrations are reported almost as soon as made, intentions laid bare and adequate measures of prevention made possible in good time. The aeroplane moreover has proved itself indispensable to the artillery by correcting fire and by detecting hostile batteries whose emplacements would otherwise be unknown. As an agent of destruction, it was not nearly so useful at first as it was in the acquisition of information. But as the war progressed bombing became generalized on both sides; with direct military results when employed against railway stations, depots, ammunition dumps, troops in concentration and even in combat. The airship (Zeppelin) has on the whole disappointed expectation: it should be recollected, however, in respect of both airships and aeroplanes that the whole subject, in spite of the experience of the Great War, is still visibly in its infancy. See MILITARY AERONAUTICS.

Whether other wars will follow the great conflict that broke out in 1914 no one can undertake to say. In the meantime it may be safely asserted that human nature, integrated into national ambitions, will continue to be what it always has been. Hence future struggles are not unlikely. When they do occur, they will call into play the whole of a nation's energy. High courage, nobility of principles, unselfishness of ambitions, these alone will not avert defeat and disaster.

C. DEW. WILLCOX, Colonel, United States Army; Professor, United States Military Academy.

It

MILITARY SERVICE INSTITUTION OF THE UNITED STATES, a society of officers of the United States regular army, organized in 1878 by Generals Fry, Stanley, Rodenbaugh, Colonel Lieber and others. was designed as a similar organization of the Royal United Service Institution of Great Britain. The presidents of the American Society have been Generals Hancock, Schofield, Miles and Ruger. The headquarters are at Governor's Island, N. Y., where the institution has acquired a library of 20,000 volumes, inThe society cluding many rare documents. issues The Journal of the Military Service Institution.

MILITARY SURGERY. Military surgery was first recognized as a separate branch of medical science about the middle of the 16th century, but was not taught as a special study in medical colleges until the year 1829. Since then instruction has been given by the ablest surgeons both in Europe and America.

At no time in the history of the world has there been so great a number of powerful and destructive instruments of war as during

the terrible conflict of the great World War. Statistics prove that at no time has there been 50 great a saving of life among the sick and wounded. We must not be surprised to note that a great part of mankind has occupied, and still continue to occupy, themselves in the improvement and perfection of the art of war, and that this art of destroying life is constantly advancing.

For the earnest, faithful army surgeon many opportunities for careful study and close investigation are offered. Perhaps on his skill in caring for the sick and wounded depends the success of a campaign. The well-defined and carefully prepared plans of our ablest generals have been defeated and come to naught through the incompetency of medical officers. It is, therefore, the duty of the military surgeon to prevent, as far as possible, all useless expenditure of life. If battles must be fought, the results should be obtained with as little mutilation, suffering and sacrifice as is consistent with life and the welfare of the cause. For this the world is indebted to our profession.

Subjects absolutely necessary and important for the surgeon to understand in performing the duties that pertain to an army surgeon are: In addition to climatic condition, he must have knowledge of the location of the country from which the soldier comes and his surroundings there; knowledge of the care of the individual -clothing and personal hygiene. It is to be remembered that the majority of soldiers are made up of youths from the age of 18 to 25, and, generally speaking, they know very little about the care of themselves individually. In the examination of the selective draft man the medical department must learn all about his habits, some of them to be corrected, as he enters upon his military life, and others of such a nature as to exclude him. The study of hygiene is of great importance, such as the care of the camp. Soon after our men were being assembled at the cantonments there was a development of chest trouble, such as bronchitis and pneumonia. Surgeon-General Gorgas made a very thorough, personal inspection, discovered it was the result of an overcrowded condition, very difficult to correct, but attended to as rapidly as possible and resulting in immediate lessening in number of the sick. Also the kitchen, cooking utensils, drainage and sanitary surroundings of every kind should be carefully studied. The subject of food supply and its manner of preparation exacts great interest on the part of the medical officer, regarding a correct diet. You might present a meal to the British soldier that would please him very much, but it would not be well received by the American soldier, or those of other nations. The medical officer must inform himself also upon the nature of all insects, vermin of every description, the evil effects of even the house-fly, for at the present time all of these factors enter into the development of diseases that disable and impair the best work of the soldier. He must understand fully all that pertains to the quartermaster and commissary departments, in order that his sick may receive such luxuries and comforts as are their due. His knowledge of camp diseases is absolutely necessary- typhus, typhoid fever, for all infectious diseases come to him and must

have immediate attention. These are conditions that will admit of but a few hours' delay, and then attention to minor cases, such as the care of the feet, is so very important. Within a few years the specialty of chiropody has advanced in a marvelous manner, and the soldiers are fortunate in having with them a number of attachés of the hospital who are competent to give proper treatment. Proper care must be taken of the feet, and perfectly fitting socks and shoes is another of the admirable methods adopted by the surgeon-general's office, all this working to the advantage of the soldier.

