one conversant with the magnificent works emanating from the American surgeons will entertain any doubt. "The French statistics are equally authoritative. Unlike the American and British statistics, they do not result from the concurrence of many observers, but have been compiled by one man of great perseverance and energy, who has utilized the innumerable documents filed at the War Office. From hospital registers, from death-lists, from pension, retiring, and recruiting returns, M. Chenu has made up his admirable report of the numerical results of French surgery in the Crimea. It is in vain to dispute the figures. Whence results, then, our inferiority? "M. Velpeau used to say: 'English muscle bears operations better than French,' in his familiar lessons on hospital hygiene; thus glancing at the difficult subject of the relative vital resistance of the two races. The question merits the attention of anthropologists and of surgeons, but data are as yet wanting to discuss it with advantage. But hereafter in determining therapeutic results, we should compare them as they are presented in the English, German, and French races, at least. Many striking facts lead me to the belief that the influence of race on surgical results is far greater than was supposed only ten years ago. When, at that time, I was studying surgery in London hospitals, I was often surprised to see men sent to their homes, treated as out-patients' as it was there expressed, who had undergone quite serious operations; such patients as in Paris we should never think of sending from the hospital on foot, and who, for that matter, would not with us believe for a moment that they were capable of walking home. It is not uncommon to read in the English or American journals of patients who have been subject to a ligation of the upper extremity, and have gone immediately in a carriage to their homes, several miles distant. Now the morale of patients has an immense influence on their physical condition, as every one knows, and I have been often impressed by the energy of character of many Englishmen who had undergone surgical operations. Is our feeble resistance to wounds, mutilations, and operations, due to a degeneration which many suspect, but dare not affirm? It is very possible. A nation, which at the beginning of this century lost on innumerable battle-fields more than a million of its strongest men; which, by its conscription laws, places the most robust portion of its male population in a condition of temporary celibacy, during the period when the generative function is in its fullest activity, and leaves the scrofulous, the rachitic, the hunchback-every man, in short, who has some physical defect-to propagate the species. Such a nation is sure to witness a gradual physical deterioration and numerical diminution of its population. Our numerical increase has so far, it is true, only fallen off in a degree to excite the gravest apprehensions. Whether the physical degeneration which we are forced to suspect and dread, is already betraying itself by certain effects, is a question I dare not decide. However, whatever influence we ascribe to difference of race cannot adequately account for the difference in surgical results; for truth, not less than national vanity, forbids us to believe that the French can possibly differ so widely from the Anglo-Americans in moral energy or in vital resistance. Correspondence. ARMY MEDICAL ORGANIZATION. TO THE EDITOR OF THE MEDICAL RECORD. M. LEON LEFORT, secretary of the Surgical Society of Paris, has published a series of papers in the Gazette Hebdomadaire de Médecine, on the relative excellence of army medical organizations in Great Britain, France, and America. "Patriotism consists," he says, "with most of my countrymen in regarding only those things of which we have a right to be proud, and, above all in giving publicity to such things, while carefully concealing those subjects respecting which we should be compelled to admit an inferiority. A son, say they, should ignore the faults and infirmities he is pained to observe in his parents, and the duty of a citizen to his country is like those of a son to his mother. A doctrine more pernicious or destructive of all progress could hardly be imagined." After further generalities M. Lefort arrives at the conclusion that it is the duty of every citizen to call attention to defective administration and to suggest remedies, however ungrateful the task may be, and believing that serious reforms are needed in the military medical system of France, he proceeds to particulars. After referring to a paper in which he believes that he has established the fact that the mortality of the civil hospitals of Paris exceeds that of the hospitals of London, and that this excess in mortality is due to preventable causes, he considers the mortality of armies, and compares, or rather contrasts, the results of the British medical service in the Crimea, and that of the Americans in the late war, with the results obtained by the medical staff of the French army. 66 forearm.... 399 Disarticulations at the hip..... Per centage of Deaths. Mortal. 