War

WAR. Contents: Sanitary and social-biological consequences of war . . . 523 Military pathology . . . 531 Military psychoses . . . 537 Sanitary and social-biological consequences of war. Being a major national, socio-political, state, and economic disaster, war first and foremost manifests as a socio-biological disaster, a sanitary disaster in the broad sense. War attempts to resolve international political and economic conflicts at the cost of the life and health of the broad masses of the population. In medical nomenclature, war is defined as a broad "traumatic epidemic"; the concept of "trauma" must not be understood in the narrow surgical sense; it must be boundlessly expanded in the biological and socio-pathological sense. If there is no area of national economic life upon which war would not exert a destructive influence, then there is no area of that same national economic life which, while being destroyed, would not directly or indirectly disrupt the physical and biological organism of the nation. War has accompanied humanity almost from the cradle of its origin down to the present day. Heinrich Schwiening in his rich essay "Krieg und Frieden", published in "Soziale Hygiene" edited by Martin Weyl (1904 ed., vol. IV, pp. 655-726), cites interesting data: from 1496 BC to AD 1861, i.e., over a period of 3,357 years, only 227 years were free from war, while 3,130 years were years of war, meaning that for every 1 year of peace there were 13 years of war (the data are cited according to Leer, Encyklopadie der Kriegs- und Marinenwissenschaften, vol. II, 1885). Only for the 19th century (1800–95) does the same Schwiening cite the following data on the number of years of war and peace by individual countries: Table 1. States: Prussia . . . Germany (without Prussia) . . . Austria-Hungary . . . England . . . Italy . . . Russia . . . France . . . Spain . . . Turkey . . . Years of war, Years of peace. These figures are given by Berndt ("Die Zahl im Kriege", Vienna, 1897); he also cites corresponding data for the same period concerning only the years of major wars. Table 2. States: Prussia . . . Germany (without Prussia) . . . Spain . . . Austria-Hungary . . . Italy . . . Turkey . . . England . . . Russia . . . France . . . Years of war, Years of peace. Such is the psychosis of war on a European scale even in the 19th century. However, the 20th century is apparently inclined to break the record compared to the 19th century: the Russo-Japanese War of 1904–05 and, especially, the war of 1914–18 and the series of wars that have now begun in the exotic countries of the far south and east, engulfing the numerous peoples of China, Japan, and India, bear witness to this. The peoples of Europe are once again facing the realistic prospects of cruel imperialist wars involving masses numbering in the millions. Schwiening in his historical review of the sanitary-biological consequences of war broadly covers the question and takes into account the consequences of war in the field of demography, natural population movement, and in the field of epidemiology, pointing out the influence of war on the spread of leprosy, syphilis, plague, trachoma, war typhus ("Kriegstyphus"), cholera, smallpox; in connection with these epidemics, he examines the growth of prophylaxis, the growth and development of military field hygiene, characterizes the influence of war on the growth of alcoholism, prostitution, mental diseases, suicides, on morals and manners; finally, he assesses the influence of war on the development of hospital care, the care of the sick, and the nutrition of the population. In general, Schwiening provides a sufficiently saturated picture of the sad outcomes and consequences of world wars in the sanitary-biological sense. But in his conclusion, Schwiening remains a spokesman for German military-imperialist ideology, attempting to justify the inevitability of war by motives of racial selection and hygiene; he calls to his aid Schiller with his aphorism: "Der Krieg ist ein Beweger des Menschengeschlechts"; he concludes his essay with Schiller's couplet: "Der Krieg ist schrecklich, wie des Himmels Plagen, doch er ist gut, ist ein Geschick, wie sie." However, of all world wars, the experience of the imperialist war of 1914–18 should have shattered the illusions even of German scientific ideologists regarding the inevitability and justification of wars. The most scientifically valuable material on the question of the consequences of war in general, and especially in the sanitary-biological sense, must be considered the materials on wars of only the second half of the 19th century and the beginning of the 20th century. This thought was expressed by Novoselsky in his monographic essay "The Influence of War on the Natural Movement of Population" and it is unconditionally correct. Schwiening's essay "War and Peace" is of great interest as a historical review, but the value of its statistical data is very small (from a scientific point of view). This applies not only to data from the prehistoric period (before the Christian era), but also to the historical period. Novoselsky rightly notes: "Not to mention the middle ages, even for modern times there are almost no data in this regard" (the influence of war on population movement). He considers even the data concerning the Napoleonic wars of the early 19th century to be unreliable. For studying the influence of war on population movement, he considers satisfactory only the data of the Franco-Prussian, Russo-Turkish, and Russo-Japanese wars. All the more must this apply to materials on the influence of wars on the change in the demographic composition of the population, on the movement of wartime epidemics, data on the killed, wounded, sick, on the military budget, on the influence of war on national nutrition, etc. Even more complex is the acquisition of data for the scientific elucidation of socio-biological issues such as alcoholism and war, prostitution and war, selection, counter-selection, culling, and degeneration in connection with war. Materials and data for elucidating and resolving these issues have been more or less sufficiently accumulated and are being accumulated only as a result of the 1914–18 war. The question of accumulating such material of scientific value was raised already during the war and, especially, towards its end. In Copenhagen in 1916, a special "Society for the Study of the Social Consequences of War" was even formed, and in 1917, 1919, and 1920, 3 issues of the "Proceedings" of this society were published (Christian Döring). There were individuals who devoted themselves to collecting materials on the consequences of the imperialist war of 1914–18. Such a person in Germany was Parvus, who in 1915 founded the "Institute for the Study of the Social Consequences of War"; today this valuable collection has been acquired by the Soviet Government and transferred to the Lenin Institute. At the same time, the statistical bodies of all countries of Europe and America of our time have provided the richest material for recording and analyzing the consequences of the world war of 1914–18, and a number of scientific organizations, societies, and individual scientists have been collecting and processing material on the consequences of the world war for 10 years already. In the USSR, the initiative in this regard belongs to the People's Commissariat of Health, which in 1920 created the "Commission for the Survey of the Sanitary Consequences of the War of 1914–1920" (Chairman—Dr. M. M. Gran; members of the Editorial Board—P. I. Kurkin, P. A. Kuvshinnikov; the first issue of the "Proceedings" was published, State Publishing House, Moscow, 1923). All People's Commissariats engaged in collecting materials on this issue; a special work "War and the National Economy" is currently being prepared for print. However, with all this, it must be recognized that the question of the consequences of the imperialist war of 1914–1918 in terms of its scientific study is still only in its initial period. There is reason to assert that primary archival materials have not yet been uncovered and published everywhere; many materials are apparently still kept as "secret," and special scientific working organizations equipped with sufficient capabilities and resources have not yet been created to utilize the richest primary rough material for an exhaustive scientific elucidation of the question of the consequences of the world war. It must be said that for elucidating certain scientific questions and, especially, regarding the "biology of war" (biological consequences), the time has perhaps not yet come, and the post-war period is insufficient (questions of: the physical type of the population as a result of war, the influence of war on the race, war and eugenics, etc.). In the end, it must be recognized that the question of studying the consequences of the 1914–18 war still remains in all its urgency as a scientific state-social problem, perhaps even acutely urgent in view of potential future world wars on the horizon. The accumulated and revealed material is only the beginning of the major work that lies ahead. Already published materials and works indicate that the consequences of the world war in the socio-biological sense must be interpreted much more broadly and deeply than outlined in Schwiening's scheme. Here it is possible and necessary to touch in figures and facts only upon the most major consequences. The World War of 1914–18 drew into the orbit of its destructive impact and influence multi-million masses unprecedented in previous wars: by the end of the war, 35 states with a population of up to a billion souls took part in it (by the beginning of 1916, 20 states with a population of 887,855,000 took part in the war, without calculating the colored population of the French colonies). In the summer of 1914, 9,681,000 were mobilized for the war in only 7 states (Thalheimer); by the beginning of 1916—64,945,168 (Novoselsky), and by the end of the war, according to Egerov—62,700,000, and according to the Central Statistical Administration—66,000,000.

