posure. It causes an eruption on the skin, at first of larger or smaller rose red areas, which will later form blisters containing yellow fluid. Later the fluid may coagulate and become infected and the mass will slough away leaving a large punched out ulcer. As the fluid from a blister runs over the skin it may produce secondary eruptions and even ulcers. In addition to the lesions on the skin, there may be conjunctivitis, and ulcerations of the cornea, and a little later vomiting, hoarseness, cough and pain with shortness of breath; in the severer cases there is oedema of the lungs and early death. Cases of intermediate severity may progress well for a day or two, and then develop a broncho-pneumonia from secondary infections through the damaged mucous membrane of the respiratory tract. Such cases die or recover, depending upon the extent of the lesion. As a precautionary measure it was customary to consider all gassed men as litter cases, to be carried to the rear to special gas hospitals after receiving first aid treatment, which usually consisted of irrigations of the eyes, nose and mouth with a five per cent. solution of sodium bicarbonate, and an application of soft soap or of soda solution to the body, or if the case be seen early enough a two per cent. solution of chlorinated lime may be used to neutralize the gas. To reach the throat, trachea and the bronchi, inhalations of aromatic spirits of ammonia, or of two per cent. sodium thiosulphate or 0.5 per cent. sodium bicarbonate were used. The further treatment of the skin lesions was much like that employed for ordinary burns. As soon as possible the man's entire clothing was changed, as the gas adhered to it and remained active for long periods, and he was given a complete bath in warm water. and alkali and a complete new outfit of clothing.

The gas inhalation cases which were severe enough to be sent back to base hospitals were treacherous and uncertain in their course, and many died after an illness of weeks. All possible lesions of the lung were present from simple catarrhal bronchitis and oedema to suppurative processes involving the trachea and bronchi and the lung itself. In the slower but

severe cases the inflammation might gradually extend from one part of the lung to another over a period of two weeks or more, the patient becoming gradually more and more cyanosed and water logged.

The treatment subsequent to the first aid already described consisted in absolute rest in bed, occasional bleeding, and occasional administration of oxygen, often for long periods, and the proper amount of stimulation, and the interval administration of alkalies, and for the conjunctivitis and skin burns, alkaline applications and irrigations. The strain on the heart was often severe requiring the exhibition of digitalis. Small doses of morphine were necessary to control the cough and to secure rest. The sputum was often purulent and streaked with blood, and in some cases profuse and watery. The hoarseness was sometimes followed by complete loss of voice and examination usually showed œdema and swelling of the vocal cords or ulceration and the presence of a false membrane. If the pharynx was also involved there was pain on swallowing, with dryness and a burning sensation in the nose, throat and mouth. The pain in the chest was a frequent symptom, occuring in perhaps 75 per cent. of the cases, and while it was not limited to any region of the chest it was more common over the heart than in any other location.

During convalescence a system of graduated exercises was used to restore the men, if possible, to complete recovery, before returning them to a duty status.

Insufficient time has elapsed to enable us to know the end results of gas poisoning. So far as one can tell at the present time, from the physical examinations of thousands of returned patients, there is no reason for believing that the irritation and subsequent inflammation of the respiratory organs tends to induce tuberculosis or to light up a focus of pulmonary tuberculosis already existing.

Further, the evidence is scant that among returned soldiers, at least, there is any material destruction of the tissue of the lungs.

RECONSTRUCTION WORK IN HOSPITALS

The development of reconstruction work in army hospitals has been one of the strikingly good results of the war. The idea is not altogether new, but it, like so many other advances in medicine and surgery, had, before the war, been confined to a certain few hospitals of the best class, and it also was of very unequal quality. The development during the war in this field consisted in applying the best features of the work to all our hospitals, in a standardized manner.

The so-called reconstruction work was really divided into two quite different sorts of undertakings, although they both went along side by side, usually using the same methods and principles, but with two separate and distinct objects in view. The first was to occupy the man's mind and at the same time to improve it, so that his spirits and morale were not impaired by his long and possibly painful illness. The purpose of the morale treatment was to overcome the condition so long known as hospitalism, a form of chronic invalidism which leads to helplessness and loss of initiative, which is entirely mental and has no relation to the amount of physical deformity or of limitation of function. The second object is the restoration of function of the injured part as completely and as early as possible. To accomplish these results, which are as a matter of fact, just as important in civil life as in military, it was found that the reconstruction work could not be postponed until the patient was sufficiently recovered to be sent to another hospital especially set aside for this sort of teaching, but that it must be started just so soon as the patient was able to do anything at all, and that, therefore, every hospital where patients were sent for anything more than emergency treatment must have a "reconstruction staff" in addition to the medical and surgical staff. These persons, sometimes physicians, but more often teachers or psychologists, went into all the wards and started instruction as soon as a patient was able to do anything; as, for example, a man might be taught to do bead work simply

as a means of arousing his interest and causing him to think of the possibilities for retraining himself for some new form of employment suited to his modified physical condition. Whenever possible the new work chosen was on a higher plane than his former occupation. For example, a house painter might be taught fancy lettering and sign painting, which required less strength but more skill, and some have been able to command higher wages after injury than they had been able to obtain before. Blind men were taught to assemble watches or clocks or intricate automobile parts, and so to support themselves at least as well as before entering the service of their country. The training was both vocational and therapeutic and the two were inseparable. A barber, for example, who had received a considerable injury of the hand would recover the lost function quicker in doing the work of a barber than by long hours of passive or mechanical motion in the hospital ward. The difference in the spirit of the men was soon seen and in its turn exerted an undoubted influence in hastening convalescence and in preventing the paralyzing hospitalism which formerly followed injuries which interfered with the earning power of the individual. Such injuries are common in civil life, in the industries and in mining and railroading and civil hospitals and insurance commissions will no doubt continue to use the reconstruction methods which have been elaborated during the war. The public, the patient and the physician now are all informed of the great possibilities of corrective vocational training and will demand its use in the future.

XVII

SOME DISEASES PREVALENT IN THE ARMY

Frederick F. Russell

T

THE WAR NEUROSES

HESE diseases early in the war came to be called " Shellshock" and a considerable amount of literature.and discussion has grown up about them. Although the forms of psycho-neuroses which appeared early were apparently new, it was soon recognized that the disease was essentially an old and well established entity, but that the manifestations of the diseased condition took on new forms peculiar to the war. In times of peace we have comparable conditions resulting from railroad and other accidents; in fact from anything which makes a profound mental impression, usually associated with great apprehension, fear or horror. Even in our training camps in this country, three thousand miles away from exploding shells, many cases of war neurosis developed. One of the commonest forms was stiffness of the spine and rigidity of the muscles of the back, usually in some markedly flexed or twisted position. Although the manifestations of the disease were innumerable they all had one feature in common: complete impossibility of performing the full duties of a soldier in the front line of the armies. It is not understood that these men were malingering, that is, faking a disability, because the man himself, unless given the proper care and treatment, was quite unable to control the malady. In other words, his symptoms were due entirely to his nervous and highly excited mental condition, and they had no organic or actual tissue