93 39.2 414 21.2 99 16.5 21 1597 116 2348 "Three important works," he says, "give precise information on the subject. In France, the report of M. Chenu to the army Conseil de Santé; in England, the History of the British Army in Turkey and the Crimea, presented to Parliament by the Queen's govern- The ratios in the three armies are: ment; in America, Circulars 6 and 7 of the SurgeonGeneral of the United States Army, Dr. J. K. Barnes, published by the War Department. One might be astonished to see these "circulars" of the Surgeon-General referred to in comparison with the voluminous and formal reports of the British and French armies, since they were printed simply as a preface to the general medical and surgical history of our war, and are modestly entitled by the SurgeonGeneral: "Reports on the extent and nature of the materials available for the preparation of a medical and surgical history of the rebellion." Yet M. Lefort only concurs with other leading European reviewers in his estimate of these well-known documents, of which the chief medical quarterly, the British and Foreign Medico-Chirurgical Review, declares, that professedly only a preliminary survey, "it will itself long form an authentic book of reference, both to the military and civil surgeon." "If," says M. Lefort, "we ask what these two great wars have cost humanity, one having for its object to maintain what is called the European equilibrium,' and the other to free a race of men, and to suppress slavery, we find that the sacrifice has been truly fright "In thigh amputations, then, while the American and British lose 64 in 100, the French lose 91.8. The former lose but 26 per cent. in leg amputations, and we lose 71.9. Such a result is heartrending; it is essential to discuss the cause of such a state of things, for the welfare of French soldiers, and the honor of French surgery, demand imperiously that they be removed. "Are the statistics exact? Do they express the truth, or have involuntary errors crept in? That is the first question. The British statistics, made with that minute care characteristic of our neighbors, emanate from the English government itself, and England is a country where the word "official" is a synonym for exactness. The American statistics do not comprise all the cases, but only those reported to the medical bureau up to the date of Circular No. 6. As to the careful manner in which they have been compiled, no one conversant with the magnificent works emanating | walking home. It is not uncommon to read in the from the American surgeons will entertain any doubt. "The French statistics are equally authoritative. Unlike the American and British statistics, they do not result from the concurrence of many observers, but have been compiled by one man of great perseverance and energy, who has utilized the innumerable documents filed at the War Office. From hospital registers, from death-lists, from pension, retiring, and recruiting returns, M. Chenu has made up his admirable report of the numerical results of French surgery in the Crimea. It is in vain to dispute the figures. Whence results, then, our inferiority? English or American journals of patients who have been subject to a ligation of the upper extremity, and have gone immediately in a carriage to their homes, several miles distant. Now the morale of patients has an immense influence on their physical condition, as every one knows, and I have been often impressed by the energy of character of many Englishmen who had undergone surgical operations. Is our feeble resistance to wounds, mutilations, and operations, due to a degeneration which many suspect, but dare not affirm? It is very possible. A nation, which at the beginning of this century lost on innumerable battle-fields more than a million of its strongest men; which, by its conscription laws, places the most robust portion of its male population in a condition of temporary celibacy, during the period when the generative function is in its fullest activity, and leaves the scrofulous, the rachitic, the hunchback-every man, in short, who has some physical de "M. Velpeau used to say: 'English muscle bears operations better than French,' in his familiar lessons on hospital hygiene; thus glancing at the difficult subject of the relative vital resistance of the two races. The question merits the attention of anthropologists and of surgeons, but data are as yet wanting to discuss it with advantage. But hereafter in determining ther-fect-to propagate the species. Such a nation is sure to apeutic results, we should compare them as they are presented in the English, German, and French races, at least. Many striking facts lead me to the belief that the influence of race on surgical results is far greater than was supposed only ten years ago. When, at that time, I was studying surgery in London hospitals, I was often surprised to see men sent to their homes, treated as 'out-patients' as it was there expressed, who had undergone quite serious operations; such patients as in Paris we should never think of sending from the hospital on foot, and who, for that