In terms of the absolute number of mobilized personnel, Russia takes first place (15,000,000—an approximate figure); followed by the countries: Germany (13,250,000), Austria-Hungary (9,000,000), France (8,000,000), England with colonies (7,650,000), Italy (5,615,000), and the United States of America (3,665,000). Regarding the existing population, the largest masses of people were directly involved in the war: in France—20%, in New Zealand—20%, in Germany—19.5%, in Austria—18.6%, in Hungary—17.1%, in Serbia—16.5%, in Italy—15%, in Romania—13.3%. Some of the small countries and nations, such as Belgium and Serbia, were driven to the extreme degree of military overstrain, exhaustion, and ruin (Belgium—due to the vandalism of destruction, Serbia—due to the exhaustion of the living force of the human composition of the population: within one year it mobilized in percentage almost as much of the population as other states within 4 years [Novoselsky]). With such a scale of a truly "world" war, when the greater half of all humanity was drawn into it, it is easy to imagine what perturbations, biological and national-economic, must have taken place in the living collective of the human race. The first consequence of such a war had to be, in the expression of A. A. Chuprov, a "demographic catastrophe." And this catastrophe is now recorded by a whole series of scientific and statistical works. Already Chuprov in his work "War and Population Movement," and then Mikhailovsky in 1917–1920, proved the presence of this catastrophe. Mikhailovsky, as well as Strumilin, emphasized that the world war in relation to the composition of the Russian population introduced such distortions and perturbations in the age-sex, family, and professional composition of the population that it will take about 50 years to level and normalize the regular composition of the population, in particular, its labor resources. The preliminary results of the processing of the 1926 census materials, obtained by the Central Statistical Administration, fully confirmed Mikhailovsky's conclusions, but the period necessary for normalizing the composition of the population after the world war must theoretically be extended to almost 80 years. The world war introduced equally profound, unprecedented distortions into the natural movement of the population—marriage rate, birth rate, and mortality. When analyzing all the European data related to this, Novoselsky makes the general conclusion that "the war had a particularly sharp impact on the marriage rate, birth rate, and natural population growth. On the mortality of the civilian population, not counting colossal military losses, the war had less impact than previous wars and than could have been expected... This fact indicates that the majority of states entered the war sufficiently prepared in sanitary and economic terms." But in the mass of the civilian population, the war left its deep mark with a negative population growth, which is especially noticeable in France, Germany, Hungary, and Italy; over 4 years of war, the negative growth, the deficit, of the population amounted to 2,860,000 for France, 1,834,627 for Germany, 895,000 for Hungary, and 524,844 people for Italy. In relation to the population at the beginning of the war, this deficit per 1,000 population was expressed in the following values: France—72.0, Hungary—42.0, Germany—26.3, Italy—14.2, England +4.1 (in England there was no compulsory service in the first year of the war—it was introduced in 1915; therefore the 1st year is "+"; besides, at the beginning and even under compulsory service, married persons were exempted, as a result of which there was a "burst" of marriages). But the absolute losses and human sacrifices in the world war are colossal. According to Herodotus, Xerxes' army lost about 1,000,000 people from diseases, Napoleon's army in 1812 decreased by one-third of its composition due to diseases; according to Kolb's calculation, during the period of the wars of 1793–1865, humanity lost 8,000,000, with 6,500,000 perishing from diseases. But all these figures pale before the figures of the victims of the world war of 1914–1918; in this war, the losses of six armies (Russian, French, British, German, Austro-Hungarian, Belgian) totaled 5,736,332 wounded, shell-shocked, and suddenly deceased (Negrobov), not counting the sick by armies. Regarding Russia, the distortion and catastrophic shocks in the sphere of the natural movement of the population repeat the regularities of European data, but, despite the extreme incompleteness and imperfection of Russian materials on the natural movement of the population, Russian data nevertheless testify, in Novoselsky's expression, to the "unprecedentedness" of the catastrophe, and especially in the sphere of the birth rate. The drop in the marriage rate in Russia, compared to other belligerent countries, was expressed in the following series of figures: England—10%, Belgium—46%, Germany—48%, Russia—58%, Italy—63%, Hungary—68%, France—70%. Compared