SECTION II. LOSS OF SERVICE FROM SICKNESS PER 1,000 PER ANNUM. (a) Number of Admissions into Hospital.-On an average, 1,000 soldiers furnish rather under 1,000 admissions into hospital per annum ; 809.1 in ten years (1870–79). The number varies in the different arms from about 600 in the Household Cavalry and Engineers, which is usually the lowest, to about 1,100 in the Cavalry and Artillery Depôts. In the first case the steady character of the men, many of whom are married, and in the second the frequency of contusions during drill, account for this great range. In the Infantry the average is from 850 to 1,020. In 1880 the highest rate was in the cavalry, 1,016.4, and the lowest in the Royal Engineers, 587.8, the Foot Guards showing 1,003.8, and the Infantry (including depôts), 943.6. The number of admissions remained tolerably constant for twenty-five years, but during late years has been sensibly declining. The admissions in the French army are not comparable with ours; slight cases of sickness (which with us are often not recorded) are treated in barracks (à la chambre), severer, but still slight, cases in the infirmaries, bad cases in the general hospitals. The mean of five years (1862–66) gives 2,028 total admissions per 1,000 "present." The admissions to the infirmaries in France (in 1866) were 323 per 1,000 "present; " to the hospitals, 306; making a total of the severer cases of only 629 per 1,000 in that year. This shows how many slight cases there are in the French army. In the eight years (1862-69) the mean number of slight cases in France was 1,745 per 1,000 (Morache). In the Prussian army the average admissions (mean of 18 years, 184663) were 1,336. In 1867 there were 1,125.6 per 1,000. In 1873-75 it was 750, and in 1876 only 620 (Roth). (b) Daily number of Sick in Hospital per 1,000 of Strength.-About onetwenty-fifth of the army is constantly sick in time of peace, or 4 per cent. The mean for the ten years 1860-69 was 4.78 per cent., (or one-twenty-first part), and for the ten years 1870-79, it was 3.95 per cent., or just under one-twenty-fifth. The numbers are therefore diminishing. It is not possible to compare the army sickness with the civil population, or even with other armies. In England, the number of members of friendly societies, between twenty and thirty years of age, who are constantly sick, is nearly 16 per 1,000. In the French army, the mean sick in hospital are 29 per 1,000 present; in both hospital and infirmary, 50; in the Prussian, 44 (in 1876 only 25.5); in the Austrian, 45; in the Belgian (1859), 54.2; in the Portuguese (185153), 39.4. The number of daily sick has, of course, a wide range; sometimes an hospital is almost closed, at other times there may be more than 100 sick per 1,000 of strength. (c) Number of Days spent in Hospital per head in each 1,000 of Strength. -The number of days' service of a battalion 1,000 strong in a year would be of course (1,000 × 365 =) 365,000. If we assume the average number of sick to be 394 per 1,000, there are lost to the State (393 × 365 =) 14,417 days' service per annum, or 14 days per man. As already said, it is difficult to compare the sickness of soldiers and civilians, but the above amount seems large when we remember that, in the friendly societies, the average sickness per man per annum (under forty years of age) is less than seven days. Mean Duration of Cases of Illness. -The number of days each sick man is in hospital (mean duration of cases) is rather greater (17.8, average of 10 years, 1870-79), as the number of admissions is below the strength. It can be most easily calculated as follows: multiply the mean daily number of sick (sick population) by the number of days in the period, and divide by the cases treated. The number of "cases treated" is the mean of the admissions and discharges in the period. Austrian army, 17 to 18 days. French at home, all cases (1862-66), 7.97 days. French in hospitals only (1862-66), 26.3 days. French in infirmary, 12 days. French à la chambre, 3.10 days. Belgian, 23.6 days. (a) Mortality to Sickness. This is, of course, a different point from that of the relation of mortality to strength. A few cases of very fatal illness may give a large mortality to cases of sickness, but the mortality to strength may be very small. The mere statement of the ratio of mortality to sickness gives little information; what is wanted is the mortality of each disease, and at every age. Otherwise the introduction of a number of trifling cases of disease may completely mask the real facts. When, however, the general ratio is to be determined, it must be calculated in one of three ways: 1. Mortality to admissions in the time. This is, however, an uncertain plan; a number of cases admitted toward the close of a period, and the greater part of whose treatment and mortality falls into the next period, may cause an error. 2. Mortality to cases treated (=mean of admissions and discharges).' This is the best method of calculation. 