The military surgeon must have an acquaintance with many medical problems: The conditions developing diarrhoea and dysentry, the exposure to heat and cold, causing sunstroke and frost-bite, all of which he must be familiar with; the condition and treatment of the various classification of burns that occur from fire and from the materials used in some of the high explosives, also the care of the soldier who suffers so seriously from multiple wounds made by the explosion of the so-called "mud shell," the particles penetrating the clothing, and where there are often 50 to 100 abrasions that are very painful. A responsibility of grave importance is the selection of the camp site, and which is usually entrusted to the medical officer, as it should be.

When the United States entered into the European War the surgeon-general's office, endorsed by the War Department, organized schools of instruction. The splendid response made by the members of the medical profession to comply with the government's request that they have a few months' preparation for army service has enabled thousands of doctors to better fit themselves for looking after the sick and wounded soldiers than in any of our previous wars. It was said by United States army surgeons, when this war began, in August 1914, that, in many respects, it would be the most humane ever waged; that it would be settled in a much shorter period of time than most persons believed possible; however, this prophecy came far short of the real result. Today dressing stations, evacuation and base hospitals are terms with which we have become very familiar. It was stated, and this has proved true, that the mortality list from disease would be very small. The control of typhoid, typhus and malarial fevers has been very perfect. Alas! that the epidemic of influenza and septic pneumonia has presented so many serious conditions hitherto unknown, causing a death rate that, while not large, yet was unexpected.

While it was believed that the rapid-firing rifle, with its smaller metal cap bullets, would disable men quickly, the results would not be so fatal in the loss of life, and would not cause so great a number of seriously injured as when the slow-firing, larger bullets, such as was the Minié ball, used during the Civil War. This, to a great extent, has proved true. The breaking of bones, the tearing of blood vessels, the injuries to nerve trunks, in proportion to the number of wounded, has not been as great in this war as some of our recent conflicts.

Much important experience had accumulated during the Russo-Japanese and some of value during the Spanish-American War. To-day, as a whole, wounds have not been so fatal, but

the prediction that there would be a less number of infective wounds and injurious complications has not proved to be true. The knowledge of preventive methods, and important sanitary precautions, has helped decidedly in the saving of life, as they have been so vigorously investigated and carried out. The sad lesson of the Spanish-American War had served to warn our medical officers and they have made a noble success of all that has been placed at their disposal for the care of the soldier. One can enumerate but a few of the many aids that have come to the medical and surgical departments of the American army, in this war, such as the Red Cross, the Y. M. C. A., the Y. W. C. A., the Knights of Columbus, the Salvation Army, the establishment of canteen huts, stations at the front for dressing of wounds, the evacuation hospitals, base hospitals, methods of transportation, which have never been equalled, and when the statistics are finally compiled, it will be greatly to the credit of our surgeons that they did all that was possible for the sick and wounded soldiers.

When war begins suffering and pain enter, and the surgeon, having everything in readiness, endeavors to relieve his patient as promptly as possible. The use of anaesthetics has passed through a very thorough analysis, resulting in the positive doing away with all mixtures of ether, chloroform and alcohol, for they have met with little endorsement in military operations. The same experience has come to many surgeons in civil life as the unequal evaporation makes their use somewhat uncertain. The administration of ether, or chloroform, separately, with plenty of air, has resulted very favorably. It is to be observed that many of the writers on the subject have endorsed placing the patient under a minimum narcosis, then watching them very carefully, and the after effects have been excellent. Local anesthesia seems to have inspired a good deal of confidence, particularly among those who are working in the evacuation and base hospitals, as well as rest homes.

