wounds associated with the formation of gas. The organism (in which I happen to have a personal interest, as it was first isolated from one of my patients in the Johns Hopkins Hospital by my colleague Professor Welch) is widely prevalent in the soil of highly cultivated districts, so that the mud-stained clothing of the soldier is almost invariably infected. It is gratifying to know that with early and proper treatment of the wound the cases have become less frequent and less fatal.

Typhus Fever.-Typhus, perhaps the most fatal of all camp diseases, has been a great world-epidemic, whose story is written in the dark pages which tell of the grievous visitations of war, famine and misery. During the last half of the 19th century, decade by decade, the prevalence lessened, until in England last year not a single case was reported. It has lingered sporadically in Ireland, in the Balkan States, in Russia, in New York among the foreign population, in Manchuria, and in Mexico. Its association with crowded, ill-ventilated, filthy apartments has always been recognised; as Bartlett remarks, it is the 'pestilence which dogs the footsteps of retreating and discomfited armies and takes up its dwelling in their tents; which hides itself within the dark and noisome walls of ancient prisons; and which lurks amid destitution and vice in the narrow lanes and unlighted cellars of great cities.' Its contagious character and high rate of mortality have justly made typhus the most dreaded of all infections. From no disease have nurses and doctors suffered so severely. During twentyfive years of special prevalence in Ireland in the 19th century, out of 1230 physicians attached to institutions dealing with it, 550 died.

The demonstration of the method of its transmission has been made within the past few years, and illustrates the modern methods of procedure in research and the value of the practical knowledge that may result. In 1909 Nicolle infected a chimpanzee with the blood of a patient ill of typhus fever, and demonstrated the transmission of the disease from one monkey to another by the bite of the body-louse. These results, confirmed by Anderson and Goldberger in the United States, have practically solved the problem of the prevention of typhus fever, and have led to the adoption of preventive

measures, viz. warfare against lice-infection in the public at large; the destruction of lice and their eggs on the clothing and body in all cases of typhus, suspects and contacts; and the use of precautions against lice-infection by persons necessarily coming into contact with the sick. The nature of the germ in typhus is still doubtful, though recent studies by Plotz have possibly determined the specific bacillus; and attempts are being made in Serbia to carry out a protective inoculation. Fortunately, the range of activity of the louse is very restricted in comparison with that of the mosquito and the fly; and the transference from one person to another requires that close and constant contact met with in overcrowding. In the present war, orders have been issued and systematic efforts are being made which are rapidly reducing the number of infected men. Bathing accommodation, thorough disinfection of the clothing, and the free use of insecticides may clean up the camps completely. Experience is teaching the men the necessity of taking every opportunity to keep themselves free from vermin.

Cerebro-Spinal Fever.-One of the most remarkable epidemics of the present war has been the so-called 'spotted fever,' which has prevailed in the home camps, and to a less extent in the expeditionary forces. Isolated cases occur constantly in the community, and it blazes into epidemics when large bodies of young men are concentrated together in camps and barracks. A larger number of small epidemics of from forty to eighty cases have occurred than was ever before known in England. It broke out first in the Canadian regiments, which had had a few cases at Quebec and on the voyage, but they are not responsible for the wide prevalence of the disease in all parts of the kingdom. Though a soldier's malady, it has never played an important rôle in campaigns. The case incidence is always small, but the mortality is high; and the disease shares with cholera and plague a malignancy that may cause death within a few hours. With fresh air, isolation of cases and carrier, and scrupulous personal cleanliness, the epidemics, as a rule, quickly subside; and with early and thorough serum treatment the mortality is greatly diminished.

Typhoid Fever.-In modern wars no infection has been more disabling than typhoid or enteric fever. With

a lower mortality than typhus, it is a more costly disease, running a longer course and having more serious sequels and complications. In the Civil War of the United States there were, at a low estimate, 29,336 deaths; in the Franco-Prussian war the Germans had 8000 deaths. In the Spanish-American war, out of 107,973 men in camps 20,738 had the disease and 1580 died. It killed more in South Africa than the bullets of the Boers8022 to 8000-and the case incidence reached the high figure of 57,684. The concentration in camps of young men at a susceptible age, and a campaign in a country in which typhoid was prevalent, aroused the greatest apprehension lest the disaster of South Africa should be repeated in the present war.

In dealing with typhoid, there are two favouring circumstances. Sanitation has caused a steady reduction of the disease in England; and foci of infection are carefully guarded. Still, in 1912 there were 1600 deaths from typhoid, which means a case incidence of from 16,000 to 20,000, an enormous number of positive germcentres. The infection is conveyed by water, by milk, by food; and we have learned to recognise the importance of carriers, individuals who harbour the germ for years and distribute it with the urine or fæces. The authorities, civil and military, are thoroughly alive to every detail in the preventive measures necessary to limit the dissemination of the germ; but with troops in the field such measures are not always possible.