to other wars, the drop in marriages was expressed by the following data: Table 3. Decrease in the number of marriages (in %). Countries: Russia, France, Germany. World War: 58, 22, 26. Patriotic War: 21, -, -. Crimean War: 13, -, -. Turkish War of 1877: 26, -, -. Japanese War: 18, -, -. Franco-Prussian War of 1870–1871: -, -, -. The drop in the birth rate in Russia, compared to other belligerent countries, was expressed in the following series of figures: Hungary—60%, Germany—49%, France—48%, Belgium—48%, Russia—46%, Italy—43%, England—25%. In previous wars, the drop in the birth rate in Russia did not rise above 14% (Patotric War), 10% (Crimean War), and in France (War of 1870–1871)—13%; in Germany (the same war)—9%. The catastrophe of the birth rate is expressed most vividly and sharply in absolute values of the "undersupply" of the population during the years of the war. The deficit of newborns only in European Russia and only for three years of the war was determined at 5,000,000 "unborn" souls, and within the borders of the entire former Russia (with Poland)—6,500,000 souls. As for the general mortality of the civilian population during the years of the war up to 1918, it does not appear sharply increased in all belligerent countries in the first years of the war; however, this mortality in European countries (Hungary, Belgium, France, England, Italy, Germany), compared to the mortality of 1913, showed an excess of 13–14%; but this value for France, for example, is much lower than the mortality of the civilian population in France in the war of 1870–1871, when the mortality of the civilian population increased by 40%. The year 1918 turned out to be terrible in terms of mortality for the civilian population, but this concerned both belligerent and non-belligerent countries, since the pandemic of the "Spanish disease" was the cause of the exceptionally high mortality. But on the other hand, the mortality of the belligerent countries in connection with direct military losses is colossal. It should be noted that the figures related to this suffer from great inaccuracy and variety; even the periods to which they relate are not entirely exact. While Negrobov for six armies (see above) for the period 1914–1918 determines losses at 5,736,332 (while he attributes only 627,686 to the Russian army), Novoselsky determines the losses of 8 foreign armies (Germany, France, Great Britain without colonies, Australian Commonwealth, Canada, Italy, Serbia, United States of America) at 5,079,660. The calculation of irreversible Russian losses for the first 38 months (from August 1914 to October 1, 1917), made by Dr. Avramov, gives the figure of 711,407, and the calculation made by Dr. Binshtok for the period 1914–1918 gives the figure of Russian irreversible losses of 1,660,000, a figure twice as large as Negrobov's figure. But everyone agrees that these figures are incomplete, and if we keep in mind the data of all belligerent armies for the entire period of the world war, irreversible losses should be defined by a round figure of up to 10,000,000, and Russia's losses—around 2,000,000. Thus, the primary, catastrophic consequences of the world war are a "demographic catastrophe," a catastrophe in the sphere of the natural movement of the population (marriage rate, birth rate, mortality), with an "undersupply" of the population for Russia alone of 6,000,000 souls and irreversible losses and sacrifices (killed and dead) of the world war. Next come "secondary" successive catastrophes. Epidemics must be numbered among them first of all. The first years of the world war in epidemiological respects (both in Europe and with us) proceeded relatively favorably. But 1918 on a global scale was accompanied by the aforementioned grandiose pandemic of the "Spanish flu," from which of the belligerent countries especially suffered: Italy (the number of deaths increased by 72%), Romania, Belgium, France. Germany and England suffered less. But from 1919 to 1922 (mainly in Russia)—to a large extent as a consequence of the world and civil wars and the blockade—pandemics of typhuses begin: typhus, relapsing, typhoid. According to Sysin's data, from 1914 to 1917 there fell ill: with typhoid fever—97,522 people, relapsing fever—75,429, dysentery—64,861, cholera—30,810, typhus—21,093. Over two years—according to his same data—there fell ill in the Red Army: with relapsing fever—780,870, typhus—579,882, and a total of 1,254,752 people, i.e., 25% of the entire composition of the Red Army. The Russian famine of 1921–1922 is also largely connected with the consequences of the world and civil wars and the blockade, and post-war typhuses directly passed into famine and the scurvy epidemic. Morbidity of both the military and civilian population must also be attributed to "secondary" consequences. Here "primary" (direct) and "secondary" consequences are mixed. Wounded and sick military ranks belong to the former.

