THE WORK OF BRITISH PATHOLOGY IN RELATION TO THE WAR
Authors: F. W. Andrewes
Journal: BMJ (1917)

IN forming any estimate of the work carried out by 'British patlhologists during tlle past two years it is necessary to bear in mind the position of medical researcl in this country wlhen the war broke out. The numerous and important medical and pathological discoveries which have had their birth in England lhave chliefly been the work of individual men, and have owed little to co ordinated researclh, though admirable work was done in the laboratories of the different universities, of the Royal College of Physicians in Edinburgh, and in many otlher places. Up to the year 1913 the State did lhardly any thing to advance knowledge in medical science; a small suum doled out yearly by the Local Government Board and sonle assistance given by the Colonial Office to the Schlools of Tropical Medicine represented almost all that was done, thiough it would be unjust to ignore the valuable researcli work carried out by the patlhological staff of the Royal Army Medical Corps. Apart from tlhe State, suchl endowed institutions as the Lister Institute and the Imperial Cancer Research Fuind proved that as a race we were capable of sustained and not unfruitful effort on the lines of co-ordinated research whlere the oppor tunities for this existed. Nevertlheless, individualism was the rule, and eaclh pathologist tended to devote hiis energies to the research wlhich happened to appeal to him wvhenever lie had tlle necessary time and freedom from financial cares. Even under these'conditions the output of good researelh work in medical science was by no means discreditable. and Englishlmen lhave good reason for pride in the share whichl this country lhas taken in the advance of our knowledge of disease and of its treatment. The Insurance Act, however, promised a revolution in researchl. For tlle first time the State set aside a con siderable aninual sum, between fifty and sixty thousand pounds a year, for tlle express purpose of advancing medical knowledge, and the Act organized m-achinery for its iDtelligent expenditure. The guiding lhand was exer cised by a body of nine persons, tlhe Medical Research Committee, establislhed in 1913, and carefully chosen from amongst those known to have the power of organizing research or distinguished in its prosecution. Much time and thoughit were expended by this committee in elabo rating tlheir sclhemes of action, but scarcely had tlle machinery begun to move wlhen the war broke out and interrupted most of tlleir projects. A gigantic var, carried out under conditions largely new, necessarily presents a continuous series of new medical, surgical, and pathological problems requiring immediate solution. It was a fortunate tlhing for the country that the Army Medical Service was well organized and efficient. Many of the problems wlicll would con front us lhad been foreseen and their solution thought out. In particular the pathological branch of the service was well developed and excellently officered by a staff trained in the well-equipped laboratories of the Royal Army Medical College. At the onset of tlle war, how.; ever, the Army Medical Service foun(d itself more than fully occupied with tlhe necessary administrative duties which it was called upon to fulfil, so that it was impossible for its staff to deal at once witlh all the new quLestions wlicih arose. It was now that the Medical Researchl Committee proved its value. It was already a  going concern, and' was in a position to divert the energies which were to have been expended on research into the medical problems of a country at peace to tlle solutio; of those whiclh arose in consequence of war. Tlle committee therefore placed itself at the disposal of the nation, and especially at the service of tlle military authorities; its flexible organization enabled it to attack ne-w problems at short notice and with mlaximum effect, and thle value of thle results whichl have beenl attained under its auspices has been inl many cases im:mediate and remarkable, as will appear in th1e following pages. It will be convenient to group thXe chief pathological problems which have been met during the war and discuss them seriatim. The Control of Enteric Fever. Enteric fever, the great medical scourge of all former wars, lhas been reduced in this, tlle greatest of all wars, to insignificant proportions. Two factors have contributed to thlis: one was a knowledge of tlle carrier danger, wlhlich was met from tlhe outset by the bacteriological examination of all suspected persons and their prompt segregation; the . otlher and more important factor was propllylactic inoculation. The practice of inoculation against typlhoid fever, wllicll we owe to Sir Almrotb Wriglht, lhad been tried on a small and inadequate scale in the Soutlh African war, witlh not wholly convincing results. It had since proved its wortlh in our Indian army, and the most efective methiods for securing protection lhad been worked out in detail by tlhe pathologists of the I.A.M.C. under Colonel Sir W. B. Leislhmiian. The methods devised were put into practice from the beginning of tlhe wvar, and in the course of a few montlhs practically the whole army. was inoculated. Small local outbreaks of enteric were promptly suppressed, and the total number of cases was extremely small in comparison with whlat miglht lhave been anticipated. The inoculation, lhowever, was carried out witlh vaccines of B. typihosus alone, and the protection afforded against infection with B. paratyp7ho8u8 (A and B) was not of highl degree. During tlle first year of the war actually more paratyphoid than typhoid was observed amongst our troops. As the result of this experience the War Office appointed a snlall committee of patlhologists to consider the advisability of including paratyplhoid bacilli in the proplhylactic inoculation. Tlle question of dosage was carefully considered, and groups of miien were experi mentally inoculated witlh tlle mixed vaccine to make sure that tlhe constitutional reaction was not too severe. The tests were satisfactory, and froml the beginning of 1916 tlhe. new triple vaccine, known as T.A.B., bas been the sole official vaccine for the British army, and lhas proved itself efficient in controlling paratyplhoid as well as typhoid fever. Tlle patlhological diagnosis of enteric fever has been complicated by the fact that practically all soldiers were inoculated men, so tllat tlle old metlhodls of serum dia gnosis became untrustworthy. At an early period of tlle war Professor Dreyer of Oxford drew attention to the method of carrying out agglutination reactions macro scopically with standardized killed cultures, which he had elaborated in Copenhagen sorne years previously. The advocacy of this metlhod by Professor Dreyer and his colleague, Dr. Ainley Walker, led to its widespread use, and its accuracy proved such that a diagnosis could be inade even in triply-inoculated nmen, provided tlhat two or tlhree observations were made at intervals of a few days, so as to follow the agglutination titres of the blood against the three bacilli respectively. The Medical Research Com mittee took the matter up and establislhed at Oxford a laboratory from wlhiell standardized emulsions together witlh the requisite outfit for carrying out the test have been suipplied free to all military pathologists, Dreyer's teclhnique being now used almost universally. Mucb valuable information about the course and diaghosis of tlle different forms of enteric fever lhas resulted from the widespread use of this standard metlhod, wliich has the advantage that tlle observations of different workers are strictly conmparable. That the freedom fronm enteric wlichl has been enjoyed by our armies on the Western front is due to the care taken in ensuring inoculation, and to the sanitary pre cautions wlhichll lave been enforced, is shown by the con dition of affairs wlhere tllis care was impossible and inoculation incomplete, notably in the Gallipoli expedition. Here, although there was little typhoid, the anmount ol paratyphoid was by no means inconsiderable, bLut exact figures are wanting owing to the lack of facilities foi diagnosis. Dysentery. Of tlhis second great medical scourge of war a less favourable tale cap be told, inasmucll as no specific preven tive measures have yet been devised. It lhas not been found practicable to employ proplhylactic inoculation against bacillary dysentery, chliefly on account of thle high toxicity of Shiga's bacillus, thoughl researchl work on this subject is in progress, and mention may be made of thle methlod of reducing this toxicity by thle action of hzypochllorites, as suggested by Professor D)ean of Manchlester. Prevention has thlerefore been reduced to hygienic precautions and tc [29471