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THE HORROR OF LOUSINESS
414
that of many other infectious diseases which cause a greater total mortality. The anxiety, disorganisation and even panic that is often produced by an epidemic of meningitis is caused by the fulminating character of the disease and its high case-fatality. If this case-fatality can be prevented cerebrospinal fever need not be dreaded any more than (say) measles. Everyone should realise that cerebrospinal fever is the disease which responds more dramatically than any other infection to suphanilamide or sulphapyridine. If every patient was given one of these drugs in adequate doses at the earliest moment that meningitis was suspected, the case-fatality would be reduced to less than 5 per cent. This has been proved true by many 2physicians, among whom may be cited BANKS for this country, and BRYANT and FAIRMAN3 for equatorial Africa. The latter showed that under appalling environmental and hygienic conditions, which could not be corrected, sulphanilamide and sulphapyridine reduced the fatality among the treated natives from about 70 to 5 per cent. Prevention is better than cure. True, but if you cannot prevent cerebrospinal fever vou may as well cure it.
THE HORROR OF LOUSINESS IN a classic of 1917-18 Sir ARTHUR SHIPLEY described the louse as a minor horror of war. But the louse may be the greatest of war’s horrors. By the disgust that it produces, by the sleeplessness that results from it, by the ubiquity of the skin lesions, and by the mortal disease that it carries in its bite it surpasses any. Because it is unremitting the soldier dreads it more than artillery fire. When all is quiet on the western front the enemy may start a small bombardment; the sentry sees the flash but knows the chance of being hit is small. Even when the great barrage of an impending attack crashes down the soldier knows that it is only for a time. But from the slow crawlof the louse over his body there is no respite. Tomorrow and tomorrow and tomorrow it will go on; after he has had his hot bath and changed his shirt it will soon start again. No-one can be blamed for becoming lousy, or punished for failing to get clear; yet the control of lousiness is not medical but administrative and disciplinary. Control, not cure; for in war there is no cure. Should control be relaxed, a single louse on a nether garment may within six weeks become a complete infestation of a company. Corps or divisions may build baths or brigades develop washing places, but officers must arrange men’s duties so that they can use them. The medical officer is the expert adviser on all points connected with the evil thing; he cannot deal with it himself. That must be done by the platoon commander under instructions from his senior. The unit that tries to make the medical officer responsible will become the lousiest in the formation. It has been said, no-one quite knows by whom, that cleanliness is next to godliness. This may not be true for those who live in luxury, with hot water, sweet-
soap, and heated towels. They have but to control their inner selves, to grapple with stomach and with sex, with anger and uncharitableness. It needs no virtue for such to keep themselves clean. But to the poor cleanliness is a part, and a great part, of godliness; and in wartime all on active service and in camps live as do the poor. To rise above discomfort and to struggle, not against oneself and one’s inner
smelling
but with oneself against those outer stimuli of cold and wet and dirt and all the foulness of insanitary surroundings, and still to keep oneself clean, means greater godliness than many know exists. It needs much virtue to wash in a bucket of ice-cold water, in the open, with the rain pelting down upon one’s bare back. And it is washing that alone keeps down the louse which likes a dirty body upon which to live. The soldier may call himself " chatty " and laugh at it; but no civilian or back-area military man has any right to laugh with him, any more than he has when he laughs at the shell he calls his " packet." Besides the body there is the mind. There are some to whom the idea of harbouring a louse is so repellent as to unhinge the mind and they become inefficient with disgust. In a unit the scourge starts in those of less mental capacity than their fellows ; and it is in these that it will last remain to spread again to all when control is removed. And that control is perhaps the worst of all; for it depends on inspections which, if properly done, are so undignified that no man would willingly submit to them, nor would any in his normal mind conduct them excepting as a
impulses,
duty. PNEUMONIA IN THE NEWBORN TwEXTY years ago the loss of life during the first month of independent existence was generally regarded as the natural death-rate of infants. It was then that J. W. BALLANTYNE began in Edinburgh to analyse the causes of what he was the first to call neonatal death, in the light of the routine performance of necropsy. The laissezfairo attitude has given place to a spirit of hopeful inquiry, of which one example has been the claim of P. J. FLAGG1 to be able by insufflatioil after intubation to rescue many cases of so-called asphyxia neonatorum. Respiratory conditions, whether certified as asphyxia, atelectasis or pneumonia, have, always stood high in the list of causes, but the data on which certification of these deaths is based are still too vague for the figures to be of much value. MACGREGOR,2 however, has found inflammatory changes in the lungs of one in ten of stillborn infants and one in three of infants who died within a month, so that measures of prevention in this direction, which seems the most promising one, are well worth while. Two different processes have to be considered according to the age of the child. In stillborn infants and those who die within the first few days the aspiration of liquor amnii seems
I
Flagg, P. J. Surg. Gynec. Obstet. 1938, 67, 153; 1938, 2, 731. 2. Macgregor, A. R. Arch. Dis. Childh. 1939, 14, 323.
1.
2. 3.
