Part 32

The Division of Tuberculosis is one of the four branches of the Division of Internal Medicine, it being the only division that has to do with a single disease. This is due to the fact that tuberculosis is admitted the world over to be the most prevalent disease known, one out of every seven of the earth’s inhabitants dying from some form of it. In order to detect the presence and combat the spread in the army of the Great White Plague, the Medical Corps very early in the war took steps to standardize the chest examinations of soldiers, all recruits being examined upon their arrival at the camps according to the standard thus devised by doctors who were specialists in tubercular troubles. These measures resulted in excluding from the army about 80,000 cases of active tuberculosis. Had the methods pursued in former wars been adhered to, a considerable proportion of these would undoubtedly have escaped detection, and, as tuberculosis is a highly communicable disease, thousands of perfectly healthy men would have become infected. Most of these tubercular cases would have had their disease aggravated by field service, and, moreover, the resources of the Medical Corps would have been heavily taxed had it been called upon to treat so large a number of patients. Soldiers who were suspected of having tuberculosis, or who developed it while in the service, were examined by specialists, who confirmed or rejected the original diagnosis, those who were found to have the disease being immediately sent to special hospitals or sanatoria for treatment. The location of these sanatoria in such recognized and widely scattered health resorts as Asheville, North Carolina, Denver, Colorado, the Catskill Mountains, Arizona, and New Mexico enabled the medical authorities to send the soldier patients to regions which, as experience has taught, promote recovery from the disease, and which were at the same time as close as possible to their homes. Patients sent to these hospitals were not discharged from the service until they were cured or until the maximum improvement had been obtained. Thus soldiers received treatment which few civilians could afford, no multimillionaire being able to purchase better medical attention than that which Uncle Sam gave his boys. As tuberculosis is a chronic disease, and as a certain number of cases will relapse after its progress has apparently been arrested, special efforts were made to teach the patients how to live in order to prevent further retrogression, particular emphasis also being laid on the necessity of observing the sanitary precautions which will prevent the transmission of the tubercular germs from the patient to the members of his family.

Though for a number of years prior to the war there had been a steadily increasing appreciation of the importance of neurology and psychiatry in the organization of a fighting-machine, the theories which had been evolved along these lines were never put into practice, at least on a large scale, until America’s entry into the great conflict, when there was organized the Neuropsychiatric Section of the Division of Internal Medicine. When the section was created, about fifty neuropsychiatric officers were commissioned; when the Armistice was signed, this number had risen to nearly 700. The chief function of the section was the exclusion from the army, by means of special tests, of men who, because of mental and nervous diseases, were considered unfit for military service. At first this section was treated with open derision or contemptuous tolerance by certain of the narrow-minded or the prejudiced—for the Medical Corps, like all other branches of the army, is not without its fogies who regard with suspicion anything that is new. The best proof of the success of its work, however, is the fact that it discovered the presence in the army, at home and overseas, of more than 72,000 men suffering from nervous and mental disorders, every one of whom was a potential menace to our success as long as he remained in active service. Thanks to the simple but highly effective tests which the psychiatrists devised, certain men were discovered to be moral perverts; the tests showed that others, if exposed to the strain of battle, probably would have suffered mental collapse, and that still others did not possess a sufficiently developed mentality to understand or to carry out orders. Imagine how grave a menace a single pervert might have proved to the morals of the men with whom he was associated in the intimacy of army life. Picture the danger to the success of a military operation of a single soldier who did not possess sufficient intelligence to understand the orders which were given him or the courage to carry them out. Such men were of far greater potential danger to the welfare of the army than were those suffering from tuberculosis. By means of the psychiatric tests given at the camps and cantonments, more than 1 per cent of all the men brought into the army by the draft were discovered to be mentally unfit and were at once rejected. On the other hand, many drafted men were found to possess exceptional mental qualifications and were thus marked out for assignments where their special aptitudes would prove of the greatest value, in many cases being recommended for the officers’ training-camps. This was the first war in which mental tests have been employed. Men with undeveloped minds, unstable nervous systems, or inadequate self-control are very bad risks for armies. They are unknown quantities and their behavior in moments of stress cannot be relied upon. Such men may cause disaster in action, they are liable to shell-shock, and they are likely to swell the lists of pension claimants. But the psychological tests, though they did not entirely eliminate these dangers, certainly reduced them to a minimum, enabling line-officers to equalize the mental strength of their commands by the reassignment or transfer of men to less exacting duties, or, in the case of those who were actually feeble-minded, securing their discharge from the army and returning them to their homes.