Negrobot for only six armies (Russian, French, British, Belgian, German, Austro-Hungarian) determines the number of "wounded, shell-shocked, and gas-affected" at 15,579,792 people (including the Russian army, which contributed 3,803,827). According to Dr. Avramov (for 38 months of the war), the number of sick in the army was 5,069,920, and the wounded 3,748,669. Not a single previous war knew such figures of wounded and sick. As for the general morbidity of the civilian population in connection with the war, there are as yet no reasonably substantiated numerical data on this score. There are surveys (Ukraine) which suggest that the consequences of the World War, the Civil War, famine, and blockade significantly changed the entire biology of the population, the degree and nature of its resistance (immunity), and affected the nature of the general morbidity of the entire population. This was particularly evident during the Russian famine of 1921-1922, which was largely a consequence of the war; the famine seemed to act as a reagent to the biological and physical stability of the organism; protein-free edema, enteroptosis, amenorrhea, cryptorchidism, heart neuroses (bradycardia), psychoneuroses, increased cardiovascular morbidity—all this can and should be interpreted as a sharp weakening of the biophysical stability of the organism as a result of the World War, the Civil War, and famine.

It has been firmly and definitively proven that such an exquisite social disease as tuberculosis, in connection with the war, showed a sharp exacerbation and development. It has been precisely established for a number of warring countries (Germany, Austria, Hungary, England, etc.) that the development of tuberculosis sharply increased with the development of the war, and that 1917-1918 showed the greatest development of tuberculosis: from 14.3 per 10,000 inhabitants in Germany in 1913 to 30.0 in 1918; from 25.9 to 40.0 in Austria; from 31.4 to 35.6 in Hungary; from 10.1 in 1913 to 18.0 in 1917 in England. The sad experience of all previous wars speaks of the growth and development of venereal diseases in connection with the war. The same is repeated in connection with the World War (see Venereal Diseases, Table 12). The experience of previous wars speaks of the growth and development of mental illnesses in connection with the war. This is evidenced by the data in Table 4 (see next article).

Table 4. Morbidity per 1,000 people. ! Armies ! Before ! During war !

WARRIORS WARRIORS | | U.S.A.-in war with Spain 0.8

2.6 Russian-in war with Japan 0.6

2.0 ! The same was observed during the World War. Among the "secondary" consequences, one must include such a phenomenon as military refugeeism (see), which reached grandiose proportions during the World War. Refugeeism, in turn, causes immense traumatism, widespread epidemics, increased general morbidity, neuropsychiatric diseases with all physical torments and sufferings, and, above all, immense financial, economic, and national-economic ruin. France, Belgium, and a number of small countries were doomed to almost continuous "refugeeism." When assessing the socio-biological consequences of the World War, naturally, one must by no means be limited to the listed factors; these consequences are infinitely broader in factors, lines, and branches; they must embrace almost all factors and aspects of the national economy, life, labor conditions, and everyday life; from a socio-biological point of view, one must take into account the influence of the war on national nutrition, the housing issue, the state and organization of medical care, etc. Only the entire complex of socio-biological factors can determine the true outcome of the World War in its destructive processes. Science is not yet prepared for such a summation; as noted above, the study of the catastrophic consequences of the World War has only just begun; an immense literature has already been accumulated, and an even greater number of materials and works remain to be accumulated.

