( 150 ) Art. 9.-WAR, WOUNDS, AND DISEASE. To the truth of the saying that disease, not battle, digs the soldier's grave the campaigns of the 19th century bear ample witness. How great may be the losses from this cause was never shown more terribly than in the illfated Walcheren Expedition (1809), when 23,000 men out of 39,000 died in four months; only 217 were killed! In 1828 a Russian army, 100,000 strong, marched on Turkey; victorious in the field, it was completely vanquished in the hospitals, which in July 1829 contained 40,000 men, more than half of the available strength. Of the whole force, only 15,000 returned to Russia. Since the Crimean War there has been a gratifying reduction in the deaths from disease. The accompanying diagram from an article by M. N. Kozlovski shows the proportion of killed in battle and deaths from wounds and disease, in certain wars of the last and present centuries. * Translated by Major G. S. McLoughlin, D.S.O., in the Journal of the Royal Army Medical Corps,' vol. xviii, 1912, p. 345. The Russo-Japanese War saw the lowest proportion, but the figures in the diagram of the Russian Army may be for only one section of the Army. Captain Culmann, analysing the losses in the Franco-German and RussoJapanese wars ('Journal of the Royal Army Medical Corps,' vol. XIII), gives the following figures: 28,800 or 4.9 per cent. of effective strength. 47,400 8.8 Killed Russians 17,300 2.7 99,600,, 15.3 The Germans in the Franco-Prussian War had one killed for every six wounded, the Russians one for every five, and the Japanese one for every four. The percentage of the men who subsequently died from wounds was 37 in the Russians, 6.6 in the Japanese, and 11.0 in the Germans. As regards the sick, the following For the first ten months of the present war to May 31, 1915, the casualties in the Army have been 258,069. A complete analysis is not yet possible. The killed number 50,342, the equivalent of the annual toll taken in England alone by one bacillus, that of tubercle. Of the wounded, 153,980, I am informed that up to date 60 per cent. have returned to duty. A gap in our knowledge relates to the 53,747 men missing, of whom a considerable proportion are no doubt killed or wounded. It is interesting to study the character of the cases and the results of treatment of an unselected group of men sent home from France. A report by Dr Beal of the first 1000 treated at the American Women's War Hospital, Paignton, states that 783 were surgical and 215 medical. Three patients died, and only 3.3 per cent. have been invalided, so that a great majority of the 1000 cases discharged have been marked as fit for duty of some kind. Of the 783 surgical cases 265 were non-traumatic, 144 of them frostbites in various degrees. Of the medical cases there were 17 of dysentery, 11 of rheumatic fever, and only one of typhoid. The public should read these heavy and calamitous casualty lists with a knowledge that a very large proportion of the wounded get perfectly well, and that up to date some 60 per cent. have returned to duty. The returns for disease are not yet available, but, when the analysis is completed, we shall find that coughs and colds, pneumonia, rheumatic fever, bronchitis, and muscular rheumatism, particularly what is called trench rheumatism, have been responsible for a large proportion of the sickness. It may be of interest to review briefly the more serious camp diseases to which wounded and healthy are liable, among which the infections due to micro-organisms come first in order of importance. Wound Infection.-At the close of the American Civil War, fifty years ago, we did not know the cause of any one of the great war pestilences. To-day, with the germs of all discovered, we have in our hands the effective weapon suggested by the axiom of Celsus-Eum vero recte curaturum, quem prima origo causæ non fefellerit.' Our position in 1865 was not much better than in the days of Hippocrates and Galen. That fevers are catching, that epidemics spread, that infection remains attached to clothing, all suggested a living something' of the nature of a ferment; and among the many shrewd guesses the best parallel was that drawn between the processes of contagion and of fermentation. In the hands of Pasteur the experimental method completely revolutionised our knowledge of disease and the methods of prevention. Certain facts of primary importance have been determined by the studies of the past half-century : (1) the specific nature of the seeds of disease, which breed as true as do the seeds of wheat, and show varieties as easily distinguished by the expert as is Manitoba red from Forfar wheat; (2) the germs, artificially grown, show special chemical and biological characters, and, when introduced into the bodies of susceptible animals, produce the specific disease; (3) the changes in the body fluids caused by the