destroy flies and to destroy or disinfect infective faeces directly they are passed. Anti-dysenteric serum was shown to be as valuable in the treatment of bacillary dysentery as emetine was for the amoebic form, but unfortunately the supplies of serum were totally inade- quate, and in none of the eastern theatres was there any central bureau of information which could inform the scattered medical officers about recent advances in the treatment of the diseases they were called upon to fight. It is probable that in the future an anti- dysenteric vaccine will be produced which will have as powerful a protective action against bacillary dysentery as anti-typhoid vaccine has against typhoid fever, but very little satisfactory vaccine was available for use during the war.
(e) Epidemic Jaundice. A mild form of jaundice was very com- mon in the Gallipoli campaign between Aug. and Dec. 1915, and in Mesopotamia during the hot weather of 1916 and 1917. The symp- toms were similar to those of the catarrhal jaundice, which occurs sporadically among civilians in peace-time, and the condition appears to have been of the same nature as the epidemics in the American Civil, Franco-Prussian and South African wars. It appears to have been due to infection with an organism allied to the bacillus of para- typhoid fever, and numerous investigations failed to reveal the presence of a spirochaete. The mortality was so low as to be almost negligible; many men continued on duty though jaundiced, especially at Gallipoli, but the majority were not fit until six or eight weeks had elapsed from the date of onset.
From the spring of 1916 until the end of the war an entirely differ- ent form of infective jaundice occurred among the troops of all the armies engaged in France and Flanders. It was caused by infection with a spirochaete, and was identical in nature with a disease which every year attacks between 3,000 and 4,000 miners in Japan. It is best described as spirochaetal jaundice rather than by the older name of Weil's disease, as it was accurately observed amongst French soldiers by Larrey at Cairo during Napoleon's Egyptian campaign in 1800, and by numerous other French physicians before Weil's paper appeared in 1886. The spirochaete was discovered in rats caught in trenches in which the disease had occurred ; the infection in rats is chronic, the organism being excreted in the urine, which is probably the source of infection in man. The disease could be prevented if adequate steps were taken to drain trenches and exterminate rats. The symptoms were much more severe than those of the bacillary jaundice of Gallipoli and Mesopotamia; the mortality, however, was only about 4% in the British army, though it was 13% in the German army and is about 30% in Japan.
(/) Malaria. Malaria had the same effect on the operations in Macedonia that dysentery had in Gallipoli. Few men in the Saloni- kan army failed to become infected with malaria during the summer of 1916, and there is no doubt that throughout the campaign the mosquito was a far more formidable enemy than the Bulgar. Pro- phylaxis by means of quinine completely failed and it was found quite impossible to reduce the numbers of malaria-carrying moSqui- tos to any appreciable extent. The conscientious use of mosquito nets was, however, very effective. The disease was of a particularly virulent form, the mortality being exceptionally high. Even after the Armistice it proved a matter of great difficulty to exterminate malaria in men who were infected in the Struma valley.
The Mesopotamian army also suffered greatly from malaria but not quite to the same extent as the army in Macedonia. The disease was very common and very severe in the army in Persia. The num- ber of cases in France was quite trivial, most cases being due to relapses in men who had been in one of the eastern theatres of war.
(g) Infective Nephritis. Acute nephritis, or inflammation of the kidneys, is a comparatively rare disease in civil life. It does not appear to have been common in any previous campaign except the American Civil War, in which over 14,000 soldiers of the Northern armies were invalided for nephritis, and to a less extent in the Franco- Prussian War. A considerable number of cases occurred among British troops in France throughout the World War, and a slighter outbreak occurred in Gallipoli and Salonika. It appears to have been less prevalent among the French and still less among the Belgians. It was very common among the German and Austrian soldiers on every front, though not a single case was observed by German medical officers among the Turks. It was very rare among officers of all nationalities, and was never sufficiently common among the men to be of any real importance to the strength of the army, the maximum incidence (in Dec. 1916) being only 104 cases per 100,000. All attempts to discover the cause of the disease failed, but there appeared to be something about the conditions of life of the soldier, as distinct from those of the civilian, which made him specially liable to develop nephritis, as it never occurred among the civilian population or refugees of Belgium and France, who lived in the midst of soldiers and with many soldiers billeted on them. This was in striking contrast to the parallel incidences of most of the epidemic diseases among civilians and soldiers.
The mortality of the infective nephritis of soldiers is much lower than that of the ordinary nephritis of civil life, being approximately I % in the early stages, though a few additional deaths probably occurred in relapses some months after apparent recovery. Most patients got well within a month, but the complete disappearance of symptoms was sometimes delayed for a year or even longer.
