1111------ - VOL. XII N0.4 UNITED STATES NAVAL MEDICAL BULLETIN PUBLISHED FOR THE INFORMATION OF THE MEDICAL DEPARTMENT OF THE SERVICE ISSUED BY THE BUREAU OF MEDICINE AND SURGERY NAVY DEPARTMENT 01\ ISIOS OF PU BU CATIONS COMMA'NOER J S TAYLOR, MEDICAL CORPS U S SA\Y IS CHARGE OCTOBER, 1918 ( QilARTERLY) W,\SHINGTON CO\'f:RNMENT PRINTING OFFICF. 1918 , VOL. XII no." UNITED ST A TES NAVAL MEDICAL BULLETIN PUBLISHED FOR THE INFORMATION OF THE MEDICAL DEPARTMENT OF THE SERVICE ISSUED BY THE BUREAU OF MEDICINE AND SURGERY NAVY DEPARTMENT DIVISION OF PUBLICATIONS COMMANDER J. S. TAYLOR, MEDICAL CORPS, U.S. NAVY IN CHARGE OCTOBER, 1918 ( QlJARTERL Y) WASHINGTON GOVERNMENT PRINTING OFFICE 1918 NAVY DEPARTME:XT, Washington, March go, 1907. This UNITED STA'l'ES NAVAL MEDICAL BULLETIN is published bv direction of the department for the timely information of the MeRITIC CALCULI IN TUE KIDNEY. By Lieutenant G. G. Ross, Medical Corps, U. 8. N................. 7!!0 FOREIOX BODY IN BRONCHUS. By Lieutenant. E.W. GouLD, Medical Corps, t". S. N... ... . .. .. . .. . . 7!!1 A CASE OF MULTIPLE SEBACl:ous CYSTS. By Lieutenant G. A. GRAY, Medical Corps, U.S. N.......... .. . . .. . 7:?2 .A CASE OF U!l.'DULA NT FEVER. By Lieutenant Commandor J.C. PARHAM, Medical Corps, U.S. N... 723 PROGRESS IN MEDICAL i:::cIENCES: GENERAL MEDICINE.-Treatmcnt of malaria.-Diagnosis of thyroid dis- ordere.-The blood plasma. and the kidnoya.-Sensitized vaccines.- X-ray diagnosis of pulmonary tuberculosis.-Trcatment of epidemic cerebra-spinal meningitis.- Treatment of Graves' disease by corpus luteum.-Enlargcd cervical lymph nodes............................. 725 SunGERY.-Purgation before operation.-Painful amputation stumps. Abdominal solf-protcclion.-Typhus iever.-Tonsillectomyin tho tubcr- culous.-Prostbotic a11plinnces.-Surgical use of human fat.-Prophy· !axis of typhus.-Transfusion for typhus.-Treatment of itch.......... 742 HYGIENE AND SA)'llTATION.-Swi.m.ming pools ....•........ - ... - - . - - . . . . . ;5; PATHOLOGY, BACTERIOLOGY AND ANIMAL PARABITOLOGY.-Diphtheroid organisms.-Flora of male genitalin.................................. i59 MILITARY, LEGAL AND I\'.DUSTRIAL.-War and psychology.-Thc Jew in America.-Relalion of drink to work and health.-Damagc by the air hammcr.-Yencrcal prophylaxis.-Vital statistics of the Philippines.- Statistics of Japanese Navy.......................................... 76".! REPORTS: REPORT OF 140 CASES OF PNEUMONIA. By Lieutenant. Commander L. W. McGumE, Modiral Corps, U. S. N. 7i5 REPORT OF 100 CASES Ot' PNEUMONIA. By Lieutenant F. J. DEVER and Lieutenant R. S. BOLES, Medical Corps, U.S. N..... .............. . ....... ........................ 7i8 EMPYEMA CO:MPLICATING PNEUMONIA. By Liou tenant J. J. TOLAND, Medical Corps, U. S. N............... 783 ,:>o. .f. TABLE OF COXTEXTS. v REPORTS-Continu<'d. P~ TBEATllE-.;T OP E:\!PYE~A. By I.ieutenant (J. G.) n. c. °WILLIS, ~fcdical Corps, u. s. x...... .. .. 786 OPERAn-.;o U)llTS AT THE FRO)o!T. By Lieutenant Commander R. G. LECOXTE, Medical Corps, U.S. N .. 787 PI.AGUE Di C!IlXA AND THE FAR EAST. By Lieutenant H. M. STENHOUSE, Medical Corps, U. S. X.......... 789 REUEP WORK AT GUATEMALA CITY. By J,ieutcnant S. M. 'fAYLOR, Medical Corps, U.S. N............... 796 As EPIDEllIC OF 3-DAY FEVER. Dy Lieutenant D. FERGUSON, Medical Corps, U.S. N..... ... .. . . . .. WO A DE.HU FROM ANTHRAX. Dr LicutenantH. B. LEIOIBERO, Medical Corps, U.S. N....... .• . . 801 IlAL.·ISTIDIU'C COLI IN THE VIRGIN ISLANDS. By PhnrmacisL('l'.) II. RYDEEN, U.S. N....... ....... . .... .. ...... 802 TETA:-OUS INFECTION. Dy Lieutenant Commander J unsoN DALAN o, Medical Corps, U. S. X . 802 UNITED ST.ATES XAVAL ~fEDICAL SCHOOL LABORATORlE$: .J.nnmo:-is TO THE PATHOLOGICAL COLLECTION.......................... 805 BOOK XOTICES. ...... ..... ... ................... ................. ..... 805 AXXOl'XCE~fENTS.. .... ........................ .................. ...... 813 XOTICE TO SERVICE CO~TRIBUTORS. ... ............. ............. . 815 IXDEX.... .... .. ... . . .. ... .. ......... .. . . . .. ......... ... . .. ............. Sli PREFACE. 'fhe publicntion nnd issue of a quarterly bulletin by the Burenu of Medicine and Surgery contemplates the timely distribution 0£ such information as is deemed of value to the personnel of the Medical Depar1ment of the Navy in the performance of their duties, with the 11Jtirn:ite object that they may continue to advance in proficiency in rc::-pcct to all of their responsibilities. It is proposed that the NAVAL MEDICAL BULLETrn shall embody matters relating to hygiene, tropical and preventive medicine, pn- thology, laboratory suggestions, chemistry and pharmacy, advanced thcmpentics, surgery, dentistry, medical department organization for battle, and nil other matters of more or less professional interest ancl importance undei· the conditions peculiar to the service and pertain- ing to the physical welfare of the naval personnel. It is believed that the corps as a whole should profit, to the good of the ::crvice, out of the experience and ·observations of the indi\idual. There are many excellent special reports and notes beyond the scope of my annual report being sent in from stations and ships, and by communicating the information they contain (either in their entirety or in parts as extracts) throughout the service, not only will they be employed to some purpose ns merited, but all medical officers wiH thus be brought into closer professional intercourse and be offered a means to keep abreast of the times. Reviews of advances in medical sciences of special professional intcrc::it to the service, as published in foreign and home journals, will be given particular attention. While certain medical oilict'1~ will regularly contribute to this work, it is urged that all others cooperate by submitting such abstracts :from the literature as they may at any time deem appropriate. Information received from all sources will be used. and the bureau extends an invitation to all officers to prepare and forward. with a new to publication, contributions on subjects relating to the profes- sion in any of its allied branches. But it is to be understood that the bureau does not necessarily undertake to indorse all views and opinions expressed in these pages. w. (). BRAISTED, Surgeon General United States l'itary. VlJ > I NTERIOR VIEW OF A WARD IN THE HOTEL DIEU OF PARIS IN THE SIXTEENTH CENTURY. Facsimile of a picture at the head of indulgences sold by the Archlshop of Bourees (1521-1525) for the support of the H6tel Dleu of Paris. (Reproduced through the courtesy of H. Champion, 9, Quai Voltaire. Paris.) U.S. NAVAL ~IEDICAL BULLErrIN. Yot. XII OCTOBER, 1918. No. 4. SPECIAL ARTICLES. REPORT ON HEART MURMURS IN RECRUITS. By .T. F. B. Conm:rno, Lieutenant Commander. :\!. C., United Stales Navy (net.). Preliminary.-By the theory of probabilities it is proved ihal the incidence of any particular event in a sufficiently large number is a fixed quantity. Thus there is a center of American population geo- graphically fixed, an American height and weighl, etc., which do not Yary over long periods. It was Qnetelet, one of the founders of onr modern system of life insurance, who showed that in the constant French population the number of even unusual and rare forms or suicide remained constant. The average yearly temperature of any point upon the earth's surface is a constant quantity. This constancy depends upon the fact that the average conditions are the same from year to year. If, however, some average which has remained con- stant for a long while, begins to change, either rapicliy or gradually it must be from some deep-lying or general cause. Thus the incidence of consumption for the total population was some years ago prac- tically constant, while recently it has been showing a continual de- crease. This we lmow to be due to active modern methods for its prevention and cure. Likewise the incidence of heart disease for the total population is gradually increasing, but we clo not as yet lmow the reason. It has been known for a long time that lesions of the rnln~s of the heart are in the great majority of cases, due to the poisons of certain acute infectious diseases-rheumatic (micrococcus) fover, i::cnrlet feYer. typhoid feyer, mensles, diphtheria, etc.-and almost inYariably it is the left heart which is affeded-mitral and aortic lesions It has been the experience and opinion of the profession, until recently shared by the writer, that lesions of the right heart were compara- tfrely rare. Thus Satterthwaite states that l<>sions of the pulmonary rnlves are only one-tenth of all valve lesions. He says that his statis- tics are that thl',V are not due to any Je.-.ion of the ::;emilunar 'a1Yes them,,,eh·es, but rather to a con"triction of the , entriculo-ttrterial orifice ·which may extend lo some distance 011 both :-ide-. of the vah·e. The majority of the pulmouic mumrnrs occur among tlthletes and I b:we de-.i!?"llatetl them as athletic murmurs. They are found chiefly 8111011!! 1·unner:s, though they occur in all forms of a.thl<'tics where there j ... a steady, prolonged grind. If a heart be examined after a .Mnrallwn. it will be found lo be acutely dilated. Percn<:sion "'ill cu:-;ily ~ho'' that the borders of dnllness a.re markedly extended be- yoml the norm1tl area. The best way to demonstrate this is to mark ~ut the a 1·ea of cluDnes::; "7ith nitra.tc of siher before the race and dircrtl~· :iftt'r. It ''ill be found that it will take senral hour:; before the heart retracts to its old area. Thn strain of a race is thrown nlmo t wholly upon lhe right heart. The left heart participates to a much le::.-:. degree. The call is for bloocl nnd air in the ln11gs and the ri:?ht heart endeaYors to supply a double amount of the fonncr. The pain in the side is a symptom of this abnornrn.1 effort. ~\..nother snb- jccth·e :-ymptom is the agonized look on the face of a runner as he doc ... the last 75 yards' sprint after a. long race. The Greek word 'a·:wvl2 means both agony and an exhausti\'e contest. In the ancient Olympian gitmes a foot race or a wrestling bout was called ~.'·f(r)'lf.7.. It j, :,ignificnnt that no man ever wins a Marathon twice been.use his heart has been permanently injured. The first Marathoner is said to haYo dropped dead at the finish. It is likewise significant that the career of all runners is usually short. ... \.ft er maJ,ing their best m111·k,.. they rapidly decline and they nc1er " come back.'' For Yarious reasons nearly all of the athletes around Boslou, both profe. ... ,,,ional nnd nmateur, haw sought enlistment in the Xnrnl Re- scrre. Some said it was because of their great lon~ for the :-ea; others becau,.e they thought it safest. This undoubtedly accounts for the !!Teat nu111ber of pulmonary murmurs found. Profes-.ional coaches, of com~e. know nothing about the heart and medical athletic nch-i~ers nm not heart specialists and usually incapable of makin~ a 1liscrim- inating diagnosis. Otherwise the conditions of which I hn,-e written woulatlwloyy.-'fhe pathological history of thes~ cases :;eems to be n:-; follow:, : At first, after each abnormal dilation. the hen rt con- tract,.. t-0 its normal size, or nearly so. But n phy,;iological hyper- troph.v ~ ccompanies these efforts and the pulmonary orifice. instead of ·contra ting to its former dimensions, cYentually O\·ercontracts and heeomes slightly narrowed. This may be furthered by the de- 582 CORDEIRO-HEART ::'IIURMURS IX RECRUITS. velopmcnt of new muscular tissue about the orifice. In a whole series of cases it is possible to follow the process from beginning to encry serious. They are told that their condition is not serious unles-: there is marked hypertrophy or other valYcs arc implicated, but all are always advised to stop running and all gruelling contests. The affection is not considered a lesion of the semilunar Yah-es, which are probably in no way directly affected, but rather a de- formation of the orifice. But the murmur is not functional, as the term is usually understood, since it is permanent and probably rep- resc.:nts a definite anatomical (pathological) condition. Its direct influence on the duration of life is probably slight unless the causes which produced it are persisted in. But no surgeon, after hearing one of these loud murmurs, would be willing to anaesthetize the subject for an operation "de complaisance," or if he did so, it would be only with the greatest precautions. Where an operation was im- pcmtive, the patient would experience a danger which would be nonexistent i£ his heart were sound. ·The importance 0£ the ttbove discussion from a militnr~· point of view must be evident. "\Ve shall assume that all the points made have been established, but the fullest investigation is desirable and necessary so that all possible doubt and mistakes may be cleared up. Having examined recently a large number of athlete:;. professional and amateur, the question occurs to the writer whether they are not of distinctly less nlue from a military point of view thnn the n,·er- nge normal man. It seems that this must be answered affirmatively. It may be thnt one of the reforms springing out of this wnr will be-not the abolition of athletics. but a revision of our present insane athletic system. Physical exercise from a recreational and hygienic point of view is necessary, bnt bP.yoncl that point is a waste of time and may be injurious. Track athletics among boys is criminal, nnd among their cldel's is of no value to the participants or the commu- nity. but on the contrary tencls to spoil what would otherwise hnve been good military material. The Loxer who remains in a comatose 584 AXDERS-OARDJAC AXD TI;BERCULUl DISEASE. condition from .1 minutes to an hour. or who suffers a hrmorrhn!!e into the brain. does not improYc his body or his mind. but in l'cbut- tal it may he sairl that he usually has so little mind to start '' ith thnt any alteration is of slight importance. It may be that onr institu- tions of learning, instead of turning out half educated foot-ball hrroes will deYelop mental athletes, and it will be recognized thnt the mind is of much more imporhnce than the bod.v. Finally the writer would sny that he is nb,,olutely without pr<'juclicc in these matters. Ile is not against athletics per se, but only against those foolish and Yicious forms which can be clearly proved to be in JUrlOUS. PHYSICAL DIAGNOSIS, PREVENTIVE TREATMENT, AND RECONSTRUCTION IN RELATION TO CARDIAC AND TUBERCULAR DISEASE. By II. S. ANDERS, A. ~I., ~. 0., I.llt.ss con- ::-tnntly indulged in while 've walk and work, run ancl climb, anrn·irn11111l'nt whieh thus inherently discriminates against the Navy must be com- pen~ated for by a steady and efficient physical supplement, if the highe't degree of health, vigor, endurance, efficiency, and cheerful morale are to be developed and sustained. f'a1diac u·eaknc.ss.-Right here the objecfrve examinntion of the henrt b~· phy~ica 1 methods rules supremely. Whether n~·ociat1•d or not with incipient or distinct disorders in the periphrrnl 'ac:cnlnr ".Y•1em, eardiac weakne$~-- hig four A:;-;: Auto- intoxic:ation (including acidosis); athleticism; alcoholism; nnxiety. To these should be added as a very Jim and Yirull'nt cnu:se chronic streptococcus infection, howeYer minute and remote or obscure the focus may happen to be. A final word pertaining to middle-aged men, parlicularly ofi1ce1 of the Xayy, arnl our s1wt"ific responsibility in detecting incipient phy ... j. cal signs of the cardiac affections to which they arc peculiarly s11hjeet. Perhaps 110 lictll'r classification need be consic1ere) Auto-toxemic (metabolic). ( 6) Myasthenic. (7) Psychoneurotic. Occasionally, even in early cases of tuberculosis, the only promj. nent symptoms may have been either gastric or hemoptytic. ATHLETICS AND THEI R RELATI ON TO WAR. By D. F. LuBY, Lieutenant, ll. c .. United States Navy. The withering effect of the great war is felt all over the world. Like a huge plowshare it rips up the traditions of yesterday, turns oYer the moss and dust which :for years have been accumulating within the institutions that are most vitnl to us and disclose, fallacies and false prophets, bringing us face to fa.ce with the neces- sity for radical change in many departments of life. The American system of athletics may be regarded as one of our national institutions, nnd through its channels pours the 'igor of the Xation, but it is only at a critica.l time like the present that there can come a general appreciation of the sad fact that for year:-; atlt- "letics in America have existed only for the sake of contests and that these contests baYe been developed, not primarily to upbuild the splendid youth of the land, but rather to satisfy the appetite for pleasure of a volatile and somewhat hysterical public. Twenty-fiYe centuri<'s ago a great nation had come to realize the £n.11 Ynlue of training its youth and was rewarded with victories which gv.ve ln.'-t· ing benefits nnd led up to a high plane of civilization. For the first time in the history of America. we are taught by the pen >troting thrust of war the real meaning and the real \alue of athletics nnd we hn.\e a vision of what they might do for the thousands of boy:; enger to strengthen their bodies, that they mny giYc the ·best to their country. In spite of the time and the money devoted to athletics nnd the hu~e interest which this subject provokes now when physical strenath and endurance is suddenly needed, we realize that we arc not an athletic people, but a people o.f athletic specialisl'l. and. becnu!'c of the urgency of the situation, we see our armic>s attc>mptin!! a rnpid development covering a period of 6 months or a year when the period of development should have covered at least 20 years. .. The athletics that count. Free physical tralninii at Cornell Medical School for men rejected by Navy recruiting offices . 592 I ?\O. 4. LUllY-ATllLETICS AND TREIB RELATION TO WAR. 593 It is the purpose of this article to draw attention to the fallacies of our nthletic ~y:-tcm ns dcnloped up to the pre.."cnt time. to point out the u:;cles.;;,ness of the object sought, and to assert thnt there was 110 !!llill but rather !'eriou~ loss to those who partici1>atetc has now become the r<:'nl kine o1 the college world. All· t,hosc who lo\·c good sport watch him nnd follow his example. He feels him~clI an Pssential and int<:'gral part of the school nnd tmins fai Lh fnlly. p11nisbes his bocly, makes eYcry sacrifice, strive"' with sup<'rhuman strength to !lccomplish the nlloted task ancl r<:'tain for as long as possible the halo of respect and nrlmirntion which Yic- tory brings him. Ile is too young to realize what the career of col- lege champion involves in the way of disaster to his body. and per- haps "·ould care little for the tlu·eat of future disaster, so long ll!' he coul THEIR RELATIOX TO WAR. 595 The first reform fr1 athletics rt•lated to proft•,,,..ionali..:m; later there wa ... n Je. .... ,.. radical reformation. People bcgnn to :tl:ik if the college athlete did any ~tud~'ing and pa::>:>ed hi::. examin.ttiotl::>. _\. cJi.•po-.i- tion now appeared1ola::-tic re- ts. The nniYer:>ity, like the preparatory school, rewards the effort::; of thc.<;t• fortunate men with all the honors at hand. and it is the least thttl can be ginn them in return £or the real sacrifices they makc. It i::> n. well-known fact that the body nccommoclntt-s it:self quickly to nil manner of changes, ancl this is perfect!:'-· true in tlic ca..:e of the boy who, looking forward to a uniYersity career. he~ins to specialize in :-ome lin<' of athletics while still in a high school or ~mmmar school. Thanks to this adaptability he is not conscious of the trace his steps, a.long the ronte already trod. h_v tnking acfo·e 596 LUBY-ATHLETICS AND TIIF.IR RELATION TO WAR. ,.Ill.XU, physical exercise in slowly diminishing amount for a peri0. I could name more than one friend or acquaintance who, after n brilliant career as a star athlete, has succumbed to diseases which those with well-developed and well-balanced bodies should success- fully resist. I could mention by name more than one ex-champion who has died or broken down following the terrible \Vear and tear of an athletic career. I could mention more than one man, whose name was well lmown throughout the country, who is no longer with us because an athletic career left him in what we might call a burnecl- out condition, with marked lowering of body tone and without that reserYe force so necessary to resist bacterial invasion. Dr. R. E. Coughlin, as early as 1905, called the attention of the medical profession to the high death rate among athletes. He is corroborated by many other writers and students-men like Lee, of Columbia; Abbott, of the University of Pennsylvania; Darli11gton, of New York; Savage, of Pittsburgh, etc. Surgeon General Charles F. Stokes, United States Navy, in his annual report for 1912, spoke in no uncertain language of the disastrous effect of athleticism upon health. While the number of retirements and deaths for 580 non- athletes in a certain period amounted to 22, there were 21 casualties in about the same number of athletes, despite the fact that the latter arc supposed to come from better material. When, howcYer, that group of diseases only was considered to which we would think athletes peculiarly liable there were 6 deaths of athletes to one among the nonathletes. Dr. Stokes said in part: The immculate hazards of sport arc lnronsequentlnl as compared with the future effects of o,·ertrainlni? nml oycrstrnlninA' for brief periods, to be fol- loweil by rears of relative physical quietude. The records naturally fall to take Into account those whose ph~·sical disabilities are of such n character as not to cause theiL· admission to the sick list, yet whose efficiency has been impairerl by them. There are many such officers In the service who conRult me1li<'nl officers for cnrdlnc irregnluritles, obes!tr, or physical staleness-In other wor1ls, for conditions thnt it appears reasonabl~ to attribute to o,·er- training- and ovrr!:;trnininA' followcll by periods of physical quietude exnrtr1l by se1·vlce conr<-tl ns to hr hrnefidnl to nil. Tl c~ should 1m1d11C<' n supple, n"lle, nll-nrou1111. well-de, el p<>d lndhlclunl. nor n mu,. le-oounllity to win Is lnrgl'ly, lf not entire!~-. 1lrpemlent 1111• 11 brut force, nml tltnt t"t her tlle muxl11n1111 efrort he mnde to <1t•\·P\op 1 :--yJnmetrlcnl. norm 11 ph~ ... iqm' in the mnn~· Instead of a hlirhly :specinlizrtl hum:m mnchh1l' In 1 few. Dr. Harlow Brook.c;, from an experience of many yf!ars of a ocin- tion with athletes anc.1 in connection with enlistments for the Xntionnl Guard. believes thnt after 10 or 15 years of business life the health of former athletes is for below thnt of the aYerage man. Dr. C. R. Ba.rdicn, of the UniYersity of Wisc JP ~in. hui:: ctlllCal training- of our hoy~. ln the past. unprepnreclncss has been onr boast and motto, and ch ilian experts on military affairs haYe been content to helieYc lhnt a few months sufiice to make good soldiers~ but. even if we gaw ~or a }'l'ar::; to military training and met every condition of military preparation from a technicnl stam1point, it must be remembered that t\ strong, symmetrical nnt 11ow wlwn the eall for men is loud in the land. I ham witne::;sed the intem,ire trnininrr adopted in Fonie of 0111· c·t1111ps and greatly fear that tlw <'nthnsia!:'~ of athletic in~trnctors will finish what milil ary le:ulers hn' e not quite accomplished. namely, the prodnction in mnny of tlw nH'll of a i-;tate of fag nncl staleness due to o•ertraining. " 7hile sen·ing on the U. S. S. P1•c1Sirl<'11f Lincoln I obsenecI t11011snnc.ls of soldiers at the moment of their embarkation and it was clisconrnging to note in what a, large nu1nbl'r of them were to be seen e' idcnccs of an o\·ertrainextent their tissue::: are oyercbargecl with tnxil' fatigue substances lending to render them more susceptihh• to tmmnunicnble disea<:e. esp<>cin lly in dew o:f the mental depression preH•n( c1ue to new em·ironnH•11t, leaYing home: etc. Fatigue an(l resistnnce become matters of pl'imc imporlance to the soldier "·hen he is as,i~ned to the troop cornpartnwnt below tatcments were particularly frequent nnd rmphittic among the nwn who came to the sick-bay with diffcrrnt zymotic cUseases. During three trips there deYelopcd on the Prcsi- ,;r.flf Linroln JO cases of pneumonia, 3± of scarlet feyer, 8;) o:f in- fluenza. 68 of measles, 3G of mumps. In view of '"hat lies ahea mgent ncecl for men how cnn the GoYernment do differently? The inrnliclism and the dc•a.ths in our ~\rmy that result from epitlrmic di!'eases may fairly be laid at the door of milita1·y nnpreparC'\hiC$'S and tllC' lack of a general, properly lhought out system of physical training for our young men, calculated to make them hnrdy and capable of increased resistunce to infect ions. The immediate irnlicnt ion is to impress upon physical clii•t•ctors, trainers, and athl<'tic manager:, in training camps the importance of acute and trying situation to rc."'ort to short cuts ttncl tC'mporary expedients, the present nntionn 1 emC'rgC'nt·~· should serve not to confirm us in bad practices too long in vogu\>, hnt rather to dm w ns ont of 0111· stagnation and i ndiff erC'ncc to the re- form of every abuse. There is a sense in which, no matter how bril- liant the Yictories of our armies, this country will suffer rle>fcat unl<'ss self-quc>stioning and self-crif icism lea\l us to men us it c;eems heyoncl hC'l ief that the country shonlcl not nlreacl;v han taken steps to i~llJH'OVC tbr> phy"i- cal condition of the sons of this generation, who will be the men of the next and the future protectors of our cherished irn;t itution-:. Jt, .'CC'IllS to me that one has a right to demand GovC'rnmt•nt c.:npervision of some systematic progrnm for the physical clc,·elnpment of tlw hoy,:; of the countr~·· U "·care to haw athletics following in a general 'YllY thr. old li1ws then WC' should eliminate the now e-..spntial icka of win- ing games at n11y cost. The coaches at the Yarious schools mnst be forhiclden to conc\'nfrntc their attention on the fow 'ipC'cialists fo the disrcgnnl of thonsancls of students who now merely stancl upon the side-lines. There mnst be 20 football teams pla~ring on the fields GOO LUBY-ATHLETICS ~D THEIR RELATION TO WAB. \'al. :S:IJ. where now we :>ee but two. Instead of half a dozen men training to jump a broad jump of :!2 feet 11 inches we must ~ee GOO boy:' lenrninlow jog trot is enough. Th~ rowing race.s must bo cut down to the Henley distance us a maximum and then there must Le 20 or 30 crews practicing daily instead of 4 or 5. In a. word, nll branches of athletics must be reclns::.ified on the basis of their effects upon the heart and other Yitn.l organs~ and we must u.· c·u·J the old cla:;sification based upon popularity and com- mercial advantage. In the grammar school the form of athletics to which a boy could be assigned or in which he would be permitted to engage in would depend upon (1) his family hbtory; (2) hi~ personal history, having regard especially to pre,'ions illnesses en- dured; (!3 )his physical status; (4) his particular type, height, wei!!ht, etc., il,1 relation to age, etc. EYery class would hnYe its specially pre- scribed athletics, both physical and tactical, and under no cir~um­ stances would a lad be allo'Yed to engage in competitive sports n;;. signed to a cla~s abO\'e or below his own. .A physical examination wonltl mark his entry nnd exit from n class and he would be marked for development of body and for ability to perform the ''arious tac- tics. 'Yhil1• in the grammar school a chart would be begun for L;n "·hich "·ould nccompany him throughout his educational career. As the boy pu~c;cs an average of efficiency. Outside competitions v-ith other schools would be reduced and the competith-e idea find its illn:-:tra- tion principally in interclass games. ·work in the gymnasium should accompany nncl parallel the work done in teams and athletic games. Where !"tudents show beyond all reasonable doubt a real and per- manent improvement in body and an increased ability to participate in nrious branches of sport they should receive credits at the hands of tho college authorities in the same way that credits nre given for scholarship. All athletics of the more strenuous type and all thos•· contests which inevitably induce even temporary exhaustion must be abolished. Mass competition, such as that in which n clnss would participate as a whole, is to be encouraged. :New :feats of prowe~ should be introduced. There should be walking contesbi, well-seal- No.4. F.A.RENHOLT--MEMOB.ANDA FOR .MEDICAL OFFICEBS. 601 in" conte::.ts. ob:,tacle raising. hurdling. shorter r('luy CYent~ with in- <'~secl pH--ounel. more "O;:ct•r football. ;.hot putting with n lighter !'hot. etc. The athletics of to-dn.y mn!-it be remolcled :md clearly defined. .\thlctics cn.n surely ha,·e no better purpose than to de- velop n robust nntl healthy boy who, though he may not be nn inter- scholastic champion or sought after by the larger colleges n~ likely to inrrdt"<' th<'ir fnmc. will H<',·ertheless enter upon his I:fo work with 11 ~,·11 1ml•tricnl. fully dt>\"Plopetl hoath front .\. V\llf''dl•ll T, ('Uptain. )I. C' .. l'ultrd 8tnll'" :->11v>. Thi:-, li:-.l of duties has been compiled primarily for the u~e of th0:>e i;!Oing- to sea for the first time, but may be of ~ervice to other:- :ts well. Whm the ship i>. fitting out the medical officer shall examine sick hay nnary; one side for wants and other for articles f~r survey. 10. Book recording operations or rough Form P kept. 11. .\ filing box or boxrs for rough Form F enrds. 12. Venereal lists made out: copies for exrcntiYe office and ili.. pensary and for man who has >enereal duty. 13. A foll supply of blank forms laid in and conveniently stowed. 14. Slips provided for report to commanding oflicrr "not in line of duty"; article 2902-1-R. complied with. OTHER REQUIREMENTS AND SUOOESTlONH. 1. A pigeon-hole locker having about 30 compartments and lock- ing arrangement for health records. 2. Instruction for Hospital Corps o;tartecl (ser 2Ci42-l- fi- I, Yic!e No. 83); Handy 13ook for Hospital Corps, 1917, United States Ka' y: Mason; lectures; dummy operations, paper work and forms; Hos- pital Corps drill regulations; optional; Instructions for Medical Officers, 26. 3. Arrangements made with paymaster for food for patients in sick ba.y; diet slips for commissary steward . .J.. Liquor, poison lockers examined carefully; also stowage of nil stores either in stores or on hand in sick bay and -!. :!1. $ee that all heads are clean; properly flushed; papers; live steam Ul'ed to clean if possible; basin to wash hands after using heads if :-urh can h<' arranged. :!:!. Carefully inspect prisoners; acute, feigned er cmnmunicnble discllse. 1431- R. Fracture of skuJl possible in tho,..1· 1h·:1d tlrnnk. '.!114-I. :2:1. ~ee that medical boat hoxes are. 0. K.; covered with canrns, marked with ship's name and medical department. .\!so metlical pa..J.;:c•t in regular boat boxes. 604 FABEXHOLT-MEMOBANDA FOR :MEDICAL OFFICEBS. Vol. XU. 2 L .\ rmngc butt le dr<':;sint! packcb for i~olu led po;,, it ion:>. lllrt-eb storing the apparently drowned. or thosCI owrcomc frn111 inhalation of poisonous gases. 27. Detcrmint> the best method of remoYing the wounded :fr0111 the fire ancl t'ngint' rooms. turrets. handling rooms. tops, and all inac- <·e ... sililc phtl't'S. :28. OLsenc regulations concerninµ: locking of btorerooms, clo ... ing of btureroom aml other doors al et•rtain ti111es-,,11nhip. Keys in hnnds of en- listed men, 2964-R., lil0-!--2-1. 29. Cotton or other car protectors fomisl1ecl it!! per:-;011.-< on hoarat guns. Carr nbo11t cars in swinunin!! in tropicnl waters. 30. IlnrbN· should be instrnricd in method of keeping his gear in sanitary condition. List furnished him (not posted) of all syphilitics. 31. Sec that food is 0. K. in quality, quantity, cooking. Dishe.., washed properly, disinfected if necessary. Syphilitics with open :::;ores have special gear. See that those who t'at al irregular hours ~Lre properly looked out for 2618-2-5, I. 32. Sec that wash rooms are in a sanitary condition and men do not urinate while under showers. 33. Prohibit use of tube in water breakers, notably in steam launch. See thnt scuttle butt is working in satisfactory manner and water cooled and aerated. 34-. ~ee that men are billeted properly and not in dangerous place" and exposed; no sleeping in storerooms or unat!thorized places. 35. H:we a landing party scheme always worked out and ready to be put into operation. Instructions fQr Medical Officers, chapter X: Inspected by flagship twice each year. Material to assemble: In- -..tr11mrnts. drugs. dressings, diagnosis tags, transportation. :rn. Prt'parc a schedule of routine and incident al returns in ord. In port land them in hos- pital: at sen in tent on deck: in some places n tent on the Jx.ach. a9. Careful to rdain copies of - 12. e~p. 63; tent pitching, 75-83; sinks, i2 ; urinals. 73: kitchen pits. i3: water supply. 77, 69, JG: position hospital tents, i5; men:s equipment clothing; position ambulance party; packing knapsack haversack, 22; at battalion drill, 4H; officers' equipment, 1!); po- sition staff bnttnlion, 473; ambnltmce party, 17; position staff rcgi- mPntn l, 492. 4:3. Guard against disease brought by animals from ashorc.-c. f. plague by rats; also pets on board ship. 4-1. Recommend :mchorage away from shore in infected ports: flies, mosquitoes from bench, in bunches of bananas, sacking~ closed boat"': sweep out canopy cover 0£ stc.un la.unch; care about breed- ing plnc<:>s on boarcl for mosquito ·s. 45. Guard against lend poisouing, gas poisoning. (Sec circular letter M. & S. 12'1713, ~far. 23. 1!)12, 3:.127-1 2, I. 40. Guard against infection by '>yphilis by band instruments. whistles (boatswain mates. officers' deck), all cooks and mess nt- temlants and dentists. 4i. "'atch for and detect presence of cocaine and other drug hnL't!'. ~s. Ilestrict liberty in ports havi11g much ::;iclrness; also rc::.trict Y<'ncreal cases. 4fl. Swabs and spitkids washed and disinfectants used. 50. Repair at once breaks in surface of linoleum covering of fron decks. ;;i. Air bedding and contents of ha.gs as often as po~siblc : a maximum of sunlight and fresh air. 52. Cubic capacity of the various spaces in the ship should be known ; or know how to determine, for use in case of disinfection. ti06 PARE.:-;uOI.T-MEl!ORAXDA FOR :\IEDICAL OFFICERS. \01.x11. 53. Before a target practice all qualified and acting gun pointer,, exnmiuc-I. • JG. Regulations concerning standing lights in sick bay and ;;paces must be obscn·ed, 2607-2-I. 57. Before going to sea secure sick bay for rolling and collision . .:>S. Use of harbor water, 2G21-I. In infected port~ . .:rn. Formulate scheme for coping with contagious disease; a few cases; many. 60. See that all spaces in ship are ventilated in bcRt possible manner. Gl. ~fonual for Medical Department, page 1!>3, suggests white clothing when thermometer 75 at 8 a. m. Bathing not allowed if water below 10. G2. See that proper awnings are spread in ship's boats and on deck. 63. ~Iu·l !<> be clM1ted from anchors nnd chains when in infocted ports. Cleaned on~rside, not on deck. Instructions )Iedical Officers, 80-12. G4. Mosquito nets for camping parties in Tropics. 65. Patients suffering from mosquito-borne diseases to be screened. G6. Disinfection of ship, see Manual for Medical Department, pn~e 206.