3. Mortality to sick population, i.e., the number of deaths furnished per annum by a daily constant number of sick. This, however, must be taken in connection with the absolute number of sick in the time, and with the duration of the cases, or, in other words, with the kind of cases. The degree of mortality to the several causes of sickness was given very fully in the statistical part of the "Army Medical Department Reports," up to the year 1873, since which time the detailed returns have been discontinued. Calculated on the admissions, the mortality to total sickness in the 'It has not infrequently happened that the mortality on sickness has been calculated in this way: the number of sick remaining in hospital at the commencement of the period, say a year, are added to the admissions in the year, and the mortality is calculated on this number. At the end of the year a certain number of sick remaining in hospital are carried on to the next year, and added to the admissions of that second year for the calculation of the mortality of that year. In this way they are counted twice. This has been done in calculations of weekly mortality, and in this way the same sick man has been made to do duty as a fresh case many times over. This is to be avoided by either calculating on the admissions, or by considering half the "remaining" at the beginning to belong to the previous period, and half the “remaining" at the end of the period to belong to the following period, or, what is the same thing, taking half the admissions and half the discharges in the period as representing the cases treated" in that time. English army at home is a little above the mortality to strength, or about 10.2 per 1,000 per annum (1870–79). In 1880 the ratio was 7.6. In the Prussian army it was 7.25 (years 1846-62); in 1872 it was 7.7.1 CAUSES OF SICKNESS. The causes leading men to go into hospital are, of course, very different from those which produce mortality. For example, admissions from phthisis will be few, mortality great; admissions from skin diseases numerous, mortality trifling. Taking the most common causes of admission in the order of frequency, we find 1. Venereal Diseases.-Under the term Venereal, all diseases, immediate or remote, resulting from sexual intercourse, are included. Secondary as well as primary syphilis; stricture and orchitis, as well as gonorrhoea, etc.; also a few cases not strictly venereal. The primary venereal forms are, however, of the most importance. In stations under the Contagious Diseases Act, 1,000 men give 67 admissions from primary venereal sores and 82 from gonorrhoea (average of 11 years 1870-80). In stations not under the Act, the amounts have been, respectively, 107 and 100. There are other admissions from secondary and tertiary syphilis, which somewhat increase the total admissions, We have no certain facts with which we can compare the syphilitic disease of the civil population with that of the army. The amount among the civil population at large is really a matter of conjecture. But whether it is greater or less than that of the army does not affect the result drawn from the above figures, viz., that there is an appalling loss of service every year from the immediate or remote effects of venereal disease.' It should be understood, also, that the action of syphilis is long continued. Many soldiers die at Netley from various diseases, whose real affection has been syphilis, so that the influence of this cause is very imperfectly indicated by the number of admissions and service lost under the head of syphilitic disease only. 2. General Diseases.-The important diseases included under this class give about one-fourth of the total admissions, or about 199 per 1,000 (1870-80). (a) Eruptive fevers are not very common, about 5 per 1,000. Smallpox is checked by vaccination; measles and scarlatina are not frequent. (b) Paroxysmal fevers (most of which have been contracted out of England) give about 13 per 1,000. (c) The continued fevers are more common, but their frequency is lessening. There is no doubt that typhoid is the chief, perhaps almost the only fever besides febricula which is now seen. Spotted typhus is at present uncommon, but does occasionally occur. The continued fevers cause about 20 admissions per 1,000 of strength. Of late years there have been some cases of cerebro-spinal meningitis. iii., 1 For numerous statistical details of foreign armies, see Roth and Lex, op. cit., vol. p. 411 et seq. The order issued in 1873, directing stoppages to be made from men in hospital affected with venereal disease, was a most unfortunate one, as giving every inducement for the concealment of disease. Happily it has now been rescinded. 3 Professors Maclean and Aitken, of the Army Medical School, are both very much impressed with the frequent occurrence of marks of continued and dominant syphilitic action in the bodies of men who die from what are considered other diseases. (d) Rheumatism gives 46 cases per 1,000 of strength. 3. Accidents give the next greatest number; mean (1870-1880) 107; range from 65 to 114 per 1,000. 4. Diseases of the Digestive system follow, with nearly the same number, about 107; range from 96 to 122. 5. Cutaneous diseases give a mean of 104; range from 92 to 123. 6. Respiratory diseases (not including Phthisis) give a mean of 85 per 1,000; range from 76 to 103. 7. Diseases of the Eye, mean 16, with little variation. 8. Diseases of the Circulatory system, 14. 9. Phthisis, 13, with range between 11 and 14. 10. Nervous system, 12, with a range between 11 and 14. 