(C.) Soldier's Heart. Soldiers not infrequently suffer from symp-
toms due to functional circulatory disturbances during their i of training and still more often whilst on active service. In neithe case do the symptoms differ from those which may occur among civilians, but their relative frequency has led to the adoption of the term " soldier's heart." The effect of active service on the heart was first studied during the American Civil War, and a great many valuable investigations were carried out during the World War.
Already by the end of May 1916, 2,503 out of the 33,919 soldier (7-4%) invalided from the service since the beginning of the wa had been discharged on account of " heart disease," and this propor- tion was maintained until the end.
Soldier's heart was most commonly caused by over-exertion, often associated with prolonged mental strain and insufficient sleep, acting on a heart and nervous system which were already weak before the war or which had become weakened on active service as a result of an infection or other form of poisoning. Some men are born with a circulation sufficient for ordinary purposes, but with insufficient reserve power for increased strain. They generally know their limitations, adopt a sedentary occupation in civil life, and do not indulge in out-of-door sports. Many of them break down during training, but even if they develop into efficient soldiers they are likely to develop cardiac symptoms on active service. Thus nearly 60 % of men suffering from soldier's heart were recruited from sedentary occupations.
In most cases the symptoms developed during convalescence from some acute infection, such as typhoid and paratyphoid fever, epi- demic bacillary dysentery as well as non-specific chronic diarrhoea, malaria and influenza. Excessive smoking was undoubtedly a con- tributory cause in many cases, and gassing was frequently followed by cardiac symptoms. In a small proportion of cases the excessive activity of the thyroid and suprarenal glands which results from prolonged mental strain was a further factor.
Over-exertion is a relative term. A well-trained man can do work which would be impossible in the early stages of his training and which again becomes impossible if his heart and nervous system are damaged by the poisons produced by an infection, excessive smoking or incursive activity of the thyroid gland. But in the absence of these factors a trained soldier rarely develops cardiac symptoms.
In addition to the effect of nerve-strain on the circulation through its influence on the thyroid and suprarenal glands, the nervous exhaustion or neurasthenia, which results from the combined effect of physical fatigue, mental strain and infection, gives rise to a condition of nervous irritability, which causes slight circulatory disturbances to produce palpitation and discomfort and pain in the region of the heart, although the actual condition is such that subjective symp- toms would not occur in a man with a normal nervous system.
The commonly accepted official diagnosis of " D.A.H." or " dis- ordered action of the heart " for soldier's heart is most undesirable, as it at once makes the patient believe that he has " heart disease." Some indifferent diagnosis such as " debility " would be preferable. Treatment by graduated exercise instead of prolonged rest in bed was almost invariably followed by rapid improvement if under- taken at a sufficiently early stage, and whenever the comparatively innocuous nature of the condition was widely recognized by medical officers most men suffering from " soldier's heart " were able to return to duty after a few weeks in special training camps. When, however, it was regarded as if it were due to a serious disease of the heart and treated for long periods in hospital, the outlook was much less hopeful, and many men were invalided from the service and became chronic invalids as a result.
(D.) Heat-Stroke. Heat-stroke occurred very frequently among the British troops in Mesopotamia during the hot summer months. It did not in any way differ from the heat-stroke which sometimes occurs in India. In Mesopotamia it was, however, more common owing to the less favourable conditions of life.
During the earlier years of the campaign heat-stroke was very nearly always fatal, mainly owing to the lack of facilities for treat- ment; By 1917, however, great progress had been made both in prevention and! treatment, and the proportion of recoveries was much increased. The most important precautions for avoiding heat- stroke were the provision of large quantities of cool drinking-water and of suitable clothing and equipment. Men suffering from other illnesses, such as malaria, sand-fly fever and gastro-intestinal dis- orders, were specially liable to fall victims to heat-stroke.
The disease was always dramatically sudden in onset, and usually within an hour the patient was completely unconscious and in con- vulsions. In untreated cases death occurred within a few hours with a body temperature of 1 10 or over. The one essential for treatment was found to be an ample supply of ice. The establishment of special heat-stroke stations in all camps and depots proved most effective in reducing mortality. Those who recovered, however, were seldom fit for further service in Mesopotamia and in most cases were eventually invalided to England. (A. F. Hu.)
IV. SURGERY DURING THE WAR
Military surgery during the progress of the World War reached unexampled levels of efficiency and width of scope, and the general results attained exceeded any limits which had been anticipated. Yet this consummation was not arrived at