· 67. Patients transferred to hospital require- 1. Hospital ticket. ) 2. Clinical card. . 3 H 1th d From med1cnJ department. . ea recor . ±. Clothing list made out. · 5. Efficiency report to .M:edi-} cine and Surgery. To Bureau of Medicine 6. Card, transfer of hospital and Surgery. corpsmen. 7. Conduct report. I 8. Senice recor-2-I. iO. Jn-.truct chief pharmacist':-; mntf' and other hospita 1 corpsmen ju~t whnt mr.dicin<'s they are allowed to gi•c nnd whnt not without order:- :from n medical dli<'er. ~ee that the,> nn. I. .i . Care tnkPn with Ycncreal prophylactic treatment; instruction concerning d:rnger; information circulars. lectures. circulars issued Ly bureau; posters on bulletin board; punishment for offenders adequate; educational and moral prophylaxis. li. Use whole (complete) name in official corre::.pondence relating to c.nlisted men. "'I. Keep vaccination of 1uen up until at lcnst three times; no prolnlbility of danger. Sec that all bands haYc typhoid mccinalion. 3 .• \. portable electric lump is useful in sick ba~· bed cases. also operating room, also store-rooms. An electric hnncl torch is useful in bt'd~idP work. 608 FARKXHOLT-:\f'E:\IORA~DA FO"ll )!ED~CAL OFFIC'F.RS. Yo(. XII. 89. Sec red cro~ in:,tructions, 3861-R., GeneYa. Conv<'ntion. Mnn. ual ::\fo&:ing::,. <'tc., taken in bundle::; to fire rooms and burned. X o boxe::; or anything thrown ovct·bonrd "ithout permission from officer of clack. :Nothing thrown out of ports 92. Ports not to lie opened w h<'n closed by proper authorit.v ( espec. ially at sea) without permission from officer of deck and medical officer. 93. Whenc,·cr nn ofl1cer lea Yes ship (detached) his room ~hould be carefully cleaned and pninted, if mattress is old it should b<' con- demned. 94 . .A high physical standard for applicants for the variou::; fire- room rates should be held. 95. Be prepared to embalm and bring into port bodies of dead. 96. Great care about "Linc of duty " in cases which ma~ pos" bly become pensionable; safeguard the Government. State all facts ery fully. 97 . ..Articles sun eyed and ordered to be destroyed should be so de- stroyeJ or cl<'nrly mnrkccl "not on charge." Metal objects mat ·ed by file; this to preYent confusion in inventory of articles on charge. 98. lnYestigat.e health conditions immediately on arrival in port: also keep post eel throughout the ship's stay, safe anchorage, etc. DD • .Arrange for the removal of infectious cases to hospitals ashore or tents on bench imlcss against the best interests of the patient. 100. If scuttle butt has not sanitary terminals keep cup immer"ccl in formn lclehyd sol.. 1-2500. 101. The United States Public Health Service recognizes as quar- antinable dist>ascs <'holera, incubation period. 5 days; yellow fever. 5-6 days: !'imallpox, H Clays; typhus fever. 12 days; plague. 7 days; leprosy, ( ?) days. State law~ impose additional restridions and quarantine, )fanuul for Medical Department, chapter XIV. 102. In a port where there is a Marine Hospital (United States Public Health Service and no naval hospital) patients may bt> sent to the former for lreatmcnt by application to authorities in charge; arrangements han> been made to that effect by Bureau of Medicine and Surgery, chargt• :30 cents per day, and at contract rate wlien hospital is not owned by the United States. 103. Dental work, especially if clone by other than com111i.ssioned dental surgeons to be carefully supervised, prices, kind of work. 10±. Spitting about the decks and ship must be prevented. 105. Visitors must not be permitted to interfere with the work ot the sick bay; loafing prevented. STRA"GSS-ENDOCRINE ~AXIFEST.\TIOXS. t>o9 101.i. The 1•xccntiw 's office must let medical officer know of all rhnn:re, of rating. Ac; i:oon as n m:tn is recefred on hoard his 11u111e niu't be ,ent to tlw me tt·un:;ft•tTcd from the ship must he report1•u ro inediPal officer for same purpose. ENDOCRINE MANIFESTATIONS. Bys. IL l'!Tll\RS, T,l~utPDODt, M. c .. United Stlltl',; NRYr In this clay oi mechanical supremacy we are unfortunately t.oo prone to forget that the human body is not a machine. rnd('r the spell of surgical domination the clinician is all too upt to forget that pathologic events, both objective and subjective, are not ::itntic events. He is all too apt to forget that c.ver-chnnging flow which spells biologic life. Are we not all too smugly content to regard n. case of measle:;, for example, as a mere snccf':-sion of nasal catarrh, Koplic spot;: and an eruption which is characterized by this and that feature'( Ifogurd- ing the case of mea::,lcti as ::;omething definite, clear cut, static, do we often enough consider ">uch a case from the angle of the iJHliYid- uul so affected? Do "e often enough regard such n c•lSC of mea-.les as a particular case belonging to n particular individual? Is it not our habit, too, having become acquainted with definite dis- ea:;e pictures, to attach to those pictures in our practice the indi- Yiclunls who come to us as patients1 Do we often enough-do we e\·e:-consider that a particular individual prei:ents to us certain ::symptoms which in their entirety spc·ll ·wbate,·er our final cliagno is may be? In the cnse o:f measles we have become too accustomed to the state- ment" All children have measles at some time." Stop and u-.k a mo- ment "Do they1" 0£ cour::;e. the answer is n most emphatic "no." but why? It is going to be my attempt to at least show the need of recogniz- ing with mor~ clarity than has been our custom t:he individual's part in this pathologic world. ·we are confronted by the questions: "'\Yhat determines the indiYiduul's liability to certain pathologic states, and secondly, how are differences in the cour:-;e of such patho- logic states caused? Anatomy is not fixed and permanent, nor is physiology, nor en- Yiromnent, nor heredity, nor pathology. By the latter I mean states of illness. Surely every human being differs from his fellow exter- nally and so more surely differs in the forces that have gone to cause apparent di.fl'erenl!eS. It should be our attempt to find how in- 610 STRAUSS-E!iDOCRINE MANIFESTATIONS. cli\·iduals differ liO widely and in that answer lies tho answer to the question of the variation in cli:,easr states. If indiYiduals are so unlike physically and m1IDtally, surely their illnesses ure quite unlike in occurrence, in character-in nil that is bn~ic. How wrong it is of us to talk of n " case of measles." How much further our medical art would have come hr.cl we paid more attention to the distinguishing features of each individual who at some time presented the symptom-complex which we. for coin en- iencc sake, hn' c labeled " measles.'' \Yould we not now be better able to r<>cognize in measles more than a skin eruption, which falls within certain descriptive limits ·~ Woulcl we not now perhap..: be able to prophesy where reasonably we should find meac;le-.-tl) prophesy which individual is liable to measles~ Had we paid closer attention to individual differences-had we looked deeper into the reasons for these differences, would we not be better able now to understand the vast army of unlabeled clinical states which we each day in our practice meet, which we curse in our ignorance to-day, using a curse word all our own, "neurotic." Gradually there has crept into our medical teaching the dictum, "Study the patient" or" treat your patient." This is carried out in a mechanical way. The microscope, the .Roentgen ra.y, and the test tube arc king. We must believe but what is printed on the labora- tory slip and through these facts we are led to one conclusion-a pathologic an:itomic diagnosis-static-whereupon the individual. the patient, is forgotten and the organ treated in a static way. There is another path which we can follow. The picture that is presented by the cretin is too well known to warrant description here. Likewise, the pictures presented by fully developed cases of exophthalmic goiter and myxedema. We know that the remarkable psychic and physical phenomena manifested by these individuals are t11e result of a disturbed thyroid gland function. They are com- pleted pictures. Latterly, we are talking a lot of the" Forme Frustc." That is a step forward, but why not look further ahead. Study many cases-well developed-of thyroidal disbalance; note in exact detail the characteristic marks; determine which of these marks are con- stantly prominent in these cases and then remember them as thy- roidal marks, signs of a thyroidal disbalance; no matter where "!CD or how unexpectedly, for example, the dullness or glossiness of ·he hair, the dullness or brightness of the eye, the sluggishnes.c; or vivacity of the cardiovascular system. Do that in disturbances of all the glands of internal secretion and shortly you will have physical marks dependent on those endocrine glands, which I believe deter- mine to a very great extent the individual's physical marks. his mental marks, and so his life history. In such a way, study your patients. ~o.4. STRA USS--ENDOCRL'iE lIAN IFESTATIONS. till Reversely, study carefully the history of all your case::; with special regard to past infections and so determine the indi>iduars future liability or immunity to the infectious disea~es. To make my ideas more tangible. I will illustrate. I ghall present n case history ana- )>zed for subjective and objective endocrine factors. ).!any of the::;c. );ave no experimental proof but rest on a foundation of repeated clinic obserntion. Mr. L.: marded, nge 291 n Ru:::sian, manager of a large fa<'tory. presented himSl'lf for exanun tion on December 5, Hll i. complain- ing of ''indigestion, constipation, attacks of weakness and dy::;pnea.'' He further st!ltecl that the attack~ of weakness and clygp1wa c:unc e>ery four or five weeks, always following a meal, and that the first attack came in September, 191G. The indigestion consisted of 11 frequent sense of oppression in the epigastrium nssocinted with nausrn and tasteless eructations. The constipation. too: dates from f:eptcmber, 1916, being fixed, the bowels acting but once in three .Jays. and then the stool being small and hard. The first sif.mificant fact for me in this is the man's career; it means o. man of ,,ill, and courage, and untiring energy, for hnving come from Russia. n few years ago penniless, he is, at the nge of 29, the mo.nager of a .factory in New York City. A parallel fact is that feeding guinea pigs adre- nal extract makes them more pugnacious. One kno\"<'i:; that cour- age and will and the desire to fight are masculine tro.its, male sex characteristics in fact, and these male sex characteristics are under the domination of the adrenal system. Is it not fnir to assume. then, that the patient is one in whom the adrenal system is prominent? He p:ave the history of hnving been in an accident on l\Iay 30, 1916. He was caught between two street cars. thrown to the ground, sustnining a frn.C'ture of the left humerus. After his fall he was un- conscious for three hours. His convalescence ended Antnist. 1916. with n return to work in September. and shortly thereafter his pres- ent symptoms made their appearance. Of course, Crile has shown conclusively the direct damaging influence on the adrenal system which is possessed by mental o.nd physico.l shock. So we may fairly presume that. whatever other damage the accident sustained Ly the patient effected, it made it necessary for him to meet an ndrennl crisis. This was met snccegsfully for the time bt:::ci~. Three months later, upon resuming his work. which called for on incren~e of nenous and physical energy. such energy being nmde pos- sible by an evenly baln.nced o.drenal system. he deYeloped certain symptoms. These symptoms were at first diagnosed hy a general practitioner as "nervous indigestion," and after a period of 1111-.uc- <'C.'-sful treatment the po.tient was referred to a neurologist. The patient might have been tmnsferred to the attentions of a gitstro- enterologist had the usual custom been :followed, 'l>hich gentleman STRA USS--ENDOCRINE MANIFESTATIONS. Vol.XIL "onltl ha ''e l:lid special emphasis on stomach tube::>, gastric acidity, and la ,·a~t'. It hnppe1wd that I considered the case one of delayed adrenal in- sufficiency, the immediate symptoms being explained on the basis of nt weight to my hypothesis were bronght out by fmthcr cxnminntion. The patient stated that his father had died at the ag(• of 59 of apoplexy. I think there can be no doubt hut that individuals who show high blood pressures and the usually ll!l- sociated n1e-that i<:, the retraction of the eyelids, protrusion of the eyeball, and the dilatation oi the pupil. ... SI'RAUSS-ENDOCRINE MANIFESTATIONS. Thc pntil'nt's ire:; were pigmcnt~ hod_,., I have found thnt this pi~ent is an adrenal sign. 1'hc ph:uynx showed a slight congestion. The cars "·ere somewhat c\'nnos cl. nn1l the complexion. though sallow. was fln:.hecl, all facts 1;ointiug to a poorly :;tabilized rn:;omotor !"ystem, which i11 part i!- under the control 0f tlw a1lrenul organiz:ltion. The th~·t·oicl ~land ,bowed no enlargement. 1'hc ',,.,ornotor r<.>ae ion on the ::-kin. or. in other words, the cnpil- lan· rc.tdion to a nwclumical stimulus, was of very poor quulit~·. In thi"' co111wction I might Hay thnt this reaction is obtnined by rnpidl~· .Jr:1wing 1l blunt instl'umenl o,·er the skin's snrfocc, excrtin:,r slight pr<':-.. ... ure. In a normal reaction within the limit of fin• seconds a pink flush appenrs nlong the course of this stimulation, whic11 im- meclintel;v facles into white, carrying along its borders a fin<' pink halo. The factors which vary are the speed of the nppcamnce of this capillary dilatation nnd subsequent contraction. the duration of this ,-i::;ible reaction nnd finally the proportion between the contraction area CH' white part and the dilatation area or pink part. It h:\, been my experience to find in normally bnl:rnccd patients a fnirly rnpid rcnrtion within 5 seconds. the entire line fading within 20 seconds, the dilatation merging into contraction slowly with no disproportion between the white and pink parts. In sub- ject~ who arc extremely thyrodial this reaction appears too rapidly, fades too rapidly, and shows an exce.-;s of vasomotor dilatation or pink. In adrenal subjects the reaction is slower than normal. There ma~· be no initial dilatation along the course of the stimulant. but immediately one sees a line of contraction surrounded by a pink zone. the white portion, however, being disproportionately promi- nmt. In extreme cases ll. wheal forms along the course of the instru- ment used. In this connection it is interesting to recall the brilliant therapeutic resullc; which are obtained at times in cases of urticaria by the sub- cutaneous use of adrenalin. The patient showed a very poor vasomotor reaction, inasmuch as il.;; onset was slow and sho"·ed both poor Yasomotor contraetion and <1.ilatation. Fading look place too quickly. But. after an interrnl of nearly a minute the entire phenomenon wa:> repented but with nn en- tirely different character. This ~econclar.v reaction showetl a ,·ery prominPnt conlrn.ction zone slightly rai!'ed nbow the :-kin·s surfnce. bordc1wl with a fine dilnlation zone. I might c;n~· that this j..., the only time that I hwc !';een such n. delayed reaction. I here took it to mean an l'Xt l'e111ely pool' rPgnlatio1i of th<.> vasomotor nerve supply and on account of its final nclrenal character I placed the hlam" on thnt mem- ber. The pul"t' rntr was 60. the rh>·thm regular. the blood pre ... sure C)l4 grRAUSS--EXDOCRINE MANIFESTATIONS. Wtb 100 ") ... tolic. ::;O diastolic. This low hloou pre'-sure can easily. too, be attrib11te1l to some adrenal fouJt. The heart showed nothing un- ll"llal. nor were p~·c>-=ent an l equal. The abdomi- nal \mil "as held rather rigid. - • o n ·1 ... se::-. "ere made out. The liver and ~plccn 1licl not show any enlargl'ment. There was :;omc slight tendcrnc:;s in the epigastrinm. There . were no changes in the skin senc;ibilitic:; of the ahdomen. The extremities showed reflexes acti\'e within normnl limits, and equal on both sides. The hands and feet were somewhat con~ested, almost cyanotic, and were cold. This fault. t.oo. I took to mean <.Orne wcnknes.« in the nlsomotor regulation. ~nbjet'fo·ely, the patient presented nothing beyond what I huve already noted. His words were: Once In four or lh'c weeks after meals I find I can't catch my breath, and I ~et 1wak. I l.Jecomc nau<:eated but l1a\·e no 1·omiting. f:.ucb an nttack lash\ 'or about twq hou1·s. I think tbat it has in each instance been caused by the in~estlon of fried fntty food or shell foocl. I lm,·e no :wt uni JI:! In with It but feel a grenl p1·essure In the center of my abdomen. I have had three atmck.« in nil, but sl.nce my accident I have been constantly troubler! with much <'ruc- tation of 11 tnstele.«s ~ns, associated with abclom!nal distress after meals. Thi,. ilistrt'ss couws on immetlinteJ~· after meals and lasts appro>.1mntely an hour . . \s~chlll'U wllh this bus been a positive constipation, m~· bowels not mo,·lni: hut once In two or three dnys. Further questioning revealed no other subjective features. I analyzed my patient in the way outlined above. disregarding his :-ymptoms. EYerywhcre I found facts pointing to some disturbance in his adrenal balance, and, still disregarding his complaints, I set my:;eli the task of regulating his adrenal balance. which I felt sure wu~ at fault. The thernpeusis in this case consisted of feeding small quantities of :tdrcnoJ gland extrad l wice a day. The amount I used was one one-hundredth of a grain at each feeding, and on January 25 the patient reported to me that he was very much better. that he had hacl no spells of dizziness, that his appetite was excellent, that hi~ cpigastric pressure had gone, that his bowels moved each day, the stool being very well formed, that he felt stronger, that he had no more eructations of gas after meals, that he was sleeping excellently. and that he had gained 2 pounds in weight. The blood pre ... .;;me had gone up to 120 systolic, 100 diastolic. This was the extent of my therapy, and I feel that the result justifies its unusual character. ·working reversely, I have used adrenal· extracts. feeding them to patients who have presented the subjective and objective symptoms characteristic of all degrees of gastric hyperacidity, and have often been rewarded with success. This paper has been written simply as a plea. for a more accurate and thorough study of one's patients' characteristics; those charac- LANE-STUDY OF DENGUE· AT ST. THOMAS, V. I. 615 teristics which separate them from other individuals, which are bnsic for those individuals. It is a plea for an increase of regard for the factors which have gone to make a patient what he is, and, finally, :L plea for the recognition of the importance of correcting faults which tincture the entire organization of the patient. I feel sure• that in the correction of such defects we must eliminate the vast ma- jority of subjective symptoms, which in most cases do not depend on ~ny definite organic change. A CLINICAL STUDY OF 100 CASES OF DENGUE AT ST. THOMAS, V. I. By l•'. l~. LAI<~;. LIPulPnnnt (J. G.), M. C., UniteL'<.'11 mad<' as mosquito proof as possible when it was put in com- mis.,ion. ~·et 011r neighbors raised enough mosquitoes to supply both thPmseln•. aml the institution. ·when tlP fir::.t few cases had been ad11:ittctl. tlw other patients, lhe members of the hospital corps. an1l doctors comnH'llCl'tl to ha\'e breaking bones and fo,·er. The spreatl was n~ry i·npid. It is generally under,.;lood that the m.osqnito 1s the infocting a~1·11t. About 99 per c ~ nt of all the mOhf(nitoes, both at the barrncln; :md the hospital, are Stegomyia oalopus. Very occasionally the ('Ult•x i!> St'l'll but no anopheles us yt->t. ft is ~v1w1·ally undpr,.,tood that tlw c·tdcx is th<' spl'eader of dengut•. In l'\'Pl'~ c·ust' th<' patient has bcc11 cxposNl t•ithC'r at the barracks or tlw hospital, and only thosl• that ha,.<' bt•Pn at one or the other of these two plncc,; li:n c bem attacked. Th<' conYerse is also true. Another point in fnstening 1 hP blamP on the proper carrier is the fact l hat dengue i~ a ,·ery rapid spl'eadl'l' among nonimmunes. The st gomyia bites by tlay n well as by night, so that no amount of mosquito bars could protect tho--e doing duty unless they were confined to bed. If the mos 111ito hacl been a night biter only, the rapid spread might have been cbeckcrl. All of the foregoing seems to put the blnme wholly on the J::ifr[;omyia calo7ms, a point which has never bcPn brought out Hry strongly. The possibility of the stegomyia as n. spreader of tht> dis- eas1> is mentioned by some but never considered sel'io11sly. ThC\ incid('nee of new cases anrl the mosquitoes would be conspicuously lacking in proportion. The incubation period was rather difficult to ascertain. but in three cases it was Yery definitely placed at four to ~ix day'. _\II thr"e 1·011tracted dengue within this period after lhe arri,·nl from thr '3t.ates. The symptomatology, in general. was about the snmc as tlr~cribed elsewhere. The onset was sudden, beginning with the rnguc pains in the back and legs; headache; malaise; chilliness or an actual mild chill; perhaps constipation or maybe diarrhea; loss of appetite: fe•erishness and occasionally a flushing oi the skin o.f the face and tho neck. These wel'e ahont the usual findings the fit·st day. Tlw second clay found the primary flush of the face ,gone uncl the pn.tient wns quite sick. The temperature was between 102 and 105 degrees; the aches and pains in the back and extremities, the 11(\atl- ' CLINICAL CHART ONE ttUNDR'f.D CASf.5 Of DENGUE fE.VU ANALY.515 BY TYPE ~-~ . ~ . lf'l . . ~ .~. 3 FO>O>OO--C\lNIO ~ . ~ 2 Ol (]) 0 0 0 0 0 0 0 Q-o:;~ _ _. __ _. .......... 3 4 5 6 ' .._ 5 ~de le }) icl 7 I I I 1 vr e To al - ~deni 1s 52. % % % 0 0 0 2 16 8 2.0 16 8 6 e. 0 2 0 ANALY.51.S AS A WHOLE. Avera~e 100 cases Rash 63, % Adenitts 17. % 10. % Vomihno 8. % 3. % Di'a.rrhea. Ja.unc:l.Lc.e 1. % Heroes La..bialis 1. % l>LOOD WORK l a.verage) White l)Jood Cells 4300 -::i Polvs 59.5% A er kne 48 uses ~~ Lvmohocvtes 30.5% l-~1+-t.._:::i:=t~+-i--!--t±:--~µ,o~I O -~ ~ L~roe Monos 7.8% 2 _i:;;;;- o o ~0 Transilionals 1.7% 3 l.J"- 10 2 A Losinonhvles 0.5% 4 l7 32 JO J 10 4 W.B.C..s as low o.s eeoo 6 ,, 4 c Polvs as low o.s 38.% 7 2 4 Lvmoho as hioh as 8 0 0 To al - a! , 58 ~ 617-1 LA~!:.-:ffUDY OF DENGUE AT ST. rno:MAS, v. L 617 ache au"<' symptom-. were not, and never became at nny time durin!! the disease. ns sHer<> us those usually described. especially the bone pains. The interesting feature at this time was the intense pain in the eye'. e:;pecially on voluntary motion. accompanied by n con!!'e::.tion of the conjuctirne and the watery condition so often -een in mea:;le::;. The pain on motion was elicite1l by havin!! the pndent k~ep the lieae had a sever\! nttack of intluenza "ithout nny bronchitis. The pnbe was quitt• .slow in com- pnri,on with the temperature, Sl!ld0111 rising abow 90 per minute, u::.milly 15 to 85, "ith the temperature at 104 F. or lO:i F. Tho~e cases that had a blood examination 111acle at this time showed a leucopeuia of from :;,ooo to 6,000, a slight decrease in the polymorphoneuclear Ieucoc~·t~ and u :slight increase in the lymphocyte.-;. In:stend of the in,omnia usually descril ed, all the patients seemed to sleep especially well throughout th<' <'ntire course of the disease. In fact. the concli- tion was quite the reYerse of insomnia, a sort of stupor for the fir.st four dnys ut least. The urine did not show any constant alteration from the normal. On the third day the temperature fell as suddenly as it rose, seldom, if ever, to normal, but to between 99 F . and 101 F. The mental and physical depression, while still pre::.ent, was much le:-s. th<' pains nnd nches better, nnd although i\ OF ugXGUl~ AT ST. THOMAS, v. T. Vol.Xii. ing rapidly 0' <>r tlw nrm:; a11tl leg--. :tbdomen. chest: ancl face. It wa most marked on the forettrms and lower legs: abdomen, and face. The itching was not a!' marked as it became some dn~·s later. This eruption was present on the fourth rable decrease in the polymorphoneuclear leucocytc:; as low as 38 per cent and an increasP in the lymphocytes ns high as 53 per cent. This fourth day was mo-;t important from our sta!l(lpoint, as it marked the beginning of a complication of which very little is ~nid in the literature on the subject; namely. the involvement of the lym- phatic glands, amounting to a general lymphadenitis ns n. rule. In 5 per cent of patients this started on the third clay, but in 25 per ('(!nt on the fourth day. The condition was brought very forceably to our attention in the third or fourth case. The man began to complain Yery severely of pain. tenderness, nnd swelling in the glands of both groins. ~xnmi­ nntion reveakd inflamed: swollen, tender. nnd painful glands in both inguinal regions. This was so very marked that although the man was known to be free of '"enereal disease (a hospital corpsm:i.n who had been with us for eight months) this possibility was carefully looked into and examinations made for the four or five succeedin_g days. Nothing of n Yenr1·r.nl nnture was found. The second day after the inguinal glands became involved, the epitrochlenr and an- terior and po terior cervical glands enlarged but were not painful. This case stal'led the careful notations of this series. All cases that had ~my history of venereal disea>'e, either active or of old standing. were thrown out as indefinite. In all, this venereal type amounted to about 25 per cent of the total number studied. The glands in all this number were found to be involved, but whether due to dengue or yenereal disease could not be determined. In the other 75, G2.'i per cent had lymph gland involvement to a greater or less degree. All were swollen. some were painful or tender, and in the Yery few cases that we were able to follow up they remained swollen and tender from four to six weeks. (See chart for incidence of aclenitis ard percentage developing each day of the disease.) The fifth dny invariably told the tale as to whether the case would be o:f the " snddlebnck" type or not. Of the cases studied, 52 hnd the secondary rise of temperature and the other 48 did not. On this f !..\XE· -STl.DY OF DEXGUE AT ST. THOMAS, V. I . 619 dar 1;, per cent. including both t~·pes, showed the th':"t signs of rash 110~1 10 per cent gnve the first signs of the ndenitis. Tho$C that hnd the rise went up one to two degrees and those that did not dropped to normal or a fraction above. Tho latter type immediately bcgnn to pick up strength, both mental and physical, and "ere m;unlly allowed 0ut of bed. On the ::ii:xth day, the "nonsadclle-back" had no fever and remained ~o. Tlw l'll!,:h appeared for the first time in 6 per cent n.nd the adcni- tis in 4 per cent of tho total number. The ':saddle-back'' type had a fall in tempernture to 99 F . or a fraction nbo' e. On thi~ 11ay one i·a:>e cleYelopere discharged by the end of the "ighth dav at the lntest. None had any fever n.t this time and all felt fairly strong nnd ambitious. About 1 per cent had the rash just starting, but no one hacl the lymph gland involvement beginning this late. About u2Q l.AYJ-:-STUDY 01'' DEXGT:E A'I ST. TII0lf:AS1 V. I. this l imc the desqu:unation of the skin c:ommeucetl. .\::; far ns l·oitld he learne1l practically enry one that had hatl the rash ··peeled." This proce-.<: -.tarted with a Yery fine furfuraceons scnle which !!radu nlly becnme (·oar,er ns time went on. In fact. wher<' the clesqu:nna. tion inYol,·cd the horny portions of the skin. such as the sole:; of the feet and the palms of the hands. the scales consisted of large pieces, In two or three instances there was almost a complete cast of tlie grrul toe. somr two or three weeks after the feyer ha.cl sub:-.iclCfl. In seYeral instances the clesqnamntion lnstetl for six ot· seYen ''eeks, ~radually becoming finer as time went on, until il fnclccl out com. pletely. Abont this time or a little earlier the appetite began to re- turn, but there wns a peculiar metallic taste to the food which almost cYery pntient complained of. ~othing much hns ever been said about the after effects of" Dand" feyer.'' ~\s far as c011lcl be learned. and in my own case pnrticulnrly, complete recoYery of strength was not attained until two or three weeks after the fever had subsided. It "·as about the same c nuli- tion as is experienced during the rccoYery from a very severe attack of tonsillitis or "quinsy." While lmcler ordinary circumstances the con-rnlec:cent felt fairly well and strong for the usnal tasks, enclur- nnce was 1ery low and any amount of exercise in excess was Ycry enervating. · Resene strength was entirely lacking. DIAGNOSIS. The absence of any throat, chest. or abdominnl symptoms or find- ings; the history of the sudden onset, in some cases beginning during the night with a chill; the sudden rise of temperature with a com- paratively slow pulse; the pains in the back, legs, and eyes, especially thl' pain on forced motion of the eyeballs; the watery, congested con- junctivre; chilliness and malaise; anorexia; the low leucocyte count ; the fall in the percentage of polys and the increase in the lympbocrtcs: and the absence of any abnormal findings in the urine woul.l bl' sufficient to give the diagnosis on the second day, the time nt which the great majority of the cases came under obc:er1nt ion. llG\i~ITY. In most cases there seems to be an immunity after one attack. Thl' epidemic begun suddenly among the newly arrived population. The American negroes, on duty in the Tropics for the first time, hnrl "breakbone" fever in even a higher percentage than the whites. The native negroes had no increase in the disease. There wcr" six or seven new cases reported by the civilian physicians, bnt these wcro among children of white pnrentage ranging in nge from 3 to G years. These circumstances only added credence to the assumption )lo. •. LANE- STUDY OF DENGUE AT ST. THOMAS, V. I. 621 that the natiV"es were immune, due most likely to the fact that they had all had the disease as infants or in early childhood. There were, however, at least 10 cases among the two hundred and odd in the town n:-; a. whole that had a recurrence within three to six weeks after a ivpical first attack. The second was always milder, but similar to tiie first. Five or six others had had dengue several years before, but had another attack at this time. There were two others who hn.d been through several epidemics without ever ]uwing contracted it and considered themselves to be immune. They both had a severe :ittack. It would seem. therefore, that one attack usually gives immunity, but about 5 to 8 per cent have a recurrence within a few weeks or within several years. Treatment.-The treatment of the condition as carried out was en- tirely symptomatic. The patient was given a bath and a purge and put to bed. The purge was usually a saline (mngnesium sulphate) and was sometimes repeated in two days. In those whose bowels were kept well opened there seemed to be a more rapid and complete relief of the symptoms. If the headache was very severe an ice cap w!\S in order. As a rule, 5-grain doses of nspiri11 I. i. (1. or q. cl. re- lieved the aches and pains and seemed to relieve thP sensation of fever by inducing a mild sweat, although in many cases the perspira- tion was spontaneous and profuse. The diet was usuaJly soft, unless, !lS rarely occurred, the patient retained his appetite. Water was ~iven freely. As a rule, the patient was allowed to do about as he pleased after the temperature had dropped to normal or thereabouts. He hnd whatever he wished to eat; he was nllowed to be in or out of bed according to his inclination, and it was found that none of them stayed up ior any length of time, for, although they felt quite strong before getting up, they were very glad to get bnck jnto b~d within 15 or 20 minutes, at least during the first day or two. This leniency seemed to act for the best in two ways-it satisfied the patient's mental and physical unrest at being laid up with a trifling disease, as he con- sidered it, and it also helped to get his mind off the aches and pains that still existed to some extent. There were no harmful effects ob- served from this method of treatment, and in fact we thought that it even improved the speed of recovery by hurrying the recuperatirn power for increased physical exercise. All cases were kept under mosquito bars during the infective stage, supposed to be five days. SummariJ.-There are some 10 or a dozen peculiarities of this epi- demic. Points that others have only touched lightly npon, or not at all, that I wish to call your attention to are: First. The immediate source of the infection was unknown and could only be guessed. The important feature, however, was the 622 l • .\~i:-STUD\" OF D1':XGUE AT ::>T. Ill0)I.\S1 Y. l. • \·01 Xll agt·nt cnrrying the infection. The Llame cnn lw pluced entirely Ulld -without hesitation on tl;<' SI f/Olll!fi.a cafo1111~. prnctically tlw onh· mo--1f11ito "l'<'ll and inhabitating the localitie::. where the tlif:ea!-oe w~s mo·.;t preYalcnt. :md the only place where the nwsrp1ito Lite seemed t•1 do any dam.age. I belie\·e thnt. the stegomyia family ha.>e been U-;- pccted before. but nothing definite has been written as fur as I ca11 finc.l in references to the subject. ~rcond. The mild character of the bone pains "as characteri-.tic. Third: The interesting and preYiously not detimtely reported in- Yoh·ement of the lymph glands. In many easel:> this was quite seYerl! and wns treated with ice. No breaking down nor suppura~ion sub- sequently has been noted. In all, 62.7 per cent 0£ the 75 free from Yenereal infection developed this. A rather high percentage. It was not one set of glands but all the large superficial glands throughout the body. Fourth. The epistaxis, although it only occurred in 10 per cent of the ca!;es, was •ery severe and difficult to control. Fifth. The pain on forced motion of the eycbalJs was the princi- pal cause of the symptoms described by the patient as" headache., or "pain in the eyes .. , Probably this was due to the muscular attach- ments rather than to the muscles themselves, for the pain was only elicited on extreme motion. Sixth. The very peculiar and sometimes startling symptom of hyperaesthesia, of a most intense 'ariety, was noted when the shoul- der was 1mconsciously touched by the examiner. Seventh. The vasomotor phenomena occurred from the sixth to the eighth day, causing a cyanosis and coldness of the arms, htmds, lower legs, and feet in about 17 per cent of cases. Eighth. The disappearance of the eruption was followeu in about 2-t hours by n quite severe and long-continued desquamntion, accom- panied by intense itching at times, a sensation as of swelling of the hands and feet, and a continual and profuse swt"?nting of these parts. Ninth. The blood work did not show on tlw average the very low leucocyte count and the discrepancy in the differential count usually acredited to dengue, yet these findings were sufficiently marked in a number of cases to accord perfectly with other description!;. It would seem from a general view that these blood findings depended largely on the severity of the attack. Tenth. A. very disturbing feature in the convalescence, from the patient'c; standpoint, was the inability to relish food due to the liad metallic taste that e•erything had, although the appetite was quite keen. J<:leventh . .All the ordinary work could be performed without an~· diffiC'ulty, but the least extra strain, such as inst walking or going up hill, brought on an intense weakness and fatigue which harl not !