As the battle opens the sight of blood is the first object lesson to the alert surgeon. For lack of prompt and efficient treatment of hemorrhage many a soldier has yielded up a noble life. The control of hemorrhage has been carried out along the lines of the civil surgeon. Momberg's method of controlling hemorrhage, for amputation at the hip-joint, does not seem to have met with any great advance, and the number of operations done are comparatively few. The use of the tourniquet in some form has been applied by fearless assistants and the stretcher-bearers in so intelligent a manner that many lives have been saved. Wyeth's method has been of service.

Surgery of the heart has presented some very striking illustrations of progress, in keeping with the advances of the past few years in civil life, regarding the operations done in this direction. Especially is this true in bayonet and stab wounds, and here an excellent opportunity is offered for securing an estimate of the final results. There are so many more cases to be studied than in civil practice. Much research work has resulted and more operations were performed than could possibly have occurred in civil life for decades.

It is interesting to note the treatment of

such large vessels as the inferior vena cava and others that have been reached when operating upon wounds of the abdomen. Injuries to the arteries and veins have developed a large number of traumatic and arterio-venous changes. Apparently nothing has escaped the military surgeon of to-day. Surgery of the blood vessels, in the form of traumatic aneurisms, as well as like surgical procedures, will, when the concensus of opinion has been reached, show that great skill has been exercised from time to time in doing this work.

Possibly there is no part of the body that will show such marked advance in immediate operative interventions as that of gunshot and stab wounds of the lungs, together with more or less fracture of the thorax and in the lodgment of foreign bodies within the cavity of the pleura. This is well illustrated by the entrance of a portion of shrapnel within the cavity of the lung. An immediate operation is done, at the nearest place to the receipt of the injury, with safety to the operator and assistants, the wound enlarged, portions of fractured ribs removed, if required, hemorrhage controlled as promptly as possible, the lung exposed, the foreign substance searched for and removed, then thoroughly aseptic work accomplished, the wound closed, with or without drainage, and a very large proportion of these patients make a prompt recovery, without suppuration. The employment of air bags, sacks or balloons to fill space, and for the lungs to press against removing them gradually. apparently has proven of value. No such splendid work as this has been accomplished in the history of any of our previous wars.

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So

This same prompt operative intervention also applies to wounds within the abdominal cavity. There was a marked contrast in the history of surgery during the first year of the World War, and that of the last, regarding the advances made in the treatment of these wounds. In the first period many surgeons were of the impression that non-operative interference in a penetrating wound of the abdomen led to more successful results, but, gradually, in the study of these cases, they became more practical, and, as a result of their observations, surgery was pushed to a point of careful inspection and operative work, where "the sooner the better" it was discovered. soon as the patient could reach a place of safety, and proper appliances, an operation was done at once, consisting of opening up the abdominal cavity, if necessary resecting the intestines, or properly closing all wounds or lacerations within the cavity of its contents, controlling hemorrhage, and then carefully closing the wound. It has been shown that many of these cases die of hemorrhage if not operated upon at once. Only in such cases as seemed absolutely necessary was drainage made use of, and the percentage of recoveries has been most marked. In these wounds, and which also applies to the cavity of the cranium, the same bold successful surgery was done in enlarging the opening in the skull, trephining as called for, placing the patient in as comfortable a position as possible for transportation — which applies to all wounds in any portion of the body- not handling any more than can be avoided, the dressing watched carefully, not to be disturbed, if all goes well, and when

reaching the base hospital keeping them absolutely quiet.

There is no doubt that when the final chapter on the history of surgery in this Great War is written, there will be largely to the credit of the skilled and able surgeon a record of such great progress as will astonish the medical man, who can yet look back and call to mind his experiences during the Civil War, the Franco-Prussian War, the Spanish-American War and the Russo-Japanese War.

Never has an army had such eminent specialists to care for their sick and wounded. Great advances have resulted in the splendid manner in which the question of transportation has been solved. No army has ever had such a perfect system of ambulances - electric and otherwise steamboat and railroad facilities, and the avoidance of handling the wounded has added greatly to their recoveries.

Especially to the credit of the American surgeon is the adoption of the method of continuous treatment from the dressing stations to evacuation and base hospitals, and the standardization of splints. This has been kindly received on the part of the surgeons in the various armies, and has proved of inestimable value. In all the various wounds that have been studied and treated, during the nearly five years' of this war, it is plainly noticeable that, step by step, surgery has advanced, with that degree of success, that the final summing up will demonstrate the greatest progress in history, in the ability to return men to the fighting ranks, with so little loss of service, and in the actual saving of life.