11. The remaining diseases of numerous smaller items, such as those of the generative (venereal excluded), locomotive, urinary (gonorrhea excluded), etc. As almost all details of these different groups are now omitted from the "Army Medical Reports," it is difficult to discuss their causation and possible diminution. There is no room for doubt that the venereal admissions could be greatly lessened; so also could the admissions from fever, which have in fact been already reduced from 60 to 22 per 1,000 of strength; in 1879 and 1880 they were only 16 and 17 respectively. The large class of integumentary diseases would probably admit of reduction. What is the exact nature of the phlegmon and ulcers which form so large a proportion of the admissions? Trifling as the cases are, they form a large aggregate, and a careful study of their mode of production might show how they might be diminished. Probably, however, these are mere conventional terms, under which a number of trifling cases are conveniently recorded, but a complete analysis of the returns of one year under phlegmon would be desirable. So also of all the other classes, it may be concluded that an active medical officer might succeed in reducing the cases of rheumatism, bronchitis, and dyspepsia. Many cases of acute respiratory diseases are produced by exposure on guard, especially by the passage into and from the hot close air of the guard-room to the open air on sentry duty. Good additional overcoats, means of drying the clothes, and proper ventilation of the guard-rooms, would probably lessen the cases of bronchitis and pleurisy. 1 Sickness in Military Prisons.—The admissions into hospital in the military prisons do not appear to be great; they have varied per 1,000 of admissions of prisoners from 316 (in 1851) to 725.5 in 1863.* Calculated on the mean strength, the result is as follows:-In 1863, the daily average number of prisoners was 1,064; the admissions for sickness, 722; the mean daily sick, 21; the mortality, 0. These numbers give 725.5 admissions, and 19.74 mean daily sick per 1,000 of strength. Prisoners are healthier than their comrades at duty in the same garrisons where the prisoners are under sentence. 1 It is right, however, to say that no medical officer ought to sacrifice his men in the slightest degree for the purpose of appearing to have a small sick list and an empty hospital. There is a temptation in that direction which we have to guard against, and to remember that the only question to be asked is, What is the best for the men? not, What will make the best appearance? * Report on Prisons for 1863, p. 24. VOL. II.-19 SECTION III. Such, then, being the amount of mortality and sickness at home, it may be concluded that the soldier at present is not yet in so good a condition of physical health as he might be; and we can confidently look to future years as likely to show a continuance in the improvement now going on. In future years, however, the new system of limited service will render it difficult to trace the progress in the infantry. Health is so inextricably blended with all actions of the body and mind, that the medical officers must consider not only all physical but all mental and moral causes acting on the men under their charge. The amount of work, the time it occupies, its relation to the quantity of food, the degree of exhaustion it produces, the number of nights in bed, and other points of the like kind; the mental influences interesting the soldier, or depressing him from ennui; the moral effect of cheerfulness, hope, discontent, and despondency upon his health, as well as the supply of water, air, food, clothing, etc., must be taken into account. And just as the body is ministered to in all these ways, so should there be ministration of the mind. It is but a partial view which looks only to the body in seeking to improve health; the moral conditions are not less important; without contentment, satisfaction, cheerfulness, and hope, there is no health. Hygiene, indeed, should aim at something more than bodily health, and should indicate how the mental and moral qualities, essential to the particular calling of the man can be best developed. How is a soldier to be made not merely healthy and vigorous, but courageous, hopeful, and enduring? How, in fact, can we best cultivate those martial qualities which fit him to endure the hardships, vicissitudes, and dangers of a career so chequered and perilous? Without attempting to analyze the complex quality called courage,—a quality arising from a sense of duty, or love of emulation, or fear of shame, or from physical hardihood, springing from familiarity with and contempt of danger,-it may well be believed that it is capable of being lessened or increased. In modern armies, there is not only little attempt to cultivate courage and self-reliance, but the custom of acting together in masses and of dependence on others, actually lessens this. It is, then, a problem of great interest to the soldier to know what mental, moral, and physical means must be used to strengthen the martial qualities of boldness and fortitude. The English army has never been accused of want of courage, and the idea of pusillanimity would seem impossible to the race. But drunkenness and debauchery strike at the very roots of courage; and no army ever showed the highest amount of martial qualities when it permitted these two vices to prevail. In the army of Marlborough, the best governed There are many sober and excellent men in the army. But as a rule, the English soldier cannot be depended upon under any circumstances, if he can get drink. Well does Sir Ranald Martin, say, Before that terrible vice can be overcome, something far more powerful than medical reasoning on facts, or the warnings of experience founded on them, must be brought into active operation. Discipline must still further alter its direction:-in place of being active only to punish wrong, it ought and must be exerted further and further in the encouragement to good conduct."-Ranald Martin, Tropical Climates, p. 263. |