\II· 4. HERMAN-EPIDIDYMOTOMY IN MILITABY SURGERY. 623 been pr~sent before the fever and which it took some dnys nnd, in mnur c:i.-.e::;. week~ to overcome. Twelfth. The Ja,.i feature to which attention i,.- callt• ufter the original attack. · The epidemic gradually faded out. About the 1st of ~Inrch. 1!)18, with tlw tlrcrcase in rainfall it had almost dic:nppeared. Only un occnsiomd · 1t among tlw aJn1c:tte-. of routine opemtion as to the ue::;t technical procedure to l'IUplo~·. Some believe with Hngncr that the mo::;t satisfactory re~ults 'lre tc he out.a.ineIOTO:MY IN MILITARY SURGERY. \'ol. XIJ. view of the foilnn' lo mntt>rially recluce the duration of the ancl because of the probnuly greater percentage los" Gf function of the epididymis in operati,·e cnses.we had adopted epidiid idyn1oti·m~. We feel that in cases of unilateral epiclidymitis the small differences in the percentage retention of function gained hy the palliative .fo1·111 of treatment is far outweighed by the advantages of rapid relief from pain. rapid and more complete subsidence of the inf11tmmatory reaction, by the much shortened hospital residence of the patient through operation, nnd finally by minimizing the probabilities of re- current epididymitis so commonly seen in cases treated p11llint.ivc>l~·. Technique of operation.-The operation of epicliclymotomy l'ltl· ployed in Na\)' BasP IIospitaJ Xo. :> is a simple procedure. The tc>chnif(tH' about to ue described is npplicnble to I hat great majority < f C:l'ies of arute :N't>is!"eri:m epididymitis in which the major pnrt of the inflammator~· prores.:; is confin<'d to the globus minor of th• c•pid. and the operation can he performl'(l pnin- le~!"ly if care is taken in the localization of the injection. .\ line of infiltration 11 inches in length is mrrcle in thl' skin of 1he lowc•1· part of the scrotum, just to the side of and parallel with lhl' mplic and over the inflamed glohus minor. The scrotum is gently !!rnspecl at its bnse by nn :1ssistant who rotates it so that the field of opemtinn is brought conYeniently into position. The nssistant makes gentle pre;;;sure in order to render the skin taut. Unnece;:sary pressure nt this time w111 cause considerable pain to the patient and accomplish nothing more than will the gentlest handling of the inflnmecl pnrt~. An incision about 11 inches in length is now mncle through the nne,,-thetizecl !"kin and subjncent tissues down to but not through the fibrous sheath covering the epididymis. Care must be exercised in order to define the line of reflexion of the parietal layer of the tunica vaginalis from the point of its reflexion at the junction of th1 epiclidymis and body of testis. This differentiation is made by not- ing the differences in consistency of the tunica above nn to gc>ntl<' pr<'ssnre. 'T'he epidicl:vmis, on so .•. HHR~1A~-l':PrDiffD10TOMY rn ~OLITARY SURGERY. the c011trary. is induratcd und exqni:itnte either punctnr" or raclicnl operation. In c:M" in "hich l:n·ge 1·01lection-: of inflammatory fluid nre demon- trnhlc in the c:w of the t11niru at the time of operution we are in the hnbit of intl'oclucing n. ~m:i 11 aspirating needle nt u p•Jint as for re- 1110,·etl as po<:siblc from the epididymis, but through the opernth·c in- ci<;ion. nwl remo,·ing the finid. Small inflammatory hydm~el<'" mn~· he clisre!!:trclccl. Thu next step in the operation is to thoroughly atw<:thetiz~ the fibrous she!lth of the epididymis in the line of the oritrinal skin inci-ion. The shrath will usually be found to be mu<'h thic-kPneJ>t'lll'd in Jon!!- •tanflin_g case,_ ancl nccrosis of the epididymis is fournl. l 11 this latter e-roup we gently curette the walls of the necrotic nrcn. In the \'ery enrlie."t C:l"'CS of acute gonorrheal cpididymifi!'; we ... ometime ... substi- tute multiple needle punctures for incision of the epirlidymi<:. The relief of tension incident to depletion of the Ye..-;.-els promote_-. nhsorp- tio11 of the inflamnmtory exudate. Experience is necc. -ury. howc"\'"er, in the selection of cases suitable for this procedure. <:iJll'e in improp- erly :;elected cases it not only fails to relieYe the conditio11 but invites additional inflamma.tory reaction. In the small group of ca--c.s in which it is indicated it undoubtedly helps lo restore the patency of the seminnl duct and thus a.void sterility. Incision of the epicliclymis mu~t, it would seem, render the testicle functionless as fnr a,.; its ;permntogcnic function is concerned, although we hnYe no definite knowledge that. this does nctually occurc in <'Yer,\• in~tnnce. .\ small o:2G HERMAN-EPIDIDYMOTOMY IN MILITARY SUllOEBY. Vol. XII, quantity of Dichloramin-T is injected through the opening in the t>pidiclymis nn1l a piece of rubber tis;:ue rolled into the form of a ;croll is then anchored to the depth of the epididymal inci:-.ion. Thi ,,iep of the operation i ~ much facilitated hy using a ::;mall ~harp}~· CUl'H'1l 1wccllc and plain 00 c;llguf. In SOJll(' i11:sta11cc::. ulcrtling occur, from the inl'i:-ed t•pidid~·mi:s a11d thi . ., l'an lir~t Le contl'ollNl by tl1e in r•11 11H:ti1n uf 1l(lt'f> . ntm·t•,..,: 110 a,tunpt slicmld J,.._ m:ulc tu clamp nnd tie such bleeding vessels. Indeed, it i:'l unnecessary in any stage of the opemtiou lo C'mploy lipatun·.,;. alHl a rul.ber ti,,sne drnin is hro·1~ht out of the lower end of the incision. The latter is closed by mean,; of a few sutures of plain catgut so inserted as to include all areas of the scrotal wall. The application of a dry dressing completes the opc'r·t- tion. The scrotum is enveloped in a gauze bandage uppliC'd in e:x.1 t ly the ,.,a me manm: r as i!> a scu ltetus bandage of the head. A T-bandage may be used to advantage. Po;yt opc1·a#1·e f1'Mt1nent.-Tbe patient is confined to bed with de\ at ion of tlw H<'l'olmn until the ruhber tissue drain C< llll'S · wn~ ,.,ponln1wously. Tl1is occurs about the fifth da~· in the :\\~~·11,:,r,• c·usl'. The drainage is selclom profuse and rarely frankly purulent. 1 '1t• wound heals by primary union except in the rarest i11st:rnces. Rl.1 I- der irrigations with weak solutions of potassium perman:i•rnatP • n• begun after tlw drain has been removed but only in patients entirely free from acute urethral syrnptom:-.. Internal medication ma~· or mn) not be gh·en at the discretion of tho iucliYitlual surgeon. R esults.-The operation of epididymotomy immediately rclieq•..; the pain which is often severe, so that convalescence is pranic:tlly symptomless. In one case, terminal hematuria followed operation and persisted for 10 days. In the second case a small hydrocelC' necessitating aspiration, appeared after operation; this patient ho\\·- e-.er was clinically well and ready for duty 19 days after the cpididy- motomy. In a series of 40 consecutive cases, the average hospital re~idcnce of the patients operated upon was 25.3 days; in thC' 111 i lei case:; which were not operated upon, it has been 3G clays on the u.n:r- ag-e. The operated cases are not returned to duty until the wounds are completely healed, until the urine has entirely cleared and ha~ remained clear for 5 clays without trentment. nnd until the patients ha\e demonstrated their ability to do a full day's duty with the hospital working parties. We ha.Ye seen only one instance of recur- rence of epididymitis following operation in either ciYil or 111ilital'.' experience. The results of operative treatment are particularly striking in l'l'" I C'nrrcnt cases as is illustrated by the following case history : :_l\f. W. II .. senmnn first class, U. S. 8. ---, :idmlttecl to 1fav~· Ba-;e Hospital Xo. ;), KoYernbcr 7. 1918, for the treatment of bilateml gonorrheal cpididymitis of one month's duration. Under palliati\'e !'io. ~. SHORT-CEREBBO-SPINAL FEVER AT GREAT LAKES, ILL. 621 treatment the inflammation subsided but soon recurred on the left ,.ide. Repeated attacks of epiditlymitis on the left :;i(le n:;:-ociated with pcr.;i-.tt·nt Ul'l1thrit is confined this patieut to the ho:spital for a long period of time so that the question of medical snncy for incurable !!onorrhea was discussed. On February 10! the left epididymi wa"' . (' .• fireman first class, 1:. S. S. ---. wa,., a days 11tte1· he was returned to duty clinically cured. We foel justified in advocating epididymotomy in all acute cac:es of :;ronorrenl epididymitis with the possible exception of those case:: with a minimum of inflammatory reaction; in all recurrent ca ... es: in all chronic cases where marked thickening with the epididymis 11 ~ociatcd with tenderness is indicatile of the pre!"ence of pu~. In this latter group of patients. the> inflammation persi~ts for a long time unless drainage is provided and later gi'\"'es rise to neumlgia of the> testis often with profound sexual neurasthenia. EPIDEMIOLOGY OF CEREBRO-SPINAL FEVER AT UNITED STATES NAVAL TRAINING STATION, GREAT LAKES, ILL. Hy J. ·r. S11onT, Lleutcnnnt. '.\I. C., United St.ates N1wy. For many years epidemic ccrebro-spinal fever has been considered n communicable disease, which, in military life., appears upon the mobilization of young recruits, and uc:nally in connection with pre- disposing factors, such as bad weather, crowding. or fatigue. Mor<.' recently it hns been shown that the cauc:ative agent is the meningococ- cus. spread by direct contagion from the nnso-pharynx of n patient. a convalescent. or a presumably healthy indiviclual. The corollary which nt once suggests itself is that if the "carriers'~ of the menin- gococcus can be segregated the danger of an epidemic will be hrgely o,·ercome. In order to make clear many of the factors that wl'rc ope>rative in the recent epidemic of cerebro-spinal fever at this :.1ntion it is neces- sary tn desrribe briefly the genera] or!!nnization of the :::tation nml the se>vera.l phases of training throuµ-h which the an~rnge recruit ordinarily pnRses, as well as to outline the work on meningitis pre- cedint? the epidemic. On his arri va.1 the recruit is first place>tention c· unp. "here he remains 21 days. Dnring this perio1l he is expected 628 SIIORT-CERERRO·SPINAJ. FEVER AT GREAT LAKEC:) ILL. \'uJ, ~II to make the transitio11 from ciYil to military life and to ndapt hin1· ~<'lf more or ll's.c: complct<'ly to his new envir011mcnt. to nb:mdon liis ine. and recrontio1 and conform to the manner of liYing that is prescl'ihed for the 11111, jorit~· of his fellows. Ho mu~t learn to sleep in n hammock. and u:>ually with more than his customary amount of fresh air. He must overcome his homrsiclme::-.s. mnke new acquaintances. and learn the l"Ucli.ments of military life unll cliscipline. )foanwhile physical ex- aminations, nec<'ss:uy dental work. nccinntion. and typhoicl prophy- laxis are completed. Following his detention period the rerrnit j., transfcrre>d lo one of the other camps, \Yhere general or special train- ing is continued for a vnriablc period. avernging three to six month.:. He may then be transferred to the outgoing detention camp. wh<'re he remains under observation and is giYen a number of medical ex- aminntions and inspections before leaving the station. In each en.mp ancl regiment a certain number of men are held for indelerminnte pl'riods to assist in administration, instruction. and the mnintenanr,• of public works. The "·ork of discon•ring and isolating meningococcns ci1rriers. n c·onformity to general practice. has been greatly facilititted here b,· taking acln.ntngc of the organization described aboYe. It has lieen the custom to make naso-pharyngeal cultures of all new men on the station as early as possible in their period of incoming detention. and to isolate those f ouncl to be hnrlJoring the meningococc11s. The m<.'n in outgoing detention ha,Ye been ~imilnrly examined. and the carriers detained and isolated . . ,,11enevcr a case of cerobro-spinal fever was diagnosed, the fol lowing procedure was carried out as a matter of routine. Tho com- pany of men nnd the banaeks from which the patient came Wel't' placed in quarantine and everyone cultured. AclditioMl cultures wN·e mnde on all possible contacts, such as hospital corpsmen ancl pat'ients in the regimental sick bay where the man with the disea:;<' may have been treated for a short time before transfer to the hos- pital. 1Jpon completion of a preliminary examination of the cul- tures. usually twenty-four hours, the men who had yielded organ- i~ms resembling the meningococcus in cultural characteristics, mor- phology and staining reaction were declared to be carrier suspects and were removed and placed in the isolation units or "cubicles," at the disposal of the regimental surgeon. The quarantine was then lifted and the remaining men discharged to duty. Suspects discovered in the detention camps were similnrly placed in cubicles. Accorcling- to the final laboratory report, based on agglutination reactions, tlw riated case. the> pof<'lltinl clnnµ-<'r "·011lcl be the samp rrom nll strain:- ?'o. 4. SllOI~l'-CEREBRO-SPINAL l'I~\'ER AT ORr:AT LAKE::>, lLL. 629 fcrrcd to the mcningococc?s carrier camp if po:-;itive. The types 1 of mcningococci were not determined in the routine work, and all men "ho~e organisms ga \·c po:>ifrrc agglutination reactions with FJe."(ncr·s polyn1lent .Sl'l'Ulll were isolated, under the n55umption that nltho11gh ull might not gi>e the type corresponding with the asso- ciated cn!'c, the potential danger would be the same from all strains thus shown to have been pathogenic. The i:.olateu cnrriers. from a.11 sources. hn\·c been cultured at in- t<'rnds of five r as the S'\ ab is passed to me across a. table, and a blood-agar Petri dish: already numbered, is immediately touched wilh the swaL and streaked with a sterile wire. By elimination o.f all unnecessary move- mcntl:i nncl the assistance of one man on the lcit to number and dis- pose of plates and another on the right to flume wires (of which two arc used to allow time for cooling), entirely satisfactory cultures may readily be taken at the rate of nbout 300 men per hour. The, plates are kept w11.rm with hot-water bottle::. at all times except dur- ing accual inoculation. are transported to the laboratory by closed motor bus, and at once placed in an incubator. The methods in use by the ltlborator~· force are briefly a;; fol- lows: The inoculated peptone-blood-agar plates arc incubated ut 3i C. from 12 to 18 hours, or until a satisfaclory growth has taken place. Colonies with meningococcic characteristics are selected an<>rt o• the lnd ted ltesearcb Committee on Bacterlologlcnl Stuillra In the l'atbology, I'ren.otlon. and Control of Ccrebro·sploal Fever Among till' lforce11 1"1rlng 191:> and llllU. London, 1, l.Js~. or t:nwlu, 1917, ()::lQ hllORT-t'EREBRO-SPlXAL FEVER AT GREAT LAKE~. ILL. uf l to ;;o. 1 to 100. and 1 to :WO, with cm~trols uf hor:;c ,erum 1 to 50. :mu phy:-iological ~nliue su~peru;ions of the orgnui,ms. The~e are in. cubated nt .->;; C. for 1 hours and the n•ading,., then mad£>. .Aggluti- nation uy I lie p0Jyn1lt•nt a11timt•ningut.:0Cd1; ,;cntlll in any of the :1bo,·c dilutions. with satisfac.tory control, has been regarded as in- dicati\C of the meningococcus. and th£> final report is made on thi' ba-,is. Typl' agglutinations with Flexner·s ~cr:t (for ''normal:· ··para;· '· irn•gul:u· normal:· aml .. irn•:,rular paramC'n1n~ococci'') have been done in a ~ew recultures. and will be reported upon com- plct ion of tho series. The practice of taking pharyngeal cultures for mmingococci was first begun at this station under the direction o:I' Medical Inspector C. ~!. DeYalin, Uniled States N"avy. in May, 11)17. This was near the close of a cerebro-spinal fever epidemic 0£ 9!> cases, distributed as follows: ,January (1917), 5 cases; February, 9; l\farch, 13: April. 25; May, 35; June, 11; July, 2. The mortality was 31 per cent. Xo further cases deYeloped until October, when three cases occurred. These were followed by 4 in No>ember and rn in December. Refer- ence to these latter cases will be made below. It is noteworthy that during the aboYe period the population of the station increased man~ times, reaching 1:>,000 in NoYember and 25,000 in December. The total number of cultures made nt. this station in 1!>17 are grouped below under se>ernl headings, with the percentages of car- rier::; founxclush-e of carriers .................... . Poe:ithe tultures, exclu~iYe of carriers ....................... . Cultures made, unda:;idfiecl .................•................ 42, ~55 .....•.... i. 294 , .•......•. Total C'ulturcs for 9fation lahorntory during l!Jl 7 .............. . . \dclitional cultures tal.en on the station for examination by oth~r laborntorics ......................... . .....•......... The epiclcmic.-Although 19 cases 0£ cerebro-spinal fovcr occurred ·at this station in December, 1917, the epidemic proper began in Janu- ary, 191 '3, with 8·1 cases. The incidence decreased d the disease in Camps Dewey and Perry, in the newest part .,f till :-.tation separated from the other camps by railroad tracks and 11 highwny. The seven regiments in these camps are made up mainly ot r<'). an) . While this camp comprises the newest recruits it will be remembered that they are not yet doing routine work, their limitations are more generally recognized, and their mode of life is ycry carnfully superintended. In addition it has been shown that in 11is camp there is an allowance of approximately 50 square feet of tloor space per man, and indoors the men are segregated into groups of but 24, while in the camps mentioned above GO to 75 men were liY- ing in one room asis of the more careful housing clnring thnt period as pointed out ubo,·c.1 By talmlnting chronologically the Lhttes of arrirnl at the stntion of the men" Io clcnlopecl the disease duri...,g Jnnunry, it "as further fouml thnt :ii. or G7 per cent, of them had come to the station between December ~ and December 15. This is also trne of the fi.r:-,t case orcurrin!! i •1 February. These elates are significant in view of the situation on the station at that time. Owing to the ruling which pre- yentcd men of conscription age from Yolnntet>ring their sen·ice.s after December 13, 1917, recruiting oflices Wl're crowded nncl many men pnli,tcd in the Navy. In fact, from approximately 1:1.000 men on Dl•cembcr 1, the population of the stn.tion by December l:i had risen to :W.000, ·where it remained. At this time nnd snhl'equently 11 scrie:> of circumstances operated as strong predisposing or clctermin- in!! foctors in the incidence of disease among these young recruits, espl'ciully of cerebro-spinal fever. Owing to the limited capacity of the incoming detention camps it was nece~snry to hnrrieclly outfit a. Jnrgc number of the men and transfer them to an instruction camp within a r.JJCek, often within two or th1·ce rf a!fS. In spite of the skillful manner in which the situation was handled it wns ine,·itable tl1at many men should lose sleep and r est, while the hurried atmos- phere in "hich the~· were rushed from one place to another to secure Yarions examinations and new equipment made it exceedingly dif- ficult for them to adapt themse]Ycs to their new environment. In the routine tests of these men by the Psychiatric Unit it was found. further, that they were somewhat below the high a\'ernge in- telliircncc shown by the men enHsted before and after this period. From this it might be inferred that they would nclapt themsl'l"es to new conditions lrss rPnclily than the others. This won 1<1 show itself in "-llch things as failure to properly protect themsehes from ex- po~urc h~· the use of overshot>s and o>ercoats, or hy tho change of \'\'ct clothing. Jn the camps to which these men went, mainly the first four regi- ments in camps Dewey and Perry, an effort "·as made to coutinue their clet<'ntion: but it was somewhat less rigid than in the detention camp:::. Thel'c was aho co11siclernble crowding. as pointed out aboYe. which brought them into relation with a larger munber of people and in mnch closer contact. The question of proper nntilation. hO\\C\er, l'l'lY be ruled out, as throughout the station tlw regimental '-Urgeon::. make daily recommendations in this respect and earh night make in"pections to determine that they arc in force with satisfactory results. 1 Mink, O . • T.: Points Jn the Epidemiology of Meningitis, nl.>str., Jour. Am. lle<.I. A.,n., Feb. 23, 191~. p. i:i03. iGQns-lS--ri 634 ~HORT-CF.REP.RO-SPI!\AL FEVER AT GREAT LAKES, ILI.. \'ol. XU. Bt•fore lhes'C new men could much more than get their bcarin!!s they were overtaken with very sewre and continued cold weather which began about December 25, ns mentioned above. .\ &!\'Cr~ blizzard boon occurred \Vith snow from 3 to 6 feet deep, requirin!! strenuous effort to keep the roads open, and making any movement about the camps Ycry difficult. Then after a short rest, the p occ.'>S wo.s repeated by the appearance of a second blizzard, with som !whnt less snowfall, but more wiml and damp cold. Subsequently the hu!!e piles of snow had to be hauled away to avoid later floods. The consequence was that several other factors pr :clisposing to disease were introcluced and accentuated, namely, fatigue and exposure to the weather in unaccustomed clothing. The latter contributed to the production of many "colds," an epidemic of which was noted as hav- ing preceded the meningitis in the second regiment. A similar high incidence of other acute diseases among new recruits (72 per cent of the pneumonia; 57 per cent of the influenza) was also noted in charts prepared from cases during this period. The summation effect of all these factors is well shown in the comparative freedom from :19. a;:: contru·-tecl "ith the English l'l'port 1 where thn•c men on~r 3G 1ir£' ment ione :mcl street curs in near-b~ toY us. the rnenim.dli in t he.<:e Jo<•alitie!'> nner assumed the proportions that it di than a week before their transfer to the hospital, and 1;; of thc.-,c hnd gh·en ne1-,Pfttin cultures prior to that. (See cases 2, !>, 13. and rn in Drcem- her: 2. lG, '27, 3-1, 37, 38, 4!), 53, 57, GS, 71, 74, 78, in January:!) in Feb- ruary.) This is in accordance with the experienee of Fiklec: and Baker· who obtained negatiYe cultures :from 2G nH'n s110rtly h!'fnre they developed the disease. Dul'in!! December and January six men who had previou::ily been found carriers dc,relope. $. B.), who hntl been negative in incoming detention, wa,; cultumcl t wir<' as n contact. On the first f'CCasion two puti<'nb (.Jnn. Nos. 13 nnd 14) had been remoYed from the oppo..:itc end of the bar- racks from where he liYed, and he was founcl negatiYc. Ei!:!ht !fays later nnother case (Jan. No. 3G) rchro-splnnl Fever In the f,ondon Tllsll"lrl, Tl<'<'l'ml.l<'r, l!ll:i- Jul7, 1:110 Spcclnl fil'JJOrt of the Jndlcnted Resenrch Comm!ttl'•' on B 1 tcrloloi:k11l ~tudl('S In the l'atholoi;y, Prevent Inn, noel Cont1·0! of Ccrebro-~plnal f~n:r among thtJ Forces during llltr. nnrl lilll\. London, 'I'. 1"!Hchrr Unwln. lnl7. 1 I"lldP1<, I'., nnd Bnk1•r, ~. T, •• J.nnc1•t, London. Oct. :!n. 1!ll7. 636 ::;HORT-CEREHEO·SPINAL FEYER AT GREAT LAKES, ILL. \ ol. XII '' hirh -.0011 became crowded, and where he developed the di~ea .. e tw0 wel•ks Inter. From the beginning of the work until the Ia--t of ,Jnn11• ary. "hen thi::. ca•e deYelopcd, 1.~~8 carrier:; had been di,.:co\e1-ed of whom only ti or 0.4 per cent clenloped the disea~e. Fikfo::. and Bnker1 report that among 485 carriers not one deYeloped c<'re>bro-spinnl le'\'er a111l they consi the organif'm cnn .tlways be recm rred from the throat after U~e di:;ensc has made its nppearance. The important, icatures of the epidemic a.t this station as detailed <.thovo may be briefly summarized as follows : The great major1t y of the rnen afl'ccted were young unseasoned recruits who had been rup- iclly rushed through the regular incoming detention camp at a litne when the station was rapidly expanding, and sent to already crowded camps where 1hey were almost immediately exposed to severe cold, stormy weather and hard work. It is noteworthy thnt while with one exception (Feb. case Ko. fl). the ~·oung unf'easoned recruits did not uC\'elop the disease in the regular detention camp where they " ·ere more carefully cared for, they were unable to withstand the combination o.f circumstances and depressing influences met in the other camps, al! hough these same factors, operating on all ulike, did not materially influence the older men on the station. This same "hardening" process may also be seen in the incidence of meningitis among the several Army groups during this period. as indicated in tho following table derived from weekly reports ap- pearing in The Journal of the American Medical .A :;Hociation.~ Meningitis al Army camps. L nnunl :le per lhotL,and, week ending- . I I I ~ ~ ~ ~ ~ . ~ ~ ~ ~ ~ ~ ~ ~ ~ s ~ ~ ~ ~ § ~ § § ~ § s ~ lg ~ ~ ~ ~ ~1~ ~ •i • -1~ ~ ~ • I"- - C... "'" -. - - '='I - CIC. - N - ;;c;.·.·~ ... ---:...:.o-..: ,o ., l ~ c;; ~ E ; a a -z ~ I " ~ ~ - - -=--=-~ 0 ..:. , .... .., ...... ;.., _::: ... (· _ ...... Nationnl .o.\rmy, all ramps .... . .... 3. 2 4.1,6. 6 8. 3 7. 4 5. 7 4. 1 I. 9 7. 4 4. 5 4. 0 2. fl:?. !1 J.3 r\acional Guards. nil ramps ........ 3. 8 5. 4rt 2 2. 9 4.4 5. 4 4, 8 3. 2 4. 3 3. 3 3. 7 3. 2:!.'.?1. !I United States ,\rmy, Regulnrs ... . 1 • 2 0 0 . 411.11. 6 5. 413. 0 4.12. 9 4. 5.:u; :i. 51. 7 American E~pNlilionnry Forces ... ,3. 8 .. t .. 5. 5i5' 0 ... r 6,5. 7' ...... 1. GI .. ·(~ (j. 0 The rat" for 1916 among United States .Army Regulars was 0.:?9. H is seen that the hjghest incidence was in the National Army- thnt is, among the newest soldiers; and that in the X nt ional G 1·1 nl. 'Loe. cit. 1 our. Am. lllcd. Assn., Dec. 15, 1017, to Mar. l(l, lfllS, ~ o.4· SllOitT-CERF.BRO-;;;PJ:XAL FEY.ER AT GREAT LAKES1 ILL. 637 compo::;cc1 generally of older men who had some military experience, it was less thnn in the Xational Arm~·. but greater than among the seuo:oned Re!!nlars. Among the latter the incidence ro::;e when they inet the new conditions opcrnti ,.e in the u,·er,,e. s force-.. Carriers d111 'ng tM; cpidcmlc.-Tl1e incidence of meningococcu::; cnrriers among seYeral groups before, DO cultures) that the epidemic of cnse:-:: coincides ";th remarkable closeness lo the cold weather, as indicated: while the increas<' of carriers does not beg-in with the cold weather or the ca~es (certainly docs not precede them), but starts about two weeks lntt'r. 'J'he percentage of carriers remains high for about thrf'l' weeks nftc1· the weather has b{)gun to moderate and the cases ha Ye almo:-.t ::;toppcm, giYe the highe,t r:itc at all tim(» ... Out_!!oing detention. comprising oldt>r rncn frolll nlJ O\'er the stntion. gin's a. some·whnt lower percentage of C'lrriers. an1l is rather com- pnmble to the aYerage curve computC'cl from all cultures taken e-week January lD-25, detention 2-1.4 per cent: week Feb- ruary 23-Mnrch 1, contacts 2G.7 per cent. During- the extremely cold weather a. charcoal foot warmer was usey the following circumstances. ..\fl er sending iww inen to the C!\r- riC'r ramp steadily for several months, somewlrnt in excess of the rate oJ discbarge, lhe quarters available Ior them hod become nearly filled. Toward the latter part of January the incidence of carrie;s ro:-;.' so rapidly that their usual accommodal ions wt>re completely fill<.'cl, including the iwailable mom in the naval hospital, where some of the more chronic carriers were sent. The carriers who were first isolated as suspects, could not be removed from the regiine11tnl cubicles, which became filled so that snsp cts could no longer be remoYed from quarantined barracks. Finally, a case of cer1.:bro- spinal feyer appeared among the crowded carriers (February. Xo. !>). About this time, January 28. when the case cune was falling nncl th<.' carrier cune still rising, n new procedure was introduced by Sur!!eon 0. ,J. Mink, United States Ni:n.r, the l-IC'nior medical oflicer of the station. of whose administration, criticisms, and sugge:;tions this report is largely the outcome. This procedurn, which affected the last 10 cases shown in the January table and those occurring sub- sequently, has been substantially as follows: The contacts have been qna.rantinecl in their barracks for five clays, cultures being taken from ever) body hut the carriers not remove reported b~- some ob::;e1Ters, hn:::. not been the experience at thi:- ~iation. nlthou~h in J:muary ca"'e Xo. ! there was nmplc oppor- tunity for carrier infection. The patient in thi-. in.--tance had hcen rn!!Ul!Nl in swabbing carriers ancl exnmining cultures for a month pre,·ion,Jy. during which time he was associated in the work with n. urnn who at the time of his illness giwe a positive meningococcus culture. In culturing many contacts, howcYer. the highest pcreent- n!!e of c·uTiers was frequently found nmon~ those len::;t closely a~--o­ ciuted with the patient, as in the opposite end of the barrack::. ::.epa- rntcd I~ a solid partition with no indoors communication. (See De- ccmhl'r cases No. 12, 14; January cases No. 12, 13, 14.) D. J.C. (De- ccmlwr cnse No. 14) had been isolated as a carrier, and yet when he rlrn•loped cercbro-spinal fever 11 clays after his return to duty and the whole company was cultured, 8 of the 10 carril.'rs found were Jh·ing in the opposite end of the barracks and ne'er came in contact with him indoors. When carriers were found in the s:1me end of the barracks, they were sometimes men who hacl been sleeping in the hamn11 ·k next the patient, but just as often in the second! thiru. or fourth hammock distant . • \ plot ma pbaryncith<. Feb. 4 GO 11 18.3 D. W. A., 2:n .......... Pneumonia. Ft•b. l!l Dr. C. 96 12 12.5 L. F. N., 12L ........ )[eru.le'. Ft!b. 3 50 9 18.0 E. II. H., 52!>-N ....... Influenza. Feb. 3 47 5 10.6 G. n. G., :m-X ....... Toll:!illitb. )far. 8 Dr. C. 55 1 1. 8 H. H. G., 330 ........... lnfiuen7..a. - ~- 'Yhen these .few instances are plotted by week,; the cune thnt re- sults conforms in a general way to the carrier index of the station for t bat period. (See chart.) ~ome" hat similar results were obtained when the occupants of n barracks were recultured. On January H,, case No. 39 was remoYed from Barracks 421-'V and case No . .13 was tnken from the same barracks three days later. There being no a"ailuhle space for caniers nil men were left in quarantine together without L-eatment while cul- tures were made on January JG, 18, and 2~, after which carriers were isolated. On February 15, all nYailnblc men ori1:?"innlly present were a!!nin sought out: wherever their location, and the culture:; repeated. This wns again done on March 4. All plnle::. were made and exam- i11e1l by the same technique. 1 Loe. cit. 642 SHORT- CEllE.HHO- SPJNAL FEV£ U A'l GHE.\1' 1..\KE:-)1 ILL. Repealed cullura in Barrarb 4JJ-1r. (Pm.-l'oUth·e by atclt:tin~Hon. o-~eZ3th-e (no c·h~m·ttristic co'o:tl•. or ll!?elt 1f .. a1lro nci:a I~ llla'lk Sn!'e• :'\o c~llnrem ;1,,_ •-li;?la•t'I aH-:.-ric.r )an. 2.; to h•b.11, l91S, a'l. I~ IJl~ l .,,..... ~="I'·· .. ;.~,, I}~~~·~~ '.':: II. F. K.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pos. 0 Pcs. I * 0 I o E . .\.. K. - - . --. ----- --. --. --- ---------. -. 0 Po..~. I 0 * 0 fJ D.L. 1........................................ 0 0 Pos. * 0 o 1''.J.L ............................................... POEI. * 0 O J. E. L................................... 0 0 0 Pos. o II . .T. ~f.................................. O 0 Poe. 1 o o ~!}L~~:.·.·.·.·.·.::::::::::::::::::::::::::: Poso g ~:: * i g i:::::: L. F. )f................................... 0 0 Pos. * 0 o L. F. M ............... .......... .... ...... Poo. PoR. I 0 1 0 O D. D. P .................................. Poe. 0 Pos. 1 0 o "17. E. P.................................. Poe. O I 0 1 0 I o F. H. R................................... 0 Poe. 0 1 O o F.\V.R .... : ............... : ........... : 0 0 Pos. , * 0 O F. R.R .......... ... ........... ...... .... Poe. 0 0 1 O O F. W. R......................... . ...... .. Poe. Po~. 0 (2) o P.L.R .. . . ..... . ......... ........ ..... .. Poe. , 0 0 1 0 O F .. r. s.................................... o o Pos. j * o o D. E. S ...................... .. .. .. ........ Poe. 0 0 * 0 o T. E. S................................... 0 POI!. , 0 1 1 0 0 C.R.\\' .................................. Poe. O 0 1 o o R. F. 8...................... ............ 0 I 0 Pos. , * 0 I 0 E.J. W .................................. Poe. o O 1 Pos 0 . o R.P.\V ................. ................ Poe. I 0 01 1 0 c. W .••••••.......... •..••.•...••••.••.•. Poe. 0 0 * 0 I O Atlditionalmennegative..... . ............ 33 Q 33 ...... 2~ - 2i •_\carrier Dec. 7, 1917. Poo.; 4 succcsslve negatives; Dao. 29, 1917 to duty. ' ~'11rlough. Percent. Positive by agglutination Jan. 16, 1918........... . .................. ... . . . . . 22 Positive by agglutination Jan. 18, 1918 ............................. - ~ ....... 9 P0t;it.ive by agglutination Jan. 22, 1918 ...................................... l!l Pns:itiw hy agglutination in first thr<'e cultures of all men.................... 4:l P~itivc by agglutination Feb. 15, l\Jl8 ................... _ ............ _..... !U! P. 3. tili. Febrnar~· xo~. a. r., fl. nnd 10). In this connection may lie mcntionc1l abo the de- ,·elopment of cerebro-spinal fever in a draft for an Ea~tern port in ))<.'Cctnl r l!lli. All han f onnd among those least associnti>d. Finally new cases occur or fail to occur without apparent reference to carrier:- who remain or are taken away. ( 4) It has been found in general by roost ob:>cner:-. with few ex- cept inns. that the segregation and treatment of carriers docs not !!i H' s:itjsfactory results in hastening the nt with military economy to deprive the organization of 10 64·1 ::>IIOHT-CEREBRO-SPINAL FEVER AT GREAT :wurns, ILL. ,·01. xu. rncn continuou:-;Jy for c,·ery one whom it is hopctmctecl report of ~!eyer, \Toltmnnn, Furst&. Griebcr1 which is here quoted: They fouwl l.i:> per c•pnt of meningococcu-1 carrier;; in O\'l'r 9,111 h1..>a lthy i;ollllers in the l\lunlcll gurrison nt u time when no <·crC'bro-splnnl fewr ,,·ns p1·e:;eur. 01w cxamlna tl011 wns mnde of each man. One thousand nine hunilrt-.1 111111 elcn~n h<>:i.lthy pe1·wns were examined mnn~·. runny times wlt!J tlH' re,ult thai. 2.·Hi 1w1· Nnt were founcl to be mcnlngococcus carriers. Of U10 totnl or 11.ll~'..? healtllr 11er>:om;, nhout 2 per cent cxnmilwtl contninctl the menlngo<·o i·u~ In tlwir thro:1ts. Isolation of the carriers hnd no ln1luence on the lnei1; that the tlrncticul benefits do not justify the care 111111 time necel'Sllry for such work. They bellcYe that the chipf foci, uslcle from factors not understood in the spr1'UU or this tlis- eas•', ~et'lll to he lhl' sic!;: nnd cs1JCcially mild cases. In order to summarize the various clinical types of meningococc 1:. ii~fcction that haYe bren described, a classification might be made lC· cording to the degree of inYasion by the mcningococcus. Pre- sumably the least degree of invasion -would amount to merely a con- tamination of nn indiYidual"i,; throat, a transient affair measured in hours. In increasing degree the following types would occur: Tem- porary carrier~, measured in days, and chronic or persistent cnr- riers measured in weeks or months; local infections of the pharyn::t, producing "sore throats; " 2 general infections. either of low grade and passing £or influenza, etcetera,8 • or ontspokC'n sepsis/ with a Ya.