M. Gran. Military pathology (pathology of wartime, Kriegspathologie of German authors). Every war drastically changes the lifestyle and living conditions of both the people taking direct part in it and the civilian population; naturally, the course of diseases during a war is also different from that in peacetime. In the history of modern scientific medicine (i.e., since Virchow, approximately from the second half of the 19th century), there have been several major wars (Franco-Prussian, Russo-Turkish, Anglo-Boer, Russo-Japanese, etc.). During these wars, the attention of researchers was almost entirely focused on the course and treatment of wounds and field surgery, because, in Pirogov's words, war is a traumatic epidemic. The works of Pirogov, Klebs, and Arnold in the war of 1870–1871 and others are well known in this field. The last World War of 1914–1918, both in the number of participants and in the number of casualties from wounds and diseases, surpassed all known wars; naturally, medical thought, working intensively at this time in all countries, as a result created a special branch of pathology—military pathology, which touches upon various aspects of diseases and pathological conditions. Based on the experience of the past war, it can be considered that the main conditions affecting health and the special course of diseases during a war are the following. 1. P h y s i c a l tension, fatigue, physical exhaustion. The physical labor that falls to the lot of war participants is very great and uneven. Troops sometimes have to exert superhuman efforts to accomplish a particular combat mission. This excessive strain affects primarily physically and neuro-psychically weak organisms (constitutionally weak, too young or underdeveloped, alcoholics, presclerotic individuals, elderly, neurasthenics, unstable persons, etc.); these individuals quickly drop out of the ranks altogether. In healthy individuals, such excessive fatigue affects, mainly, through general malaise and is sometimes accompanied by the picture of cardiac w e a k n e s s. Since in war one has to reckon not only with the physical labor performed, but also with constant neuro-psychic tension, it is clear that both influence the disorder of cardiac activity. His (Wilhelm His), Kraus, and others point out that the majority of such cardiac disorders belong to so-called neuroses, rather than organic heart diseases, but in some cases, as a result of overwork, long-lasting heart insufficiency is observed, accompanied by cardiac attacks and edema. Excessive fatigue is also accompanied by a whole series of clearly expressed neuro-psychic disorders. Cardiac and neuro-psychic disorders are apparently the only consequences of excessive fatigue. The albuminuria observed after forced marches is a transient phenomenon and has nothing in common with "war nephritis" (Kriegsnephritis), which depends on a whole complex of causes and, mainly, on temperature influences. In any case, the phenomena of fatigue, as well as the various disorders associated with them, are of a transient character. 2. Nutrition. In matters of troop nutrition, one always has to reckon with two factors: a) a sharply altered dietary regimen for people torn away from normal conditions, and b) the impossibility of eating properly during military operations; troops have to starve for several days or remain without hot food for a long time. Such improper nutrition is manifested by frequently observed disturbances of the secretory activity of the stomach, predominantly nervous dyspepsias. It is noted by many German authors that at the beginning of the campaign achylia is more often observed, subsequently replaced by hyperchlorhydria (a fact not sufficiently explained by anyone). Stomach disorders appear especially clearly in post-infectious states (for example, achylia after dysentery or after influenza). Ulcers of the stomach and duodenum do not become more frequent, but manifest themselves in individuals who have had them before. From the side of the intestines, one can note a decrease in chronic constipation and the appearance sometimes of mass diarrheas, while it is difficult to say whether their cause is improper nutrition, bacterial infection, a cold, or a nervous disorder. With a long-lasting war, a period of undernutrition usually sets in, which manifests itself in a whole series of diseases. At the beginning, the majority of authors note an increasing number of volvuli, intussusceptions, and strangulated hernias. Subsequently, other diseases appear, of which the main ones are: 1) scorbutus, 2) edema disease, otherwise starvation or protein-free edema, and 3) a special, poorly studied disease which Lubarsch designates as starvation osteopathy, or epidemic softening of bones. The picture of this disease resembles rickets and osteomalacia. The main symptom is the softening of certain parts of the bone system, predominantly the ribs. 3. T e m p e r a t u r e and meteorological conditions (cold, heat, dampness). Apparently, catching a cold plays a significant role in the etiology and course of such diseases as angina, respiratory catarrhs, pneumonias, pleurisies, muscular and articular rheumatism, influenza, gastrointestinal disorders, and some types of diseases of the urinary organs. In war—more than anywhere else—favorable conditions are created for catching a cold, and all the listed diseases noticeably increase. The influence of cold clearly affects their number: in the German army, such diseases were significantly more numerous during the cold winter of 1916/1917 than in the comparatively warm winter of 1915/1916. His (on the basis of enormous statistical material) divides these diseases into two groups. To the first group he refers anginas, pneumonias, pleurisies, and articular rheumatism. The morbidity rate for these diseases in active units, having risen at the beginning of the war, gradually declined and was on average no higher, and often even lower, than among the civilian population. In other words, the influence of colds on these diseases was not noticeable. It must be remembered at the same time that in peacetime the troops consisted of completely healthy young people, while in war, age groups from 18 to 46 years old were called up almost immediately, whose health was "relative." To the second group, His refers influenzal states and that complex which is customary in reports to be designated as "other diseases of the respiratory tract," as well as diseases of the urinary organs. The morbidity rate in this group remained at the same level throughout the entire war and even increased somewhat towards its end; it always exceeded the morbidity rate of the civilian population. Here the influence of cold is significantly clearer. The increase in the morbidity of urinary organs during the war is attributed, predominantly, to acute nephritis and that disease which Ludwig Müller designates by the term "irritable bladder" (reizbare Blase); the disease is accompanied by polyuria and pollakiuria and depends on the influence of dampness and cold. Regarding acute glomerulonephritis (war nephritis), it must be noted that although its connection with a cold, in the opinion of His and Hirsch, is unquestionable, it can also depend on other causes. The influence of heat is felt significantly less. Sunstrokes are rare; the asphyxial form of heatstroke, the so-called heat asphyxia, is more common, observed during long marches in the heat and sometimes ending in death. The influence of a hot climate (in the tropics) affects, mainly, the increase in tropical infections. By itself, the effect of heat has little impact on the organism. In general, the experience of the past war showed the extraordinary adaptability of the human organism to climatic conditions. 4. Crowding and unsanitary conditions. In the active army, as well as partly in reserve units, it is often impossible to observe even the most primitive rules of hygiene. Crowding of people, dirt, the impossibility of washing and changing underwear lead to a sharp increase in infectious and epidemic diseases. During the war of 1914–1918, the role played in this by various parasites (fleas and especially lice) as transmitters of the infectious principle became particularly clear and prominent. If troops are transferred from afar (for example, the participation of so-called colored troops on the Franco-German front), they can bring in infections uncharacteristic of the given country, and, in turn, diseases uncharacteristic of their native country can be encountered in these troops (for example, mass diseases with primary tuberculosis). It is known that with any war a large number of epidemics develops and that in previous wars losses from epidemics were greater than from direct military actions. 5. Nervous tension and psychic trauma. The constant threat to life, shocks, and experiences that active troops have to endure are so great that it is necessary to take into account their influence on all diseases. Somatic diseases are inextricably linked with the general state of the nervous system, and therefore the influence of such factors as cold, fatigue, infection, etc., must be linked with the general neuro-psychic state of the patients. On the one hand, nervous shocks and a depressed psyche can worsen the course of the disease; on the other hand, constant nervous tension can stimulate the vital activity of the organism.