Banks, H. S. Lancet, 1939, 2, 921. Bryant, J. and Fairman, H. D. Ibid, 1939, 1, 923.
see
Lancet,
that of many other infectious diseases which cause a greater total mortality. The anxiety, disorganisation and even panic that is often produced by an epidemic of meningitis is caused by the fulminating character of the disease and its high case-fatality. If this case-fatality can be prevented cerebrospinal fever need not be dreaded any more than (say) measles. Everyone should realise that cerebrospinal fever is the disease which responds more dramatically than any other infection to suphanilamide or sulphapyridine. If every patient was given one of these drugs in adequate doses at the earliest moment that meningitis was suspected, the case-fatality would be reduced to less than 5 per cent. This has been proved true by many 2physicians, among whom may be cited BANKS for this country, and BRYANT and FAIRMAN3 for equatorial Africa. The latter showed that under appalling environmental and hygienic conditions, which could not be corrected, sulphanilamide and sulphapyridine reduced the fatality among the treated natives from about 70 to 5 per cent. Prevention is better than cure. True, but if you cannot prevent cerebrospinal fever vou may as well cure it.
THE HORROR OF LOUSINESS IN a classic of 1917-18 Sir ARTHUR SHIPLEY described the louse as a minor horror of war. But the louse may be the greatest of war’s horrors. By the disgust that it produces, by the sleeplessness that results from it, by the ubiquity of the skin lesions, and by the mortal disease that it carries in its bite it surpasses any. Because it is unremitting the soldier dreads it more than artillery fire. When all is quiet on the western front the enemy may start a small bombardment; the sentry sees the flash but knows the chance of being hit is small. Even when the great barrage of an impending attack crashes down the soldier knows that it is only for a time. But from the slow crawlof the louse over his body there is no respite. Tomorrow and tomorrow and tomorrow it will go on; after he has had his hot bath and changed his shirt it will soon start again. No-one can be blamed for becoming lousy, or punished for failing to get clear; yet the control of lousiness is not medical but administrative and disciplinary. Control, not cure; for in war there is no cure. Should control be relaxed, a single louse on a nether garment may within six weeks become a complete infestation of a company. Corps or divisions may build baths or brigades develop washing places, but officers must arrange men’s duties so that they can use them. The medical officer is the expert adviser on all points connected with the evil thing; he cannot deal with it himself. That must be done by the platoon commander under instructions from his senior. The unit that tries to make the medical officer responsible will become the lousiest in the formation. It has been said, no-one quite knows by whom, that cleanliness is next to godliness. This may not be true for those who live in luxury, with hot water, sweet-
soap, and heated towels. They have but to control their inner selves, to grapple with stomach and with sex, with anger and uncharitableness. It needs no virtue for such to keep themselves clean. But to the poor cleanliness is a part, and a great part, of godliness; and in wartime all on active service and in camps live as do the poor. To rise above discomfort and to struggle, not against oneself and one’s inner
smelling
but with oneself against those outer stimuli of cold and wet and dirt and all the foulness of insanitary surroundings, and still to keep oneself clean, means greater godliness than many know exists. It needs much virtue to wash in a bucket of ice-cold water, in the open, with the rain pelting down upon one’s bare back. And it is washing that alone keeps down the louse which likes a dirty body upon which to live. The soldier may call himself " chatty " and laugh at it; but no civilian or back-area military man has any right to laugh with him, any more than he has when he laughs at the shell he calls his " packet." Besides the body there is the mind. There are some to whom the idea of harbouring a louse is so repellent as to unhinge the mind and they become inefficient with disgust. In a unit the scourge starts in those of less mental capacity than their fellows ; and it is in these that it will last remain to spread again to all when control is removed. And that control is perhaps the worst of all; for it depends on inspections which, if properly done, are so undignified that no man would willingly submit to them, nor would any in his normal mind conduct them excepting as a
impulses,
duty. PNEUMONIA IN THE NEWBORN TwEXTY years ago the loss of life during the first month of independent existence was generally regarded as the natural death-rate of infants. It was then that J. W. BALLANTYNE began in Edinburgh to analyse the causes of what he was the first to call neonatal death, in the light of the routine performance of necropsy. The laissezfairo attitude has given place to a spirit of hopeful inquiry, of which one example has been the claim of P. J. FLAGG1 to be able by insufflatioil after intubation to rescue many cases of so-called asphyxia neonatorum. Respiratory conditions, whether certified as asphyxia, atelectasis or pneumonia, have, always stood high in the list of causes, but the data on which certification of these deaths is based are still too vague for the figures to be of much value. MACGREGOR,2 however, has found inflammatory changes in the lungs of one in ten of stillborn infants and one in three of infants who died within a month, so that measures of prevention in this direction, which seems the most promising one, are well worth while. Two different processes have to be considered according to the age of the child. In stillborn infants and those who die within the first few days the aspiration of liquor amnii seems
I
Flagg, P. J. Surg. Gynec. Obstet. 1938, 67, 153; 1938, 2, 731. 2. Macgregor, A. R. Arch. Dis. Childh. 1939, 14, 323.
1.
2. 3.
Banks, H. S. Lancet, 1939, 2, 921. Bryant, J. and Fairman, H. D. Ibid, 1939, 1, 923.
see
Lancet,