- riety of metastatic involvements including meningitis itself. In accounting for rnriations in the type of disease Thompson & "'Wulff• conclude that meningococci vary in virulence at differ ~'nt pe1·i0ro-splnnl meningltl~, nt Cnmp :llcClellnn, Jour. Am. llf Pd. Assn., Feb. 10. 11118, p. 4GS. •Thompson, o.; Wulf!', I<'.: Menlngococcus infection nntl mcnlm:ltls. rrospltalstldende, Copcnbagcn, Dec. 0, l!l17, Jl. 1102; nl>stt·., Jom·. Am. Med. Assn., Feb. l!l, 1018, p. 40~ • llcnlck, "" W.: Elpldrmlc of ;\lcnlngltl8 at Cnmp .lnckson, Jour. Am. ;\led. A:wn .. Jan. 20, llll8, p. 227. l(o.4- SHORT--OEREBRO-SPINAL FEVER AT GBEAT LAKES, ILL. 645 Granting the wide distribution of the meningococcus and its dis- semination by carriers and patients as the basis of both propositions, tho alternative explanation of the variable incidence and type of disease would obvious1y be that of a variation in the susceptibility and immunity of individuals themselves, as by the factors already discussed. Since control of the carrier is so inexact, and of doubtful efficiency, while harboring of the organism is of itself insufficient to produce the disease, it appears wiser to concentrate attention on the roore general measures of proved value and easy application. In addition to lhe avoidance of haste, crowding, exposure, and ex- brmsti·on in training recruits, all considerations of the utmost im- portance, other hygienic and sanitary measures available to combat· epidemic meningitis may be briefly outlined as follows: The 'men who have been in indoor contact with a cerebro-spinal fever patient should b6 quarantined in as small groups as po5sible in commodious barracks with good ventilation and ready access of available sunshine. A. nasopharyngeal spray with an antiseptic solution should be given at regular intervals to combat the organisms in the throat if possible, bnt more especially to accompany those which leave the tlu·oat in ta1king, sneezing~ and coughing. Special attention and treatment should be given to men with "colds" and coughs, including instruc- tion in properly screening others from an unavoidable shower of saliva. Curtains or screens may be placed between the hammocks or beds at night, as has already been instituted at this station by Dr. Mink. Light exercise may be taken outdoors, with proper clothing and protection from the weather, the danger of carriers being prac- tically negligible in the open air. After a period of five days or a week, when the temporary carriers will probably have cleared up, and the chronic carriers become relatively harmless, the whole group may be discharged to duty. During an epidemic large and promis- cuous gatherings, as in Y. M. C. A..'s or tlwaters, should be pro- hibited. During a quarantine cultures may be taken and repeated at pleas- ure, with a preceding temporary suspension of antisepticsJ and as a midd1e course during an epidemic the chronic carriers might be seg- regated to the extent of preventing contact with other men indoors. It is unnecessary to call attention to the usual precautions in ' handling the patients, who should be iso]ated through illness and conva]escence, and the desirability of masks for the attendants.1 The recognition and prompt treatment of the mild and previously unrecognized cases will undoubtedly do much to prevent outbreaks. 1 Weaver. Cl. H. : The value or the face mask and other measures, Joor. A.m. Med. Assn., Jan. 12, 1918, p. 76. 646 HJGBFE-DISE.\SF.S OF CEXTR.\L XER\'OlrS SYSTEM. Vol. Xll ('()~ CT.l""10~ "'· 1. Epidemic cerehro-:::pinul feYcr is a dise:be cau--ed by the menin, !!Ococcus: which j,., E'preatl for the most part hy dirl·ct contagion from putil'llts ancl healthy inclivitluals. In military organizations the me11ingococc11s hn ... a predile<·tion :for young recruits, but is usually inert in the ab--ence of depressing or resistance-lowering factors. ~- The :11·guments for isolating meningococcus carriers to pre,·ent the disease are not conYincing, since consistent practice on that ba-:is has proved not only extravagant :rnd against military efficiency, but also impracticable and noneffective. 3. The search for meningococcus carriers ancl their disposition shoulcl not cause neglect of the more generally effective and easily controlled measures of hygiene, of which the following are of tl1e greatt'~t. importance: The pre,·ention of crowding among young re- cruits; the allowance of ample time for their " hardening " and "sea- soning;" protection from weather, o,·erwork, and fatigue; and the use of all measures that will promote the general health of the camp. The laboratory work reported here was done under Surgeon 0. J. Mink's direction by Assistant Surgeons C. W. Barrier, ·w. E. ~for!'•', R. M. Choisser, and D.R. Higbee, United States Xavy, and .Assistant Surgeon C. Koenigsberger, United States :Nanl.l Resen·e Force. Ynl- ual le data ""ere contributed by ~\ssistan.t Surgeon R. R. Spencer, Unite;pinal fluid. Pre-vious to the year 1891 the cerebro-spinal fluid ha.cl been the subject of much specula.tion among physiologists, chemists, and pathologists. ~fony, inclPed, were the theories aased c.tntcs. ,\s a result of the very exten:;ive exn.mination~ anll re:,:eard1es which h:n·e been cnrried out it is now po$$ible for the clinician and the technician to arrive at certain definite diagno .. cs nn1l probable prog-noses in diseases of the central nervonR system ancl also to re- t•eiYc indications :for certain methods of treatment. It is only by a complete laboratory examination of the Uuicl that 11 correct interpretation of the pathologic processes 1lcvcloping within tJie central nervous system may be revealed. The lack of coopera- tion between clinician and technician has too often led to gro:,;s error in din,!!nosis, treatment, and progno~i>;. Since the entrance or our forces into the war tlw n-;sembling of lnr~<' :rroups of men has kept U:3 on the alert for the early detection of nil contagious disca!;eS, particnlarly meningitis. .\s a re:;ult much thnt is new has been disclosed and much thnt was formerly consid- e1·ed of little significance has come into its proper recognition. This adrnncc has been made lnrgcly through the spirit of mutual help- fulness and cooperation which abounds in the military service. The Inbomtory worker has familiarized him!>clf with the clinical aspects of this disease and has even been permitted to take chn.r:rc of the wards \\here these cases are segregatecl. The clinician has abo profitetl by visiting tJ1e laboratory and obserYing th(' methods fol- low11(l for the detection of e.vidence of disease. For example a new meaning has been :rhen the term clca:r 'fluid. It hue; b~n shown that a water-c1<'nr fluid h~; artua1 count may <'On- tain an~· number up to 800 cells per c. mm. Consequeully we no longer wait for a fluid to be definitely cloudy or 11ndl'r marked pl'('C..;,Ure before we consider the cast one of mcnin!!'it i:- or administer th 0 rap utic scrum. Lumhar puncture as a procedure has in limes pa t he"n rc!!arded ns nltog('thcr too serious a manipulation, nnd I helie,·e in time>.:; pres- ent is much too lightly regarded. Ther<' r-houlfinitc inclicn- tions for it when clone ancl it should ncver be 1wrf ormecl n::, n l>hort r·nt to 11 diagnostic end. By so cloing we clcprcciatc our power:, of o~. ernition ancl fail in conscientious phy--kal e.'l:nminntions. I pro- pose no"· to describe n detail in the technilJUc of tlw operation which i11a' Le of scr,•ice to those who work in the field whL·rc there i ... little op1;ortnnity to render the hands surgically clenn. Select the exact 648 Ji IGBEE-DISE.\8I~S OF CE~TUAL XERVOUS SYSTE~f. Yo!. XII spot" lwre it is proposed to insert the needle and touch this with the tip of an applicator immer-.;ed in iodine 10 per cent 5olution. Allow thi to clry and then with the broad surface of the npplicato1· paint the field of Opl'ratiou up to ancl including the etll!e., of the ::,mnll ::ite Fclectcd for punctme. This small area. will r('main sharply clcfined. The first two finp:c 1·s of one hand are widely spanned acrcss this area, stretching the skin and holding it firmly against the spinous proc- e"'scs lo JH'C\•ent motion. The palm of the hand should rest on the back of the patient. The neeclle is engaged ·with the other hant the side. The:- munipulntions stretch the large plexus issuin!! from the L-erdcal cord. Thi.' sign is posith e if the mu!'rle8 of the shoulder nnd fore:\rm inhibit the action and pain is procluC'ed in the back of the neck and head. Th11 fir:-t phl.'nomcnon generally noticed as evidence of an nbnormal condition within the spinal meninges is th:it of incrC'nsed prC'.:-;:;ure. The fluill is forced out in a stream and runs out in continuous flow. When under normal pressure the fluid comes out in a !':ucces.-;ion of clbtinct drops, and enough should always he withdrawn to reduce the pressure to this state whether or not scrum is to he introduced, cx~pt in those instances in which the patient's heart action or res- piration is seriously disturbed. Increased pressure usually accurs in nil disturbances and diseases of th!.' central nervous system. but is not of itRelf pathognomonic of any one condition. The next cYidence of an 'lbnormal fluin cloudy "hen !'llch n process is present. Typicn lly the fluid of tuherculous meningitis is water clear and under increased pressure. As c:tnted nbO\·e the term water clear is only n provisional description applied to th·1t physical characteristic of the fluid. There mny be as many ns 800 cells to the c. mm. before any degree of opacity is perceptible. ~o in the early staires of nny of the ncute infections which typically yielcl a cloudy fluid at a later period. the fluid nppNtrs ns perfectly c)(•:tr. A microscopical examinntion for the exnet cell count is the only reliable practicable way of determining whether n fluid has in- crea ... e of cell counts and in suli,..tanee t('nding to show that a differential clia!!nosis could he made bY f his ml'thocl. One such instance in pn rl icnlar followed in the wnke of the epidemic of poliomyelitis in Kew York City in HllG. The nuthor attempted to cliffC'renti'a.tc poliomrclifi~ from :-pinul menin- gitis on the basis of a cell count. Nothing in medicine is le.:is !'Cientific. Any one who has a knowledge oi the pro~re::-si,·c tencll'ncit•s of in- tla111mation. will rcndily appreciate tlrn.t a high or relatiYel.'· low cell count i,, a fairer inclex as to the stage and t1w ncntencs.' of the process than of iii> particular identity or etiology. This rule. of cour,,e, would iTifl.18-1 't---G 650 llIGllJ:E-DI:;E.\SES OF CE~TP .. Al ~RlffOUS S1f;TEnL \oL Xtt not embrace tllO"l' Yery \'irulcnt infection.;., "hich :ire culled fulminnnt aud proclucc death 1 efore a reaction can occur. Consiou system ii. c;ubject. l:f the cells are found to be mononuclear om· mind~ travel Yery difiercnt paths of thought than if they are polynuclcar. In the former instance we think of noninfectious irritations. tnucr- culous meningitis, syphilis of the central nervous system. In the lat- ter imtance we are concerned with the various infectious meningitides which run a relatively short and severe course. For the identification of bacteria cultural methods should be em- ployed. It frequently happens that a reasonably cc>rtain dia!!Ilo~is can be ma.de by centrifuging the fluid and making Efained "lllenr.:; from the sediment for microscopical examination. The sediment from a centrifuged steril" specimen should be he:n il~- inoculated into n rich slant medium. First only a small area about the fluid of condt>n:;ation is inoculated to instigate a goocl initial growth. Four hout':; I.1ter the entire :;lant is inoculatc(l. The culture may be exam- ined at 18 to 2-1 hours and subinoculations then performed with ,·ari- ous sugar media to determine its fermentation reactions nnd with whole blood agar plates to determine the nature of its reaction with the erythrocytes. The chemical analysis of the cerebro-spiirnl fluid is for all prac- tical i,urpo:;es l imilctl to the detection o.f incrcnscility of this plexus and stimulates sr.cretion will consec111P11lh· inci:ease the amount of protein. Such an incrPasc. then. m 111;{ :d wa ·,, ,·ot. ,:1:11. IIIGBEE-DJSEAGES O.F CEXTRAL XERYOUS SYSTt~:IT. G51 lw J'('~nrdl'd ns indicuti,·c of nbnormnl conlt>mr.nts increased in the fluid to so marked an exle 1t nhsorb the :ou!!tlJ', Tile theory has also been achunced that th<' bacteria pre:-cnt u:>e up 'l porlion of the sugar in their metabolism. Yery pertinent objections can be ndvnnccd against both of thrse statements. The C{'rebro-spinal fluid normally is not a satisfactory medium l'or the growth of organisms. It becomes much more nutriliYc nnJ fa- rnmhlc to gro"·th when the changed conditions which aro prc::;ent in infectious irritations prernil, ,·iz., increase of protein. If the l'cllular elements absorbed the sugar present, then lhe centrifuged macerated sediment should disclose this fact when the test for copper rC'll11c:t ion is mncle. I believe that the natural law of physics can be i,uccessfully in- rnlml for the corr<'ct <'Xplanation of this fact. Sugar is a clialyznble :ouh:;tance and normally penetrates the choroid plexus, hut in the conase of pressure show a lrss marked r('uciety-nol>les of the court. wealthy burgher~. the Yery b"ggnrs on the streC't--and, finally. because it was so intimately connecteS for caring for the sick existt•d in Eµypl and in Greec(• in connC'dion "ith certain temples ancl llw mctlirnl schools attached to them. Jn lndill hospitals wel'e nnmero11s nncl extcnsi'e :fully three centuries before Chri<:t 1 nncl it was not until the time of Constantine, three centuries after Christ. that the C1lri ~tians them.;;elve,; began to found in titu- tions of this cliarnctcr. :Xor is there any ground :for the clnim thnt Harun al Rashid aJHl his )Iohammeclan succes.-ors \H'll' t·onseiou,lv imitating t.hc ('hristinn t'Xnmplc when they started im;titutions <;f this kind in Arabia. On tho othcl' ha ml, ell•emo..;ynary enterprises ancl charitable i11-:t it11- tions, being typical of the Christian spirit, became more an to fall to the lot of the church, which took up the task more and more readily as its own organization was pcr- £ected and it acquired the authority and the funds necessary for the prosecution of all kinds of business. And so while in many case.., hospitals "·ere founded by bishops and other clergy, the Hospital of the Holy Spirit in Home owes its origin in 1108 to no less a personnge than a pope, and to one of llie ablest that ever occupied l he chair of Saint Peter, Innocent III. It was this Innocent who completed the work of Gregory YII, who made himself protector of Itt1ly again<:t foreign aggression and thus consolidated the temporal po"·er of the church; who bitl nn interdict upon Eng1antl and threatened En!!- land's ltln~ with a t•ru~acle; who compelled a King of France to tnke back the wifo he hae the open arcade there is n seri ~·of group representing the SeYen Work~ of )forcy. the figures 1nnkina n frcize rich in color nnd light and shade eifocts. The Hall of the Sick in the hospital at Tonnerre is a beautiful ti111LPr-roofcd apartment dating from the thirteenth century, ancl now us(!{l ns a chnpl'l. :.'lfargaret of Burgundy, wifo of Charles of .Anjou. the fonndre'-'S of the hospital, and Louvois, war minister of Louis XIY. briug bmitcl in it. Ben,une, most widely known for its win<', Loal>iS a li1'~pitnl c::o well constructed that, though mainly of wood. it is ~iill in good pl'eserrntion ititer nen,rly five centuries of existence. Cts hi!!h-pitch<'tl roofs, dormer windows, and elabornte gable:;. its council chamber, its tapestries, and the mural paintings and altar piece!> musl have delighted the eyes of the beuuty-Jo,·ing people who went there to be cured n,t a time when our country was but one rnst Indinn territory. In the dn,ys gone by. pleasure was belien~d to con- tribute to convalescence, and pious patron, architect, and builder were trying to benefit the sick us well as to gratify their own in- stincts. when they enriched the hospital ward and the hospital chapel with cnrvingi:i and pictures. In Santo Spirito, Rome, the wards were frescoed with scenc>s from the life of Innocent III nnd of Sixtus IV. Plntina, the distinguished humanist, the papal biog- rapher. the custodian of the Vatican library under Sixtus IY. com- posed the insc:r:iptions for the pictures. The belfry of its church is one of the most beautiful and graceful towers produc ~ d by the early Reuaissance. Its nltnr boa!':ts one of the few works of PalhHlio extant in Rome. In the spring of 1014 I SJ>l'llt many a ple:umnt hour wnndl'ring about the streets of old Paris. but grie•ing to ob-.ene at c,·cry corner how fast old landmarks were disnppearinf!. for tl1e :-traig11tening of ~treet and the frenzy of sanitary reform in Paris did not entl with Bnron Hnussmnnn and the Second Empire. That part of the left bank of the Seine between the Petit Pont :•nJ the Pont nu Double hn::- n peculiar charm and interest for the sight-seer who is a s at their near-by school. Here is a cougerie of queer old $frcet,-H11e Dante, Rue du Rat, Ilue des .Ani:rl::tis, Rue de la Bucherie. Hue dn Haut Pa>e, Rue de la JuiYerie1 Rue St. Sc!,·erin- many of which are doomed to disappear ns ha.Ye so many others al- ready. I searched in Yain nmid builders' l~igh wooden fences for the ruins of the wall of Philippe Augustus, looked in for n moinmit at the Church of Saint Julian the Poor, which Baedeker snys was once the chapel of the old Hotel Dien, and then sauntered down the street of lhe Hotel Colbert, a building in the shape of 1i rotnnr were moved from Toledo, Spain, to Saint Denis, in 6-10. ' Alexis ChcvullN' In "L'IlOtcl Dleu de Paris et Les Soonrs Augustlu~a." II. Champion, l':ll'IS, lUOl. HISTORICAL. 657 they Wl'l'C dl'po:>itccl in a chapel name(l for him. and that when under the patrou:H!' of Bishop Landry n ho,-pital was founded here, the n•lll" from a ron\'ent near-by were per~uadeTOBICAL. \II XII or two feather pillows. hu!!e bol::-ters and strnw mattrr::i,cs rc4in~ on cord:' in lieu of c:pring~. These mattrc::;scs w·cre made O\ er thrCG time::. a year. The ::.upply of linen wns plentiful, a thous:uHI sheet l>ei n!! the allov. an cc per week in v. t~rds, with a rcscne of a thou- ::.nud in the linen presses. ThPrc were gray quilts for use in cold winter wc:tlh<•r. They were lined with :fur from dog, cat, i,.heep, s iuirreJ, or fox, seYeral kinds to a quilt. The wurk of renorntiug the beds 'vns done by nuns. noYices, and convalescent patients anll the <.'omplet ion of this huge task was inrnriabJy celebrated by a hnnqnet. Crude as were many of' the pro,·isions for the sick. we must re- member that they were in harmony with the times and analogous to "·hat patients had been used to in their own homes. It was not till Yery late in the Middle Ages that a trtwcler could cxpecl a bed to himself at an inn,1 and certainly among the middle and lower clas--c:; any special nightdress was a thing undreamed of. If a person n11ythin~ 1 A st::iio~d-glnss window lo the church nt Trkl, Canton of f'olssy, Department ot S~loe et Olse, shows three travelers lo bed together at an loo, looking comfortnlllc and lrn111 y. IIJSTORICAL. asn definitl' hnd been a<'c1 11 plishcd in c:uppre,,.,in!! the rimiLivc a::. wcr0 the arrangements of the llotrl Dieu up to the br!!·nning of t.ho eightee11th century, it mnst hn.Yc accompli::.lwd an incrc-clihlc amount of good. Not only did it rrceiYe the ~kk but the roor and the destitutr resorted thither for free lodginl!, he!!~:tl':. sometimes receiYed alms there, and in time of war it slwlt1•rl'1 l a l'-'o refugee<> and soldiers. EYen when cured the poor patit•nt wa~ allowed to remain for another week, a well-meant regulation "hich unfortu- nately did not always bring good to the beneficiary. sim·c it wns quite common for convalescents to pick up some new discn ... e on the r<'r!!C of their departure. There was pro1?rcssiYe improvement in the installation anenth and twelfth centuries there appears to have been no surgeon or physician regularly attached to the hospital, attendance beini:r ginn by priests who had some notions of medicine or by sisters. The patients were fed twice a day-at 11 a. m. and at G p. m. Deshle each h<'d was a rack or table for the earthenware wine bowl, the drinking r11p, the wooden bowl, and ,...-ooden spoon provided each patient. There were three fa!':t days a wrrk for all hands. )futton was the commonest \'ariety of meat sened. Beef was rare. and veal, lamb, or pork was only to be had on special holidays nncl feast clay-,, pcrhap~ ten times a year in all. The dietary inclu rd~n or Louis .-1v. B1llls, lll•tory or :lfodlclne. 660 HISTORICAL. \"ot :'\It .small. delicate fried fbh. Bread ''.tis lalkPd in the hu,.,pital four times a Wct'k. aml it wa-. of three grades--ordinnry brculp. In 1209 a royal order assigned to the Hotel Dieu the straw of the ldn!!'F room and of his palace dnring the monarch's aust>nce from the city. Reference has already been mnde to the nrchitecturnl t·on- struction carried on unclc•r Philippe Augu~tus. Louis IX and hi:; motlll'r. to the generous contributions of Yario11s guikls. to thl· lc~a­ cies of the canons of the cnthedral. Saint Louis a:osigned a pcn1ion of the taxes to the Hotel Dieu and exempted it from pa~·ing tolb on proYisions brought to it by land or water. Under thi=-- ruler the custom of giving money and :food (grain and herring:::) to the poor of hospitals and laznrettos during the Lenten period was ~:rnc­ tione initinlt'cl the prnctice of letting the hospital send it:; henl of ho!!:; In :feed in thr royal :forests, mere})' limiting the l111mhC'r of nnimal-. to :!00 tl ~~ . It became the fnshion for the queen to 'isit the Hotel Dieu M'<·r~· Good Friday. and, of course, a Yisit nt !'melt a time mean! lihernl clona- 662 HIS I ORICA L. \ oL Xtl tion,; from member" of her court as well Ml from the monnrch. In time. too. the cw-lom sprang up of prc.c:cnting to the hospital ea.rh roynl crndle and of buying it back at a fonc~· price when needed, while on the death of a queen the furniture of her apartment wa,. !!i H?n to the hospital. Iu the twelfth century the cathedral chapter pn!ise1l an ordinance Ly which eYery canon was required to beqnNtth to the Hutd Dieu his feather bed and sheets. Likewise, e\ cry canon who recei>ecl a promotion had to make a similar offering. As we turn oYer the records of the hospital we come in the com'l>e of time to m •ntion of a lawsuit before the Court of Parliament of Paris. brong'ht by the Go,·crnment commissioners of the Hotel Dien against the h •1i.:, of a certain canon, the complaint being that saicl heirs had turned on~r to the Hotel Dieu the feather bed, bolster, and sheets belonging to the ckcea~ed, hut no covering. tester, or curtains. The lawyt'l' for the defense replied that the sister-; no longer tPncled the canons when they "ere sick and so did not cle~crve liberal alms and le~acies. The Procurator General. howeYer, com;iderecl thici countercharge irrcle\lmt., approYed the contention of the Ilol el Dieu, and orinelc nrd1 for the p1-e,·ions douulc groin. a moU"~ing of the Gothic :-I.\ le. Ycllefnux wa,, follo,,cd by his pupil, Gamard or G:unart. "llO cnn.;trncted the Pont nu Double and on this erected the Hosary Duildin!!. n t" o-.. tory :;tructur" opening on thl' Hnc de la Blichcrie. En!ll before comiug to the throne, while still engaged in the ll't'ril1le :.tru!!gl(' "·hich had r<'duced France lo poYerty anrl st:1rrntio l, Henry of XnYnrre had shown 1111 intere.<:t in the inmates of the JIOtel Dien. It is not hard to helioYe that genuine sympathy as well n.s shrcw1l polic,· prompted him to sencl relief to the unfortunate p:iticnts o this c:-tnhlishmcnt while he was actually besieging the city. We r<'ad tlrnl in 1;;oi. while occupying Chartres, called the granary of Paris, he dispatched Ji~rnl prm·isions of wine and wheat lo the Ilf>tel Dieu. It was by such acts as thjs that he prepared the way throurrh men's hearts to the throne, and many a Parisian burgher would h:\\'c \H'komccl him to it cYen before the hated heretic h:ul remoYed tl1e h:,t ob- :;tncle in his path by abjuring his faith. Throughout hi~ rd!!n the Yert Oalant showed himself n. l:n·ish patron of the hospital and his cxnmplc was, of cour~e. followed by the court. who!"C mcmbe1s Yied Fith each other in their display of generosity. It became the fashion to !!'iYc and to giYe liberally. During the declining years of Louis XIV the financial admini~trn­ tion of the H otel Dieu became heavily invohcd and royal sanction wn,., obtained for converting into cash n consjderable part of the real c~tntc owned by the institution. A huge lottery wns n],o organized in this reign, the king being one of the chief promoters of the scheme and buying n thou~and tickets. The tickets werC' on sale all over Frnnce, and the lottery netted a \Cry large sum to the hospital l"nder Louis XIV a statute was enacted. (hough 11ot enforced until the time of his grancl~on, Louis XY, by which a levy was made on nll money paid for admission to public ~hows !lncl C'lltertninments. Thus one-ninth of the price paid for ticket:-:; to O!JUU or comedy in Paris went to benefit the inmates of the U titcl Dien. Still "O n to raise further sums n.nd r·lmritnble "·omen banded themselves together to contribute to the 1omfort and welfare of the patients. From its Ye1·y founda6on the hospital had d~rin.'ll. n Yery large 11:1 rt of its income from the legacies of cleYOnt or d1ttritable per~ons. TJ1e IHitcl Dicu 'vas beloved of Parisians trnd Fr<'nchmen anpt in cases of mmcler, homicide, theft, treason, nnd rnpe. It was the common prnctice also to assign to the Hotel Dieu a definite proportion oJ the yield of certain vineynn1s, wheat fields, forests, nnd form lnncls. One Simon, occupation not giren. 1 Archives de l'l'olcl D!cu dll l'nrls (1157-1300): Bry~lc, lmprlmcrlc Nnllounlc. l'nrls, 1804. tiut rtyktl rfr Xobili~ . pre 00l'llt~ tl11· Jlftel DiNt with n barn locatl'd 1 ot :far from wher<' the H ott>) de Chmy now stnn'-;<.'1 t ., to the Hi1t<'l Dieu n hou..:n in a c..'rtaiu street. another in a cN1:tin alley on condition that a portion of the rC'\'t.>1111c frotn the,..C' hou-=cs h:-ill l 1' emplo~·cd CH~r.\• year on the :umiwr,..ary of tl•e d"'nth of the givcl' to f. np p l~- tlw pntien1s at the H otel Dieu with "hnte,er thC'y mny cl1•mand to l'at. There was Perrmelle. who in her Jifetiml' £?;aw to the Hi\tel DiC'u n vineynr m;Hle from it::; proclnct for her own u e. Amon~ the humble bcnefuctors of I he great :m u pop11lnr institution we flu' harness makers, saddlcrs, blacksmiths, tick 111nkers. wc~n·ers. ppwtct. rs. m11~ta n l rnakt•r:-;. Jm·k~n1it tis. lrn th-r~. barh<•r-.. clyPr". pa$try cook-=. ·ud old-clothes men. .\ little hig-}1er in tl1e <;ncin 1 "<'ale come" the ,..,•rgP::rnt of th· s\'hools of Pari'i, a ki111:(s cook. a 1 t>atlle. a \'hnrch TI"nrden, a knight, a librnrinn. an abbot, :t grand chamberlain. Th nanws of the -;fl'<'!'t:- rPfor1·<·d to i11 thP Yariou:; 1l('(>d, nre inter- esting. There was a rue des .\ nglais. des P eintre:>. de Jn .Tniverie. like the old Jewry of Lon owned by it all sorts of things were constantly falling 0 n hi-: own house. He had to pay the cost!'! nnd was told that he could remedy the situation by acldinp: stories to his rec;iclence until it dominated the source of trouble. One broad-minded individual divided hi:-: <'state between the Hotel Dieu and four poor students of Paris to be selected annually by properly constiutNl nnt hority. Unremembered for face or figure, Alice.1 waioherwomnn to the Bishop of Paric;, hnc; her small niche in the hall of fame, because she L ·qurathed her arcnmulntcd savings to the gr<>:it hospital for the poor. During the middle nges a Yery large n n-enue was deri,·cd from the sale of pardons nnd indulgerw!'s or tlwir be,..townl 0 11 :renl·1·011:- hene- facti :-s of the hospital. Each year the m n~ter of the hosp itnl '-Olicited from the Pope the neccssar~· hull nnthorizing the pr:wtic1•. " Then it was r ceived the churches of the cit~· would be crowdecl n11d likC'w i~ the chapel and bnilding-s of th!' H titel Di <>u. On the 1lny of the por- don high mass was <;aid at N"otr<> D~me while the r-nthe1lml hells • ln turning ovl'r the nrchlvc" of tlH' ITM<>I Dleu, or Perl•. from 11;;1 to 1300 on ~ Ii< !trud;: by the llnll~tUll cb.1rncln or t h t> WOIJl('D 0S nnmP.S In \'Ot::ne durlni: that per1o hncl anticipated, tbey came nwny horrifieult that u small nnmber were nt once adopted and removed from the Conche. and in a few years the entire care of the foundlings of the Hiitel Dit'U was a~snmecl by this worthy !'oriety. Thus the Hotel Dien participated in tlw ge!l<~rul improYement of c·onditions which characterizeign of Henry IY under the abl<' directorship of his prime minisl<'r, Sully. .As stated ahon~. the first Bourbon made it the fashion for one's ch:1rities to center around n 110:-;pital. It would appear that tlw l'llthnsinsm ancl Z"al 0£ some of the noLJe women who took to visitin~ the Hotl•l Dieu pa<;<;ed tlll.' hounds of moderation. for WP find the hospital nnthorities invitin~ them to come and watc·b tht• 1lif'lrihntio 1 uf food, to obscne the clet:1ilf.: of h'e:i of hi~ he1lfollow-ns in dying oYcrnight. It was. onlcred that CH'r~ -.·. nrcl hould li:n c n 1..'0t1ple of ~pare beds to which patient~ coulneh yt•ar. In 1609 Henry IV had promulgated :m cclict on the snh- jcct ~ nS!:iigning nll fines and confiscationc:, in connection with the sup- pre-·ion of duelin~, to the benefit of the Hiitel Diru. The periotl from the middle of the fourteenth to the end of the fifte nth crntury was apparently that of the HOtcl Dien's gre~'ltC'"I prosperity. .\l.Jsolute ckanlincss prcYnilcd in the wnrdc:. ln n ~ingl" y<'ftr n m·rny as 1,300 brooms were used in th<' buildin~:>. "Every 10oming llw floors WC'rc washed by ':"1lcts nnd there wn;; n ur:.md mmual scrnping and whitewashing before Easter. 1t is l'emarkable thnt about the l>c!!inning of this p<.>riocl running wnter wn nrnilable for u e in the wards, being piped to them from hu!.('e o,·et·hend tnnk,., <111 thC\ roof. Such an equipment n1t11r;1lly r~snlted in !!rent economy of time :md labor for the employees. Thon,gh the records of the Hlitcl Dien abound in interesting de- tails rcgi 1'fliug the architectural structure: intcrnnl arrnngf'ment. nnd ndmini. tmtion, and though there i:s a considt>mblc litc>rnture dealin:? with th<• :ulminist r:ttion of this great asylum fol' tlw -:nfferin!! nml need::;. thnu~h nll the different phases of it,., career n-. n chmch institu- tion whose purpose was to confer spiritunl blessings ns well ns relief llG HI:::T•)nH'AJ.. to bodily nilmcnt al'e hundc>d dical ~taff co1lt1c>~tl'd with thl' ho-pita) b. forc the "bHmth or twelfth century. tlw priest::: and mms gi\'ing th·' rNpiirecl treatment n~ IJrst tlwy rnnld. St ill. there is some grnl ificntion an1l comfort in th~ siJCJl('l' 0 f hislOI')' l't'!!;arding the cloclOl'S, !'illC:<' 1101 a few Of the lHtll!ef: lllOSI com;picnonsly t•mblazonec.1 on tlw histo1y •lf th 1Ti\td Dieu ~re there held up to the obloquy of posterity. Witl th \i(·~inninµ: of the thirteenth ccnllll'_\ lhc> maslc1 f the Hotel Dieu made u. clefinjte agreement by which the sel'\'ices of t doc- tor and a surgeon were retained for the patients of that e~t hlish- 1111'nt. ln 1:?·.!l a certain Hubert a~1·ees lo gin~ hi~ profossioual ,.:('n-. i1•c · gratuitously It> the lto,;pital. To thi'i -.nuw t•pod1 I elon!!'; \~incl nt d<'"' Boi~'· who not only offoretl his sen ice:; free. bm mude 11 gift to till• ho:-pital of 40 ponmh pnrisis. In spite of these \\Orthy rlispositions the nffnirs of des Bois did not prospe1· and penury Ol'(!I'- took him iu old age. when the master, in recognition of past. serYice.;;, gmntecl him tL !"mall annnity from the funds of the hospital. From thr thirteenth century on the IIOtel Dicu \\:ts :rn integral part of medical instruction in Paris. and gradnalc;-; in 11u·tliti111· were required lo receiYe the master's robe either at the Hotel Dieu or at the Mathurins. By the fonrtcenth century the p rofos.o:;ionnJ scrvico at. the HOtd Dieu stood on still firmer basis. Jt was intrustecl to two snq .. 'l'Ons, who were r<·t before undertaking the ·'king's senice" nt the Hot.cl Dieu. During the :Middle Ages there was no pharmacy in the modern ::wnse at the Ilokl Dieu. T he master honghl :from the spic<'r,:; arnl grocers of the neighborhood the drugs and medicinal plants required. The concoction Of simple draughts and the prepara- tion of ointments fell to the lot of the nursing sisters, and it would "eem that the earlier physicians reliecl largely upon very simple remedies, baths, exercise. and modifications of diet. Special provision wns made for the bathing of patients. Stationary baths were not employed until Yery recent times, a::; il was found ~ulli- 1·ic•ml~· c>a~:v and conrt'nic•nl to use portable copper tubs. which ruuld liC' rolk1l into the ward and to the bedside as occasion demanded. The bnths were hot, of course, and the water for them was heated in h11g~ cn.nltep::- of the building. \\ hile ol ht•"' hnd bec·11 brought t lwn~ hy :-ick n)l)tht'rs who had no pl.1c w leaH! them, but Oil<' Wt't 1mr"<' wa:- permnn<'ntly employed for II t•luldrc.'n at thc brf':1st. Tho snnitnry fr:itun•s of rhc hospital haw .1h·t>ady bN·n allmled to. liut it :-houl iron wagons full of glowi11~ r•nal;:;, 011 the othl'r hnnd. WP find :i \\ortli.' p1·iorvs.,, 1·•1m!>l:1i11;ng of tie r--i1 on·f)lb adrnini fratio11 of affairs nnie11. full of thfl pet ,. ,.trifc of rival 1tspirant!' for c·1 ntml ,.f t I" ·n 1'tnti1 1, •ill • f tlw bickering..; of c1wious fadions a111011:..: th!." 11u11s. full of ilw bitter stnt!!!.!le bebwen the lay :rntho!'itit-s oi' th• < io, c· :rn1t•11l m cl ti ._,,..dc·- i,i:L-.ticul officeri;;, witho11t rea 1 izing how li tt Ito L1~111:m 11aturP ch~mg-cs from u!!'e to agl'. X ow. a-. in t lw pas(. tlw !-ndurr. humiliatious of all sorts without a mu1·11111r. lint c·omplaiu bittPrly a ncl p1·0111pt I.\' of insuft1eient lwat ;\lld p.i11r foo· J. whether in nn <':Xpcnsi\",l' l'OOlll i11 n priY:tte infirnrnry 01· in !It .. frt•f' w trd" of n c•lmrity l1ospital J li~h 11p undrr the roof were windows wliic-11 hy n1cm1~ of cords uncl pulley!' could lw opened in s11111mrr t imc• to i111prm <' n•ntilntio11. In the :-e\'rntl'enth ccnti1ry a supply rd jnnipm· wo01l wu kept on hand. and u little of it was burned from time tu time in tlw ward ... tu drhe n"n~· bud i::mells. The glas"' was -;tainrcl -.o a-. lo ~often the li:rht. .\t night thr warcls \Y<'l'l' in darkill'"" e~cept for mi mule 1·11:-h li~hts hetw(•e11 the beds. It is noteworthy that within a !',paci.: of 10 yl·ars' tinw in the la her part of tlw Jifh'<·nth ('\•nt ury at lc:i-t two donations were made to the Hotel Dicu tu pro' ille li!!hti> for the toilet-. that o\·crhung the riYer and for li!!htin!! tlw npproadw., l<' them. Tl1c ::.itc of the hospital on both bunks llf thr "'lllnller Lrnnch of the rinr and on two bridges favored clnmpnc•""· Owing to its location in the basement. the lying-in ward w1"' pnrticularly b.1d in this re~pect. Worse still was the main wa!:'hrr om or ln11n1lry. wheru n numbrr of thC'. novices werl.' employed nil rlny in wac;;hing the ho"- 670 HISTORICAL. \ ot. iu1 pitnl lincn.1 When tho tiYcr was high the laundry wa::. often iloodco. and it wns considered a wise precaution to hnYe a boat moored the~ nncl pro,·ide the l>ontmnn with a bout hook so that he could sah-nrre laundress nnd linen if the tide threatened to benr them ofl'. "' The good nur::iing si!