Statistics establish an increase in nervous and mental morbidity in the troops, but it is possible that this increase depends not so much on the horrors of war as on the exhausting influence of campaigns, traumatization, alcoholism, malnutrition, etc.; the same can be said about neuroses: they manifest themselves predominantly in neuropathics. 6. Traumatic injuries, wounds, bruises, gas poisonings. The direct effect of these factors on the organism is self-evident; the only interesting question is whether they can exert an influence on the course of other diseases. In peacetime pathology, it is generally accepted that trauma as a predisposed, and sometimes as an etiological moment, can play a role mainly in diabetes, malignant tumors, and in tuberculosis. The experience of the past war showed that the percentage of morbidity from diabetes both in the rear and at the front decreased during the war. von Noorden considers that trauma to the pancreas is hardly likely to lead to diabetes and that traumatically-neurogenic diabetes, resulting from an injury to the nervous system, was not observed during the war. As for tumors, the question arises here whether a single trauma (wound) can have an etiological significance in the development of a tumor; this relates mainly to bone sarcomas and brain gliomas. Hansemann, Aschoff, and others resolve this question in the negative sense, because, despite the enormous number of bone and brain wounds, no increase in the number of sarcomas and gliomas was observed either during the war or after it; similarly, no development of tumors was observed at the site of the wound, tracts, fistulas, and scars. Apparently, the war does not exert any influence on the increase in the number of tumors. As for tuberculosis, the question of whether a blow or a wound can cause the exacerbation of a latent tuberculosis is resolved differently by various authors. The majority, without fully denying this possibility, point to the extreme rarity of evidentiary cases. On the contrary, it can be considered fully proven that an existing tubercular process can sharply worsen under the influence of trauma or gas poisoning. For the civilian population during the war, living conditions also change somewhat: here, in protracted wars, malnutrition comes to the fore, sometimes reaching true famine, as was, for example, in Germany and Austria in the past war. Many diseases, which German authors call "military," for example, "war edema" (Kriegsödeme), "war amenorrhea" (Kriegsamenorrhoe), actually do not depend on the war, but must be attributed to the consequences of famine. In our country, these diseases appeared after the war, during the general devastation. In general, all the listed factors are closely intertwined with each other, and it is difficult to isolate the significance of each of them separately. In general, diseases that are most often encountered during war can be divided into three groups. 1. Diseases specific to war; these include injuries in the broad sense of the word, i.e., a) damage caused directly by military operations: wounds, wound infections (of which tetanus and gas, malignant edema gangrene are of particular importance); b) damage caused by crude physical impacts, e.g., falling from aircraft, concussions, contusions; c) damage caused by thermal factors: burns, heat stroke, frostbite; d) damage caused by chemical factors, such as gas poisonings (see Chemical warfare agents). 2. Diseases characteristic of war. These belong predominantly to infections and epidemic diseases inherent to any war, such as: abdominal typhus, relapsing fever, and typhus; paratyphoid fevers, dysentery, cholera, malaria, meningococcal meningitis, epidemic jaundice (Botkin-Weil disease), epidemic influenza ("Spanish disease"), lethargic encephalitis, and a special disease, the so-called trench or five-day fever. 3. Diseases not characteristic of war, but proceeding somewhat differently than in peacetime. Special attention here is deserved by heart diseases (predominantly neuroses), gastrointestinal diseases, helminthic infestations, acute nephritis (war nephritis), tuberculosis (increase predominantly in acute forms of tuberculosis), neuroses, and psychoses. The significance of military pathology is very great not only for military, but mainly for peacetime. Suffice it to indicate that from the 1914–1918 war there are the following achievements and discoveries: the pathology of typhus has been entirely developed (the method of spreading the infection has been clarified, the patho-anatomical substrate of the disease has been discovered, diagnostic methods have been developed), the pathology has been entirely developed and the causative agent of Botkin-Weil disease has been discovered, the pathology and pathological anatomy of malaria, relapsing fever, dysentery, wound infections, and wounds in general have been significantly developed, new diseases have been introduced into pathology, such as, for example, trench fever, "Spanish disease" (see Influenza), lethargic encephalitis, hunger edema; the significance of anti-typhoid and anti-cholera vaccinations has been clarified, and so on. By a general enumeration of what has been done, the goal of military pathology is also partly indicated—to use the large material placed in special conditions to clarify the essence of diseases and their course. An enormous aid to this must be the correct organization of research work in the army and, in particular, of autopsies. Unfortunately, little attention was paid to this side of the matter in all countries. Only in Germany, and even then not from the very beginning of the war, but starting from the spring of 1916, at the insistence of the well-known pathologist Aschoff, were field prosectoriums organized in the active army and the positions of army pathologists (Armeepathologen) introduced in the active army and consulting pathologists (beratende Pathologen) in every rear medical institution. Thanks to such an arrangement, about 70,000 military autopsies were performed in Germany during the war, and a huge museum of military 587 pathological anatomy was formed in Berlin. On the Russian fronts, attention was paid mainly to the organization of bacteriological laboratories, the work and significance of which were very great. The correct organization of autopsies was arranged only at a very small number of rear evacuation points, predominantly of the Western Front (Minsk, Novo-Borisov, Bobruisk, Orsha). There were no field prosectoriums. Meanwhile, it is especially important to perform autopsies in the most detailed manner, weighing and measuring all the organs of those killed on the battlefield, since much can be extracted from the obtained numerical data to elucidate the average norm and resolve many important questions of constitution and anthropology, since under no other conditions can such a quantity of corpses of healthy people be obtained. It is even more important for military pathology to properly organize general medical statistics.

