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Germany soon after peace was signed. In our own Spanish War we were assailed with a plague of typhoid fever, which left its imprint upon our civil death rate for years after 1898, A recurrence of either of these diseases had been rendered impossible by the general practice of vaccination against them. Indeed it would not be an exaggeration to affirm that the war could not have lasted as long as it did, had it not been for the success of the vaccination program in all the armies involved, including those of the Central Powers. No one ventured to prophesy that influenza would be the scourge of this war, although it would not have been illogical. It is a very old and well known although little understood disease. Since the fifteenth century we have had periodical pandemic waves of the disease, extending to the remotest points of the world. The interval between epidemics has usually been twenty or thirty years. The last preceding world epidemic was in 1900. It is characteristic of the disease that it travels as fast as the modes of human transportation permit, remains at any one place for little more than a month and then passes on to new regions until it has reached the most remote corners of the civilized world. The long interval between epidemics makes it inevitable that each new epidemic must be studied by a new group of investigators. It takes the men an appreciable time to learn the difficult technique which is necessary, and before many have acquired proficiency the disease, and with it the opportunity for its investigation, has passed. Pfeiffer did not discover the influenza bacillus until 1902, two years after the crest of the epidemic had passed, and for this reason many skeptics doubted if he was dealing with the true epidemic disease.

In this visitation, the disease was called the Spanish Influenza, an old name, since several times before the disease has first been recognized in that country. Almost as often it has been called the Italian influenza. The epidemic of 1900 came out of Russia and was commonly called La Grippe.

There is really no reason to doubt that it has always been the

same disease, although the laboratory proof is still lacking, because the clinical course of an attack of the disease is so characteristic.

What is the history of influenza in inter-epidemic years? In the absence of complete proof it is impossible to be sure about it, yet the most commonly accepted belief is that the disease is always with us, as the ordinary influenza, a form of common cold, but that only under exceptional circumstances does it become virulent and cause any appreciable mortality. Dr. Welch showed years ago that the influenza bacillus could be recovered frequently at autopsy from the cavities in tuberculous lungs. Others have shown its presence in chronic diseases of the sinuses accessory to the nose and throat. In other words, the causative organism is regularly present, but of low virulence, and it does not prove sufficiently fatal to cause an appreciable influence on the annual mortality curves. Why some diseases, such as infantile paralysis and influenza, should suddenly become extremely virulent and produce wide-spread epidemics we do not now know. During the war it is probable that it obeyed the same law as measles, and spread among our soldiers because they were young, many of them from the country districts, and, therefore, not immune to the infection. As the conditions were ideal for the rapid passage of the virus from man to man, it is concluded that there was a steady increase in virulence, until the virus was capable of causing a very severe and fatal illness.

In

During the last four months of 1917, when the camps were filled with recruits, there were reported 40,512 cases of influenza, yet it was not noted as a severe disease, and it was not apparently followed by pneumonia to any serious extent. the Winter and Spring of 1918, particularly in January, March and April, many cases of influenza were again reported, as well as many fatal cases of pneumonia. It was not until the Fall, however, during September and October, that it was recognized that the fatal epidemic form of influenza was present, and that pneumonia was reported as a frequent and fatal complication.

The particular strain of the virus responsible for this seems to have been brought to Boston from Brest, the first week in September. From Boston and Camp Devens the disease spread as rapidly as human beings travel to all parts of the United States. The further history of this virus we do not know, and we may indeed never be able to trace it. We know the disease in a mild form was present in our camps from the beginning, and that our troops presumably carried it with them. wherever they went. We know that the French had a similar experience with their own colonial troops, and it is probable that the experience of all the warring nations was the same. From a military point of view one is justified in saying that travel was free and uninterrupted from the ends of the world to the seat of the war in France. Troops from all the world were poured in daily and a returning stream of wounded, sick and broken down men, returned to the home countries and carried with them the germs of any respiratory infection to which they had been exposed. The virulent virus, therefore, wherever it first arose was soon carried across the battle lines, to friend and foe, to the lines of communication in the rear of the battle areas, and finally by ships, from port to port.

It stands as one of the most fatal pestilences of history. For 1918 there were reported 688,869 cases in the American Army. This gives a rate of 273 cases per thousand men. The number of deaths charged directly to influenza was 23,007, giving a rate per thousand of population of 9.14. In addition to this number of deaths, there were 431 charged to bronchitis, 6814 to broncho-pneumonia, 8407 to lobar pneumonia, and 405 to pneumonia unclassified, 262 to pleurisy, 330 to various respiratory diseases, a great many of which should, no doubt, have been charged to influenza. If these deaths are added together it would give a total of 39,701 out of a strength of 2,518,499 during the year, a rate of approximately 15.75 per 1000 of population. The total deaths for the army for the year from disease amounted to 47,384. Approximately 82 per cent. of all deaths were, therefore, caused by diseases of the respiratory

tract. If we deduct this respiratory rate of 15.75 from the total rate for disease, it would leave the exceedingly low rate of 3.07 for all others.

We may conclude, therefore, with this evidence, that it is possible to prevent deaths, under conditions of mobilization and warfare, from all diseases except the respiratory; that so far as such diseases are concerned we have advanced but little, and that the field for future investigation and research for all concerned in public health and medicine lies in the diseases of the respiratory tract.

Some progress has already been made; secondary pneumonias from the hæmolytic streptococcus are now recognized and methods for their control are now available. There are those who believe that epidemic influenza, and the influenza of interepidemic years, is caused by the bacillus of influenza, but even so, there does not seem to be at the moment of writing any method of preventing an epidemic which has once started. This is, perhaps, the greatest of the public health problems at present awaiting solution.

XVIII

ADVANCES IN SURGERY DURING THE WAR

JOHN W. HANNER

HILE there has been nothing startling or revolutionary

WHI

in the surgical art as a result of the recent great war, substantial and valuable gains in the surgical field have marked the progress of surgeons of all nationalities through the multiplicity of conditions met with, and valuable knowledge for future use has been stored up in the literature.

Perhaps the outstanding and most spectacular achievement, one that shortened the period of disability greatly and resulted in the early return of the soldier to the fighting line, as well as prevented large, mutilating and often disabling scars and contractures, was the early closure of wounds, after thorough excision and cleansing of the lacerated, devitalized tissue found in and around the track of the projectile, a procedure called by the French" débridement."

This excision of tissue and immediate closure of a wound is successful only when it can be done within a short period after the receipt of the wound, usually given as eight to twelve hours. As a rule, when a longer time has intervened, infection of the wound has already gained such headway and has become so widespread, since the organisms have had time to multiply and penetrate into the surrounding tissue, that it is unsafe to close the wound immediately. In such cases, it has been found safer to delay the suture of the wound for two or three days, when in favorable cases it can be closed without fear of future infection; or to employ antiseptics to combat and limit the infection; or to use simple drainage, as was formerly done, until the

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