Another chapter has been added to making surgery a more exact science. The art, the skill, could scarcely be improved, for in other wars we have had evidence of some of the most scientific operations possible for human ability to perform; however, the great advantage this modern military surgeon possesses, in instruments, operating paraphernalia, dressings, splendid nursing, can not be excelled in the best of civil hospitals and all this aided materially in the wond rful success.

Great gratitude is due the women of America for much of these splendid results. Their weary days of preparing surgical dressings have been well rewarded. Out of it all is to come a knowledge of the treatment of wounds that is apace with the fierceness exhibited by the cruel weapons employed in this recent war, and with more destructive surroundings than ever known in the history of the world.

What can directly be called military surgery has never presented such an amount of material, including research, laboratory investigations and the study of all forms of wounds inflicted by every possible kind of missile-gas, mustard and poisoned bombs, liquid fire, disease-producing germs, everything conceivable for the destruction of human life. All of these conditions our surgeons, aided by the chemist and investigations in the laboratories, have been able to treat promptly and successfully, as our medical journals so clearly indicate.

In collating the advances made in the department of military surgery medical journalism deserves great credit.

In the War Supplement of the 'Index

Medicus, 1914-17, the classification of all papers and addresses on the subject is a marvel.

The energy exhibited by the bacteriologist and the ability to bring the laboratory up to the firing line has aided immensely in obtaining methods of relief; however, it is yet too early to give any positive, concise summary of the methods adopted for the treatment of these differently classified wounds, under the care of the evacuation and base hospitals, but out of the vast amount of material there will result unmistakable evidences of success.

X-ray work has been of a superior quality, particularly when applied to the extremities, such as the long and small bones of the arms, hands, legs, feet and all irregular bones, as well as soft parts, muscles, vessels and nerves. The apparatus is now so perfect there is little risk in the development of X-ray burns.

Great progress in the treatment of wounds followed the Russo-Japanese War, yet no war has ever presented when the ability to treat injuries of the kidneys, ureters and bladder was equal to that which has been accomplished in this present conflict, regarding the immediate care of these cases. It may be stated here that the rich supply of X-ray apparatus has enabled the surgeon to study with great exactness or to obtain such important information, after receipt of the patient in the evacuation hospital, as was hitherto unknown.

There is now a record of the application of modern dentistry, by employment of the X-ray and producing radiograms to be studied carefully, that not only is of great value in immediate treatment, but will continue to be in all reconstructive work.

There can be no question but that the wearing of steel helmets has lessened scalp and skull wounds and injuries of the upper portion of the face and neck by a large percentage.

It is interesting to note that in shaping the latest patterns they had had in mind even greater protection. The one objection has been their weight.

It is a matter of great interest to note the similarity of wounds in connection with the American Civil War and the European War.

The free use of shrapnel presents a bullet producing a wound very much like that of the Minié ball of the Civil War, but the bullet of the machine gun of to-day is not so destructive as that of the rifles during the earlier conflict.

Aside from this progress, to which we have referred, the study and treatment of tetanus became a very important subject. The first year of the war very rapidly developed the danger of immediate infection of the wounds, and a large percentage of the cases when they reached the base hospitals were in an infected, suppurative condition. In association with these wounds was also the development of cases of acute tetanus, largely thought due to the nature of the infective soil where the fighting occurred, and here, near the battle line, laboratory work has been of great assistance. The consequence is that prophylactic treatment by use of the tetanus antitoxin serum, in all lacerated and dirty wounds, lessened the number of these cases very decidedly.

The British were slow in making use of this antitoxin. The American military surgeon had

learned from civil life its great value and was at once prepared to employ it. Here credit should be given to the great State of New York in early establishing a State laboratory for the study and free distribution of this serum to its boards of health.

The one great department that can be classed as a division of military surgery will be known as orthopedic or reconstructive work, and the hospitals that have been established by the United States government will undoubtedly result in the restoration of the functions of various portions of the body in a manner hitherto deemed impossible.

Reconstructive occupational therapy in the study and treatment of lesions of the organic nervous system is apparently receiving a good deal of attention.