M. Alekseyev. Military psychoses. The question of the existence of military psychoses as a separate nosological entity, as special forms of mental diseases caused specifically by war, is answered in the negative based on the experience of previous wars and the war of 1914–18. But there is no doubt that war, and especially the World War, which created an exceptional experiment in its scale and intensity for the study of mass traumatization, could not fail to leave a specific imprint on all mental diseases of the wartime era, wherein exogenous factors (exhaustion, trauma, infections), alongside affective experiences, played the greatest role in the development of all kinds of psychotic outbreaks and psychopathic reactions. The experience of war showed that the participation of an overwhelming number of external factors did not affect the usual clinical forms of psychoses (schizophrenia, manic-depressive psychosis, epilepsy, progressive paralysis) to any significant degree, contributing only in some cases to the manifestation of their latent course. According to statistical data, the total number of these forms did not increase noticeably. However, there is no doubt about the fact of an increase in the total number of mental diseases during the war, as can be seen from the reports of all preceding wars, which must be attributed mainly to traumatogenic and psychogenic forms. In the German army during the Franco-Prussian War of 1870–71, the number of the mentally ill rose from 0.37‰ before the war to 0.54‰ in the first year of the war, to 0.51‰ in 1871, and to 0.93‰ in 1872, dropping to 0.2–0.3‰ in subsequent years. In the British army during the Anglo-Boer War, mental diseases reached 2.5‰; before the war they constituted 1.4‰, and after it 1.2‰. In the Russo-Japanese War, the number of the mentally ill in the Russian army was 2‰; whereas the average number for the 10 years preceding the war was only 0.6‰. The same phenomenon is noted during the Spanish-American and Balkan wars. Everywhere, mental morbidity in the army increases by 3 to 4 times compared to peacetime, wherein the growth in the number of psychoses gradually increases as the war lasts longer, with the maximum occurring towards the end of the war. The experience of the last World War could not be fully encompassed in a separate numerical summary, especially since the mighty wave of revolution that surged immediately after the maximum of general tension and exhaustion towards the end of the war, with its heroic ideological upsurge and elemental destructive forces, largely obscured this extraordinary wartime experience with new overwhelming material from the field of psychogenic and reactive states. The increase in the total number of military psychoses must be attributed to exogenous and psychogenic disorders. According to data from the statistical psychiatric bureau in 1917 (P. P. Kashchenko), obtained over two years from the reports of 23 hospitals, the percentage of individual forms in relation to the total number of all discharged patients (6,064) is expressed in the following figures: 1. Congenital mental underdevelopment . . 7.3 2. Psychoses of all forms (excluding hysterical neurasthenia, epilepsy, and trauma) .................... 40.0 3. Convalescents and recovered after psychoses ................ 0.4 4. Hysteria, neurasthenia, and hystero-neurasthenia with psychoses ..............

11.1 6. Epilepsy with psychopathic complications . .

4.7 7. Epilepsy without psychopathic complications . .