=tcr:> had a pa;;sion for linen. It was abundant and of fine quality. CJo,.;.-Ls, !=heh-cs, bureaus, wardrobes, clr ers. chest:; in hall nnd linen room. in ward and corridor were filled to oYerffowing. < Jncl' a month tho priore::i:; \\'Cnt lo market. Enrly in the morning a cart would be bitched up, and accompnnieJ bv n brother and Ollll 01· two sisters the prion~l's wolllcl :"tart for· t:. Denis, her chaplain following on horseback. She retumed I~ le in the evening und next day the new linen would go to the laundry, the dyer, or the f-ewing room. The itinerant linen merchants pa ing through Paris never :!niled to go to the Hotel Dieu to offer their wares, because they could often dispose of the entire lot then•. The Februnr~· and J nne fair~ were occnsions of great moment and many a. hnrd bargain 'ms dri' en at them. All tho year around four si-..ters were busy from morning till night repairing, sewing, hemming. or cutting up bedspread~, bolster cornrs, sheets, and pillowcases. The big laundry and the mall laundry between them occupied the '·hole time of nine sL.ter,.. nml six no>ices. The) worked near what we might cnll the traclc.Emcn's entr:mce, where boats made fast to u~liver the butcher's supplies and lhe prm·isions and stores from the furm~ belonging to tho Ilotc.l Dieu. It was here: too, that brothers em- barked when going to Yisit remote estates to inspect the crops, collect rc11ts. etc. \\'hen the clothes were all washed they were hung along the balconies to dry, but often so great was the quantity of linen there wus no plncc outside and much of it had to be brought in and hung in tho ward&. Patients often complained of the dumpne->s that resulted. ~Iention has !Jeen made of the syphilitic patients who swarmc1l in Paris nt the time of tho Italian wars and of the wholly inadequate measures for their segregation. It is equally terrible to road how the place wu~ o,·crrun during the prevalence of tho pestilence, 1llld that by putting the beds close together the~· could uccommo known as the Chef St. Quent in uncl the Fishing Cut. When the IH'W W to their kn~e,, lu ord .. 1· to wnFh lbe clotbu of the poor," so.Id Gerson, prenchlni; In the presence or Charles VL HISTORICAL. 671 At this time pro\•ision wa..: mnde for some 50 ndditionnl cape..., for the co1n-enicnce of patients who hnd to get out of bed. There hnYc hcen many gro<=<= exa:r~erations al out the number of patients lodged in the ho::pitul nt different time.". Up to the begin- nii g of the Bourbon d~·uast~· the maximum of the Hotel Dien wns 1 obabl~ bet" l en ~en~n ttJHl nine hundred jnmnte..:. with tI1rce or tour hundrc but VG patients in the institution. It speak~ we 11 for the hmm.nit,\· of the times that when the plnguc imadecl Pnri..: in l.Hfi nil infected prisoners from the Conciergerie were trnnsferred to the Jlr.trl Dien for trratmcnt. and it was f>trictly l'njoinr to th~ jailPr of the prison. It j ... not until the ~eventeeuth centmy that we obtain definite documentary eYidenee of measures instituted to in:-ure the aclcquntl! nrofcc.sio11:11 care of the pntients of the Htitel Dien. I•rom now on. in addition to the two phy!"icinn~ attnched to the ho'-'pital. there is n mn"t<'r ,..ur~eon with fiye apprentices. The minute,, of the mccting- uf the hospita 1 board on ,July 18. 1G2V, contnin th is en tr~·: The "'fll•I Millot. huvin.t: heen rcc~ived a,.: urnf'.h•1· "ur~C(m nt tlw bltl!l Ilr.tel D NI nnd hrln;? fed, pnltl. nncl lmls,red. ~bnll himself he on hand to exercl. e bhi 'uuctions '\\Ith g,·('nt nssiduity in prri:on nnd shall 0 h:wr under him th·e Pxpert enr.cd nncl l'fl! nhlc npprcntke l'Ur;::cons, also fed nt Uw charge;:; of the hm:pltul. Tt1r. flJ)Pl'l•ntic:e ::;urgcons Rhnll not absent themsehcs without the nuthorlty of their rnn ... ier, nor shull the~ go out except when ut lcnst two remnlu for con- tent senic·c In the wnrcls nnmsehes 11 t the t•ntrullCfl nntl another to ~tnnd by in cn;;e of 111·ciclent!I. On April 22, 1UJ1, the medical. nnd sunricnl :--tnfT of thr. Hotel Dieu rPported that, within a. period of a few dnys three lithotomics hnd bE- ~ succe,.;sfully performed and stated thnt in order to obtain uniformly safo;fnctory results special facilitie . .; :-hould be nliorded th<'m for caring for this clnss of patient'. After clue drliberntion the go,·crno1·:-;, recognizing the justice of tlw demand. directed tl1nt the new ward. preYiously destined for the sick members of tlu· pl'rsounel of the in .. titution. ,,.honld ue assi~ed to tlw lithotomy cn-.c,.. From the1 on. in conjunction with thl' fncully of flw School of ~foclicinc of Paris. the IIiitel Dic>u gn\o marked attpntion to this operntion. During tho year 1602 operations for stone wen.• performed nt the ll•'itrl Dicu 10J: time::; with 18 deaths. a mortnlit) of 1 i.3 per ccnl. In re<'ognition of the !"ignnl success of the --urgeoth who hnd operated on and rnred for these cnse8 the maua!?:ctnenl of 1lw ho::.pitnl \Olt•rl them n ,.pccrnl honomrimn as a rcwarcl for what thl'y Jmnl for _men to h· l'lllplo.' "tl it delh·eries <'X<'t•pt in ca!'es of nna>oidable nec1.>::;sity, wh<'n the senior ~:urgeon of f liC' c·st:1bli..,Jrnwnt ong-hl fo hC' callrrl :ind. i11 lien of him. his senior assistant, the mnnngement is urged to grnnt no forlhl'r :ulmi,,sion to s! ranger::." Tlw l1ospitn l boa rel. on D1 cPmher :11. 17:.:'0, is.,;uecl nn order forbiclcling th<' entra11ch of :rn 011t,;itll'1' for :lllj rc11 son wJintt'\'l'l. but it \\'ll fo11111l t•asic>r fo "l'ilil' :lllll lllHkP l't1les than to carry f hem ont. Exceptions were mad<· in fa \Or of ccrtnin English physicians, and they were permitted for three succes .. -.h·e years to attend the obstetric clinics of the> HOte>l Dicu. This wnc:; ap· pnrently done as an act of courtesy to the King of England. In 17:'25 the nttmdnnt of the Queen of Denmark wns allowed nccei::s to the sacred precincts of the lying-in room. '\Ye hnn ~h·cn above one of the two 1111h ron1 bk l'o111111(·11!s cxtunr upon the behnvior of medical men at the hospital. It is to be noted. on the other hand, that the doctors were not nlwnys satisfied with the con nur .. ing sisters, ancl in the sixte1•nth century period of demornlizntion, mark<'d by religion~ exrrcises nncl nt>glcct of work, the charge wns made that when the doctors gan~ onlt>rs for blisters, euppings, nncl bleedings, their directions were not nl ways carried out. As we sur,•ey the 13 centuries of the Hotel Dieu's existence the most prejudiced observer can not fail to testify to the devoted service and loving care bestowed by the nursing sisters upon their patients, and they were in the main generously hncke(l up by the peoplo of Paris and the civic functionaries and clergy of the city. There were HISTORICAL. frequent disturbnnces und occasionally bitter contests, due to ambi- tion nnd the stru~gle for control of the institution. Laymen were prompt to decry the .m~ngcment of the clergy, and the ~lergy w~ro often jenlou:. of outside influence, though always wclcornmg outsHle ll"sistnnce. Politics often had a disastrous elfect on the efforts to i.Inprovc the hospitnl service made by participants in ench ~ide of the ar;:!'ument: but while the petty wcnknes,.;es and Hil pn':.;ons of humnn nature often rhcckcd for a uioment they could not wholly arre!'t the progt"C'" of this noble institution nor check the lwttPI' impulses oi sclf-sncrific' nncl devotion of the bulk of the sisters. 'fhc following extract, a, sort of panegyric on the nursing si:>tcrs, ib from the Liue de Vie .Acti\C, a 111un11:-cript of thl' 'l<:o11tl ltalf of the fifteenth century, whose author, a canon of Xotrc Dnme. wns for ycnr:; one of the provi:;;curs or commissioners of tltc llote,I Dicu: t'onsh!l»·. oh 1h1111 11F 1l1 lil'nl•' .ip111 tit.·. whl\P hl'f111·" thi· ch1111, \\h,11 1111'l' lh •U lw ·1 for Ill~· llll'ill nt lilt! t:i ·tcr,;' lnhlP, CPIHli'g ""thou •lo I 11 m 1111 w. r Is 11f 11te 11;d> lnrlc>n with lilt• U1l<•r of pu111-. 11c>edy hm11n111ty. ll••W • 1h ~ N·ll-h rlesh 111 tl1t·lr rpfrctory wlwu lht·~ t·11UJI' "tr; i"ht frnt:1 1)1!' ~t k :.1111 tltl~ht!! tbC'm 1111 :1fu•1· 11:it11 c>'" h11111bl1•s1 f111u·ti1111,.:: il thou ht• I 1111;:1·y ... .,111:11;: 1lin•.-1 rrolll tlw w1·.-.:c•1•'ll hi. \ h·• t llhl not cnt, hnl fot·•·Pd tl11w11 llll)l'•PIS wit hPnl appct ill"' 'l'ht• :,10,·in;; t'{'l"\ l•'l ~ uur l'bters rcllt!C'r hi orl' thl'\' ;1" c·nlll'ri tn n•fr1•U1111 and lhl' sCJ1·1·1m·s 11 f•\ hn\•' wlllll'l;.~<'d in llw wnrd nove tlwm nithPr tn pious ll"tr,.. thrlll 111 11!ra~:i1i1 hum.: ... \I tl11• oufbrt•ak of die Frt>nch Rcnilution the al!':tirs of 1lw Hotel lfo•u \\ere at a lo\\ ebb. Xot only b:ul all :;oJ't,.; of allll'-l!:" t•1·rpt into the ndministmfion, but the bnilding ~ had bc-conw the CClll! of clirt and \\ rei<'lwcl1ws:<. Dr. ,John .Tones. of N' t•w \ 01·1'. "ho ... 1• 111 bor, c1111- trib11terl lo tlw fo11mlation d the Xcw ) orh. Ilo-pital. "C'lll to Eun>Jh' in 1 ii~ to s! wl.v the s11bjr t of ho::,pitaJ ... and buy me.dic:il and ::urgieal apparatus under anthorily of lhe ~<•H•rnor..: of Ki11g·s Collr!!c (now Cohnnbia Unin!rsity. Nrw York). Ill' wrote: 'fhe llt"Hl'I ll!cu-a 1:1,;t bulllliu:; ~irna11•d in thl' mt.1<11,, uf till' l'lt;\·-n.'l'd\"e- :tboul :!"..!,(ll)(I ppr:.:ons 11111111:111~·. 1111<>-lirth of whom •lie l'\l'r~· ~.:·nr. It b lm- 1111~ lhl•• for a ma 11 of any humanity to walk thnmi:h the 1011::: wnrd,. of tl1b c·ro\\ll•~I ht1>')1ilal withuut fei>lin;: a rnixlllr,• of horror nntl 1'(.1111m!--erntlon :i.t the •11d ;;p1'l'la•·ll' whi"11 pri>s1•11ts it~l'lf. Tlw he.ls nr•• 1'hu::1'll In trl11lo r11w:.. \\ith fou1· :11111 six p:tlh.'11(:< Jn l'Hd1 bed. :m'f'>', some 11f \\hum llrC W•lllll'll Of family ;mil tnk(• ti" vril arnl pinu-'t m1111lwr of patlPllt«, to he~ t o\\ timely n,.; ... i,t· :tit<'•' upon c:1<·h l11dil·ld1111l. 1 1 llospltals, Thell· fll~tory. 01 !lnlzntlon, ant.I <'onRtrnell"n. b)' W. <:Ill W)·llr, M n. l• Appleton & ~o .. Nt>w Yo1k, 1S77. 674 RISIORICAL. The pcoplP in uuthority during thi~ stormy pori0tl sought to re duce to a minimum the influmce of the religious order:;, but the sisters of the Hotel Dien were permitted to continun their noble function n~ nurseq, prO\·iclell-di:,1'0Sed incli\·idnals. no official recognition being ~inn to their relation to the chmch. Ily 1816 the Hotel Diem wa,, again iu t•xcclk•nt orclcr. if we mav trn::.t the report of a capable aur number o( prh all' holl1'l'S In .~rl'at l'ities on tiw ConUucnl. Tltl'l'C~ wcr1• ::o i:;p:11•Iom: wnrtl;i, some conta!niu~ as lTlnny ns 90 LlL>tls. 'l'hl! bnllnris to obsene the routine of the great Paris hospital. In Paris itself the nursing sisters of the Hotel Dieu were always in great clemnnd to nurse privnte cases in the homes of noble and affiuent families. This practice was the subject of endless debate between the sisters themseh-es nnd the supreme authorities, the lntter clniming that these outside undertakings detracted from the interest and the energy available for the legitimate work in the wnrcls of the Hotel Dieu; that jealousy was apt to be engendered; thnt the strict lis- cipline of the Augustinians was interfered with. The priores5, on the other hand: held herself to be the be::;t judge of hrw to utilize the services of the sisters under her control and w:.s loathe to abolish u custom which undoubtedly made for contentment amon~ the sistt>rs by giving them occasionally a reireshin~ change frcm the hard, unvarying monotony of the wards. Besides all this the outside nmsing did much to popularize the hospital nnd the order. thus bringing in lnrge returns for the benefit of the poor nnd mnny 'l\"elcome gifts to the sisters themselves. 'Cnrtcr, II. W., M. T>., 1r. R. 8. (Edlnburl\'hl. A Short Account or fiomc or the l'rlnrl- JIRI lloapltolH or !11·1111<'•'. Ttf1ly, Switzerland. and tlle Ncthcrluntl~. 'rhomaR nnd t'ndcr· ,..ood, London. l A1 !> IIJSTORICAL. 675 nut the nurses of the olden time were prone, like tho~c of to->-s to lea Ye the IItitcl I>icu nn:n·c of :ibs.,.nc<' in defiance of the pl'iorc~s'~ i·cfu:::.:d. • \ t a mretin!! of the c:ilhc>drnl ,chaph'l' on December 13, 136S, the prioress lod;ed n form:tl complaint. against the ma. ter, charging him with usm·pation of her authority and setting forth her case with great cle:.rne<;" nnd vigor. Thinking. cloubtles:s. to conclude her :irgumcnt by a telling blow. ~iEter Philippa clo::.ed her app:-al by a c;.mtic reference to the dnnge~ ri ing from un~· a ociution of tlw master wi.th the sister;; and cited the case of Marguerite de Chicle. a sister o~ the Hotel Dieu. who for 14 yenr:.: had been confined in tlw prison belonging to the cathedrnl chapter. in expiation of the crime of inf:mticide proYeprc"ent<'d by the prior~ and other nuthoritv. usuallv that. YCSted in the master. It is interesting, too, been.us~ .it cont;ins one of the two, and only two. di ·tinct references to immoral conduct on the part of the si<:ters 1dTorded hy the docnmentnry history of more than a thousand yenr~. 676 HISTORICAL. The :-eco111l iucident i briefly referred to in the n1inutrs of Uie 1uceUn!.! of Ti'ebrunry .... 1400. in the follo" ing l:m!!unge: B~1rn-•• 1:1·11th1•1· .Joh11 I..----, 1u1'111ber .,r tl1e religious onlcr of the lIOteJ Dk•u, urn! Sl~tcr .Jane, of fhc uboYL'-nnmc to h~t' <' bonw I he brunt o{ I he unpleasnnt consequences. "'hilt• the records of the medical scnice are :-:cant, Ill<' <111 1u1cnts rclnting· to llw organization and ndmi.nistrntion oi lll<\ ho .. ' nl, 3 a whol<'. :tre alrnmlllnt and interesting. From them we learn thnt the rcspon:-;ibility for the conduct of the institution pa::;sed from the bishops of Paris to the cathedral chapter when the IIUtcl Dieu lllat establishment. The master and proviseurs together selected from the nnrsint! sister,.; a priorl~ss or mistress. Though lhe sisters wore suppo:;ed to ,·otc in 1he matlf'r and record and length of senjce might give n certain f>ister prior claims, the master and tho proviseurs were bound to ~1ppoint the person that they considered most capable and most "ort hr for the Illa intenance of charitable work and strict discipline. The mnlc members of the Augustinian order at tlw ITlitC>) Dir.ti were few in number and, in time, cea,,ec1 to function, bnL I lie i-i-.ter,.. ha Ye bce11 associated with the nnerable institution clown to our own timr'. The brothers, for the most part ln.ymcn, nc,·er execer as \";"Cl! as another. and the fir,t one up in the morning could don nuy oue of tlw clrl'::i.-.e., nud '' l'llr it as C'Ont- fortnbly n'> nny of the re t.)' At one period of their bi:::.tory it "a proposed by the chapter to change the heuchlre::;s of :,i:,,ter:::. nncl 110,·icc~ in the ho:--pital. Tho cil"iiiau admini,,tralor,., objected. in vie'' of the fact thnt no 8pecial object would be gained by altering a style that hnd prcrnile l imPs and that hu of the "i"lt>r .... it is n~t· only well adapted to them but a necess\v. becau:ic1 as it b more or le"s clo'>t>ll in :rnd projcdecl in front of the foe\', it doc.:: them goo:] senicc when they communicate. as their profc,,,,ion require,,. with tho well nnd the s:ck. preventing the.-;e people from gettiu1!' too uenr :mcl really keC'ping them far away wlwn they talk together. Then. bcin~ 5.tarched nns flowing therefrom, bceause they nrc tight fitting in front, the pad being placed well back so that nothint! i11tt•r- feres with working and mo,·ing freely, whatever they haw to do.'' Girls were eligible for the work of the 'Ylute Daughter:; between the ages of 12 and 20, a.nd after five or six years' service in this CRpncity could become full sisters, provided they scned nt lenst u year ac; novices prior to taking the rnws. . The drat b of a :;ic;ter cau"ce ''hen the main purpo~e of nn ins itu tion i-. ob.,cured. Tho worthy brother;:, nnd ::il~ters were nl" oys in danger of letting their religions piety and devotion drnw them nwny from prncticnl ministrations to the ::iick. It is remarkable thnt in 1G3G we find the hospital board compelled to remind them that. while it was a good thing to pray the principal function of uur~es wus to ~uccor tho neelly, :wd the novices and White Daughters were told that if they i:,tayed up until 11 o'clock at night for spiritual cxc.rci they would be too tired aml :;]cepy on the morrow to do goo l \\01k in the wards. A peril of an opposite nature. the decay of vital religious fcC'ling. wns likely to produce equally unfortunate l'C' ult to the pntie11t by destroying the sbtcrs' motive for enduring Lnnlcn E:; and by inclining them to seli-indulgencc. That these fears were not imaginary is shown by regulations p:t"!'ed in 1559 forbidter::. we~ uot to talk with sisters :rnd White Dnnghters except about affairs con- nected with the p:1ticnts and then only m public places frcquen~d by all. Likewise it becnme necessary to forbid the employment of pri>nte serrnnts when their number had grndunlly increased to n hundred, and nll persons were forbidden to give or scnfl or 'ausc to be tnken out of the hospital builho regnlated the cominn and going of sisters and daughters, who behind closed doors imparted corporal punishment to those who hr..d misbehuvccl, who cared for the liiwn room nnd the laundry, who looked io the general clcnnline of tl1c institution, und super\ iscd the sick and poor ~dtl1in its wnlls The brothers and sisters aro~c at 5 a. m. in suuu11cr ancl at G a. m. in winter, and aflel' their ablutions betook themSPlrns to ::;cr,·ica- in the hospital chapel while the prioress m~dc a rapid tonr of inspe tio11. This inspection was repented se-rcrnl times a duy and made at leuct once during the night. Ma.tins over, men und women hurried to their posts in Juundry. linen room, cellar. wards, etc. Night lij!ht.., were extingni .. heel nml preparations wen~ made for the work of the that obtnincd th<'rc· The 'Yhite Dnughter..: bcl'ame rnutinon, "hen trnnc;ferred from the can• of one si:,l er to an<]ther. X 1111s <'n me und went a, the} 1,Je eui<: XIT in 1:)01) appointed 12 notnhle bm·gl' .. c~ of the <'ity n, a hurenu of ndministrntion for the hospital. From thi.:; time dates the struggle for !'Ontrol o)f the Ilf•tt'l Die11 \\aged between the religious and ciYil 1rntl101·ities, which has contin- ued tlown to Olll' own time and thrown into the .;}mill' all le~·er di:-.- !-(>nsions. That these dissensions had been fur from i11signifiea11t. J10WC\'C'I'. i~ -hOWll uy tJip :lC'C01111t Of I hr t'H,'lli<: !'Ollll!'!'(PiJ ~with the 680 IIISTORICAJ •. career of one J ohn Ldcn-c, 11111~tcr of the llotC'l Dit>u i11 1 Wi.: gain whom :-uit Ll•forr the Parliament of Faris \\ n. Lroughc by the Ii(>:> l,itnl nuthoritil•s, charging him w-ith rnriou:s irn•gularities of n mini:otmtion. ln the cour-=c of tLe trial the :;i,.tcrs and lhu~hl joined b~· a few of th(', young<.'r brother,_, made an atta('k '.:· ,; In• it or:· ·· rohlier : re ~ounclecl throug!1 the; lmilclin~. greatly to the terror ·uul
  • of a sister nicknamed "The Cake." who, feelin~ thot some crime would he committed, diverted the crowd from further violence by making Rrother Lawrence promise that he woul1l go and bring to tho l>pot lhe haled LefeYre. Lat.c>r in ll1l' da~ when the dean of the chapter and the proYiseur:s betock themselves to the hospital to remind the sisters of their duties to the sick, who were being -wholly neglcclecl-both male and female member;; of thl' order broke into open mutiny. They were joined by 20 or 30 of the patients, who jumped from their beds. and, in concert wit b the tlome;;tics of the im;tilulion, lwc:unc so ins111tiJ1g ancl tlm·alt·1 l ,!! to the canons that they hnd to withc1raw and only just succe"ded in escaping by the wicket gnte. The burenu of administration founded by King Louis was not a success. It held solemn assemblies and issued orders to which no one paid the least attention. T hen, appeals would be mn.do to the K ing, and ewr~·onc knm\'s that while merry monarchs mny Jw-.tow !'.tenerous swns in charity the~· ofttimes seem disinclint>d to worr~· their heads about the fine points of other people's concern~. For 1;, years John Lefevre had manngrd the hospitnl to suit himself nnd made no prett>nse of keeping nny accounts of his financial ac1mini trn- tion. EYerything wns in confusion and disorder. The hurgh<'r:- nat- llrally could not imn1edintely produce system out of chaos, and yet re :-nlts and accurate r<•po1-ts were wanted at once. The new commi~sion, charged with the reform of the entire service, showed itself dis:oatis- ficd with the condnct of religious affairs in the hospitnl and witb the cure given the sick by the brothers anr:11ly rcgarJcd n~ of HISTORICAL. 681 ~ye import. At fir5t they "ere but 11 m number nnd did not ~rry sufficient weight to make nny material changes or dominate tho hostility and malice of the older section. Later, they were in- crcn<=cd to 30. \uy ~eriou~ reform of morals~ however, wns forgotten or lnid . sick. owing to the l'onfinnc11d to their tcg1timatt> work nml at the same time prosecute their spiritual duties. Thi~ \\ n::, offC"recl ns an excuse for the mcintcnance of owr :.!00 con- , 01escents to do the work of the \Yard.;;. These conYtil(·"cenb mis- npprapriat<•cl food by way of wages, nnd the nuns tht•msel\'cs were a cused of stenling s11gn1· frvrn the dispensary. The sisters ret,llintecl by accusing the pro,·iscur.-; nncl masters: blaming them for the lnck of heat in the wnrcls: nnd declaring that the patients stnn cd or iron. to death. Thcy "·ere directed co be more patient and more pains- tnkinrr 'vit h the sick. whilr t~1c master was reminded that it was his duty to OYersee the beb:n ior of the sisters nncl to proYiclc ccmpetcnt I ersons to instruct them in the art o:f n11rsing. Nothing came of thi..:. nnd in 152(i we fincl the personnel of the Hotel DiNt mnkin:! common c-nnse with the <·nthedral chapter against the Oon•rnment nl(' c·ondition of the patients, she often had been constrained to bn,\' \\'hiting nnfl ttounders to fry for the hungry in order to keep them :din•. aud that she luul h<'g-gccl mon<'y f< r the purpo.;;c from relati\'<'8 and others. She declared that during the two previous winters she hnd h<'Pn con. strained to burn tlw sfrn\\ from the rnattre;.:i::c.;; of the l>Nl!'i in nrder to be able to pro1wrly dry thr ~hPc•b intc11ter ll"S. ~11ed as their spir itual mother or ir11icle th:rn to the- priore..,s' orclc'I' ... for ~enice with thc patiC'nt". "These girl,-." she said. ''disdain to rnit on the sick becanse of th<.> spiritual exercises ''hich thr said mother lays upon them daily nnd which the)· find sweeter. They no lo 1ger care to occupy themselyes with wn!'ihing clothes, cleaning the poor. rutting their hnir, paring their nail:;, nnd doing other ncrc ... c:nry things, so th :tl as a r11le the hcacl nurses Jun<' to grt in women :from the outside to lwlp them." _\. lady, deeply inlerrsted in the sick of the Hot cl DiPu and "ho worked h ard in their bclrnlf during the trying prriod 0£ rivil tir; HISTORICAL. 1'83 bet"-ecn Henry Ill and Henry of X a ,·a1Te. "rote> in l\,:).i to the ;idminic;trators of the hospita 1. complaining of the -hm tugP of bed:> for the :,ick owing to the lar~c number of poor propil' who '' 1 re i11 the habit of !!Oing ea<'h y<.>.\r ro the Hotel Dit•n to pend t lw winkr. S}w a -ertccl that the fir::-t ward could rradily holll :!.J :Hldit:fon:il ~d,, :md tllat tlw i:arpenter and mates attni:hL•d to tlw in. litution could ensiJ~· proYin tlw night lamp., \\Pr,' "ithout oil. that t lw windo~v-panes wer1' broken. :mcl tl11• Lo\ 1·, in.de1p11tll'. On!) a fot·t11ight. before her co1uplui11t the clool' of the h ·n!!-ill "an! "·11s l<•i't oprn and :~soldiers t':ll11<.' iu .llld i.111m• l:11li1•'; ,~·ho h:1p1w11<'d to l>P nt tlw 111.LPl Dien Lalkt-r wi>nf to nurse a case inn priYntP hothe notice was to be given by the mttfr, :incl others, :-o that they mighl stop the issue of rations until hc•r return. It was likewise the duty of the master to know the h•ngth of her a~ence and the house to which she went, so thnt he could nscertain the exact amount of money she had earned for the in-titution. Another wise and businesslike measure was the order to determine how much wine there was in the cellar and then decide. by the num- ber of patients present, the amount to be is::.ued to end1 one. The orders for the wine ration were to be signeieve Bouquet, the dnughter of a rich jeweler, wns £e11t to court nt un early uge und entered the service of Marguerite of Valois. It is to be hoped that her contact with th~ dissipated d::rnghter of Catherine de :.Medici and di Yorcecl '\ ife of Henry of Xarnrre di years scrYecl as tt 'White Daughter before becoming a Lc.;ter. After a Yaricrl S<'nirc in the pharmacy, the lying-in wnrd, nnd th"' other wards she was elected prioress, and continued to be a model of piety and practicnl charity until her death at the nge of 74. The founding of the ::;ocicty of the Dames de ChnritC-. or Ladies of Charity, is commonly nscrib<'d to Vincent c1e Pnul. though ns a matter o.f fnct he actually opposed the scheme in the beg1 rniug. The idea originated with l\i)]e. Le Gns (Louise de Mnrillac), a nm!'eln$ together for the purpose of visiting the Hotel Dieu. On the ~Iondny iollowing, n.fter communion. 10 people met to initiate the society, the noble mother of Fouquet. the rr hister of finance, bring 'nmont: the number. M. Vincent made n tactful speech, in which he explninetl thnt, as 'the visits of the ladies and their practical interest in the '' orkings of the ho~pital mi~ht be expected to mnke public some deficiencies in the administration of the Hotel Dien, they wo11h un- doubtedly pro,·oke sonw hostility. Accordingly. he urged his heare~ to be more than careful in their attitude toward the sisters. They appreciated the point nt once and displayed so mnch tact and grnco in their "·ork that they won the affection nnd esteem of th!:' priorc.;;s and those under her from the start. l:USIORICAL. In JG3-! the Associntion of the Ladies of Chnrity began its work. In trying to comfort the sick they did nn humble bearing an1l tried to feel awl to :-how"-.) mpathy for the ills of mind and body. In accordance with the wise directions of Vincent de Paul, they forbore to talk about themseh-es anr,:;hip of n hundred women, one-fourth of whom were me111h1•r; of thP nobilit . .-. Two .rear,., aft<'t' iti;; organiz.1- tion it was rlee111Nl Pxpedic>nt to aivitl1• the work at the H1jtcl Dien in !'lll'h II \\ ny that '-Offil' of' the l:tcl ic:-; OCCUj>iNl thcmseJ VCS whoJI_v "ith rc11dc1 ing· ~p!rit11al aid vd.iilt' otlll'r cfo1·oted thcmselvc>.s to !'('lie' iug phy!:iirnl di<;fl"c:s~. Tht> pestilence of 1G3G fuuml both tho Oamc all,, or tlw mC'eting of the board of dii·ectors of the Hotel Dien. 1111<11•1· the dntc of ,\n~nRt ::!G. li05. \\C Tend ihnt it wa..<:: \'otcd lo «Ontinne to J\foster Petit. -.nrgeon. his nnnunl nppoint- 1n<·nts. by way of testimonial and favor, so u · to reliPve tht· needs :mo infirm1til'" of hi <:: gl'en( '\gc. ,\nd in the deliluwnlinrL" of .\ngnst. :!:!. 170s. we rc>nllll';.;"l'Ull or till· HMt>' l lf••u. ,, In~ siit·k lllll of nicorl' than 1-:lJ .rear,.. HISTORICAL. \·o1. XU OthC'r ~trikin!! l'XampJc,. of lwroi"m and •le,·ot ion :t re furnL,hed by the rl'Clll'(l of thC' great fire "·hich on the ni~ht of Di!i.:ember ~9 171::!, dcdroyld a :rt·cat part of the I-fotel Dien. The fire oric:innted in the chancllcn oi the h< "nital. anIH·ld l'O\llllfo women, lrn lf mHlres~ecl ancl weeping in I error. their.· natural 11ai·rn being heightened by the loud alarm 'vhich pealed forth high abore tl l'ir head· iro• 1 lh<' I Plls of Xotrl' Dame. ·Forthwith 1he clc or:, of the cathedral were thrown open, the nave was lighted 1tp, antl the refugees W<'l'<' dirrctes of the no\·ic:os. lhey were ns8C'mbled :i.nrl counted, and when it was found that no one of them was mi-sinir they were sent in haste to the cathedral, nncl in less thnn nn hou; they had prepared beds there with mattresses, pillowc::, and feather beds for the accommodation of the sick and injured. l\Ieanwhill' Sl'nfriC'<. hnd beC'n stationed nt the portnb of tlw church to prevent the entrance of all nnnnthorized persons, and Yalorou,, efforts were macle to sa,·e ns much property as possible from the burning building-. From the chapel of the hospital the sn<:r<••l ve.;.,. sels. cross, chandeliers. and various ornn mentc:; and vestment" were remoYecl to lhe trc;1sm·e house of Xotre Dame, as well as thl' hirth registries and th<' recorcls of burials and funerals. .At thr first rumor of the fire the procurator ~eneral, the president of Pnrli:unent. the lieutenant general of police, the head of the criminn l <'Olll't. the kin~'s prosecutor, and other functionaries arriYed, one by onC'. The clooN of the hospital WC'l'C' ordered opened, biat nt that moment the chil•f night nurrn. who had th~ keys. was busy elsewhere rescuing the :-ick nnd could not be found. _\.n attempt was made to bre1tk lhe lock-. and so. when the keys were #inally broui:rhL they were of no usr. The doors hnd to be battered down. and owing to their great strength thi;, took a long time. Before the task was completed the firemen had arriYed, accompanied by city wat<'hmen nnd numerous fri9.r" oi Yarious orders. .\bout 3 o·clock 1n the mornin~ the archbishop arrived and, after ob::;ervin_g the flames. entC'red the cathecll'al anrl \'isited the ~ick. He immediately took steps to furnish broth anci wine for them. The clean of the chapter toward 7 o '('lock in the morning roceh·ecl as his guests the si>;ters ancl 110\ iC'es and nrr:inged ior them lo hn\'C' somethini:r to eat. At 8 o'clock mass wa'i !'aid as usmd ann<' to relieve the sitn1ttion. _\..11 dav the fire continued to burn and lh·el v fears were entertnined le"t the ·in-y. the wine cellar with its store of wine~ nn.i HISTORICAL. U87 liquors :rnxtinguished and patients w~re carded back .from the cuthNlral to such portions of the ho3pital a:; "ere !;till sta1Hling, us it wns anh•ntl,\ desired to clear the church au cl prepare it for the cn::otomar~ religious services tlppropriate to the new y<•ar. That evening after their dinner the sister::; to the n1unber of !10 und the no\icc.s, :Win number, pao;;::;ed from the large ll'lll of the arehui:-hop':i pnluce to his audience roo111, and, haYing thanked hi111 for hb hospi- tnlity. fell on their k11ees and i1woked his ble:.sing. During the two days that the patient:; of the Hotel Dieu were lodgell in the cathedral one woman gaYe birth to a child and 12 paticnh died. Owing lo the cold. numerou:. braziers Imel ix-en ;,Ct up in the mn c antinrnled nt over a million livres. It was in the reign of Louis XYI, under the able igbteenth c:entury the profo~sional stnti' of the hospital uppcars to hn ve been organized on modern lines. It con,.i,;ted of :;e, ·n doctors, one of whmn was specially delegut<''l to treat the rwiPst<:. sisters, ·white DatLghters, and 110,·ices. The others \H'rc us- ~i1.?1wd to various wards, :,,cl'\'ing in turn for four mvntJ1, in l'ach. They mucle their rounds betwt>en q and 10 n. m. daily. Each wn:, itc- cornpanicle understudy, capable of replacing her in need; that one Echnee Oonet, ha' ing &hown herself throughout a period of 12 yc.>nrs i11 e,·ery way capable: deYotrd, and entirely fit to ron08 births in 1757. About this time serious complaints began to gain circnln.tiun in regarcl to the professional ability and behavior of the doctors of 1ho hospital staff. It was reported that instead of coming nt 7 o'cloek in surnml'l' nncl nt 8 in \\'inter to mnk<> rounds 11111ong tlwi1· patient,., they ofl<>n dicl not come till 9, 10, or 11 o'clock in the forenoon, this to the great inter ference with the propc>r hospital care of flte patient,. Their rounds should Inst at least two honr!', but instead were often View of the H6tel Dleu of Paris and surroundings In 1734. Courtesy or 11 . Champion, 9, Qua.i Voltaire. Paril. 6811 I so . .f. lllSl'ORlCAL. 689 made in hnlf nn hour, n. quarter of nn hour. or less. This illlfoccnt precipitation was not clcemcns often ::et !'.Xterne" without experience or nl.Jlllty to tnke their places at nl::ht In tht> i::unrd room or night-duty room, these substitutes beln:; quite unfit to rc111ler the requireI' r11 r il' rot, dHensc ll. Dku ne fulre mlrncle en ce Heu: whi<'h we may translate as follows: No mlrnde or wonder raising thing ~fay Clod do here. By order of tbe King. While the Jnnseni.st doctrines were warmly chnmpionr .Marie cl'Anbonne. was born on the 2d of Februnn lGlfJ, grew up al lhe coun of the Duche"s of :Maine. and con:-,tnnu; attended the ball-.; ancl festirnls at the royal court of Lotti XIV until she wm; ~2 ycnrs of age. ·whether suddenly '· con,·crtcd · in true Jnnscnh;t style or acting on convictions gradually £om1ecl by the contra~t Let ween her inward thoughts and the worklly. licentious surroundings of cou rt life we do not know, bnt on a certain day we .find her getting up from her lmees after long nnd earnest pra~er in Notre Dame and hurrying into the presence of the prioress of th2 H otel Dieu to beg admission into the order of nursing sister,,.,. We can picture the scene and readily appreciate the astonishment, al111ost horror, of the prioress when this fashionably altirecl young lady made her sud Marchiorn'SS dl' l\1ontmorl'nc~· and thl' frc>quc>nt yj:;its and tommunjcations recci\'ed Ly her from member:- of thi, :rnd other noble familie!-; nnd her clo-.c alliancc> with Canon Lenoir :,ta ,.c lo ::\in rie Louise a position of considerable import tmt·e in the Hotel Dieu. nnd ns the year~ f!O b~· we find her using her in- creasin~ influc>nce to attempt a chang-e in the n~ry coni;t it ution of t!1e order. _\ ssoeintcd with her in the enterprisr were l\Iothc>r of ~ai11t Gertrude, who had been selected prioress~ though but 1.) out. of ~O ~isl er::; \'Oted for her for that po3ition. and otht'r mt'mbers of tl1e order, her de\C>tt'd friends and aclmirers. Fl'om thi::; re\·olutionary entc>rprise sprang ;1 long i1westigat.ion and n111rh diR<'orcl. Under tlw regime of lh<' Duke of Orleans, acting as regent during thc> minorir.' of Louis XV, n board of inquiry delil>cratecl at the Uf>tt'l Dieu anti called Lefort> il tho prioress, nnd then, after some discussion, tlw :i\fothrr of Mer<'.\ and her followii11.?. C'Ol1Risli11g of S0111(.; rn (lJ' :!fl HISTORICAL. de\ ot<'d nuns. There hatl been much di!<.:Orll bl'tWt•en the priol'l.!s~ :tnd the Ml-re de l:t 1iliH'ricorde, and it is doubtful if the bn•acli wa,.. eHr rrnlly l11.•;tlt•1l. but tlw Kiug:s commisf'ioncr succet~kd in mnkin!! thin:.."' <-mooth 011 t]H• finrf:u•e. and J:111::cni..:m i:1 the prr:;on of Lo11i"t' de:; Tournelks was thoroughly suppressed at the Hotl'l Dicu. Our anthorit~ !-:l1iffs at tlw temerity of )farie Luui ~c in livin~ and .ivili!!' ;1 ,Jamt•ni!"L antl quotr;-; from the horrific,l ncco1111l gi' en by L.;nnon Le Gernlrc, a mock I of orthodoxy. of what thl' rcfor111cr tl'ic, who had di;-;(.'ardcrl ro• ~c ancl me on this ship. I would like to be sent to our largest ho5pital nnd n1Jowed to specittlize in :;urgcry, for which I feel myself peculiarly fitted. I lun·e been very successful in surgC'ry prinr to joining the naval scr\'ice nnd fe1tr lhnt my talents would b<> wnstcd on this ship, ns tlwre have been uone but dispensary cases and 111eclicnl rast•s dur- iu~ the month I have been on it.'' Oh the glamour of surgery, the fascination of the title" surgeon:•_ whether narnt militar), or civilian! All that history, fiction, or a fc.n·id imagination has pictured flushes before the mind's eye :uul one is compelled to rrgard tlH':,c young enthusiasts with tender s_ylllpnthy. Who has riot thrilled nt the description of the surgeon working- im- perturbably~ swiftly, skillfully, nmid shot and shell, as Zoln has c.le- scribl'd him, as he is reportrd in the chronicles of the ~npolconic wnrs? We recall the brilliant operators of the French school nnd the marvelous manual dexterity with which they nmputatetl by trnns- fixion, we realize "·hnt our leading operators do to-clay ancl arc not surprised that the definite and conspicuous results of surge1·~· !'