According to the 'Medical and Surgical His tory of the Rebellion' (Medical volume, part 1, pages xxv and xxvi), there were in the Northern armies altogether 235,583 gunshot wounds with a resulting mortality of 33,653 or 14.2 per cent. These figures represent the total returns from about nine-tenths of the mean strength of the Union army and exclusive of the injuries of those killed in action. In the late war, so far as the figures are available from the beginning, the deaths from wounds, that is of all those who came to the surgeons alive, no matter how badly wounded, have been calculated to be less than 5 per cent. This is, of course, merely an approisimation but made on reasonable grounds. Exact figures will not be available probably for some time. The seri ous infections with tetanus and the gas bacillus at the beginning of the war make the available statistics much worse than would otherwise be the case. With the control of these the mor tality among the wounded in the closing phase of the war was probably below 3 per cent.
The health of army camps at the beginning of the war was most satisfactory. As Doe tors Vaughan and Palmer said in their article on ((Communicable Diseases in the National Guard and National Army of the United States" (Journal of Laboratory and Clinical Medicine, August 1918), "Preventive medicine has made it possible to prevent half a million cases of disease and save the lives of ten thou sand soldiers," and they give the figures from the Civil War and the recent war for corre sponding six months to show the truth of this. The improvement has affected every form of infectious disease. There has been only about one-tenth as much mouth and throat inflamma tion, less than one twenty-fifth as much intes tinal trouble, not one-hundredth as much fever. Malaria, which even in the Northern army was extremely common, has now become a negligible morbidity factor and the mortality from tuber culosis and pneumonia is more than cut in two.
The sad epidemic of influenza proved that it was not the general hygienic conditions that brought improvement but the specific sanitary precautions against particular diseases. Un prepared for influenza in this virulent form, it raged very seriously, while the well-known camp diseases were kept entirely under control.
Typhoid or enteric fever which has played such a fatal part in all previous wars, carrying off in the Spanish-American War more than five times as many as the bullets of the enemy and in the Boer War causing ever so much more havoc among the British than the Boers did, has had almost no place in this war. The reason was better sanitation and careful pro vision of uncontaminated water with the guard ing of latrines from flies and other insects that might find their way afterward to food, but above all, the typhoid immunity of the armies was due to typhoid vaccination, that is the inooulation of the soldiers with cultures of typhoid germs prepared under conditions that produced immunizing results. There is no doubt at all that this is the genuine source of the great saving of life that has been effected. The inoculations cause almost no disturbance of the general health, soldiers have gone into battle the same day, and only rarely have any serious effect. It is evident that in civil life travelers in distant countries or to parts of the country of whose sanitation they are not sure, will take such vaccinations against typhoid as a protective.
Trench fever was an affection peculiar to this war and replacing typhoid fever some what in its ravages among the soldiers. The
men came down rather suddenly with a con siderable degree of temperature lasting for from three to seven days, gradually disappearing and causing a great deal of prostration. After some days of normal or sub-normal temper ature, the fever occurs again and the relapsing character of the affection has been quite marked. Careful investigation has shown that the disease is distsibuted through the body lice which have proved such a pest to the soldiers under the very difficult conditions as regards cleanliness to which they have been subjected. The discovery has made possible the prevention of the spread of the disease to a great extent, while the segregation of the relapsing and chronic cases in camps by themselves under favorable conditions of health has brought about such a reaction as has enabled the pa tients to throw off the disease. The study of trench fever, its etiology and its successful treatment as well as prevention, has been one of the triumphs of. the war.
The great medical surprise of the war was the development of a large number of cases of a very severe form of functional nervous dis ease. Men lost control of themselves corn pletely, very often had disturbances of the special senses, deafness was rather common, blindness not so f requent, and sensory dis turbances of other kinds, with mutism and tre mor or paralyses of various kinds, were noted. At first a great many of the cases were set down as forms of insanity and the patients were sent to insane asylums, but after careful study the purely neurotic character of the af fection was determined. The cases were called "shell shock" and unfortunately, early in the war were grouped under this term, besides the neurotic cases, a number of latent injuries to the central nervous system, as from actual wounds by minute particles of shells at high velocity, severe concussions and the like. It was thought for a time that the intense com pression of the air with immediate release near an exploding shell caused air at high pressure to be given off from the blood, leading to nip ture of capillary arteries of the central system or other definite physical lesions resembling those of caisson disease. The prompt and complete recovery of many serious cases under proper treatment contradicted this theory and made it clear that there must be no organic basis. The term shell shock was suggestive of something much more than a psycho-neurosis, which the affection really was, and the term nervousness, the word sick or wounded in pa rentheses being added to the diagnosis `accord ing to the external conditions to which the man was exposed at the time of breakdown' was suggested for it. This would have been a much better term but the original name maintained itself, as so often happens. The condition was entirely due to an emotional storm with loss of control over nerves, and nothing else. Its im portance will be readily appreciated from the fact that during the first half of the war, one seventh of all the discharges from the British army, or one-third of the discharges if those from wounds were not included, were for "shell shock." It was four times as prevalent among officers as among men. Cowardice was excluded as the basis and there was no malin gering, except in cases readily recognizable The study of the affection has thrown great light on the psycho-neuroses of civil life and above all has been valuable in the matter of treatment.