To the Division of Laboratories and Infectious Diseases were assigned the duties of ascertaining the causes of communicable diseases and of establishing methods for their control. The immensely important work of this division was handled by five sections, as follows: (1) The Section of Laboratories, whose duty it was to furnish and train personnel, supervise the work of the laboratories, and standardize the equipment. (2) The Section of Epidemiology, which followed the progress of disease and recommended measures of control. (3) The Section of Urology and Dermatology, which was specially charged with the treatment of venereal disease. (4) The Section on Combating Venereal Diseases, which elaborated and executed measures for educating the soldier on this subject, for the enforcement of legal measures against immoral conditions, and for venereal prophylaxis or early treatment. (5) The Army Medical Museum, which collected pathological material and other specimens of interest to medical men, the scope of its activities being greatly enlarged by the formation of an organization for collecting material in the field.

The problems handled by the Division of Laboratories and Infectious Diseases were both varied and vitally important in preventing wastage of troops. The view held by the experts of the division that the enteric group of diseases, which wrought such havoc in other wars, could be controlled by typhoid and paratyphoid inoculation and by adequate sanitary measures, was confirmed by the fact that, though typhoid occurred in the devastated and extremely insanitary regions along the Western Front, it never became a serious menace to the American Army. With the practical elimination of the enteric diseases, the respiratory diseases provided the most important problem for the Medical Department. The most vigorous measures were pursued in studying and attempting to control the incidence and mortality of respiratory diseases, and many facts were ascertained which proved of great value during the period of operations and which, when the lessons to be drawn from them have received sufficient study, will eventually place in our hands more adequate means of control. Epidemic cerebrospinal meningitis is another disease which always has to be feared when troops are mobilized. Infection is transmitted by the discharges from the respiratory passages, usually being disseminated by “carriers,” who spread the disease without having it themselves. In order to detect these “carriers,” any one of whom might unintentionally create as much havoc as an enemy agent in a munitions plant, hundreds of thousands of men were examined, our knowledge of the methods by which the disease is transmitted being thereby greatly increased. The problem presented by the venereal diseases has always been of vital interest to all armies and the fight against this class of infections has been vigorously waged in the American Army for many years. With the passage of the Draft Act it became evident that it would be necessary to extend the fight to the civilian population not only because it was a source of infection of the army but in order to diminish the occurrence of these diseases among drafted men. To accomplish this a close alliance was formed between the Section on Combating Venereal Diseases of the Medical Department and the War Department’s Commission on Training Camp Activities. The methods pursued in preventing venereal diseases aimed, first, at diminishing exposure to infection, and, second, at giving medical treatment to soldiers who have been exposed in order to prevent the development of the disease. One of the most immediately effective measures in preventing exposure was the repression of prostitution and its ally, the liquor traffic, in the neighborhood of army camps and to a lesser degree throughout the country. The surgeon-general assigned specially qualified officers of the Sanitary Corps, mostly lawyers, to the Law Enforcement Division of the Commission on Training Camp Activities, with orders to see that the federal and local laws against prostitution and liquor-selling were rigidly enforced. The results exceeded all expectations. In a year and a half about 130 red-light districts were closed at the instigation of these officers working in the name of the Law Enforcement Division. Street-walking and the connivance of lodging-house and hotel-keepers, taxicab drivers, and others was kept down. Trained women social workers, experts in the management of reformatories and detention houses, and civilian investigators co-operated with the military authorities in the work. Seven hundred and fifty cities and towns were investigated and a thorough clean-up was made in 453. As a result of this work, _it is estimated that to-day not more than five openly recognized red-light districts remain in the whole United States_. It has repeatedly been asserted that military life is conducive to immorality and that the army reeks with venereal diseases. This charge is effectually disposed of by the statement that of a total of approximately 225,000 cases of venereal disease found to exist in the army, 200,000 were contracted before enlistment.

[Illustration: FIELD-HOSPITAL.]

[Illustration: AN INFECTIOUS WARD.]

[Illustration: CLEAR, FILTERED, DISINFECTED WATER.

Complete water-purification plant and laboratory on truck, known as the “steri-lab.”]

[Illustration: WATER STATION ON THE WESTERN FRONT.

The hose of a “steri-lab” can be seen in the foreground.]