.'bould entrance the tyro and that h(} should feel the challenge of a calJing thnt offers dnily chances of brilliant success or dnmni11g failure. E,·en the grotesque figures drawn by Smollct and Mnrrynt do not disillusion or daunt the aspirant for renown who enters the medical service of the Navy. He argues thnt all the portraits wcrP dmwn on the same scale; that admirals, captains, and first lieutenants were portrnyecl in the snmc ludicrous guise as the medical men. nnd if the former "·ere heroes in spite of their foiblrs then the nmazing creatures who sailed with them as surgeons wern probably c.lc,·er handicraftsmen. Kor is it; a misnomer for the naval medical officer to be called a snr~eon. Surgcr.'· is an essential part oI his work. Xo medical officer while nvnilable for general service and on crui~ing hips enn nlljurc surgery ns cnn the medical practitioner ashore, who politrly refers cases to the surgical confrcrc on the next block. However, the young mnn who enters the senice "·ith the iclen thnt lie ·will find there u large fil'ld for 8pecializin,q iu ..,uqrery is lnhoriug 00:1 EDITORIAL. 11ncler a misapprrhr11sion and c1oomN1 to disappointnwnt 11nlr he can find irratification for his ambition along other Hnes. If he holds to his surgery. th<' ·oont'r he lea\'es the "l'ITicr the better it will b for all couc·erned. Tlw 01wrntor who tries to see how many hernia or app<'ntlicrs or p:nll blndcl1•rs he c:tn opemtc on between one c•ruise nnd another is simply depriYing- other men in the hospital with him of an oppo1 tnnity to acqn in• tlrn l reasonahh• 1·ompt•tenc·y whi<'h f1!l oflic ·rs should po:;:;ess in oras lik<'ly lo unclt•rgo '<'l'im1s moclifiC'ation as they :ulrnncr in k11owledge of men and things. There is no desire to 11rg11e all)'onc out of his ta<:les and prcdil ·c tions. but it is an int. 'Ve oursel...-es, after n sm·vey of the past and a consideration of tho future. must take account of stock unul. If the attraction of the senice resides in its militnry feature:; alone, then, it should be entered by but one door-the Na val Academy. ,o. 4. lWlTORl.\l.. fiH5 Jn the next plncc 110 111an ;:;lannls is unconsciow;ly "'Calin~ hie: own doom by con~mtinp: to mediocrity and inertia. The linr oflicrr ronsiders his life wol'k n hip:hly sprc·ialized pro- fr.,.ion ~incl :ulverli8cs i ! n~ !-inch, and lie is right. He may lir kc.:s \H~ll informe1l about c·xplosi' rs thnn the chemist or rv1•n th1111 the intt>IJjgent fore111an of some lnrgt> powder plnnt. lmt he knowF th<' procticnl applicntion of explosiws for pul'poses of n:t\':ll wnrfnre. Ile 111ay not be as cll'eply YCI'SNl in the s11bjcct of en~inr~ as t lrn mun \\"IHI designs and huilds tlwrn ashm·t•. nnc1 in otlwr department-: of knuwclge he may haw less cxpcrt ability than many ciYilinns, but he will stand high in his profossion if hc succes3ful]y brings to lwar rxperi nee as orp:anizer nnrl disciplinarian with skill as n:l\·igator, 1'ngincer: and artilleryman on the training nnd dewlopment of man- of-\ntr's men ancl tlw upkN'P of battleship, submarine. or clt•"troycr n!..rnim:t the po,..sible tla \' of bottle. The fact that on the em of battle hdp mw he receiYccl from ciYilian chemist. engineer, elrctrical <'X- pert. inYentor. and scientist of eYcry kind does not rcdu<'c the merit or !!!or)· of the oflicer of the line whos(' ;reneral Imm\ h'd; .. 1·mhr:u~1·s the whole field of n:trnl cnllenvor, conpting. harmonizinp:. and hh·n essentially different from that ofthe ciYilinn practitioner or oi any practitioner on shore. a real career cliffl·renl in ib nims and requirements imd essentially different in its r<>wnnls. He must not be allowed to think of himself as renouncing amhit ion, <'ompromising with fort11ne 01· ~:terificin~ hi~h pmvoi-e::, of nobll' en- deaYot· in exchnnge for guaranteed snb~istence :mil frretlom from nnxiety in the years of declining "igor. The physician who dons for life the naYal uniform ( nrnl there is no pos~ibility oi contentment and pence of mind 11nlcc;c: a mnn do<',., take it up as n life work. one to which he is committed for lietter or wor,..e) becomes part of an organization. liYing lar!!Ply.apnrt. pcc11lia1· to itself. little nnder:-;tood, a. highly specialized. diffcrt'11tinte<1 botly of men. Their physicnl s111To11nclings, tlwir phy"'i":d nc•<'d!". ancl the physi<'nl details of 1heil' eYcrycllly life. are romplicntcd and peculiar. Thi~ function of the medical officer is to study the physical conditions 696 EDITORIAI- Vol. xu and requiremenb of naval life, to amcliorn.te them, to mini. ter to thl'm. The variety of the subjects within his scope is only hinted at when we mention the proper illumination of an officer's room. the working ration of nn nviator. the mC'ntion fo1· liis 1·pcom111c1iclatfon.· nnd to win the confidence and affection of his j nniors. to commanrl the rPspect of nll in the close juxtaposition and the trying intimnU! relations imposed by the conditions of life nt sea. From the risin" of the snn till the going do'\ln of the same nnd into the silent ni!?ht wntches cYerything that hears on the life of n sniJor has an inte for him and furnishes him with food for thought ancl inYestigation. In a word. the NnYy surgeon is a specialist. nncl he has a ,·cry peculinr sperialt_v. One of its anomalies is the fact that few nppre- cinte the clistinctiYe tC'atures of his c!\lling. To a large number of people ashore a n:wnl surgeon is an agreeable fellow of some edncn- tion. pC'rhaps culture, with n. hearty, jolly manner. nncl plenty of time on his hands. The popular conception of the Nn'y line officer has 1mtil recenlly been eqnnJly inaccurate n ncl nnfnir. 'With 1 htl passing of the wooden ship ltav(' gone forever the dnys or elegant lei. nre. the long stays nt Villl"franche and Yokohama. The wnrship of hi" generntion is n workshop and all hands nre bnsy . • Just ns it would he wrong to compare n line officer with Eclison or )foxim. so it is wrong to meac;ure the nttainments of the KnT) doctor by those of nlC.'n C'tninent in a singlC'. limited fip]c] of profe3- sional work. Dr. Ride's opinion on some obscure disease of the ~kin may be worth $~0, but how many years have pnssC'd since he s<'t n. fracture or nttt>ncled n cat in he might knock off n couple of hundred, but would you trust to his jmlgmcnt in diagnosing some tropical mnlacly or conducting a cnm- pn.ign U/!a inst an cpi"Cllluln~e ~ The publie, most generously and sympathctirnlly di:,po ... <'«1 j11i-l now undi'r the stim11 l11s of wnr condition'-. probably holds that tlw e1111n- tr\ .. !-> braYC uefcndCl'fl al ::;ea, in Order to be adequately tn•atcd when ... i~k. ::-honld have "ith tht·m as many expert;i a~ tlH'l'; arc :lC' outfit of tht•st• peopl(• the -.:hip wculd lit• dnn. l,!'l.'ron,f~· clown hy the lwad. I~ is impradical, richculou,- to think of pro1 icling n whole fncnlt~·. What can be fnrnishecl and is furnished i ... tho man of reasonable competence in a preponderanee nf the proL- Jem!'> which may arise. The rnn-al surgeon is not the equal of th£> mo::.t eminent operators ashore, I.mt he is superior to tlwm in medieal knowledge. He is not the equal of the distinguis1wd intcmi:-t a ... J1nr<'. but he i;-; r·apable of doing good emergency surgery, vdwreas hi-: .-.u- (>(lrior in internal medicine would undoubtedly fight shy of a bi:-.- toury. His kno" ledge of the eye, ear. and throat arc limited. but he npprecintes his limitations. It is his ambition and constant aim to l·e as good as he can along as many different lines as possible. This conception of the nantl medical officer may well stinrnlall' the nble:-.t, the best equipp<'d, the most ambitious man. To flw one with n leaning ·for sllJ'gery, a period of tPmpornry in:lcti,·ity alon!r thi<: line will but giYe opportunity for brnshing up on thr r~·(' or i-kin or nenons clisea~es. The man whose passion or clinrsion i::, bacteri- oloir~· ""ill· when sent. to recruiting duty, have n11 opportunity to come in contact again with men :rnd to reinforce his pre,·ious stmlie-, of human nature by fregh observation of its Yagnries. With a clne appreciation of the nature of his cnreer, of it:; oppor- tunitie.c:: antl dn6es clearly fixed in his mjnd. the ml'clicnl offic<.'r will be able constantly to rl'legatc petty wxntions nncl disappointment,; to the subordinate place where they belong. Ile will hnvc no time to brood over wounded sensibilitic>s and worthy moti,·e,; mi<:umlcr:-tmxi Dis..;;afr::faction because n. giYen suggestion wns not acted on will be brushed aside hy tho lively consciousness of the infinite number of 'thinl!" to he learned if n medical officer is to be up to cfote. well informed, ready with sound. expert adYice when it i~ cnllecl foi· ancl urgently needed. FU:SCTIO~AJ, AND OflOANlO LESIONS. A prolific source of mistakes in the ·examination of recruit-;, e~pe­ cinlly when conducted by civilian physicians or by young medical 7600~ -lS-!) 698 EDITORIAL. officers without practical experience of senice conditions, is the fnil. ure to distinguish between the candidate·s expectation of life and legitimate grounds for the expectation that he will be a useful mcm. her of the military body he ~eeks to enter. It is not eaough to be able to say that in all probability a candidate will live for 20 yenrs. The examiner mu:-.t have a reasonable assurance that the candidate will be able to giYo from 8 to 12 years of satisfactory sen-ice in re. turn for the GoYernmenl 's outlay in feeding, clothing. and training him. A candidate for enlistment '~·ill often say with perfect tr11tl1 of some disability \\hi ch the examining surgeon has disco\·ercrccl me:' The vital consideration then is, will thi., di . ability bother him under the peculiar conditions which wilt s11rro11nd him in the ~ervice , conditions entirely different from any he h·1 pre- >iou -;ly known. It not infrequently happens that a clisabili•y ar- countecl trifling by a man working in a store or factory assumes con- sideraule real or imagined importance after enlistment. \Yl en nn enlisted man hns to Le curried on the sick list for purpo~es of ob er- >ation, when frequent examinations and consultations nre nece ary in his case, when the defect which "neYer bothered him'' grnfect nncl maintain-: thnt it docs bother him now, his ultimate discharge from the service is almost n matter of certainty. The time and energy dcYotecl to train- ing this man has been wasted jusL as truly as if he had been a sutferer from a physical defect which should have caused his i~ejection at the recruiting oflice. The expert civilian physician constantly n.ssures candidates for en- listment and their medical examiners that this or thnt pl1ysical defect is merely functional and so negligible, but medical officers of ex- perience know only too well how often these negligible defects utterly inYalidate a man·s eventual usefulness in the service of his country. En~ry medical officer who has serYed at sen cnn testify to the fre· quenc~' "ith which the medical suncy and discharge of a man lends to re-quest::. for discharge from a large number of other;;; from men who han: Lecome disgruntled or dissatisfied when the glamour of sailorirg has worn off. The effect of a medical survey and dis- charge is peculiarly clemoralizing when it is occasioned by some rle- fcct ''hich was a:-s11med to Le trifling at the time o.f cnli~tment. In the majority of cnses an experience of service conditions hnc: demonstrated that "hilc there is a rnst difference between fnnctionnl lll1U organic lesions (of tho heart for example), SO for as C'Ol1C('l'OS expectation o( life, thC' 1mdesfrability of a candidate for enlistment " EDITORIAL. 699 i:: about the same whether his lesion be organic or functionfll. The :::ubject of n. functional cardiac disorder is not apt to he a cheerful, indefntignble worker, and, whene•er he wishes to aYoid any arduous or di::ngreeable effort, his slight disability provides him with n way of e::cnpe. Such a man creates around himself an ntmo.:;phere of :;,'11lpath_y that will often seriously embarrass the ::::olit:iry medical ,;racer embarked with him, no longer backed up by the testimony of t•niinent specialists and open to criticism on many counts. \\"II l r. 'l"IJI: PSYClll.\TRI RT J/°AH.8. If the remarlrnblo and a:-:tounding ucti,Titics, th<' proj'o11ncl ngitn- tioi going on in mnny branches of business, if tho conntk•ss mter- prises recently undertaken in this country were all in one pince nml could be cxpres!'ed by word of mouth, thPre would be a pnn-. n boa rd and g:111u·anh•e3 to st a mp 011 t P 11·r~' form of n•noin. 700 EDITORIAL. \'ol. XII It was recognized that thet·e \vus grl•at danger of taking in unu- wnres weaklin~ unable to <'1111111·" th(• as1wl'ities of a rnmpaign aud that the nwnaee of the unfit wa:-. mon• to bl• dreaclecl than PH'r 11n•IPi· the emotional stres~ of wnr tillll'. .\1111 so an effort has- bel.'n made to supply our training camp:-. "ith a sufficient force of psychiatrists to <'Xamine the recrnits witl1 sy:-.ll•t11at i<' <',U'l'. The n•stilts ha Ye bt'l'H Hltisfnctory to the extent tlrnt a larg1• n11111bl'1' of men haYe lwen cli-.- chargl.'d who were prt>snmnbl,r 11ot pos-'t'SSl'd of the stabh• mental bal- am•e necessary ior ·war t•nd111·ancl\ nnd out of till' num1wr 1lisc0\et'l'd by om ;30 odd psychiatrists !:'. but then' is a problem of wider scope whose solution »oulcl bring large returns to the GoYernment. \Yhethel' the solution has been seriously attempted ic: not known. but 110 answers haw been sent in as yet. :N" ow that the expert exnmincrs refl•ned to lrnn:• had a reasonable opportunity to beconw fnmiliar with the conditions of narnl life. it lllll"t he clear to them that tlwre i,., no permanent demand for any considerable number of ps~·chia­ trists in the ~foclical Department on n peace ·footing. This statement 1s no disparagement to tlwru, for. as n matter of fact. the recruiting- oflice ancl training station examinations for the cletel'tion of mPntal dt>foC'l ives hardly offer H'op1• for a Ii f<> work. \Yhi le tlw yonngcr specialists in this branch might be glad to put in a year or so em- ployed in such routine work. the ambitions and able alienist will in time find this field monotonous and restricted. When the war ends and the country releases these experts from the patriotic duty of sr1·vice with the colors, the :Medical Corps of the Navy should be in a position to continue the active protective efforts now employed. We ask, therefore, of the psychiatrists as.c:ociated with us the elahoration of a brief. comprehensive method of procedure capable of being u~erl h~· en•ry medical offic<.>r for detecting the defectives. That examin:i- tions conducted by the general praC'titio11el'S of the Xavy will be pro- clncti ,.e of resuJts as satisfactory ns those obtained by specialists we do not claim, but, once a proper routine method of testing is ai:rrced npou, our recruiting surgeons can certainly perfect themselYes in its u!"e, and the kno\Yleclge thry acquii·e in this way \\'ill haYe permnnent \·alue for them. If. on the otlwr hand. the psychiatrist should not he able to ;;t>tt le upon a practical method capablr o C snc·c:essfnl cmplo~ ment b~· some> one other than an expert, he fails to meet the clemnncl laid on him. The best things i11 science, in art, in medicine are for the 111any. 1md the practical helper has always saicl, "I will show you how to Clo this," which is considernbly hetler thnn i;ayi11g, a That is my !·wrn'L 1 'llU the only pt>rSOD who ('fill SllCCl'SSfu1Jy Operate the device." f 9. e n d I - llt' Fla. 1.-Dtslocatlon of left aemllunar bone and normal rlaht wrist. 701-1 CLINICAL NOTES. DISLOCATION OF CARPAL SEMILUNAR BONE. By Jt. El. IlOYT, Commander, M. C .• lJnlU>d Stnte~ ~nvy. CaS<'. J. G., private Marine. 58 year!; old, 22 years' senico in Ca v- nlr·y and Marine Corps, and famous for a prolonged alcoholic rec- ord. frll into an excavatir X-1':1), plates showing ;rntero-po~t<'rior and foteral 'i1•ws of the wri..,t were taken and from these. <'~P'-'Cially from the la tern I 'iew (fig. 1), the characteristic picture of dislocation of the i;emilunar bone '"as obtained. This cast> emphasizes the importance of \'c1·y cardnl X-ray cxa111i- nntion of nll lesions involving the wrist joint. Disregarding the common Colle's fracture. which, as a rule, is diagno~ed wit bout any special difficulty nncl tho rare condition of dislocation of the wrist as a whole, most of the less definite abnormalities about the wri&t fol- lowing injuries or falls, and having as their signs and i:;ymptoms, pain, swelling, and limitation of motion, are classed under the head of "sprains." The X-ray has been most rnluablt> in the."<' obscure caRes and has enabled us to correct the indefinite blanket diagnosis of "sprain" and to realize the comparnti•e frequency of carpal injuries. The three methods of treating a dislocated scmilunar are: Fir::.t, forcible reduction by manipulation under an nnresthetic; second, re- duction by manipulation through an anterior incision; third, in case these methods are unsuccessful, removal of the bone, through an an- terior incision. Owing to the swelling of surroundh1g tissues ancl en- croachment of the other carpal bones on the space formnlly occ11pi<'d by the semilunar, it becomes an exceedingly difficult matter to re- place the latter bone even after cutting down upon it. In cases of 701 702 McMULLEN-RUPTURE OF POSTERIOR CEREBRAL ARTERY. Vol. Xlt complete dislocation, such as shown in this case, the reposition is practically impossible without extensi>e injury to the wrist, which is not justifiable, considering the fact that a good functional result usually follows the removal of the bone. After unsuccessful attempts at reposition by the first two methods mentioned, the bone was removed through an anterior incision. Re. coYery was uneventful and a good functional 1·esult obtained. ~\ picture was taken several months after the patient had been restored to duty, and figure 2 shows the condition of the wrist at that time. ANEURYSM AND RUPTURE OF THE LEFT POSTERIOR CEREBRAL ARTERY. By J. J. A. Mcl\Iui.1.1:-:, T.l ~ut~nant Commander, lll. C., United States Navy. This case is reported bC'crwse i1 has point::; of medical, snrgical, and medico-legal interest. J. R. 0., a carpenter in the navy yard, CaYite, P. L 5-1 years of age. entered the hospital at 2.30 p. m., May 11, 1918, in a deeply comntose condition. According to the history the patient was much adclicled to natfre gin; had a remarkable tolerance for alcohol; was app:rr- ently neYer much ail'ected by his imbibitions. It was also learned that 12 hours prior to admission he stumbled to the floor while walking about in the dark, and that he strnck his head and imnwdiately be- came uncomicious. Ile wa:-; seen by u physician scn'ral hour.-;; latrr ancl pronounced under the influence of alcohol. P 1Lysico7 c.cam i11atio11. Large, well--f c·~~r, u. (i_·.....,_,.f~ 1 tu ,-.,, c ~ c.I. . 702-2 :;o. 4. McMULLEN-RUPTUBE OF POSTElUOR CEREBRAL ARTERY. 703 The question of diagnosis in this case was complicated, as it fre- quently is, by factors which pointed to alcholism, uremia, and intra- ,-r;inial pressure from fracture, rupture of a meningeal vessel, or ,·t"rebral hemorrhage. In this case there was a general suspicion of "foul play," and the marks of external violence about the head seemed to bear out the !>uspicion. Did the patient have a fracture of the skull? Did he h~we meningeal hemorrhage without fracture~ Did he htwe cerebral hrmorrhage 1 Or did he have none of these things and lhe coma result from uremia? The evidence in favor of intra-cranial hemorrhage led us to be- lie,·e that the signs and symptoms were due mainly to that cause. The probability of kidney damage in a gin ury .. 111 and do~ thereto an intact miliary aneurysm. These art !'iurn 11 in the accompanying illustration. Till' l'li111i11ation of uremia and alcoholism wn:- eo1Tt!CL and th clia:rnosis of intra-nanial hemorrhage was correct. Localizing "Ytnp~ tom~ !wing ab .. ent. the locntion of the bleeding Yesscl w:t:-- a matter of :-peculation, hut tlccomprC's"ion was ju~tifinble since we had E'Yidt>nce of lal•:ul injury and intra-cranial hemorrhage. ThC' 1·C'reliro-~pinnl fluid withdrawn bt>forC', but examined after death gan• a l'ompletely positi,·e Xogouchi rC'action. This ('OtuplN~d tlw picture of b.' philitic aorlitis, nrterio-sclerosis, nncl nn<:'urysm anti rnptltr<' of tlw posterior cerebral artery. Tlw injury to th<> head wa incidC'utal an that the patient wac; engaged in au ntirny of some sort and that the history given was will:fully mislC'adi• I!· I~ this instunc'<' the nuthorities inclined to this opinion and 1t1Tl'Stccl a man with whom the patient was alleged to have fought. ~11b:-l'<111ent inYl'stigat ion sho\\ eel this ..,nrmise to lie corrl'C't. It is readily cOJH'eirnbll' that a conYiction for 111mdcr or 111:111 slaughter might be made in a. ca:-:e with circ11111stnncl's similar to thi:;. pro\'icled syphilis was not ~ou~ht for, a11d llw anc•m-y::;m n ncl ruptme of t lw artery owrlookl•cl. REPORT OF A CASE OF CAVERNOUS HAEMANGIOMA. II~- C'. W. i'lll ·u. f,l1•utt>11ant Comm:intl.-r, )l. C, l"nllt·d Stntcs .'\nvy. Yirchow ha<.; obsCl'\"C'd bnt onn pure caS(' of l'rnous hacmnnhriom:i. The foll cl\' i 11g t:asl' of caYcrnous haemangiomu u ( I he :-.u pr:tclu vicnlar region woulcl t hE'n'fol'e beem sufliciently interl'sling and unusual to be maport ancl placed ou record. ,J. R R.. ~C-!3. agl' ~3 years. enlisted in the United States Xa, .. y .May ~4, l!H i, and has licC'n a .. u ,o. 4. :->M:ITH-CA\"1-:RNOUS IIAEM:ANGIOMA. . 705 in this region h,, the
  • fit·st notic('d it. He st11tcs that the wearing of u collar ea11,..l-'s him discomfort, ancl that wbt>n he rxercist·~ tlw tumor becomes tensr and cause,; him slight dis- <·omfol'l antl pain. :-\incl' lw hns been in thr N:ny hr hns pcl'formecl all thl' clulic>s of his rating- without any discomfort, <'X<"Ppt 11 ''tight" feeling nnd slight pain when reqnirc•d to mnkt' an_\ unusual ph)'sicn.l effort. Ex:uninut ion of the patit•111 re1 t•als a so ft, i rregulnrly '>h:qwd f um or. ll'hich. whl'n d, t~xtt-ncls from the sl<'rnnl he:tcl of the i:Mrno- mat-itoid mus<"h1 lo n point lJ inehet; from thl' ant(•rior hor and abo comes to tlw ;;11dace be- t\\een the claYicnlur and l;t<•mal hends of th.! muscle. (Sec> fig. 1.) \\'hen the pnti<•nt i,.; 1·el11xcd and sitting quietly at re-;t the lumor is harr while tlw p;ttient \\':IS sitting qtii<>tly at rest. (See figs. 1 and 2.) Tlw clingnosi., of inl<'l'lllllsc11h1r c.tn•rnous haem11ngioma wa-; con- firmed by Sm·gpon .r. Chalmers DaCostn, rnifc·d ~~tulPs Xn\~ll Hv- sene Force, who mntll' n <:ardnl examination of this CllH'. Ile "t:ltnl that in his opion tlw tumor probably <•xtendt>n Da- Co,;la as to the cl iagno~is nnd suqpcnl prognosis. Racliogrnpliic examination was made by Pns.-,ctl .\ :-;sistant :)urgeou U. :h-f. ~eubcrger. United ~tate-: Xayal Hr~cn<• Force. Lt•agttP Island Naval Ilospit11l, Philadelphia, ancl his interpl'l•tation of the mdiograph is here quoted: ''Dense shadow in left aprx cXll'ncling down lower border first rib. lI<.>arl unnsually lnl'ge and displnc<.>cl into right chrst." These findings wonld tend to eonfit·n1 the opinion that the growth l'Xlenery little. Blood circulates through the tumor and is supplied in most cases by the venous system. The tumor occurs in the skin subcutaneous tissues, intermuscular tissues, bones. and viscera. It i~ most commonly found in the lh·er. The etiology iti obscurl'. :Some authorities claim thut trauma has un importa!1t be:1riug. othe1 thnt the condition is almost ahrnys congenital and that the tumor inav en1argc later in life. Cavernous ha~mnngioma oi tho neck -.houlit b.e distinguished from the following conditions; .\crocclc, hernia or the lung. vascular goiter, fi.broma, lipoma, cold ah~ccss: :mcl an~urysiu. In this case the flat note on percussion. lhe absent(' of breath sounds or bruit, the rapitl distension antl relaxation of the tumor. and the sensation imparted on palpation as of an accumulation of ihtid under slight tension, made the diagno"is clear. Sutter states drnt there arc on record 51 cases of cavernous and telangicctatic angio- muta. and only 11 of these arc of the pure c:wernons type. Their distribution in the body is as :follows: Lower extremity: 19: upper ext remit~·. 1=>: back and neck. 12; :lbdomen. 3: brcnst, 1: head. 1. J. B. Carnett reports two c:tses of cenicnl :;ubcutnneous cavcrnOlL'> hremnngiomn. He states that these tumors wer~ rather c·1c:-ily re- moved after n long dissection with no unusual loss of blood ns they were situated high in the neck nnd surgical approach was compnra- tinly easy. The dial!Jlosis in these cases was confirmed by laboratory examination. m:n:ru:='iCES. (1) Cnrnett, .J. B., 'l'ruusuctlons of the rhllndelphlu Academr Of Sur::ery. 1910 (Yol. XII). (~l KnOcw~ki, W . .\., Chicn~o Clinic, lSOS (Yol. XI). (:I) Reltlener, :\l.. MUnchen, 1010. ( 4) Binni>, .\ .. Kiel 1003. (;l) Suttl!r, hi.. Dcut:;che 7.eltsehrtft fiir Chlrurgie, 1!103. (G) Petit nntl l'a~non, Purls, lOOG. R:EPORT OF A CASE OF ACUTE BILATERAL DACRYOADENITIS. By J \ 0 , l'O::'iSOI c, f,leutcn:int (.J. G.), M. C~ Cnllcd l'lntes :'\n..-y. Dacryoaclcnitis, or juflammation of the lncrim:tl gland. may be acute or chronic: unilateral or bilntcral: suppuruti ve or nonsnppu- rntive. Weeks, in considering all forr •s f'i dacryon'e. Temperature on :ulmi.ssion 100.G F .. which g1:aclunlly i-nhsillecl until uormnl was reached in four days. The. swelling of the lids and :rluncls and the redness of lids gradually disappeared in five clnys. F1mction of the glancls is not altered. Blood examination, including Wa"Sermann negati.Yc. Urine examination n<>gntive. Slllears from eyes showed fow Grnm positi,·e cliplococci. Cultures showed scanty growth of pneumococci. The features of interest i.n this case are the unnsnal occurrence of the condition and the question of etiology. In vie'' of the fact that although no history 0£ exposure was ob- tain<>. :!\lump~ cle '.rhriiuen-drilseu. (('e11tr11lhlntt filr prnkti~ct1~ Augenheilkunde, 1890.) 4. Sendra I. De::; Oreillons m·ulah <'S. ( HPcueil t.l'Ophtl11du10logle, J!lOl.l :>. Hirio:rhlwr,t?. :'.\lumps llt>r Thriilll'lHlrii~n. (Centrnlhlntt fl11· prnktI.nnnt (J. n.) . :II r.., Cnlted ~tat~ :-.-11,-y • • \n unusual case of cutnncons diphtheria w·t" n'Cl'llt ly ob-.l'ned at ihe Cmtrcl Stales NaYal Ilospilu.1, Chelsen, Mass. The patiPnl wus rcceiH 1 for tren I ment of a gangrenous ulcer. 12 cent imet<'l's long nnd i erntinwtl'l'S wide, oc·enrring onr thC' external mallPolus of till' ri~ht foot. Th .. 11ke>ralNl !'nrfat't' "as CO\ C'red with a §?I H,\ ish-" hilt• 111em- br:1111 :rnd smTotmclcntli11~ a-; hi!!h a:- the knre. :-ho,Yed rnnrlwcl indurnlion. l'l' matl<' from tlw t'OY<'ring rnembr:ine or C'Xudate ho\\ C'd pre- d0111innting numbers of !!l':llll po!'iti\'C~ b:i.cilli with typic1tl morplwlo~!Y nud -.taininf! qualities of cliphllwria bacilli with methylene Llue tt1JCI ~eiS,.:;er's stains. ThC'l'l' were also COil!'>iderable number., of nmm po-.itiw coC'ci nnd diplococci. which proYcd on culture to h<' ..;taphylo- rocd nnd "t reptococci. CulturC's on Loeffier's blood serum :?:t \'t' a w1·y positiw ~rowth of diphtheria bacilli of typical morpholog,,· and staining qualities. A slight huskine,.;s of the pn.lienL's voice was noted. although no -.pecial !-on•npsc:: of the throat was complained of. The tonsils and po-.te>rior pharyngeal wa JI \VC're dark reel and rather rough. Thue wa-. uo nembrnne on:•r th<' ton!'ils but n. few areas of l.!l':l,\'i"h-whitc 6Lrinons exudate \\ore noted on the po~terior pharyngl•nl wull. ( ul- turrs :fro111 t h e~e on Loelllcr's blood scrum gaYc a pmv :!l'owt h of diphtheria bacilli. Th<> prcaclmission history of the case record-: a small pres•:urc ~ore from a tight shoe, nbout seven dnys ngo, which spreaJ n~ry rapidly. a-, a lnrge bleb and was op"necl three da.ys before a. This ''as treated with sterile dressings, but resultC'Cl in a large h1l· perficinl slough. increase in size of the ulcer, and marked inflam- matory ext nsion into the surrounding tissue. The p:1tient t!ave no hb•tory of ~pecial throat, symptoms. The huskiness of the rnic·e hnd been present two clays Lefore admission. The clinical history was negative. The temperature was about 99° and the pulse 80 to 90 for a few clnys. The nlc'r was treated first with a dressing moistened with cliphtherin. antitoxin ancl !l.000 710 LECOXTE--OALCULUS BEMOVED FROM COMMON DUCT. Yo!, XU units of diphtherin antitoxin were injected intramuscularly. Be f scrum dressings were applied daily thereafter. The surroundi: inflammation subsided rapidly and healthy granulation tissue fiUe~ the floor of the ulcer. Twenty-one days after admission the ulce had reduced in size from 12 ems. by 7 ems. to 8 ems. by 5 crU: Throat cultures were positiYe for diphtheria bacilli nine days after admission and ulcer cultures positiYe only two days. The literature records many instances of cutaneous infection with the diphtheria bacillus, which, however, are rure when the ~reat number of cases of diphtheria are considered. These are chiefly cases of extension from the oral mucosa to the face, to the surface of wouncls, or to the female genitals. Authentic cases of cutane u diphthel'ia without evidence of clinical diphtheria are very rnrc. It is ncccs..<;ary to pron~ these cases by guinea-pig inoculation of cul- tnn~s of the organism to tlemonstrnte its Yirulcncc and iclcntitv 11 a trne di pht hcritt bacillus. ' · The present case is int rpreted as a probable prima1·~· pharyngeal infection with the diphtheria bacillus, with mild symptou1s: nnd the tram;mission oi this to the skin abrasion on the foot, resulting fa cxtensiYe alJsce~:; :mu ulcer. There was undoubLelllY a sccondnn streptococcus infection of the ulcerated surface, ca;1sing in large pnrt the '"ide surrounding erysipelatous in!lamrnation. 'l'lH' cl!R"!-1 slmilur 10 the present rei10rted cnst', with abscess, r,nngreuous ul cerntiou, nml ::;m'l'un1Hllug eryslpelatous iuflum11111tlo11, nre not numerou<;. W11- lilllns (.Jour. :\led. Hes., 1002, viii, 83) and Ahcl (Chit. f. Bukt., 18!).t, n~ 45G), Isolated vin1lcnt diphtheria bacilli from n lesion on n finger of a patlei:t wltb clinit'nl clit)lltherta. 'l'otld (The Lancet, London, 1808, l, 458) briefly records the finding of tliphtheria bacilli in two pustulC'S or the foot, compll eating cases of diphtheria. Ueelis (Brit. l\Iecl. Jour., I, 5:30) cllscovm·ccl ,-lru- lenr t1l111llht!ria b.1cllll In two cnscs of ulceration of Ula foot. thought to ~ 1luc to chllblnlns. Ll'llr~· (C\Iell. Snrg. Rep., Boston Cl1~· Hosp., l8DG, 129) found a pure cultun' of Yirulent diphtheria hacllll In nn nbsccRs which de- Y<.>loped about a lmlr follicle two dayi; after nn 1111to11sr on 11 case of dlphtl1crla. The ah:-;n'i<;; rr·mnlnc=. An- tetior wnll o:f stomach nenr "pylorus also nclherrnt in mas-,. \Vhile ~eparating t hcce adhrsions the gall bladder "as torn from anterior nhd 11in11l wnll. It was large, thick-walled, nncl fillecl wit11 currant- jell~ clot without visible bile. The head of the p:mcrcns wa:::. hared from the common duct. together "it h sc\"eral smaller stones. The am pull:~ of Yater wa:::. fr('e from stones. The hepatic duct. although greatly dilatl'd, .cC'mctl cmilty. After emptying the gall bladder and common duct of "lob. a thick. altered11re in chancroidal case,,;. ha:-: usutllly r<>s11Hed i11 g1•11• ernlizecl infection of the line of incision with sp reatlh1~ ulet'rntion and prolonged ronvalc•st•c1ice, and oftrn with urnrk<>d Hltimatt' de- formity of the> penis. In llw less Yirulent cases of penik ch:rncroirl,.. wit ht ut l'Olllpl ica t ions, local treatmE>nt Hhoulcl be• adhered to since in tlw ... c mild t'n•c-: th<' op<'mtion of <'ircnmC'ision n ·i!lwr ha:-; •11...: tl1e •'tll'c nor contribute!; to the patieuf~ ~afpty or l'Olllf'nrt. Jn the\ int- lent etbC::l with serpip;eno11:-; fornh of 11lcPmtion. t•ftt•n c·ornpl:c·de,t .,,. mm·kl'll etlcma of the prepncc and phimoc;i~ •. "t• han• lately -ubstf tnted rrimnry eircnm<+.,ion fo!' thE' u:-;11nJ pr< Ct"l1tn• of clor ·1} or lateral :-plits. 'Ve ban: fo1mcl that prinmry l'irtunwi:--inn 1·a11 ~ performPX()('C'lntion of primary union of tlw wound in prac·tically all in..;tant·<':-- l•XC<'pt wlwre the line of i1wisioa nctu:dly tr:t\l':·:-:1•:- thl• 1d1"!':tk1l arpn,,_ E\l•n in this latter group there is ·1 11rnrk"cl 1·pd11dion in the c·o11- Yah••cenr<' time over the old metl1ods of trentment if the tl'rhnique clei:criu<'s of tlu• penis by injections of rorni1w solution C: pt>r ernt) .. \ 1·irc11ln1· vent :futur<> conb mi nn ti on the denuded :n·Pa i ... !nt- siclc of the ulcerated area except in caBCs where the coronal sulcus i;; inrnh·ed in the destrnctiYc process. The same technique is followed in tho latter gr011p 0£ cas<>s with the addition 0£ thorough cnutcriza- tin1 of thE' remaining areas 0£ ulceration. r Persistence of the thyroglossal duct. 7l:l-1 J>o.4. PARISH-PERSISTENCE OF THE THYROOLOSSAL DUCT. 713 Besults.-We hnve followed this technique since January 1, 1918, in 28 cases. O.f these, 24 (86 per cent) healed primarily; delayed primary healing occu1Ted in 3 cases (10 per cent), while complete !•reaking down of the wound occurred in only 1 case (less than 4 per cent). PERSISTENCE OP THE THYROGLOSSAL DUCT. By B. D. PAit!SII, Lieutenant, 1>1. C., United Stutes Nnvy. Congenital cervical fistulre require radical treatment when they !!ive rise to much inflammation or to cystic tumors or for cosmetic ;,ffect. Cervical fistulre may be lateral or median; when lateral they qre known us branchial fistulro due to failure of closure of one of the branchial clefts; when median the fistula is the result of the non- ' obliteration of the thyroglossal duct. Congenital fistulre do not always cause symptoms ancl may not lie discovered until adult life or until some distention and irritation bv mucuous-hyaline or muco-purulent discharge has called attention t~ them. The term "duct" is rather misleading as the thyroglossal dnct has no such function, being merely the unobliterntecl canal · lined with npithelium through which the thyroid sinks from ihe base of the tongue to its final resting place in embryo. From the dissections of Moragni, and later Minot, it appears that the thyroid sinks from its original position on the dor::;um of the tongue, normally obliterating its tract. In some mammals, "\Voelfler, .Memon and Van Demmclen found that the thyroid sometimes snnk nc: low as the arch of the aorta, but never below the top of the sternum. Unoblilcmted portions of the descending canal with tt lining of epithelium form congenital thyroglossal tract~. This congenital malformation is better upprccintccl if the manner of arly <'mbryonic lifo: the gland consists of three parts, two of which arc ~it­ uatt'd }att>ralJy and deriYCcl from endodermic linings ( f the fourth 'isccral furrows on <'ach side, while the third one, which forms the central portion of the gland1 is an outgrowth from lhe ycntral wall of the phnrynx, about the position of the second visceral arch. which out- growth. known as the thyroglossal duct, or canal of His. grows down- ward through the hyoid bone and joins the Intern! portions. Xor- mnlly this outgrowth of glandular tissue should lose its connection with the pharynx, and the connecting band become obliterated by the eighth week of fetal life, its origin being representecl in the normal individual by the fornmen caecum at the lmsr of the tonguP. 