Shell shock is a new term, possibly to be followed by a better interpretation of this new lesion in war surgery, but its proper understanding and treatment is being worked out in a most admirable manner. There can be no doubt that men are seriously affected by the bursting and passing of shells and the firing of these high explosives. The system receives a shock that afterward manifests itself in various ways. The patient may become temporarily insane, his mentality receiving a severe shock in many forms. It may be only functional and disappears when surroundings are such as to restore his confidence, returning him to his former normal courage and ability to get control of himself. There have been a good many of these cases, and great care must be exercised that no injustice be done in their diagnosis and treatment.

The treatment of gunshot wounds of the face and jaws have attracted much attention. In the building up of the face, the nose, and especially that portion that relates to fractures of the upper and lower jaws, our military surgeons have recognized the aid of the up-todate dentist.

During the entire time of this World's War civil practice has been quite entirely overshadowed, the study and treatment of wounds received in battle claiming the greater attention.

In the care of wounds it was early observed that prompt treatment was of great importance. The removal of all possible sources of infection, giving a clean incision in the soft parts, then bringing them together, resulted in excellent recoveries.

It was assumed that wounds passing beyond the eighth hour were in danger of infection and more serious complications, giving a prolonged and anxious line of treatment.

Free incision, when once the wound showed evidence of infection, care in removal of any material that might have been left behind, brought out different views as to irrigation, drainage and the use of antiseptics. There has been great discussion regarding the use of the latter, some surgeon writers coming to the conclusion that any sterile preparation and keeping the part clean was sufficient.

The Congress of American Surgeons and Clinical Surgeons was arranged with great care by its officers for 1918, and many surgeons connected with the armies abroad accepted invitations to prepare papers and discussions on the classification and treatment of wounds,

In consequence of the epidemic of influenza this meeting had to be abandoned, which was a great disappointment to all; however, the foreign delegates who did come visited a number of our larger cities, attended hastily called meetings and gave clinics, that, later, as they appear in our medical journals, will add greatly to our present literature on military surgery.

As has been stated, it is impossible at the present time to make any positive report on what is ultimately to be shown as the better treatment of all wounds; however, this can safely be said: At dressing stations, so far as time and the wound will permit, such dressings should be applied as will enable the patient to reach the base hospital. More serious wounds are to be treated at the evacuation hospital, such as the control of hemorrhage, amputation that may be necessary, all wounds that can be, and time will allow, to have more permanent dressings, in order to transport distances to the base hospital with as little handling and disturbance of the dressings as possible. Here should be used prophylactic doses of the tetanus antitoxin in such wounds as seem to require it. On arrival of the wounded at the base hospital all cases to be carefully inspected, those found infected to have free incision, all necrosed tissues, or foreign substances, such as pieces of clothing, dirt, fragments of missiles, anything that may conduce to the spread of infection, removed, and bringing the wound into a better condition for immediate union. Also in these cases there enters the application of the drainage tube, and the beginning of the Carrell method of treatment, the Dakin antiseptic solution, the use of the newer antiseptics, such as dichloramin-T., chlorinated eucalyptol, chlorinated paraffin oil, aceiflavin and proflavin, brilliant green and other methods of antiseptic dressings. Wright's theory of thorough irrigation and the 20 per cent solution of picric acid in alcohol have been used with good success in the treatment of sepsis. In the cases of gas infection, or gas gangrene, emphasis is placed upon long and free incisions, amputations without any attempt at bringing the flaps together and also the use of the serum treatment. Keen's book on "Treatment of War Wounds" has afforded much valuable information.

In the treatment of convalescents it is very much to the credit of our government that the wounded are being brought as near to their homes as possible, and one has but to notice the almost daily arrival of steamers to observe how faithfully this is being carried out.

ALBERT VANDER VEER, M.D. MILITARY TELEGRAPH, commonly applied to the use of telegraph wires in warfare as in the Civil War when a corps of engineers constructed temporary telegraph lines from the front to points in the rear of an army. In later years this system has been superseded by the heliograph (q.v.) and still later by wireless telegraphy and the use of flag signals commonly known as wig-wagging (q.v.).

MILITARY TENURE. See TENURE.

MILITARY TERMS. The numerous changes (strategically and tactically) and advancements in the science and art of war brought forward many technical military terms, most of which are known and understood only