growth of the germ have been thoroughly studied-we know how immunity is produced after recovery from a fever, and against many diseases this immunity can be artificially induced by the inoculation with the germs or the products of their growth; and (4) the part played by insects in the transmission of disease has been determined-Texan cattle fever by the tick, Malaria and Yellow fever by the mosquito, Sleeping Sickness by a fly, Plague by the flea, Typhus fever by the louse, and a host of minor maladies by other insects. Some of these discoveries have proved the most lifesaving instruments ever placed in the hands of man. Malaria, the greatest scourge of the tropics, can be absolutely controlled, while Yellow fever, the most dreaded pestilence of the western hemisphere, has been dislodged from its strongholds. It is not too much to say that the Panama Canal could not have been built without the researches of Laversan and Ross and of Walter Reed and his colleagues. The first practical fruit of the new studies was the application by Lister of Pasteur's principles to the treatment of wounds. It had long been recognised that a wound occasionally healed without suppuration or the formation of pus, but both spontaneous and operative wounds were almost invariably associated with that change; and, moreover, they frequently became 'putrid,' or, as we should now say, 'infected.' The general system became involved; and death from blood poisoning was so common, particularly in old and ill-equipped hospitals, that many surgeons feared to operate, and the mortality in all surgical cases was very high. Believing that from the outside the germs came which caused the decomposition of wounds, just as from the atmosphere the sugar-solution got the germs causing the fermentation, Lister applied the principles of Pasteur's experiments to their treatment. We may quote from his original paper in the 'Lancet,' March 16, 1867: 'Turning now to the question how the atmosphere produces decomposition of organic substances, we find that a flood of light has been thrown upon this most important subject by the philosophic researches of M. Pasteur, who has demonstrated by thoroughly convincing evidence that it is not to its oxygen or to any of its gaseous constituents that the air owes this property, but to minute particles suspended in it, which are the germs of various low forms of life, long since revealed by the microscope, and regarded as merely accidental concomitants of putrescence, but now shown by Pasteur to be its essential cause, resolving the complex organic compounds into substances of simpler chemical constitution, just as the yeast-plant converts sugar into alcohol and carbonic acid' (p. 327). From these beginnings modern surgery took its rise ; and the whole subject of wound-infection, not only in relation to surgical diseases, but to child-bed fever, forms one of the most brilliant chapters in the history of preventive medicine. Pus germs are ubiquitous. In civil life surgeons strive to work, so far as possible, in a germ-free (aseptic) environment, with the result that in hundreds of successive operations the wounds heal without suppuration, and with a single dressing. Infection is an inseparable incident of the wounds inflicted in war. In civil life we had almost forgotten what suppurating wounds were like, but the pus organisms have again become aggressive, and more suppurating wounds have been seen by British surgeons in ten months than in the forty years since Lister's methods became general. The nature of the commoner wounds due to shell and shrapnel favours infection; and in spite of early first-aid dressing, the germs are carried far into the tissues, and suppuration is inevitable. Trench warfare can never be aseptic. The uniforms of the men are caked with mud, which in highly cultivated districts always contains dangerous micro-organisms. The usual pus germs, streptococci and staphylococci, are ubiquitous ; and everyone harbours less important forms, so that any wound, however slight, unless treated immediately, may become infected. The one bright feature has been the frequency with which the high velocity bullet sterilises its course, so that many perforating wounds of the chest, abdomen and limbs recover without suppuration. The torn and bruised shrapnel wounds invariably become infected. The surgeons have found it hard to adapt themselves to pre-Listerian conditions quite foreign to their usual work; and methods used in civil life have proved quite unavailing in dealing with wounds infected by these highly virulent organisms in trench warfare. Tetanus. From time immemorial tetanus, or lockjaw, has been one of the most dreaded of human maladies. Following often slight injuries, curiously limited to localities, even to special farms, and in horses to special stables, the discovery of its aetiology is one of the most |