70008- 18- 10 714 PARISII-PERRJSTENCE OP THF. TlIYROOLOSSAL DUCT. Yol. :\II If glandular ti!isne persi~s.in tl~e whole or any portion of the U1tct course: we ha>e in the rcmammg tissue a nucleus for the development of a pathological condition which may assume one of scvernl fornb Thc.c;e forms are solid tumors of thyroid tissue at the base of th; tongue (1), cysts or solid tumors of thyroid tissue in tlw hyoi1l bonl'. or betWC'C'n it and the tongue (2), or below the. hyoitl bone, between it nncl the tb~Toicl gland. ~ometinws the whole duct persif-t..; as n canal lined with <:'pithelinm, although it is said usna ll ~, to b\• inter. rnpted at the th yro-hyoie plates were taken by P·assecl Assistant Sm~edy. one with a st-gmentetl opnqur pl'Obe in- set·ll•tl. and one after injection with Li:-muth pa'111rn11, A nwrl1•11n ~1edi c ine, June, 190 1. Persistence of the thyroglossal duct. 714.-1 DEVER-RUPruRE OF POPL.ITEAL ANEURYSM. 715 J1JPTURE OF :POPLI1'EAL ANEUllYSH FOLLOWING TRE ADKINISTRATIOl'l OF SALVARSAN. 81 F. J . Osna, Lieutenant, M. C., and ~· S. Bou:s, Lieutenant, :\f. C., C:nlted .'tate..i ~ary. The following case is reportell in order to illnstrntc the harmful n':-nlt that may follow the administration of the arsphenamins in ... rphili:- of the cnrdio-vasculur system. · H. JI. A .. firl'mnn second class. 47 years old, wns utlmitled to the rnill•d States ~aval Hospital, League Island, Pit .. Non~mher ~o. Ifll'i. Ile complainl'd of n small mass of four \\CCk!S' duration in till' ri!!ht popliteal space, causing li.l tle discomfort aside from oc- t•:i•iorml aching following unusual exertion. From the time it was first noticed it. did not increase in size to any appreciable. extent. The patient believed the mass resulted from riding a sli('e uar. He has be<·n a fireman for four months, prior to which time lw was a. bookkeeper. While a fireman he almost constantly rode the !Slice b:ir. The patient states he had a chancre 2:5 years ago. Ile wns nntll'l· 1re:itment for same for two and a half years, receiving mercury an1l iCldi. YPssl'ls hnrtlenecl. The area of cnrntuation of the aortic scconcl :-ound and no uudil It> nH1rm11r:;. Lungs were negatin>. Liver an was 14.l inches nnd of the right lmee 15i inche,,. There wa~ no difference in the surface temperature of the two legs. Blood examination reYcnled -t:+ 1'Tnsscrmann and normal coagula- tion tirnt>. Systolic blood pressure was 140 mm., and diastolic ;} mm. Urine was negative. The patient wns confined to bed. 'fen grains of potnssium iodide were administered t. i. d. and mercnrial treatment by inunction was ~·h-en in the usual manner C'ontinnom; digital prec;sure was ex- 716 DEVER~RUPTUBE OF POPLITEAL ANEURYSM. erted over the right femoral nrtery for 48 hours, at the encl of which time the pulsation over the aneurysm was distinctly less Yiolent, al. though the size remained unchanged. Ten days after ndmission o.4 gm. salvarsan in 100 cc. solution was given intravenously. The drug was properly dissolved and neutralized and the solution was free from sediment. Following the injection the systolic blood pres. sure was 5 mm. higher and the diastolic blood pressure 5 mm. lower than immediately before. There was no constitutional reaction fol. lowing the administration of the drug. Within 48 hours after the injection, the patient co mph' necl of seYcre pain over the aneurysm which became so intense at the C'lld of !)6 hours that morphine was required. The mass was observed to be distinctly larger, pntcl icnlly filling the popliteal space. Dnrin" the next 10 days the mas!': became progressively larger and 111or~ painful and extended about 4 inches down the calf of tho le:?". The eJge was not clearly defined. The circumference of the right knee at this time "as 17t inches and the left knee Ht inches. Becau.;e of the rapid extension of the mass and the great increase of pain with total disability, the leg was amputated at the junction of the upper and middle thirds of the thigh. This was followed by an un<'wntfnl con>alescence. Dissection of the leg following amputation revealed a rupturl'cl saccular aneurysm of the poplileal artery occupying the entire pop- liteal space. The skin over the aneurysm showed conaidernble JH ·. sure atrophy and discoloration. The wall of the aneurysm "·as YC'r~ thin, softened and inflamed and had ruptured lhrongh its lo" er aspect. As a result, the onUine of the aneurysm merged incl<.'finitely with an extravasntion of blood into the subcutaneous tissue cxtentlin!! about 4 inches clown the 1cg. The aneurysm itself contn ined a "Oft 1oose clot. In our opinion. the rupture of the aneury!'m may be nttrilmted di- rectly to the action of the sah·arsan on the wall of the sac:. Sub · qnent to the injection of snlrnrsan in a case of tertiary s~·philis pre- senting large, inclol('nt incrustecl ulcers, there resulted act in~ jn. flammation and softening of the ulcers. Their edges bel'ame markedly swollen ancl they were surrounded with a distinct nn•a of redness. It is very probable that the same sequence of eYents took place in the affected tissue of the aneurysmal sac, sufficient softenin~ occurring to cause the rupture. It was most unlikely that the rnp· turo was due to the flnicl injected, as the solution was injected slowly a.ncl caused a rise of bnt 5 mm. in blood pressure. Furthermore, the rupture did not occur until at least 48 hours after the injection. In view of tho results obtufoed in this case, it is important to t'm· phasize the danger of the administration of lhe arsphcnnmins in syphilis of the cardio-vnscular system. Mm. ~ co ~ I I I Hg. ~ co ~ ~ 130 I I I - ..... ..... 120 110 100 - / .,,,,, -. 90 ,.....,.. " 80 70 60 50 BLOOD PRE55URE CHART fig. c ~ ~ ~ ~ ~ ~ dJ - I I I I I I I 0 ~ I"') co I') LI) -D co I I I I I I I ..... - C\l .... ~ ~ ~ "" -~ I \ / "v \ !'\.. - / r----./" 'w""' ~ c:o cO ~ - - I I I I g - N C1) I I I I ~ ~ '4: cases of diseases, there was ~nl~· one case of pericnrditis. In the same report we find 4,0!)2 CllSCS of acute follicufor tonsillitis. 81 of chronic tonsillitis, :HV of b,rpertrophiecl tonsils, 212 of ucnll' rheumatism, and I~ of subncnte rhcunrntic fever. 0:-let fonnd U p~r cent of his cases of acute rheu- matic fornr to he rcmplicnted with pericarditis. The rarity of pericarclit is in the X a ,.y is striking, when we con- ~idcr the large nnmhcr of cnscs of tonsillitis and rhcumati m. "·c do not yet fully realize the rnlne of the :X-rnys in helpin!! ll" IO follow the progress of diseased conditions. "\Ve are too prone to b~ content with a single rndiogrnphic examination. A s •rie~ of X·r:ty pictures would often giye us \cry Yaluable information. ""hat would we think of the clinician who would lay nside his stetho~cope after his fast examination of n henrt or lung c:1se? Let us use the .X. .rays more often to stud~· the pro~·c-.s of our ctl:-;t•s . ..... G. ,\., age 31, was admitted to the hospital on January 1, ~ · : '-. complaining oi painful joint!'. Past history is irrelevant ex- cept that in February nnd August, 1917, he had Yery miltl atlacks of tonsillitis, without any complications. Pre-.ent illness (.latcs back to six 11111ococcic lobnr pr ·umonia, which affected the left lower loLe and terminated by cri~is on the seHuth day. Durin!! the pneumonia the jointc; were normal. A week after recowring from hhi puht?onary complication the patient began to complnin of a feelini;r of fullness under the upper part of his sternum. A pl •uro- pericnrclinl rnurmnr was then beard m left mammary space, just nt. the edge of the heart. Ten clays later the tempcratme ro"e to 100 F. 'Cnsc report frnrn tbe tinlted Stn1cs Naval IJospitnl, cn~aroln. Fin. 718 PERRE~PERICABDJAL EFFUSION. Physical examination now revealed a bulging of prectirdium. '!'ht" apex beat could neither be seen nor felt. There was dullness 011 both sides of the sternum in first and second intercostal spares, nii increase of C'~lrcliac dullness to the left. and a well-marked ohtu~ cardio-hepatic angle>. (Rotch's sign.) The heart sounds coul still invisibfo and can not hr felt. The cardiac dullness is approi1chi11!! normal. The patient was surYcyed out of the service because it was not deemed likely that his heart could stand th:i arduous work of a ~en· faring life. If he can secure employment in civil life which will not demand too much muscular exertion, his prospects of gcU in;.: along seem fairly good. It is well lo recall the old paradox: "Prr sons rarely die of the disease with which they suffer." Table of heart measurements from skiagraphs showing transverse diameters of heflrl. !jig. 8 First intercostal space ....................................... . Second inlercostal space .......................... . .......... . Third intercostal space ........................ . .......... . . . Fourth rib .............. .. . ..................... . . .. ....... . Fi£th intercostal space ...................................... . I Ja: 28, ':Feb. IR, I "pr.6, 1918. 191fi. 1·•1'. - ---- cm. 10.6 15 18 18.7 17.6 cm. 8.7 11.8 16.2 16.8 15 cm. 7.6 10.6 15 15 15 Symmetrical enlargement of salivary glands. 718-1 Symmetrical enlargement of salivary glands. 718- 2 ~o. 4. BOLES-ENLARGEMENT OF SALIVARY GLANDS. 719 J:&PO:R.T OF A CASE OF SYMMETRICAL ENLARGEMENT OF THE SALI- VARY GLANDS. Hy H. :::. llm.i;s, Lli·ull•nant, .\I. C., Lnltecl St11t1'< :\11vy. ~y111mctrical enlargement of the saliYary and lacrimal glands ''as !ir,,L clcscribc>d by Yon l\likulicz in 1888.1 Since that time the l'ondi- uon has been lmown as .Mikulicz's cliseaRe. .\.ccorcling to H.il'-.111an.~ it is n ''chronic inflammation affecting tlw lacrimnl and saliqH·y !!lands, but there• are casl'S, eYidcntly of thl' same nn.turc. in which the ~.diu1ry glands alone n.re affected.'' Some authoritit>s lwfa•n' the cnlnrgcment of the salirnry glands is due chiefly to a diffuse lym- phoid hyperplasia and not to the hypertrophy of the parcnchyma proper. The etiology of the disea~e is unkno'\\ n. Hiesman l'iassifics the cases into two main groups, namely, tho:-(' with and those without blood changes. Among those without blood changl'"· there is a group prescn tin~ symmetrical cnla1·gement of the :-,a]irnry !!lands alone. Filipino, age 27 years. wardroom :itcward, admit led to the United States Xa ml Hospital: League Island, Pu .. with chief com- plaint !hat for thn•e and a half years he had been troublell with a swelling below i\nd in front of either ear. Ifo states that the s"·ell- ings fir:=:.t nppcarccl in ~oYember. 19H. without any apparent cause. They quickly became the size of a lemon and ha Ye so n•mn inNl. They occa;.ioned no pain or discomfort. The~· appea1·erl i-imnlt.111rously aml enlarged symmetrically and synchronously. His general health hns been unimpaired. Ile believes that he hnd mumps n1 7 years of age, but no swelling was ever observed after this. Ile has ncYcr !:>Ufferetl from any distnrbnnee of the saliYiu·y en· lucrinml secretions. The family history is negatiYe a!> regn.rch; tu- L<'rculosis nnd syphilis and no other member of tlw family has e'er bren known to suffer from a condition similar to Ins. The patient has been in the Navy three years and eleven months and taught ~chool in the Philippine Islands prior to this. He doc::> not recollect ernr having had any parasitic infection or tropical disease nnd is not nddicted to alcohol or tobacco. The physical examination is as follows: The patient apparently enjoys good health. His station and gait are normal. The pupils rPact to ljght and accommodation. There is no enlargement of the Iacrimal glands. The salivary and lacrimal secretions are normal. The pulse is regular and of normal tension. The epitrochlear and nxillary glands are normal. The teeth are in good condition. The tonsils arc not diseased. Both parotid glands arc soft. of the same consistency and swollen symmetrically to the size of a lemon. They lll'Cl not '-ender, not adherent to the skin and nonfluctuating. They do not interfere with the movements of the jaw. The lnngs arc nor- mal on physical examination and this is confirmed 1.:,y :X-rny exami- 720 ROS&-DENTRITIO CALCULI IN THE DODY. Vol Xll. nation. Cardiac examination reveals a faint systolic murmur at the apex, following exercise. The lmee jerks are 11. trifle exaggerated. The liver and spleen ure not enlarged. The systolic blood pressure is 144mm. and diastolic 72 mm. The urine is negative. \Vasscrma 1,11 tl'st negative. Hookworm ova were discoYered in feces. W.th appropriate treatment subsequent examinations were negative. The blood count was as follows : Hemo;:rlohln ----- ---------------------------Per cent {Suh II)__ l)Q Heel l.Jloo, aclmittccl February 10. HHS, from U. S. S. ill onar;lwn. Upon cxamina.tion, he complainecl of pain in npper right abdomen and right loin ancl of what he termed "stomach trouble." Ile had never been sick in bed in his life, but for the preceding five or six years had experienced at intervals a Dendrltic calculi of rl11ht kidney. 720-1 Early picture of foreign body In bronchus. 720-2 GOULD--FOREION BODY IN BRONCHUS • 721 • ('li.sation of fullness and heaviness in the epigastric region. There ~:is tlistinct tenderness in the right bypochond1·ium, not only over nnll blatlterile. On llfarch 2 patient '"as transferrecl tv surgical sen ice. ()11 March 6 the patient wm; operated upon. An Israel incision ,rn::; ma.de in the righL lumbar region. As the kidney was adllCrent Loth at upper pole and posteriorly, it wa::; dclivcrctl with some dif- ficulty. 'l hrough kidney cortex. se>eral large calculi could be pal- pated. .\. small incision was made into the conYcx surface of the kid1wy lo cnaule the operator to Yerify the presence of the stones ancl 10 en:1ble hi111 to decicle whether or not rcmo,al of the :.e,·eral calculi co•tkl be accomplished without complete destruction of the kidney ~ubstancc; or whether or not nephrectomy wou lcl be the logical surgi- cnl procedure to be followed. As the calculi were \'cry large and ir- regular in outline, filling up all the calices, they could be remo\'ed neither via pelvis nor via cortex without complete dt·struction of kid- ney substance and dangerous hemorrhage. Nephrcctomy therefore ~as pcrformccl. There was no pus. Muscles sutmecl in series with catgut. Hubbcr tube drainage. Dichlorami.·1-T was nsed to control n•t infection at lower angle of wound. Otherwise there was un- complicntcd recovery. The removed kidney, when sectioned, showed brgc C'Ome emhedclccl in tlw 11111c·ous mc•111hruiu~ She was then taken to Philaclclphia, Pa .. wh(>re X-rny exami11atio~ showecl the pin to he in one of the small bronchi in th<' lmwr ri~ht lobe not far from its present position. During the succPeding years there haw been very few syn1pt1. 111, She has had occasional slight cough with mueous expectoration an i occasional attacks o[ slight pain in Lhe right anterior chrst ca"\~ more frequently by J if! i ng: or vigorous elm ngP of position than by deep inspiration. Sht' nen~r spat up bloocl 1111til l'nrly in ~ltn, 1918, when she had an hem.optysis of abo11t 1 01mc<' of fre~h blood, which was not preceded by severe cough. She has had a , e11 !>light cough since that time. bnt no blood has bern seen in the smnii amount of expectoral ion. The general health i" ,·pry good ancl th. !'I ight pains which she sometimes experiences in her right ant<'rior chest do not in any "ay interfere with her duties. No signs of th~ pr<'sence of this pin can be made out by physical examination. 'fhe accompanying X-ray picture would seem to indicate that there had hecn >cry little irritation of the lungs surrounding the pin. Com- parison with the X-ray picture taken 11 years ago shows that the pin is in practically the same position but that it has rotated on its long axis about 90°. A CASE OF MULTIPLE SEBACEOUS CYSTS. Oy 0. A. GllAY, Lieutenant, M. C., United States Navy. The .following condition was noticed on a recruit reporting for draft, and Wl).S thought to be of sufficient interest on account of it~ rarity to be photographed and reported for record. PrivatP II. G. M., United States ~farine Corps, agt• 2.'i }'Pars. first noticC'd the nppearnnce of a t·~·st on hi~ srrotum nhonl 10 y<'a1·s ago. The lC'sion started as a small yellowish-reel ~welling near tlrn top oJ his serotum and increased slowly in ~iir.e. Before the fi~ c.\·st had bet'ome Yery large others dc,·eloped, and at the end of the fir:::.t year of the condition there were sev<'n tumors on the right ~ide of his scrotmn and eight on the left. Since that time other growths have mncle their appearance in no definite sequence, until at the pre~· ent writing 114 cysts are noted, varying in size fron1 that of s marble to thnt of a small bird shot. The lesions arc usually symp- tomh•ss but at times one or more break down with a typical cli-- churge. Eighteen years ago he had a small cyst the size of a pea oYer the k•ft malnr region; 10 yenrs ago one the size of n hazel nnt on hi• Later picture of rorelitn body 1n bronchus. SetJaceous cysts of scrotum. PARUAM-CASE OF UNDULANT FEVER. 723 Jdt elbow; eight years ago a slightly smaller one in the right. maiHlib- u::u· region. These were removed as they occurred . . \. t tlu> XaYal Hospital. l\Iarine Barracks, Paris Isl:lntl. S. C .• one nf thl' crotal tumors was 1·emovecl and 1lingnoH•d as being a selm- 1-eims c)·::'l. This diagnosis was con.firmed after 1·emoY ing four of the nmiors. The H<'Companying pictures pre"ent the subject graphically. A CASE OF UNDULANT FEVER. i:y .I. l' l'.\tlft.\ 'I. Li<'Ut!'nitnt ('ommnnd1·1-. .\I. C .• Unlll'd S"tul1·s Nu,·~-. (Tnclulant fever is almost a total -;trangt'r to the Na, . .\ rrturi1:-. of "irk lmt upon learning that the destination of 111)' ship would be in 11 ione where it is endemi<' I rc,·iewt•° F. There was no family history of llote or personal history that pointed to tubercu- lo,,is. There were no night sweats or coughs und hrnce no sputum. Ile• eomplained of constipation of receni origin. SC'Yera1 days later 1;ppornnity for consultation presented itself and another medical ofli«cr c>xaminC'd him. He was told the history of the case but was not informed as to my physical findinp:s. Ile reporlemperntnrC' by this time wa~ be:,rinning to show a typical 1ypl10icl ascent and a Wiclal showe(] ngglutinntion in 1- 12;), T he meclic:al officer in charge of the case did not confirm the chest findings nnd indinet.1 to a diagnosis of typhoid or para.typhoicl. Patient ha,d l11Hl typhoid prophylactic in Jun<', 1917. The "\Tidal reaction was 724 PABHAM--CASE OF UNDULANT FEVEB. Vol. XIJ, negati>e for paratyphoid, ~\. and B. Cultures of blood, feces, and urine were negati,·e for B. typhosus and paratyphoid, A and B. Diagnostic tuberculin could not be gi>en on account of bis tem. perature and by an unfortunate coincidence an X-ray of the lun~ was impossible at the time. · Close questioning by the medical officer in charge, who had seen service in the Mediterranean. deYeloped the fact that while a~hore on patrol duty in Gibraltar some weeks previously, this officer hnd had tea diluted with goat's milk. An agglutination test was posifrre in 1-400 dilution for M. melitensis. In this case the fintli ngs in the lungs which were corroborated hy an. other metlicul officer; the foct that the pa.tient had had typhoid fever in 191.:> nnd the prophylactic less than '1 year previously; tlrn foct that no milk is allowed on board when in Gibraltar and that all milk imported from Spain is required to be sterilized before being offered for sale, all served to lead to the conclusion that the case wns one of incipient tuberculosis instead of Malta fever. The latest :.wnilablo Annual Sanitary Report for Gibraltar, lOlG, shows that during this year six cases were reported, the year pretl. ous two cases, and during 1914: three cases occurred. Investigation showed that five of the cnses reported in 1916 originated in milk import\!d frum Spain nnd that there was reason to believe that the milk hacl hc>en sold by the oral administration of quinine sul- phate in simpl<> t<>rtian malaria ancl their conclusion should be of grl'at interest. In the ob~er' ations recorded all the cases were a.'lched grains 45 it was found that only seHn out of nineteen cases 7!!5 726 GE~LR.\L MEDICINE. wer(' able to complete the full eight weeks' treatment. Iu the •e- maining twl'h'e the treatment. had to be stopped pn'mnt111·<.>Jy owj 11,. to tremors and vomiting. ~ The author:; conclude that the superiority of thl' grains 4;-, treat- ment is clenr. as the maximum percentage of relapses possible iu nn 01.t~errn.tion pHiod of 60 clays is less than the obS<:'r\'e .. treatment on one or more chtys at in. lernils, inst<'aS' llnd a 45-grain series, and the results obtained wert> considered from l1. palliative point of view and a curntive point of view the same as in the series of cases in which quinine was give.11 continuously. In comparing tho results of the various forms of prolonged inter- rupted treatment the authors found it necessary to give two l'el;; o:f figures as some of the cases could not be observed for the full period of 60 days after treatment; (1) minimum figure, i. c., the>. pcrcenta!!e nctnnlly obsened to have relapsed: (2) maximum figure. i. e .. one based on the assumption that ull cac:es not obsl'ned for a p<'ri• 1 of 60 nt:1ge of relap:-<'s possibll' in an olist'I \:1tic>11 period of GO clays is Jes-; than the ob';l'l'\'Pd rni11i11111111 \11)11<·~ 111 tlw grains 10 series. The curative value of grains 45 on (,wo consecutive days weekly for a period of 8 weeks-no relapse in an obsern1tion period of 60 days being the criterion of cure-lies be>tw<'cn 71 4 and 61.9 pe.r cent. .\11 the patients were able to take without di1ficully the Iare:est dose of quinine employed, namely, grain" 4:) (tlll'<.'l' do.:<':-; of J.i /.?;rain::) on two consecutive days weekly. Comparing the results of the interrupted and continuous treut ment tho authors conclude that interrupted treatment with quinir.e grains 30 or 41> twice weekly is preferable to continuouc; trl'ntmcnt with quinine grains 30 or 4.3 seven times weekly. Grains 4.i twice weekly is better than grains 80 t~ice weekl.\ ot· thnn grnins :rn tlail.L both as a palliative und as a curative treatment. The interrupted treatment requires over any gi rpn period only two-sevenths o.f the quantity of quinine required for tho correspond- ing continuous treatment. I w. \. n.] . ~ lil-:XERAL MEDICINE . 727 tiot:T"Cll. E. Newer methods in the diagnosis of thyroid disorders: pathologi- cal alld clinical. ~1·w York l'tatl• .Junr. ~lt-.1. .. July. 1~11 . The author from thC' study of nlllllt'l'Oll' cases of thyroicl tlis- 11Jer.- has clr.Yi"lNl n<'W<'l' rn<>tho cellular content of mitochondria. (B) .Adr<'nalin hyperBCnsitin'n<"•s in elinfra) •1.itt'" of hypcrthyroitlis111. l'nder th<' fil'st hcacling the author outlines the diffie11lties whid1 1.:xh .. t at present in <.'stablishing Hn associatio11 bC'tW<'l.'11 tlini1·al symp- 10111;; nnJi ~11·11rt111·e~ which are clo::-ely a;.soeint<•tl with its functional ac- 1hi1~-. This is not a cliflicult matter to rct'ogni:w in glandul:u· organ;; ~ucl1 as the p:uwrras. whosp H'Cretory actiYity is <.'Yiclenres of tl1l' lifl' of the c·Plls and climini!-'h prog1·e~sivPly i11 nmulwr 11:- tlw rcll:- l ·<'OlllC senile. Tl11 01wnniw material of about :200 ca::;es of th~ J"Oitl di;.ea .... e W:l" x•u11i1 cd Iot· tlw occn1Tencp of mitochondria in thC' gl:ua!-. :rn1l l'm11t• interc-.ting and Ycry constant results were obtained. Thuti in the \\ell-r1'l'ognizNl 1·11:-;es of colloid goiter unas.~or.iatrcl with ... ymptom::; of h~-p· 1 ,hyroicli::;m very few or practically none of tht•~l' :-;tl'llcture~ \1e1-e found in the thyroid cells. In <'very cnst• of l'Xophthulmic goitl'r examined !he mitochondria were found to he prl':::ent in enor- nu111s 1111111bers. Thus tlwir occurrence in '-'lllall or lnrge numut'rs, lls an in.-;pontl~ 1c1·~ rlo::.ely to our conception of ftmctional Ltrtivity of eolloid and exophthalmic goiter. 728 OE?-."ERAL MEDICINE. As further C\'idence of iucrea!;ed secretory acfo·ity of thn .d ndenomata the author describes the <:'hypersensitiYeness to adren~J:., test. which is carried out as follows: The patient having been in bed thoroughly at r<>sl n day or more previou::.ly and having become acquainted with the attenclin!! physi. cinn who is to do the test, is assured that the examination i~ it; no way painful and is in no way associated with any danger. Two readings are taken, at 5-minute intervals, of the blOOd pressure systolic and diastolic, pulse rate, and respiration. .\ nott is made of the subjective and objective condition of the. putient This includes the state of the subjective nervous manife:::.tations, the throbbing, heat and cold sensations, asthenia, and the objcdi,·e signs such as pallor or flushing of the hands and face, the size of I he pupils, throbbing of the neck vessels and precorclium, tremor. tt•mperature of the hands nnd feet, perspiration, and any other characteristic signs or symptoms. These signs are all noted previous to the injec. tion of the adrenalin so that comparison may be made after the in. jection. A hypodermic syringe armed with n fine needle "'hfrh, when in. serted, causes little discomfort, is then used to inject 0.5 cc. (i.5 minims) of tho commercial 1-1,000 solution of adrenalin chloride into the deltoid r<>gion, subcutaneously. Intramuscular and intravenoru injections were not giYen. Readings are then made eYery ~l minut for 10 minutes, then eYery 5 minutes up to 1 honr, a11d 11 n e\·erv 10 minutes for half an hour longer. At the end of H ho r . som~­ timcs earlier, the reaction has usun.lly entirely pas:;ed otI The re- peated early readings arc made in order not to miss certai1 reactions on the part of the pulse and blood pressure that may com<> on in lt'.~ than 5 minutes after the injection is made. This is partic11l11rly true of cases of aclh e hyperthyroidism. In a so-called positive reaction there is usually an early ri~o in blood pressure and pulse of oYer 10 points at least; there mny be a rise of as much ns 30 points or eYen more. In the course of 30 to 45 minutes there is n moderate fall, then a slight secondary rise, then :1 second fall to the normal in about 1! hours. Along with these one secs an ex:1qgcrntion of the clinical picture of Grnxe's disease or hypcrtbyroidi~m brought out, especially the nervous nmnifrstntions. The particular symptoms of which the patient has complained are usually increased, and in addition there nre brought out m:11 y symp- toms which ha Ye bcon latent. Thus it is not uncommon to hwe extrn systoles bron~ht out, aft~r the injection of the adrenalin. The pa· tient is usnnlly aware of them and mny tell one that she has felt this samo thing a year or two previously, n.t which time the !'.ymptoms of the disease were more active. ,io. t . GE~TERAL MEDICTh"'E. 729 The following mny nll or in part be found: Increased tremor. np- 11rchension. throuuing. nsthenia, and in fact nn increase of nny of the symptoms of which the pntient may ha'"'e complained. Yaso- Jtlotor changes may be present, namely; and early palor of the face, lips. nnd fingers, due to rnsoconstriction, to be followed in 1.3 to 30 Jtlinutcs by rt. stage of vasodilation "ith flushing and sweating. There may be a slight rise of temperature and n slight diuresis. In order to interpret a test ns positirn it is regarded nc: necessary to ham n. majority of these signs and symptoms definitl'ly brou~bt 0ut or increased. A normal perwn shows no signs nnd symptoms, no reaction whnt- C''<'I' on the pnrt of the blood pressure or pulse, when 7 minims or 0.5 cc. of 1-1,000 nclrenalin solution is injected. The test hns been of great rnlue and help in the cliagno~is of that J:trgc group of borderline cnscs resembling in some re~pects true byper1 hyroiclism, but without definite recognizable si::?ns on the part of the patient genemlly or in the findings of the thyroid gland. which may 11ot be palpnbl.v enlarged. In summarizing, then, the following conclusions are drnwn: Thyroid ac.lenomnta nre responsible of themseh·cs for hyperthy- roicli~rn . They are .often multiple and should be rernoYed whcneYer it is possible to make lho cli~gnosis. The '\"'cry common belief nmong mnny physicinns that they nrc innocuous nncl need no surgical treat- meut except "·hen they produce mechanicl\l pressure is incorrect. In n smnll pcrcentnge of cases, 2 per cent in this series, mnli!!nant drgeneralion OC'curred. Symptoms of hyperthyroidism disappear wh"n an aclc.>noma formerly acti vc degenerates, only to Le followed by n Ec .oncl wnYe of hyperthyroidism when a mw health~· nclenoma arises. •lS i!:i !:iO frcqnentl.Y t.hc case. Almost e\'Cry form of c11?~enern­ tion ncognizecl by the pathologist can ocenr in these ndenomntn.. The 1I1yrohl glancl itself a~socinted with an nctiYe nclcnomn presents n simple'colloicl nppeurancc, contains :few or almost no mitochonclria, and is relntively inncth·e. The abundance of mitochondria in the thyroid cell forms a good index for judging of the nctidty of the tissue under consiclerntion, "\Vhether this tissue be from nctin~ colloid goiter. cxophtha lmic goiter, or from an nclenomn; the grentc:r the number of mitochondria. in the thyroid cell the grenter the functional ncth·ity of the latter. In f'tates of hyperthyroidism there is a hypersensith·eness to acl- r:rnalin whether administered hypoclermically or intmdermicnlly, which hypcrsensiti\·encss is proportional in n. remarkable way to tho degree of hypc1·thyroidism present. 'iGOJS-18-- 11 730 GESEBAL MEDICISE. The rcnction to nclrcnnlin should be of considerable Ynlue in tbt din~rnosis of obscure l>ordcrline cnse.s of ncrrnus ery interesting conclusions from , longs ries of exn111inntions of the inorganic composition of the s ra of certain Yertebrntes, the function which the kidney exercises in regulating this inorganic composition and the ancient f:tclor which appears to goyern the concentration of the inorgn.nic Fn lts in the blood plasma. Among all lho organs with their yaried history as to structure ancl function, the kidney function in one particular respect has not changed from the time it first began to evoh·e in the very fn1· past. This function is the regulation of the inorganic composition of the intcrnd medium of the body, known as the blood plasma. The renal orgnn in the embryological history of the nrtcbrnte is ns :mcient us the neural canal nncl appears to unteclatc the clo3Ure of this canal. The salts of tho blood plasma rnngc between O.iS nn,'·eii.el~rate .which must have exbted in thl' early Cambrinn or pre·lnmbna~ times. . . . . '.fhe followmg table shows the strikmg parallel cx1stm~ between the inor!!anic constituents of ocean water ::tnd the inorganic composi- tion of the common jelly fish, Aurelia. fb.vidula: --- ~~~~~~~~~~~~- Occ:m w:i.tcr (Dittmar) ................... . Aurelia ll:i.viar:; lo rnr~· with the concentration of the oce:rn water of their habitat, nncl in brackish water it folls to that o.f the I. ttcr. The re is then a profound cliffcrencc between the Lloo 1 plasmn of >ertcbrntes an:u-...;. The parallelism ulrcatte and (1ucrin for protection against boYine tuberculosis in cattle. Sensitized gonococcus Yaccine hns been extensively cmplo)'('d ns n therapeutic measure with apparently gratifying results. Sensitized streptococcus, stnphylococcus and pneumococcu<: vac- cincs hn,·e beC'n employccl ns well as sensitized tuLerculin with re-· suits which appear to justify further work nlong these lines. llesrccllrn. emplo~·ed sensitized plague and typhoid bacilli in 1002 and fo11nd that the sem;ilizcd hacilli. 'both subcutaneously and in· trapcritoncally, were consiclerably less toxic thn.n tho nonscnsitized bacilli; furthermore, thal injections of sensitized bacilli were fol· lowed by nn almost immediate increase in immunity, in contrnst to the nonsensitizecl bacteria which excited first a so-called "ncgntirc phnsr." The anthor has employed sensitized vaccines of typhoid bacillus, gonococcus, streptococcus and staphylococcus nureus nncl tubercle bacillus. GE~""ERAL ~DICIXE . 733 111c typhoid Yuccine was employeusons for giYing it a trial. "ensitizc>c.~ gonococcus Y:tccine wns employed in lG cnse of gono- coccus infection, chiefly gonorrhoeal Yaginitis uncomplicated and complicated with cnclomctrit.is, salpingitis. nncl arthritic;. 'Jhe inocu- lations were gi ren at inlervn ls of 5 to 10 days, the do nge varying from 100 million to 2 billion. The renctions were u~ually miltl. there Leing u~ually. howeYer, n shnrp local reaction followin~ tho first inoculation. Six of these cases recoYcrcd complctcl~·. und nH bul 2 showed improwment. 'fh<' author employcidence of the disease. While nn increase in reflex irritnbility is not uncommon in a. ,-ariely of in fcctions the incrense is uniform on both sides, while in cerebro- spiunl fever it is unequal. Hendnche of the "pressure" or "bursting., frontnl or Hrtical, 1~~ often occipital, type occurred early in about S3 per cent of the cn~cs. nnd chills were common. Rigid neck, Kernig's sign, and llrutl- zin Id's were nlmo,..t always ab.Qent during this :,tage. The clinicnl su~picion aroused by any combination of two or more of the signs or "ymptoms enumerated demnncl lumbar puncture. During the stage of sepsis the spinal fluid is usually clear. In GO per cent of his cases there was slight increase in press.ure, a normal number of cells, the fluid reduced Fehling's solution and in somo instances showed n trace of globulin. After long centrifuging nn18, 70, G84.) Tho manifold complications of the epidemic constitute a strong armmwnt in :farnr o:f the Yiew that the disease is primnrily a sepsis. The rapidity of invasion of the eye, for instance, points townrd hemu.- togenous infection. Prompt enucleu.tion of the eye n.s n focus is ur!!~d in coses of pnnophthnlmitis. The myocnrdium seems lo suffer little; one case of cnclocarditis, six of dry fibrinous, and two cases of pericarditis with effusion were noted. Otitis media was common but no case required mastoid opera- tion. The accessory sinuses of the nose were frequently fouuery 12 hours until the temperature became normal or until six or eight injections had been given. In severe cases the serum was repeated every 8 hours until the GENERAL MEDICINE. 