The Division of Surgery is subdivided into sections of General Surgery, Orthopedic Surgery, Head Surgery, and Genito-Urinary Surgery. In each of the forty-five army hospitals in the United States a surgical service is maintained, the chief surgeon and his assistants having practically the same freedom of judgment in deciding upon the kind of treatment that is to be pursued that they would exercise in civilian institutions. To some extent, however, the matter of treatment is governed by the rules laid down in the Army Medical Manual and the regulations established by the Surgeon-General’s Office. Thus, each month a duplicate of the record of every operation performed, a list of the patients who have died and the reasons for their deaths, and a list of the supplies used by the surgical service must be sent to Washington. In addition, the hospital must report upon the number of patients received from overseas and the character of their injuries, and the number of cases of peripheral nerve, empyema, fractures, osteomyelitis, etc., which are in the hospital, together with the classification of the stage of the disease, that is, whether it is improving, whether it is stationary, or whether it will require operation. In this way the Division of Surgery is enabled to maintain a supervision over the operation of each hospital without interfering with its actual workings. In other words, the surgical service is permitted to exercise its own judgment untrammelled and without interference, but it must render a faithful report of all its doings. These monthly returns are carefully scrutinized in Washington and the work of the entire surgical personnel is carefully watched and card-catalogued. Monthly reports from the various commanding officers and from consultants, as well as information picked up here and there, are entered on these cards, so that no officer can remain for any length of time in the surgical service without the department knowing exactly what he is doing and having a very accurate estimate of his ability.

When war was declared, the army possessed in the United States two hospitals for general cases, one for tuberculosis, one for rheumatism, and 113 post hospitals, with a total capacity of 6,665 beds. In order to meet the anticipated needs of our great new armies a vast programme of hospital construction was started in August, 1917, and, though it was greatly curtailed after the sudden collapse of the German war-machine, by March, 1919, the Medical Department had at its disposal in the United States alone a total of 130,564 beds. In other words, the capacity of our army hospitals was increased 1,850 per cent in twenty months—a record which is, I imagine, without parallel in the history of medicine. The total number of medical officers, nurses, and enlisted men on duty in these hospitals during the period of the war was equal to the population of Albany, New York, and the number of cases which were treated—2,000,000 in all—was equivalent to the total population of Chicago. These gigantic hospitals, with their cool, clean wards, their ridge ventilation, their wide corridors, their elaborate heating, lighting, water, and fire-fighting systems, are not surpassed by any civil hospitals of their size in the world. To realize this, one has only to visit them. Indeed, it is not the slightest exaggeration to say that the American soldier received the most expensive kind of medical treatment, in hospitals of the finest type, at the hands of physicians and surgeons many of whom had given up princely incomes and leisurely lives in order to work eighteen hours out of the twenty-four at a captain’s or major’s pay.

It did not take the Medical Department many months to realize that it not only had on its hands thousands of sick and wounded soldiers but it also had the great American public—and the public required the most careful and tactful handling. Before we had been at war a year every conceivable sort of rumor in regard to the way in which the men in the hospitals were being treated was making the rounds. It was whispered that they did not get enough to eat, that they were not properly clad, that the physicians played poker and the nurses danced while their patients lay dying, that out-of-date methods of treatment were the rule, that the medical officers were incapable or overbearing. No rumor seemed too fantastic to receive credence. One woman alighted from her limousine at the entrance to the Walter Reed Hospital in Washington and asked to be shown the “basket cases.” Upon being asked by the puzzled attendants what she meant, she explained that she wished to see the soldiers who had lost both legs and arms, and who, she understood, were kept in baskets! And she was quite frankly sceptical when assured that neither at Walter Reed nor at any other military hospital in the United States was there a soldier who had lost both of his legs and both of his arms. In order to combat such ridiculous and harmful stories, to keep the public informed of the splendid treatment which the soldiers were receiving, and to cheer up the depressed and lonely soldiers themselves, the Publicity Section of the Surgeon-General’s Office established a series of hospital papers which covered the entire country. _The Come-Back_, edited and published at the Walter Reed Hospital, Washington, D. C., jumped in one issue to the ranks of the big dailies and steadily held its place in everything—news, editorials, cartoons, advertising, and circulation—that makes a successful newspaper. _The Right About_, published by the patients of Debarkation Hospital No. 3, located in the former Greenhut store in New York City, soon ran up a circulation of more than 50,000—at five cents a copy, too. Among the other papers was _The Trouble Buster_, published at Fort McHenry Hospital, Baltimore; _The Ward Healer_, at General Hospital No. 12, Biltmore, North Carolina; _The Pill Box_, at Debarkation Hospital No. 1, Ellis Island; _The Reclaimer_, General Hospital No. 34, East Norfolk, Massachusetts; _The Stimulant_, General Hospital No. 19, Lakewood, New Jersey, and a score or more of others with equally amusing names. The joyous, humorous, American spirit of these papers set a fashion of good cheer and sportsmanship among the patients, their attitude being characterized by the slogan shouted from the top of the first page of one of them: “The Come-Back chirps so loud that nobody has the nerve to growl.”