matter, would not with us believe for a moment that they were capable of witness a gradual physical deterioration and numerical diminution of its population. Our numerical increase has so far, it is true, only fallen off in a degree to excite the gravest apprehensions. Whether the physical degeneration which we are forced to suspect and dread, is already betraying itself by certain effects, is a question I dare not decide. However, whatever influence we ascribe to difference of race cannot adequately account for the difference in surgical results; for truth, not less than national vanity, forbids us to believe that the French can possibly differ so widely from the Anglo-Americans in moral energy or in vital resistance. We "Were the French surgeons in the Crimea inferior in talent, in knowledge, in devotion to duty, to the British surgeons?" To propose such a question is to answer it negatively. Was the after-treatment directed by the British surgeons preferable to that employed by the French? Evidence on this point is wanting. know that the former used after their amputations the same sustaining and stimulating regimen which they employ in their civil hospitals, while our colleagues of the army followed substantially the same practice we adopt in our Parisian hospitals. We resort too little, in my opinion, to the supporting measures employed by our neighbors across the water, but the immense difference in mortality cannot be attributed wholly to this cause, were we even to exaggerate its influence. The real cause seems to be such as can readily be removed, namely: the numerical inadequacy of the medical staff, both in surgeons and in nurses, and the inadequacy of hospital supplies-a penury which involved the necessity, so to speak, of prematurely removing the wounded and amputated of the Crimea far from the scene of strife. "It is well known that at the commencement of the Crimean war, the French medical staff had a good outfit, whereas the British surgeons were deplorably unprovided; but the fact that in the course of a few months the rôles were inverted, has been studiously ignored. * * * "The English journals freely and earnestly denounced the evils that existed, and numerous medical men were sent to the East, and unlimited hospital supplies, so that at the end of the campaign the French army was often indebted to the British for succor to its wounded. "The insufficiency in numbers of the French medical staff was a public calamity. The over-crowding of the wounded was such that they had to be laid outside of the barracks, and God knows how dreadful then was the task of the surgeons, called on for aid simultaneously by hundreds of mutilated men. To cite but one example among many given by M. Chenu: M. Pillet, 80th Infantry, on May 23, 1855, was struck by a fragment of shell, which tore off the wrist so that it hung only by a few shreds of mangled flesh. Amputation was of course imperative, and yet "taking his turn" amid the crowds of wounded, this officer could not be amputated until two days afterward, May 25, on account of the want of medical officers.' M. Chenu adds that, if the personnel of the medical staff was doubled, the number would still be less than the wounded had a right to demand. hospitals. But it was in the Crimea that this system of evacuations beggared description." M. Lefort here quotes at length from M. Chenu regarding the horrors of the French hospitals on the Bosphorus, and then resumes: "The English surgeons kept their wounded at their field hospitals, at Balaklava, at the monastery of St. George, and only sent them to their hospitals on the Dardanelles when they were able to be moved. Why were our wounded so little cared for? M. Chenu replies that the French army had six times the effective force of the English. Then the necessities of the former were six times greater. It is a culpable want of foresight to send a numerous army far from the mother country with inadequate supplies. The question reduces itself to this: Now, who was responsible? Was it our army surgeons? Surely not. Eighty-two officers of the French medical staff laid down their lives in consequence of epidemics brought about by maladministration and the neglect of hygienic precautions-dangers encountered by the entire medical staff with that courage and abnegation which everywhere characterize the true physician. But, alas! in France, the medical service of the army is not directed by medical men, and such men as MM. Levy, Larrey, Serire, and Legouest have no voice in the arrangements indispensable to the physical well-being of our soldiers. When the medical director of the army of the East wished to erect a few pavilion field-hospitals, he had for weeks to exhaust his patience in demonstrating their necessity to intelligent, well-meaning men, who were quite incapable of comprehending his reasoning, and who followed his advice or not according to their personal prejudices or predilections. "Happier than the French army, the Americans have no system of military 'intendants;' and though their medical officers had to grapple with difficulties very far greater than