The second favouring circumstance is the possibility of protecting the soldier artificially against the germ. Certain acute infections so alter the body that it is afterwards resistant to the germ of the disease. Experi mentally, animals may be rendered resistant or immune to many diseases by repeated injections of small doses of the germ; and the protective forces thus called out remain mobilised and active for a variable time. Very few persons ever have a second attack of typhoid fever; but it is not possible to say how long the protection lasts. There are persons with a natural immunity, in whom indeed the germs may live for years without causing disease; on the other hand, there are families with a special susceptibility. Of a series of 2000 patients with typhoid fever at Hamburg only fourteen had had

the disease before, and one had had two previous attacks. Of 500 cases in which I had special enquiries made, eleven had had the disease before at intervals ranging from nine months to thirty years. It had long been known that an infection artificially induced by inoculation of material from a case of the disease, or of an allied one, is milder and protects against the natural disease. Small-pox

if inoculated took on usually a mild form; and it was Jenner's merit to discover that vaccination with material from the cow-pox protected from small-pox equally well.

On this principle Sir Almroth Wright, in 1896, introduced inoculation with dead cultures of the typhoid germ, which produce changes in the body by which the individual is protected or rendered immune. The practice has been carried out on an extensive scale, with results convincing to all save those who deny the elementary facts relating to immunity. Figures may prove anything—even (as Sir Berkeley Moynihan said the other day) the truth. In America, India, France and Italy inoculation against typhoid fever has been shown to reduce the incidence of the disease, even to the vanishing point, as in the case of many of the stations of the American Army. The technique of the procedure has been greatly improved; and the percentage of cases in which serious discomfort follows has been reduced. Though not compulsory in the British Army, more than 90 per cent. of the men have been inoculated. Ten months of war have passed; at home and abroad more than two millions of men have been in camp and at the front; and, so far, typhoid fever has not prevailed to any serious extent. The figures to May 22, 1915, are:-1006 cases, 61.5 per cent. of which occurred amongst the 10 per cent. of uninoculated men. The analysis of the cases is not yet complete; but amongst 508 uninoculated cases there were 106 deaths, a case mortality of 20.86; amongst 155 inoculated twice there were 11 deaths, a case mortality of 7·09; and amongst 164 cases inoculated once there were 11 deaths, a case mortality of 6.70. Many of the cases have been caused by the paratyphoid germ, an allied organism, against which inoculation with the cultures of the ordinary germ does not protect; but measures are being taken to combine and standardise the procedure.

Widespread experience in different countries shows that properly performed vaccination against typhoid fever protects for periods varying from a year to two or three years. There is little or no danger; nor is there any probability of transference of other disease or of rendering the subject more liable. Its use is indicated in soldiers and sailors, who are specially liable to be exposed to the germs of typhoid fever, to nurses and doctors, and to persons travelling in hot countries.

Cholera.-Though it prevailed in the Russo-Polish war of 1831, the Crimean War, and (much more seriously) in the recent Balkan wars, cholera has never played a very important rôle in European campaigns. The mode of transmission of the germ is largely through water, through carriers and flies. Protective sanitation is effective; and successful inoculation is now possible. In the western area of the present war there is very little danger that the disease will prevail to any extent. In Hungary, between Sept. 15 and Nov. 30, there were only 3024 cases; and in Galicia, between Sept. 23 and Dec. 5, 2047 cases and 793 deaths. A few cases have occurred in Germany; between Nov. 8 and Jan. 16, sixty-four cases. The Marine Hospital reports of the United States of America down to May 7 do not refer to its prevalence in Constantinople, Asia Minor, or Egypt; and so far the armies of the eastern area have been spared.

cent.

Venereal Disease.-From 1 to 4 and even 5 per of the men in home camps are invalided for venereal disease. Though we know the germs both of gonorrhoea and of syphilis, no satisfactory measures of prevention have been devised, either in civil or military life. The incidence is lessening through frank and free education; and the disability is much less protracted owing to better measures of treatment. The terrible nature of this scourge comes home when one sees it, so to speak, wholesale. Passing through lines of tents in an outlying portion of a camp, impressed by the silence and loneliness, I asked, 'Where are the soldiers?' At command a bugle sounded, and out of the tents came between 500 and 600 victims of the disease, stricken in one of our pest-haunted sea-ports. It was a tragic sight, the sorrow of which was heightened by the knowledge that the offender's cross is not borne by the sinner alone. The gonococcus