Even before the first of the constantly growing streams of wounded began to trickle home from France, it was recognized by the Medical Department that a system must be devised and put into operation whereby these men, instead of being mended and turned loose to shift for themselves as best they could, must be carried along, receiving treatment and pay, until they had attained the maximum degree of physical and functional restoration. For a quarter of a century after the close of the Civil War the streets of American cities were filled with disabled men who eked out their scanty pensions by selling shoe-laces, pencils, novelties, or by begging, because no intelligent measures had been taken to refit them for their former occupations or to fit them for new ones. It was determined that this condition must not occur again. The plan for physical reconstruction of the soldiers, as ultimately adopted, was simple, direct, and effective. It involved primarily the establishment of an administrative organization known as the Division of Physical Reconstruction, divided into departments of physiotherapy and education. Certain subdepartments were also made necessary by the special requirements of those soldiers who had lost their speech, their hearing, or their sight. The sympathy and interest aroused by this work throughout the country quickly drew into it as officers or advisers many men eminent in those walks of life which best fitted them for the exacting duties demanded by this service. The work of physical reconstruction has been eminently successful in its effect upon the disabled soldier, bringing him to a realization that, however great and disheartening his impairment, he might hope for usefulness, happiness, and self-support in the future, and in many cases leading to the adoption of a new and better vocation and a better standing in life. I knew one man who had had both legs blown off by a shell at Château-Thierry. He was a young, fine-looking, exceptionally intelligent fellow, but, with the prospect of spending the rest of his days in a wheel-chair staring him in the face, he had sunk to the depths of misery and discouragement. But one day one of the experts of the reconstruction service sat down beside his bed, offered him a cigarette, and started a conversation.

“What did you do before you went into the army?” the reconstructionist inquired.

“I was a carpenter,” the man answered. “Made good money, too. But I guess the only thing I’ll be good for in the future will be peddling shoe-laces,” he added bitterly. “No one wants a legless man.”

“Ever have any other occupation?”

“No. I always wanted to be an architect, but my people didn’t have the money to send me to college, so I went to work after I finished high school.”

“Would you like to take up architecture now if you could get the training?” the reconstruction expert asked.

“Would I?” the soldier gasped incredulously. “Would I? Say, friend, what’s the use of hitting a fellow when he’s down and out?”

“You’re not down and out,” was the cheery answer. “Not by a damned sight! If you want to be an architect, Uncle Sam is ready to give you a chance. He will give you an education, and pay you while you are getting it, and then he will get you a job. Don’t get the idea into your head that he has forgotten what he owes you boys who have fought for him.”

The last time I saw that soldier he had already commenced his architectural education.

“If he keeps on as well as he has begun,” one of his instructors told me, “he will make several times as much money without any legs as he did with them.”

The educational work starts at the bedside as soon as the patient feels the need of some activity or diversion. Each patient is treated as an individual, an educational activity being selected for him which will have the greatest curative effect and will at the same time present the greatest interest and incentive because of the future usefulness which it holds out to him. Simple crafts, light, desultory, and diverting, gradually give place to more exacting, more purposeful studies and occupations. For one man the series may be bead-work, mechanical drafting, wood-shop, carpentry; for another, knitting, basketry, penmanship, and accounting; for the illiterate it may be some textile project followed by instruction in reading and writing. Since the work began, 75,000 men have been enrolled in some form of educational work in fifty hospitals. Many have regained control of palsied muscles, limbered up stiffened joints, revived dulled mental sensibilities, steadied shaken nerves, or obtained improved physical tone by the application of these methods. To thousands the educational service has brought the discovery that, in spite of the handicap of their disabilities, they possess unsuspected ability in certain lines of useful and profitable endeavor, thus substituting hope for despair and showing them the way to a useful and contented future.

M—— was illiterate; in fact, he could not sign the pay-roll or read the simplest orders; he was bedridden with wounds in his shoulder and arm. He came from a remote mountain community, where the need of even a rudimentary knowledge of the three R’s was not deemed necessary. For thirty minutes a day for six weeks he studied reading, writing, and arithmetic. When he was ready for discharge from hospital he was able to write short letters, though he found spelling puzzling. In reading he made unusual progress, though his oral inflection left something to be desired. His greatest pleasure was to receive a letter from his brother, who had had five years’ schooling but could not write as well as M—— himself, or to write to his mother instead of being compelled to ask the other boys to write his letters for him.