those we encountered in the Crimea; although their theatre of war embraced a territory larger than the whole of France; although in the first two years only of the war, the enormous aggregate of 143,318 wounded was one of the problems with which they had to deal, the American military surgeons, left to themselves, free to display all their energy, to avail of all opportunities, to profit by their special training, found means to open to the sick and wounded soldiers 205 general hospitals, containing 136,894 beds; to tend these so that they lost but 33 per cent. of those operated on; "The state of things at the field-hospitals found parallels at Varna and at Constantinople. Everywhere too few surgeons, everywhere inadequate supplies. Public edifices were crowded, even the old barracks of the Janissaries. Soon the admissions far exceeded the "And yet France was supposed to possess, before the discharges. The wards were first crowded with beds, campaign began, a complete medical organization, and and then the corridors. Soon the deplorable results of sufficient supplies, while in America it was necessary overcrowding were manifest, and hospital gangrene, to organize everything. The United States maintained erysipelas, and pyæmia forbade the surgeon to under- a standing army of a few thousand men only, employed take any operation hopefully. How were such diffi- chiefly in protecting its settlements in the far West. culties to be met? Recourse was had to the homicidal When, therefore, the Southern States revolted for the measure of premature removal of the wounded-a policy protection of the institution of slavery, menaced by the to which I attribute the frightful mortality of the French legislation of the United States Congress, the Great Rewounded. I have witnessed these evacuations. I have public was totally unprepared for war. Volunteers came seen the working of the system in Italy, when, at to its armies in multitudes, it is true; but, if patriotism Genoa, we received the wretched wounded of Solferino may make a soldier of every armed citizen it cannot coming from Milan and Brescia to embark for France. improvise administration, and so for several months I saw in midsummer, in the finest weather, under the there was a chaotic state of things, which terminated loveliest sky in the world, in a friendly country abound- in the disaster of Bull Run. Soon the nation, learning ing in supplies, multitudes of wretched men suffering from its free press the condition of affairs, came to the from gunshot fractures, who were subjected to the aid of the Medical Bureau. There was formed the Sanhorrible torture of long journeys, sent off to die, when itary Commission, an institution little understood in it would have been easy to have improvised pavilion! France. The direction of the sanitary service always remained absolutely within the control of the Depart- military intendants in the most important matters rement of War. No physician was allowed in the army un-lating to the treatment of the sick, the secret of our less appointed with the approval of the Medical Bureau. disasters is to be found. Let not the lesson be lost for It was not, as some persons ignorant of the necessities France. Victims enough have been sacrificed. 'Caof an army in the field have stated, with the fanciful veant consules."" belief that independent civil medical establishments can be substituted for the military medical staff--it was not to the Sanitary Commission,' that the honor was due of organizing the most remarkable and important military health-service that the world has seen. "The medical staff was soon amply provided with the necessary supplies. To give a single item, we may state that the depot at New York issued 12,867 stretchers and that at Philadelphia 5,548. Numerous transient hospitals were erected as near as possible to the seat of hostilities. When the removal of the wounded to the rear was imperative, they were conveyed on hospital railway cars, or on steamers converted into salubrious hospitals, and not like those of the Crimea pestilential prisons, in which hapless patients were crowded without any medical men to succor them. But above all, and we may well repeat it, and so earnestly and emphatically that everyone must hear it, the American Union sick and wounded were treated by their own medical staff, in hospitals constructed according to the designs of the medical bureau, erected under the supervision of medical officers, and administered by medical officers. If the French army lost so much larger a proportion of those who underwent operations than the English and American armies, the fault was not in the French surgeons; it was with those who, without the right acquired by special professional studies, tyrannize over the medical staff; with those who give orders instead of receiving advice; these men must bear the responsibility of disasters which were a great national reproach and calamity. "Yes, it is with legitimate pride, with the authority acquired by vast experience, with the palpable obvious proofs in his hands, with the logic of accomplished facts, that our eminent