The largest number of works in foreign and Russian literature on war psychoses is devoted to observations in the field of traumatic and psychogenic-hysteroid forms. Among the cases of traumatic psychoneurosis in war, two categories stand out: in one, commotional symptoms with an anatomical substrate (in the form of circulatory disorders or molecular changes in the brain) predominate; in the other, psychogenic-hysteroid symptoms play the dominant role, with phenomena mainly of emotional shock, while the factor of exhaustion also manifests itself here. Both types of symptoms can be combined. In the former (organic) cases, one is dealing both with a peculiar concussion of the central nervous system and sometimes with damage to peripheral apparatuses, most often in the auditory region. Korsakov's syndrome and other memory disorders are not uncommon here. As for the second group of cases, what stands out first of all is the disorder usually occurring on the basis of exhaustion with an emotionally hyperesthetic state of weakness, described by Bonhoeffer, which, mixing with other psychogenic and psychopathic manifestations (especially in individuals with an anxious character), is designated by some authors (Avtokratov, Birnbaum) as neurasthenic war psychosis. Among other disorders, clinical pictures of a depressive-stuporous character are described, sometimes with features of anxious tension, sometimes with delirious features, with theatrical, childish behavior, and with Ganser's twilight state. Sometimes patients relive battle scenes with the enemy with all the manifestations of fear. Gaupp considers these pictures identical to the cases of "apathetic stupor" mentioned in the 1871 sanitary report, with transition to "intermittent mania of the epileptoid type" (recovery after a few days). Stieffler, from observations of those besieged in Przemyśl, found 15% of acute, mostly rapidly passing psychoses, with amentive-stuporous and hallucinatory-delirious clinical pictures (with delusions and confabulations, often colored by rose-tinted dreams and desires); cases of acute delirium with a fatal outcome were observed. Sukhanov describes two cases of acute confusion with delusions of enemy captivity in mentally feeble individuals, as well as a case with a depressive-agitated syndrome, the latter of which he is inclined to interpret as the onset of schizophrenia. According to Amenitsky's observations at the front, out of 29 psychiatric patients who arrived from the combat positions in 1915, 4 had a twilight state (2 amentive, 1 with stupor, 1 with absurd behavior and answers of the Ganser type). The central point is the question of whether the development of such acute outbreaks and such reactions is possible outside of psychopathic constitutions. Opinions differ, apparently depending more on whether observations were made near combat positions or in the rear. The staggering impressions of the combat environment can cause the same reactions without special predisposition as in psychopaths (twilight and poriomanic states, states of pathological affect and pathological intoxication, etc.). Observations of the last war, in Bonhoeffer's opinion, showed that an excessively prolonged and intense struggle between the idea of duty regarding participation in combat and the natural drive for self-preservation gradually leads to the victory of the drive over the idea, and then a tendency toward defensive reactions easily develops with an unconsciously instinctive desire to escape reality into fantastic-delusional experiences (flight into psychosis). It is not accidental that in view of the particularly severe conditions of war, the distinction between hysteria and malingering was often blurred, and such hysterical defensive reactions—as phylogenetically old and primitive reactions (Kraepelin), suppressed only by the influence of culture and resurrecting anew under the influence of the animal feeling of fear in war—could be resorted to by individuals who had been healthy until then. Where the acute symptoms of shock do not pass within a few days and phenomena such as hysterical paralysis, astasia-abasia, deafness, mutism, tremor, pseudodementia, stupor, etc., become fixed in the patient, it is usually a question of secondary psychogenic factors that arose after the action of shock, which are most often associated with the unwillingness to be subjected to further dangers of war. In prisoners of war, who are not threatened with participation in subsequent military operations, few hysterical reactions were observed. It is nevertheless unquestionable that the predominant number of psychogenic-hysteroid reactions were given by psychopathic and predisposed individuals (especially of the emotionally labile type). For some psychopaths (psychasthenics, hypochondriacs), frontline life, on the contrary, turned out to be useful in terms of a tonic and distracting influence. Some epileptics and epileptoids rushed to the front with special enthusiasm and displayed wonders of bravery. Certain schizophrenics with autistic inhibition also unexpectedly displayed bravery and fearlessness in risky situations. Infectious psychoses, observed in enormous numbers in war in connection with epidemics of typhoid, typhus, and relapsing fevers, proceeded in the acme stage by the type of febrile delirium, with an abundance of hallucinations, fantastic weaves, and confabulations from the combat environment (the majority speak of received military awards); while in the stage of temperature drop, especially in connection with the crisis in relapsing fever patients (according to Amenitsky's observations), they proceeded by the type of epileptiform excitement. In many typhus patients, phenomena of residual delirium were observed upon completion of the disease. Alcohol psychoses in the World War were observed strikingly rarely, even in Germany, where there was no prohibition on the sale of wine. A comparison with the statistics of the Russo-Japanese War shows that back then, over 11 months, the total number of alcohol psychoses was almost twice as large as during the four years of the last war in the entire German army. The large number of alcohol psychoses among officers in the Russo-Japanese War (in connection with which mental morbidity among officers exceeded morbidity among soldiers tenfold) was compensated in the last war by an increase in functional psychoneuroses (23% according to Reformatsky's statistics). Also noteworthy is the large number of cases of pathological intoxication in war (the influence of exhausting moments). In place of alcohol, an increased craving for morphine and cocaine developed. In the course of the usual clinical forms of psychoses during war, certain features are also noted. In all forms, the content of the patients' delusions reflects in one way or another the impressions of the surrounding combat environment (pathoplastics) only in fresh, initial outbreaks; in later stages—in schizophrenia, progressive paralysis—these impressions pass almost without a trace. In schizophrenia, it is often difficult to decide whether one is dealing with the onset of a disease process or with an exogenous influence on an already existing psychosis. Part of the cases that were described as mobilization psychosis were an undoubted exacerbation of schizophrenia. In war, difficulties also arose in recognizing schizophrenia and psychogeny (hysterics were considered schizophrenics). Regarding manic-depressive psychosis, as the one most connected with the emotive sphere, it seemed most probable that cases of the disease would become more frequent under the staggering impact of combat events, and yet only a limited number of authors (Stieffler) found a larger percentage of manic-depressive psychosis compared to peacetime. Most authors note only a comparative predominance of depressive phases over manic ones. A tendency toward depressive states was also pointed out in previous observations by Russian authors, still during the period of dominance of symptomatic diagnoses in psychiatry (in Sukhanov—depressive-amentive, stuporous, and hypochondriac states based on materials from the Russo-Japanese War; in Ozeretskovsky and Shaikevich—on peacetime material). Regarding progressive paralysis, most authors believe that the hazards of war did not contribute to an increase in the frequency of cases of the disease. Some observations indicate a more accelerated and even galloping course of paralysis during war. The opinion that in an overfatigued organism syphilis is preferentially localized in the nervous system did not find factual confirmation in the material of war. Regarding epilepsy, trauma and concussion during war in many cases played the role of a provoking moment in the development of seizures. Also worthy of mention are seizures in the concussed with hysteroid twilight states, with vivid experiences of active participation in the combat environment (commanding). War provides abundant material for the study of mass psychopathology and mass hypnosis, being in itself a consequence of the active manifestation of overvalued ideas dominating and accumulating in a given situation. These ideas assume 1) a megalomanic and chauvinistic coloration during periods of military success and 2) a depressive one with obsessive-paranoid elements during failures at the front (spy mania), and this general coloration of mass mood naturally is also reflected in the content of psychoses, especially exogenous and psychogenic ones.

The negative aspects of the impact of war on the mental health of the population—the increase in psychopathy in connection with general traumatization, the enormous mass of traumatic invalids, drug addiction, the devaluation of human life, the increase in crime, antisocial elements, and so on—all these horrors of war stand vividly before our eyes, only gradually being outlived in the conditions of the powerful growth of modern construction.

D. Amelinzky. I