colleague, Dr. Barnes, tells what the medical staff may do when untrammelled and at liberty. "Never before,' he says, 'in the world, was so vast a system of hospitals brought into existence in so short a time. Never before were such establishments in time of war so little crowded or so liberally supplied. They differed, too, from the hospitals of other nations, in being under the command of medical officers. Instead of placing at the head of establishments, intended for the treatment of disease and wounds, officers of the line, who, whatever their other accomplishments, could not be expected to understand the requirements of medical science, and who, with the best intentions in the world, might seriously embarrass the action of the surgeon, as was sadly the case in the Crimean war, and has been since in the English hospitals, our government, with a wiser discretion, made the surgeon the commandant of the hospital, and thus, while holding him responsible for the results of its management, put it into his power to make those results favorable. The medical staff can point with pride to the consequences of this liberal course. Never before, in the history of the world, has the mortality in military hospitals been so small, and never have such establishments so completely escaped from diseases generated within their walls.' "This then is the opinion of the most competent and impartial of judges in relation to an institution which sycophants and men who have intelligence enough only to repeat what they have heard, hold up to the admiration of mankind. Here, then, the system of military intendants is condemned, not only by men most capable of judging, but by facts! In this intrusion of After describing at length the different plans proposed at the international convention at Geneva, in 1859, for succoring the wounded on the battle-field, and protecting their surgeons and attendants, M. Lefort proceeds to comment on the impracticability of substituting any voluntary system of relief for the operations of an organized medical staff. The avowed object, says M. Lefort, of many of the delegates to the international congress at Geneva, was to initiate a system in which the voluntary association should "immediately assist in the surgical service of the army, working with the military surgeons on the same footing, and having their own supplies, their own organization, their own ambulances and hospitals. Such were the aspirations of some of the delegates, and several of them avowed their desire to substitute voluntary for official service." "The strongest arguments are ever drawn from the experience of accomplished facts. We are told that the proof that voluntary associations can succor the wounded better than the medical staff of the army, is found in the fact that they replaced most advantageously the medical military staff in the American war, and worked side by side with the army surgeons in the late Prussian war. This argument is based on an utter misapprehension of the true state of things. Most French writers on the medical organization of the Federal medical service in the United States have strangely enough ascribed to the 'Sanitary Commission' a part which it never enacted. It was the Army Medical Department,' directed by Dr. Barnes as surgeon-general-it was through the War-Office, directed by Mr. E. M. Stanton, that there were erected in America 202 general hospitals, containing 136,894 beds, successively occupied by over two millions of sick and wounded. It was the War Department that provided hospital transport steamers and railway cars, and innumerable ambulance wagons and stretchers. It was the War Department which throughout the campaigns put in motion men and supplies, and not a medical officer or an employé of the military hospitals was ever appointed by any other authority than that of the Secretary of War. "In Prussia the voluntary associations interposed more directly. In the Schleswig-Holstein war, the chevaliers St. John of Jerusalem, directed by their grand master, Count Stolberg, converted one of the finest houses in Flensburg into a little hospital for Prussian officers, and established near the Nubel church a temporary field-hospital for wounded soldiers. Accompanied by my friend, M. Liouville, I was able myself, in going through the lines of the Prussian army at the siege of Duppel, to appreciate the value of this field-hospital, established by private enterprise, and directed by Professor Klopsk, of Breslau. But what would have become of the great number of wounded in the assault and capture of Duppel but for the regular army medical staff?* * * So in the seven weeks' war in 1866, the voluntary associations (Sociétés de Secours) arrived a few hours after the battle of Laugensalza, and a few days after Sadowa, with army physicians and students, who greatly aided the regular medical staff, always and everywhere too few in numbers after great battles. They tended the wounded in temporary hospitals, or buildings turned into hospitals, but took no part in the active duties of the campaign, nor appeared on the battle-field. In Prussia, as in |