73~ tre:tt'ed with large amounts of serum intravenously and average or gn:1Uer amounts intrathecally, 16.4 per cent. lfild cases do well under either treatment; it is in the most severe tl'pes that intravenous methods give the most striking results. · Mnj. Herrick clafrns that the value of the treatment is found in the shortened course, diminished number of complications, prompt dis- nppcarance .of meningococci from the spinal fluid, and decreased 111ortn.lity. In cases showing signs of a blocking of the foramina Lieut. Cobb devised a method of starting the flow of spinal fluid. Chloroform is given to relax the neck muscles and the head is manipulated to break up adhesions that tnay be forming about the foramen magnum 11nd fourth vcnticle. Liberal drainage and tho use of this method is advised by Maj. Herrick when drainage is slight and symptoms persist. [n. s o.] UoPPE, H. II. Tbe Medical Treatment of Graves' disease with special refer- ence to the use of corpus luteum extract. Jour. Nerv. and Ment. Dis., April, 1918. The author discusses the origin, structure, and physiology of the corpus luteum. He shows the results of various investigators who conclude that the corpus luteum is epithelial in character and is derived from the epithelial cells of the membrnna grnnulosa of the Graafinn follicles. There are two kinds of specific cells in the corpus luteum, namely, the lilteum cells and the pnraluteum cells. The corpus luteum is therefore regarded as a ductless gland, pouring its secretion directly into the Llood vessels and having a most important function in regu- lating the sexual life of woman. Being one of the ductless glands, the ovnry, perhnps through the corpus luteum, stands in relation to all the other ductless glands nnd is the avenue througµ '\\hich all the other ductless glands in· fluence the function of the female generative organs. Falta divides the ductless glands into two groups, the accelerntory group and lhe retardative group, in so far as they produce nccelera- tory or retarding hormones. These groups through their hormones exort an antagonistic effect on the metabolic process of the body. Thus, the hormone of the thyroid gland is regarded as acceleratory. It quickens metabolism and increases excitability, as is evidenced in Graves' disease, ,,·hereas the absence of this hormone which we see in myxedema, causes an arrest of growth or an inhibition of meta- bolism. Opposed to this action is the group of glands with retarda- tion, nnabolistic, or nssimilutory hormones. The author regards the secretion of the corpus luteum ns having this function. 740 GENER.AL MEDTCIXE. ~\s the result of his clinicnl experi<'nce in the treatment of Graves's disease. he Hl!!!!C'Sts that the internal secretion of the corpus luteurn has an inhibitory effect on tho thyroid :;ecretion~ and that hyperthy. roidism i:- au C..'\:pression of a er of Pfeiffer. Scoplasms are the least common of the enlargements and ns types · arc mentioned lymphaclenoma, lymphosarcoma a~ primary diseases and carcinoma nc; a f'econdnry process. Enl:ugement of the cerYical lymph nodes, other than that clue to infections, is usually nccompanied by signs of disease elsewhere 11 hich serve to estnblish a diagnosis e,·en if the enlnrgements them- .;eb·es can not be diff ercntiated. The glandular swellings accompany- ing the exanthemata arc acute and the symptoms and physical signs of the primary disease are present. Those of scarlet feyer nre typically of the deep ccnical glands, both anterior and posterior, and may progress to intense infiltration and to suppuration. The enlarged lymph nodes of diphtheria are nlso acute and o>er- shadowed by the symptoms of the primary disease so that the diag- nosis is reasonably certain. In measle3 the enlargement is apt to occur days or weeks after the original disease. In mumps the S\\elling of snli\'ary glands may be confused with corresponding gl'Oups of supcrficinl lymph nodes. Particulnrly is there likely to be confusion between submaxillary mumps and en- largement of the submnxillary nodes; the latter are situated above the sn.liYnry gland, often on the horizontal ramus of the mandible. A bilateral swelling in this region senes to establish mumps as the diagnosis. The acute glandular fc,·er of Pfeiffer runs a characteristic conrso of feyer, constitutionnl symptoms, nncl enlargement, usually uilntcral, of the deep cer,·ical lymph nodes. The nodes may become the size of walnuts, but nre discrete, hn1'Cl, Ycry .sensitive, do not suppurate, and subside after a week or two. The enlargement of cervical nodes which occurs in syphilis is part of a general :ulenopathy. The posterior cervical group is likely to be im·oh·ed. The nodes are di"crete, without signs of inflammation, and not adherent to adjacent structures. The ·wassermnnn reaction and the luetin Rkin te:;t will clear up the diagnosis. Hodgkin's disensc shows constant progression of enlnrgamcnt with- out coalescing or suppumtion, the invol\'ement of other groups of nodes, particularly within the thorax and abdomen, the splenic en- largement: n.nd progressive anemia. Lymphosnrcoma ma.} resemble Hodgkin's disease at fir~t hut thcro is a tendency for the capsule of the node to rupture ancl the nodes to become adherent to each other and the surrounding ti ~snes . .A.cut~ lymphntic leukemia presents enlargement or noclcs up to walnut size, discrete nncl with little or no redness or tenclcrncss. Tlrn diagnosis is made by blootl exa.mination. Anemia with 1 to 3 mil- 742 SURGERY. \•01. ~ 11. lion red blood cells, hemoglobin of ~O to 30 per ccnti nnd leucocytc:s of 50.000 to 150.000, of which !JO to !JS per cent nre lymphocytes complete the picture. ' Enlargement of the occipital, ma,,,toid. preauriculnr, nnJ parotid nodes may ha due to n tuberculous infection such ns lnplls but moro probably is due to n pyogenic infection such as results from cczemn pediculosis, furunculosis, fissures, and cracks about tho nostrils 0 ; corners of the mouth. Enlargement of the submental and submaxillary grollps may be due to pyogcnic infection of tho teeth and gums. Differentiation between simple and tuberculous infections mny be very difficult. In pyogenic infection there is likelihoocl of c, idence of inflammation in mouth, throat, or nasopharynx. Usually the swelling is larger, comprises more lymph nodes, has mor\\ pcrinodu- lar swelling, is tender, rcdclenecl, hot, and elastic, all the tissues being bound up in the swelling. Examinntion of tho blood will sh°'v a polynucleosis in pyogcnic and a lymphocstosis in tuberculous enlargements. Tho tu\Jerculin test, the complement fixation test, or the von Pirquet reaction are valuable aids in diagnosis. · In some cases excision of the gland itself may be necessary for n positive diagnosis. [w. A. n.l SURGERY. ALVAREZ, W. U. Is the purgation of patients before operation just !lable1 Sur;;., Gyncc., nml Obst., June, 1018. The :rnthor's Yiews nrc startling and would. perhaps, be, more con- vincing if he '\Yere less rnclicnl, but it is rare for crnsaders to occupy middle ground. There is probably no single detail of surgical pro- cedure upoi1 which there has been such 'rnrldwide agreement ns the rule to erncuate the bowels of n patient about to undergo opcmtion under n general anesthetic. It is no easy matter to renounce tho habits of years, and the more fixed and uniYersal n practice has be- come the more likely it is to outlast its usefulness. W11cn the pro- priety of such a measure is questioned in :i. dispassionate and scien- tific way we should listen to the arguments without prejmlicc. Dr. Alrnrez clnims (1) that the administration of the anesthetic is not rencleretl. more safe or easy or agrecabJe by preliminary purbrn- tion; (2) tlrnt preliminary purgation does not lessen 010 dttnger of autointoxication, gns pains, or peritonitis, but, if anything, ti-nus to induce these conditions through disturbance 0£ the normal mesentcric circulation. ~o. 4. SURGERY. 743 The author states that the 'idea of preparation preliminary to operation is partly ascribable to the patient's desire for some such thin[! and must be a " relic of medical practice 2,000 ancl more years 11go." He connects it with the humoral theory of disease. Experiments on rabbits demonstrated that purgation induced npathy and appearance of sickness. The bowels were found injected, full of gas, sometimes atonic and flabby, often irritable here and there, and inclined to contract down into hard white cords. In many rnLbits the mesenteric vessels nncl intestinal walls were engorged. The author's summary of reasons for avoidinp: pnrgat ives before operations are in part as follows: Pmgatives "bring about patho- logical conditions by interfering with intestinal absorption and upsetting the balance of salts. The body is WC'akened and not strengthened." "There is an increased gro"'Yth of bacteria." "There is a tendency to flatulence and distention." "Purgation makes the bowel react poorly to drugs." "The purge must be responsible for some of the post-operatiYe nausea and vomiting." ''1iile not agreeing with the contention of the author, the reviewer hopes that the article in question will be widely read and believes that it will do good because there is undouLteclly a great deal of thoug-ht- less prescribing and there are not a few in the ranks of our profession who believe thnt if n thing is good the more of it the Letter. 'Ve habitually speak o.f seYerc or mild purgatives and dictionaries classify them as drastic, simple, saline, laxative, etc.; therefore the term "purgation" does not imply the production of excessive al vine dis- charges. To induce violet cntC'ric activity and copious loss of fluid does seem irrational and. of course, in certain cases eYen the mildest purgative will be harmful, as in cases of appendicitis, intussusception, Yolntlus, etc. Aharez says: If n patient's bowels move normally eYery clay and particularly if th£>y move on the momln~ of the 011erutlon. ns they probably will iYid recollection of the increased comfort and well-being that came to the women of the lying-in ward when they were rclieYed of their faecal accumuln- tions. Experienced matrons often begged for the "C. 0. nnd G.'' on the second clny, nnd there were few "·ho did not ndmil n.ftcrwnrds thnt the relief secured amply made up for the horrid tnstc. The third-dny purgnth·e constantly brought down slightly elcn1tcd tC!m. pern.tures or seemed to do so. If not related as en.use and result, still the two c>ents wero constantly related in point of time. The trouble with purgation before operation is that it is part of a routine pl·occdure, uncl routine procedures. though beneficial in 1nn0,. ways, haYe huge disadvantages as well. Had Dr. Alvarez contended that the routine administration of drastic cathartics prior to opern- tion was wrong there would be no disfient. Routine procedures mnke hospitals run smoothly nnd are good. but in the long run that sur- geon will ha>e the most lasting success who. besies, and it has been found n.s ln.te as 38 months after the amputn· tion ir a healed stump. Amputations were rather neglected b--fore the war and in large hospilnls used to be handed o>er by the surgeon to his house officer. Painful ner"es in stumps were not unknown be- fore the war, but painful !"cars and bulbous nerYc endings were un· common. In 1!)13 there were no such cases among 529 applicants for artificial limbs to the Royal Surgical Aid Society. In 1915 1 egnn the work at Roehnmpton House, nnd here, out of the first !)3 r,ase.s sent to be fitted with artificial limbs, 38 were found to be 1111re:uly. However, now, improvement in the technique of amputations is progressive. S'lJRGERY. 745 The encl of n ncne in healing hus to go through three stngcs, which may be brief but can not be obvinted. They are: Fir:::t, the stage of repair inflammation: secondly. the E.tn!!e of compres.<;ion: thirdly nnd finnlly. the stago of regeneration. To reduce the first stage it is necessary to close t!ie end of crery :,tructure left open by the cutting nncl sawing of the amputation. There mu!'t be no infection. so that the "·ouna potential source of trouble-it may encounter un inflammatory notlule_ or b~come compressed. Thus, possibilities of future trouble arc manifold; the early regeneration enables the yonng fibers to become long enough to be strangulated before the scar tis ue hns ceased to contract, nncl the greater number of brunches of new fibers make the occurrence of trouble still more probable. After the wowing fibers of nerve regeneration hn ,.o escn peel from the nene bulb and the zones of certain uncl poc;sible compression I thl'y follow the direction of the scaffolding of connectiYe tissue and make their appearances in strange places, completely foreign to tho course of a ne1Te. For instance, in one example regeneration hnd taken place :from the sciatic nerve and reached the popliteal artery, where pnrt of the ncl rnncing regeneration fibers followed the nrtl'ry through the adductor magnus and appeared on t.he front of the thigh, forming a. tender lump. In other cases the progress of thn regeneration fibers is like the course of a river. nnd where nn ob- struction is met the flow pools up until the obf'trnction is owroome. Thus regeneration neuromatn. are .formed and mark the site ns 11. regcnaration "pool." No less than three neuromnta were present, attached to the long snphenous nerrn in the case of Thomas nnd tho small sciatic nene in the case of .Anstey. So far ns I know at pres· ent these regeneration ncuromata seldom possess foci of in'lnmmn· tion, but they may be somces of pain, not of spontaneous pnin but they ca11se pa.in ''"hen pressed upon. In inilnmmutiou uud compression, two forms of the causation of pain are in evidence. The inflammation does not remain in tho nerve bulb and only extl'ncled peripherally, but it also progresses up the nerve as an ascending nl'uritis. Clinically there may be distingnished at least £he types of pnin in amputation stumps, the first of which is universal and the Inst un· common. Fir~t. Early pain. coming on immediately after the amputnlion, dependent on an enclonenritis set up by the injuries inflicted on thn nerves at that operation. ·when alone present this accession of pain dies nway in a. few days or weeks. Secondly. Compression pain, coming on about two months after the intennl nnd sonietimes steadily increasing. Thirdly. J nfinmmntory pain. The early pain neYcr passes off, or it may become paroxysmn.1 and seYere, or it may even be still moro dearly , for two reasons: First, on the inner sicle of the upp ~r arm there is n hngc lymphatic and blood course, enabling the l <• pi17. Among the few symptoms that may be considered pathognumonic in surgery is rigidity of the abdominal wall. Thi~ symptom or sign should be sought in eYery case of injury to the belly or where chest, loins, or pelvis are iiwoh·ed. The examination is made with tho patient on his back, the head low, the thighs flexed, the knees npart, tl1e mouth open. The patient is told to relax the abdominal musdrs ns much as possible. The hand is placed flat on the belly, slow gradual pressure is made. Gentle, steady pressure may cauc::e pain, Lnt if rigidity is not present the abdominal contents may he com- pressed by this manem·(!r. If rigidity is present the muscles become hard and bonrcllike and ofkr stubborn resistance to pressure. In its most conspicnons form nbdomin:il rigidity is general but there may be loculizecl rigidity only. General rigidity indicates a perforation of the peritoneum, but e due to a perforated gut. Injnries to the kidney may cause localized rigidity which migl1t be a mii::lea18, u5, 47. Wederhake reports on tho surgical uses of human fnt, which he nhrnys obtained from the living hocly, either from the omentum or from li pomata. .Aiter clue prcparu t ion and sterilization it is in n liquid state. Before use it is heated to body temperature. The author employed it with ach·nntnge in the following groups of cases: (1) By way 0£ hypodermic injections to raise depressed and de· tach adherent scars. (2) In connection with suture oi tendons. (3) By injection into the she1tthc; in case of tendovaginitis crcpi· tans. ( 4) By · njcction into lhe sheaths of the flexors in Dupnytrcn·s contraction. The author claims that no other mode of treatment brings about reliable results in so short a time. SURGERY. 755 (5) In traumatic oedema, the moc:t important field for the use of bum:m fat, since here it shows in a preeminent degreo its striking r:ipncity for dissolvinrr scar tissue. (G) In dealing with the after effects 0£ phlegmonous tendovngi- nitis. (7) For patlclin~ the skin over bony prominences. Thus it proved 0seful in a cnsc in which the plantar fat 0£ the he~l hacl completel.v uisappearcd from trophic lesion. (S) For filling vein grafts used for bridging defects in the con- tinuity of n nerve. (D) Ily hypoclermic injection in pruritus ani et vulvro. (10) For detaching nerve adhesions. (11) As a dressing for wounds. I3ut it does not supply an oint- ment base. Its chie£ 'alne, however, lies in the £act that it dissolves cicatricia1 material, chiefly in conection with the sheaths of tenclons. It is superior in this respect to thiosinamin, fibrolysin, nnd cholin; but its effects arc purely local. MARnNI, E. ~Illncllen. l\Icd. Wcbnschr., WlS, G5, 40!, recommends the use of the following epiln.tory powde~ in tho prophy- laxis 0£ typhus; Two parts of strontium sulphate and one part ench of zinc oxide and talc. The powder is made into a paste with water nnd applied to the hniry pnrts of the trunk and limbs; the crust is '."CIDOYcd in about 10 minutes. The patient is then wa~hed nll OYer, nnd the skin, especi1llly of the scrotum u.ncl n.nul region, grensecl with oil or vaseline. The pnstc is not applied to the face or hend, the hair 0£ which is rnrc>fully shnved. The patient's clothes arc in the meamYhilc deloused in another room. This epllntory method is ap- plied to nll typhus pntients, to those suspected to haYc the disease, nnd to those known to hnve been exposed to infection. Durin~ the last 18 months this rout inc has been in •oguc at the "'locl:nYck feyer hospital nncl none of the stnff. the male and £cmafo nurses. or the washerwomen haYe contracted typhus. Trnnsfuslon with the blood obtained from com·nlescent patients lf1 18, points out thnt psoriasis is now Jess severe in type in Germany, owing to the reduc. tion of meat and the increase of milk and Yegetnbles in the genern} diet. Scnbies is a serious scourge among French troops, as under war conditions vexatious complications arc numerous nnd common. These are persistent ulcers, boils, superficial phlebitis. MILIAN, G., In Paris Mc;licale, recommends the use of an insoluble sulphur preparation whereby the treatment is simplified and abbreYiated. The ointment is macle by mixing nscline and lnnoline, 250 grnnrn of cnch, to which is ndcled first n ~olntion of sulphide of potassium in 2.10 grams of water, nucl then oxicle of zinc (5 grnms) in 200 grams of liquicl 'a~· lirn>. ~\.fler a Lt-th or wash with soap and water this ointment is applied all OYer the body. ancl the patient puts on his clolhc..:;: the next cln.y the process is repeated. and on thr followiug e been contracted through the ingestion of polluted rh·cr water by bathers. Trachoma 11ncl ear infections ha.Ye been reported following the use of swimming pcols. Cases of gonol'rhen nncl infections of the Yaginn. by the bacillus procligiosus following use of public baths have been re- ported. The greatest menace to health i~ represented by the B. coli communis and tho B. 1yphosus. · 11! anagement of tlie watrr.-There is no direct relationship be- tween number of weekly fillings and sanitary condition oi the water in a swimming pool. Dilution is expensi>e and efficient. Rcfiltni- tion improves general :tppearance of the water, lowers bncterinl con- tent of swimming-pool 'rater, and reduces cost of maintenance. Chemical disinfection.-Copper sulphate destroys bncteriu and nlgro. From 0.04 parts of copper sulphate per million of water used each dny to 0.5 pnrts per million is reccmmencled. The effects of bluo vitriol taken internally in small doses frequently repented hns not been determined, but in concentrated form it is poisonous, hence tho need of great care in its employment for purposes of disinfection. Cnlcimn hypochlorite is an effectiYe germicide through the liberation of chlorine. Tully recommends 0 .. ) parts hvpochlorilc of calcium (30 p. c. available chlorine) per million. Others believe tlrnl us much as 3 parts per million nre necessary. This subject is still nnd sufficiently to make up tho Joss by splashing~ etc. No definite amount can be stated. This shoulc.l de- pend on the number of bathers. frequency of refilling. etc. .As a rough ·working rule it is suggested that the dilution be suflicient to amount to one filling between re.fillings. Refillings should be determined by the number of bathers. size of pool, nnd bactcrin 1 content, as there is no direct relationship between the number of weekly refillings and the sanitnry condition of water. The general appearnnce of the water counts for nothing. Ohemiral disinfection is impemtive.-Doth calcium hypochlorito and copper sulphule have advantages-the latter probably being tho favorite. Either should be used in strengths increasing from 0.5 parts to the million of water, depending on the Rize of the pooJ, num· ber of lmtherR, lhe hardness of the wat~-. and the bacterrnl rednc- tion obtained. Blt>uch must be tested frequently for nrnilnblo chlorine. It quirkJy di$appears from the pool. Superl'ision of 7Hrthers.- Full shower bath wilh soup should be demanded of nll bathers. To make this possible the shower nppa· ratus mu~t be inspected very frequently. Instruction should be gi,·en bathers in the purpose of the bath. Especial attention should be given the perinea! region. When water strikes n pcl':"on's body the nat urn] tendency is to urinate. This should occur in lhe shower, not in the pool. The floor should be taken care of to prevent trnck· ing the dirt, bacteria, etc., which have been washed off by the ::.bower, onto the deck about the pool. On the pool pltitform inspcc· tion of eYcry entrant should be performed. Dnthers shoulcl ' car no clothes. If this be impracticable the auLhoritics of the pool should furnish lhe snits· one-piece, undyed, scanty-and sec that they nre properl) sterilized nnd dried between usings. PATIIOLOGY A.:\D BACTERIOLOGY. 759 PATHOLOGY, BACTERIOLOGY AND ANDrlAI. PABASITOI.OGY. £I:J:B~OX, F. A b3cteriological r.tudy of the dlphtheroid organisms, with special reference to Hodgkin's disease. .Toni'. Infect. DI-<., Jul.r, 1!:11 . The "-riter h:ls given an excellent historical rCYiew of the diphthc- roicls. He states the difficulties in cln5sification nnd ::,ui?gei:.ts that they be placed in nine groups, under the term '· Corynebncterin.'' He realizes thnt his classification is far from being complete . .Agglutination and complement fixation tests were carried out to determine the idenlity of strains isolated from Ho lgkin's cliscnc:c. Scrn from four patients hnving Hodgkin's disease fa~!cd to cnuso ng_!!lutination of elenm strains of bacteria, eight of which had been bolatcd from glands in cases of Ilo . ..........•......... .. + + ,+I - + .... ' .... ······ - , Asciticf)~d ............... . ~ + + + - ........ · · · · · · . . . . .\ppendix .................. . I+ ............ ····,···· .......... ···························· Ilrolh clear with ~cdiment. Small and dolicato. Dclicnte gro11 th. Small, ovoid. Ilca.vy; glistening growth. Lou~; scanty growth. Ovoid, coccoid. White growth on agar. Do. 1\Iuny club-eh!!pcd fonns. No cloud; Nci.sser'11 brrrumles; fiocculcnt sediment. Abundant 1J11t imperfect ttrannlcs, Sllmon-c·olorcd m scrwn. + 1 • •••• • ••••••••••••• .' A AN ................................ Coccoid; orange J>igmcnt. + + ± ......... ... ' .............. Hodgkin's disease ........... Ovoid and coccoid; col. dry and heaped up. + - ... -i-......................... 1 X11S1! mucus............... L~W~~k 1 :~rs~lar granules; . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - .•... do..................... Polar hodtt'B. - I ,\ I A:-: •••• Ascitic lluicl ••••••.••••••••• , o~ilii~ivo odor; li<1uclies gel- 7 Cl. Typb.Ml'DDthC!matfct •••• + + 1···· ..... ... ... . .... . . .. A'N + 'J'7pbut-..•.... ...... , A&l \1\ \nu\tA .all 11l1•omorphk. 7 1·. Ar11r1. ........ . ... .. ... + + -+ ........ I + ± A AN + Pmtule11 (dt>op) ............ , Acid in inulin. R I <'. P11P11doh1b1•rr11lotris •.• •.. + + ........ .......................... .Anirnnle .....•.....•.•..... ·\ To:i~~(.mlfhlC'Ptl l(0\111•1\ pig· 8 0. Pyogcncs ................ - .... ,. . . . . . . . . . . . . . . . . . . . .\ AN ± ............................ , H<'moglobinophilir. 8 C. Yaccinnc .................................. --1·... . . . . _\ AN .... Vaccine P-ustulcl! in calves .. Yellow pi!!m•·nt 9 ' l'. Lymphopbilus ........... + ... +... .. .. .. . . . .. . . . . . .. .. AN : - llodgkin s discn11e ..... ..... . ~ lrndt>r; plN1rnorphic-. [o. '· o.1 • 762 'MILITARY 1 LEGAL AND INDUSTIUAL. \"01.~,I. Xooucm, II. The spirochetal 1lora ot the normal male genitalia. .Tour. l::i;. per. :\f<>cl .. June I, 1!)18. On account of the reports by Mnrtin, Knnki,·ell ancl Sundell. und by Patterson of the presence of spirochaetes in urine in case:s of trench fever or" P. G. 0.'' (Pyrexin of unknown origin), Xoguchi hns studied the spirochetul Hora of the normal mule genitulin. His discus:;ion and summary is as follows: 'l'he nirletiPs of splruchl'll'" enumerated nnd photomltro~raplw1! rorn t e male smcgmn llol'll n•111·t•sp11{ Lll'Utlically t'Yer~· l'orm hllh<>rto 1lPsc·ril>ctl liy Xnn. klvell and Sundell and l>y Patterson in the specim1•n!-l of urlne from treu<.'b- fever cas('s. TIH' Ul'l'I hrnl !lorn, ns stmlied l>y Stotlclarll, se<'m to cont1. n more vurieti<'f:, hut, f'X<'ept lllosc of his more detalle>d morphological 1le>sc·ription, every form obKl'l'Ye1l by hirn Is umon~ lhost' founcl ill thP srneirma. ~ O(lilurd i;aw c1•rl11in forms with hnokf.'tl L"ll!lS su~c:e!'>liv!.' of the Lc>ptos11lrn ktt>roha<'m ?· rhairic·tl of inf<'<'tiY<• jauntli<'l', hut llw l'<'SClllhlnnce encls with t)li,.: nil(' fenture, and differenti:ttlon shoulcl nl\\ 11~·::; he ims,..il>Jp under the durJ,-lield micro OOJ!e. by uwanf: of whir.II the lc[1tos11ira rc•\"l'ttls it'I highly (•)\11rac!t>1·islic m nute el mentar~ >;piruls. lJl'eH1•11ting- fhl' nppeantlll'l' or 11 c·hnin nf 1lot:< ....•.••• Of all tht• :-:piro<·lwh"'. 1um1• 1111-; "'1 c·Jo,..ely s1•t :pto'. spira, the dist 'll<'I' lwt \\l'\>ll t\Yll :;pint!:< bdn~ 0111~· o.:; ml<-rons. Ynrit '" IDl.'tb- o(]i;, includi11~ 1"011lt1111t'N, Bennins·s, the mortlant gentian viole>t staln, or Burrl'a india-lnk 111f'tlt<1tl, ar,• lnudt'f(unte to spt-ciuien:< Clf 111·f11c was 11ot obtuine1l is llift1cuh to ('XJll:tln, escept on the ~-rounds of llH' paucll) of spt>dmpns P'l::tmined. .\t nil e\·e111 s, I he l'!'crnl nc:,.'llthe rc- i;ults l'<'lJOl"tt'cl that in times of peace• people nre \'<'l'Y linlilc to lose MlLITAlt\' 1 LEGAL Al\J) INDUS'.IBIAL. 763 I sight of the higher ideals, become self-centered. ·ind indulge in n.x- c~ses of all kinds. In times of war the heroic q11:1:1ties of the people sre de'"eloped; they become as a rule. ~lf---acri licing. nml hu\'ing n de~ire to bb of some assistance to their relatiYe.-, who nrc on either. ::.ide they do all manner of things, inYoh-ing manual labol'. It is not un- common in times of war to see imliviCJl!l- rntC'd it from EuropC'. A poor under,,tanding of ;11ternnt ion al p::;y- chology resulted in the unpreparedness in England, ns well as in .\mericn, and so the pr<'sent conflict is being prolongNl n1:rny years. If thP ulliccl 1rntions ha,>ish extriwtion. the patif'nts as n rnl<' recovering when lhc service ronditionR of :-,Ire's and diH- c·iplinP ha.ve bt'en l'<'movecl. To be of assistanee to I h<•s(• pat iP11(s it. is. of <'Onrse, desirabk to Jun'<' an insight illto tlw d1:trnl'lt>J' anti 1•mo- tionnl 111·1ke-1q> of th<' race. its normal conflict-; ancl its reactions. "'> 764 MILIIARY1 LEGAL .U."D Th"'DUSIRUL. Vol. :tlt that uny illness dc,eloping in a mnn mny be discovered in its in- cipiency nnd possibly kept from actually assuming the o.spects of a definite psychosis. The general features, as outlined above, o.re won. derflllly expressed by the o.uthor of the article, and it is rerommend!l(} for careful study by nil medical officers of the Navy. Aside frona the professional vo.lue of the article it is interesting from the psv. cholcgicnl standpoint and contains valuable information which e\·ery American in an executive position should be :fnmiliar with. The physicians specializing in mental conditions have realized for years that the Jews, as n ruce, usually evidence functional mental derange. ments, almost to the exclusion of organic brain lesions and the senile conditions found in the non-Jew. Ileco.use of conflicts through which the Jewish race has gone in the past centuries, as o. result of the treatment of other peoples o.nd nations, the Jew, o.s o.n individual, is now realized to be oversensitive and inclined to repress the t?reater number of his difficulties. As a result, when repression is not success. ful, a psychosis develops usually of functional type. There hare been two definite psychological factors involved in the emotional make-up of the Jew that we see to-day. The first is a reaction which has come as n. result of religious conditions which ha ''e made il nccos- sary for him to develop along very narrow lines. It is therefore difficult for him to adjust to outside life, be is a poor competitor for existence, aside from financial and business matters, is usually cod. dled and spoiled, self-willed and egotistical. Ileen.use of the action,. of the non-Jews with whom he comes into conU\ct, he, as a rule. re- presses his emotions and becomes an isolated individual. His feel· ings, bis desires, and his ideals are not understood by those with whom he is thrown, and because of bis inability to meet the difficult problems in an outward manner he apparently prefers to remain by himself. The second factor is said to be the family situation. where all of the patient's love, affection, and interest is centered in the home. He is not allowed to select his own mate; he is suspicioll:: and fearful of outsiders, is a poor mixer, and as a result when he gets into a difficult situation, given added responsibility> and r!l- quired to use initiative, he, as a rule, develops !t paranoid reaction. It is not uncommon to see this reaction in officers of the NaYnl Re- serve Corps who are pushed into difficult situations, having left a home of ease where their every want had been supplied by the parents. They usually develop ideas of reference, feel that the people about them are not showing proper respect, and a little lnte1 on, if this tendency is al1owed to develop, they will feel that ~me definite action is being taken against them by their associates. [o. o. s.l so 4. MII..lTAllY, LEGAL AND INDUSTRIAL. 7uf> AKll ~RO:\ll-.lo=-- cs. ll. Notes on drink and its regulation in rein ti on to work. and health of Great Britain. .\m .. lour. In,.anlty. \",11, 'i4, ::\n. l. .\J)rll. 11ns The question of prohibitin11 and allier! s11g~e~tions h:n·c b<.'en con- ,.1untly before the pubhc in thi;:; country in a politic:tl mhl social wny for n nuwber of yl':n·s, but 110 effort had been made for a GoYernment l'l'g:ulntion of liquor traffic until the onset of tlw pre:scnt wnr. Since thnt tinw there has lw~n a l'egulation by the .\rmy and Xnvy. in the ,·icinity of cantonments, mt Yal base:>. etc .. in t lw form of nh:solutc pro· ltibition. nrcat Britain det·im·- tWl'ntieth of lhe populatioll of lhe whole. In 111o::;l c a :'CS thi~ board 0 wm> to lie kr pt open, l<•galizcd the sale of spirit::. u11d bct·r of a Jo" l'r :-t1 cngth than formerly mncle, and made Yery definite efforts to lei\\ <'I' incidents of drunkenness, especially at week ends. It also abolisheLl the -.ale of intoxicating liquors in bottles from grocers and other places, so thut the 'ntoxicant could not be co1weniently carric>rl away for conswup- tion later. The canteens and eating houses were tastefully decorat t•ll, the pro- prietors of these establishments were paid on n commission IJa.:;is, the l:irp:c•r rate of commission being allowed on ecliblcs and n011e on in- toxic>nting liquors. As a result the efficiency of ilie workmeu, soldiers, snilon;, etc., was raised to a great degree, there wns less drnnkenncsc;, 8DU llt the SUJllO lime the laboring class apparent)y made llO objection to the procedure~ llS outlined. The success of tho board's efforts was apparently very mnrked over the outcome. fn. '·· ""·1· Hum.rol\, .\. Effect of the air hammer on_the hands of stonecutters. Monthly Re,·IPw. l'. S. Um'. Lah. ~tntlstks. A1>ril, WlS. Dr. Alice Hamilton has investigated a curious condition in th~ hands of stonecutlers which seems to follow the use of the air ham- mer m cutting and carving stone, and which is fonn sandstone mills of northern Ohio. The pneumalic hammer employed consists of a handle l'Ontnining the lrnmmer. which is driven by compressed air nnd ic; snirs 11rP t>X<'l'Jllioually go0tl 1m1terinl for ,.;ul'h a Htufl~', for they arc lntelligC'nt nwn. usun ll.v of ;.:ooc\ P 1·h•11rls. 'l'h1•t'l' is 1111111ng some of them 11 tt>ndl.'11<')' t<> 1lwell, perhnps too mul'11. 1111 tlw 1ic1·,·ou:; tliRorclerR whi!·h the)' believe nrl.' cnusccl by tbe tiring \'ihrations of th!' hnmmer·, and whirh gh·p them a ;?OOcl cleul of worry. Of ni>arJy•u]) of the Hll'll. howc\·er, this is not true. '.\Inn~· of thC'lll ha\'e no romplaint at nil, exc1•pt of lhl' tt<.:tual conclition In tile hand!!-. hut others Huffer from more• or [pss 1lls1 l'l"-Nill~ ,.;ym1>toms which thc•y thin];: arc mu Heel b~· the vibra1ing h:rnnnel'. 'l'hc> 111ost 1·ommo11 s~·rnptom !:; covered by lhnt \'a;:?uc term "nerrnusness." 'l'h<'Y say thnt lh<'Y fc<'l jump~· n111l irritable, UJISCt by n slam. min~ tloor. unublP to sl•ttlP tlown after a full clay',:: work with th1• tool. Their sleep Is 11ist11rhe1l 11ml r1•sth•,:,.;, nrnl thl.')' hllY<' hnzzin:! or ritH!ill!!' In tlw <':11'!1. The numbness In the hilllll?-\ ls Inconvenient, for they can not holcl a 1:ewspaper or a book for nny h'll~th of tllll<' without !Jein;:? forc1•d to put it tlnwn 111111 ruh aucl k11Pa1l their ha11d, or lhl' nnmhne"s \\;l11 walwn lh<'m, aml then they must gPt up anti Hwing lh1• arms nhont or bathe lhe hamls in hot water. Some of them nre not trouhlt•ft haml ii:! more uffectecl than l\Je rii;:ht. In the fir!'t pln1·c• n !!t'1•nt1'r dfort must be ma1ll.' hy tlle lrft hnn!l In gro.spln~ MILITARY, LEGAL AND INDUSTRIAL. 767 we tool. hulo.li11:: one end :1::ul11:;t the hammer, allll ::uhlln:: nncl prc,-.lng the other eurt along the surfn<'<' 11f th<' .:tone. 'rlw fini;<'r" ofh'n cJn-,11 the tool l<() tJghtl~ th:it tlu• I.l<> :I l'U!Hlltl1111 ill llW h1UOI\ \'I'"<:(•),- Which lend' to 'lm~rundlc t.'On· trill'rl•ms :mo.l tlw 1·N<111tln~ hl:111<·hPtl am! "hrunk<·n n>11tlitl1111. The ri~ht hnnd c:nn bolt! tht· lar)!er ha1111111·r rnor • loo' •lr :•nu can ..;lJiCt il In dlff<'r<'nt wny" cturlng work. ancl tlw 1·ibrationi< :ll'l' 11ot !<•It so """'l'l'I~· as i11 the left hnml. ~(IIJH' mc•11 1•011tin11i> tn hp llnhlC> to atrn<'kH of white flll!!l'l"' even nfter tlw~ 1::nc i..P that prophylaxis is not sufficiently effecti \'C an nltimall'ly for its success 11pon the r·nopp1·ation of men in the :,;pr,·ic<>; t hnt •1 continence should be ronsiclercd by the practical man. not c1n the grotind of moral~" lmt lwcause reJ!nl:ition h~-; £ni1ec1. The e::,Snyi-:t ~iws as her final argnmc1~t against prophylaxis: ·· It is an cllort on the part of the Go"\"ernment to make it safe for n,en to satic:fy their !-=exnnl pa-.s ons without reganl lo the primary purpo:::e of sex:· In the beginning 0£ her paper the essayist seems to concede that the ·· practical impossibility ·• of a rnca;.ure make;; it of ·· nt Jea~t deLntable vnlue,'' and we rather think that this thought ;;houlelts of the midr xo. 4. MlLlTABY, LEGAL AND INDUSTRIAL. 169 bride to be he ma.de the unwitting victim of a clisease that can in in:tn.\' cascs--nlas, not in all-be pre'\"entecl by physical means; who refuses such physical prcrention of suffering because a :far better, 11 more irlea1. a worthier prevention would he thnt due to mornl 11~encies. -If men are hardly preYented from improper conduct by a full kflowlecrn" it. As E. II. £looker is not 11.Jo1w in her ignorance on this snhject, it is hriefiy rehearsed here. Prophylaxis in the Navy began to be employed on a considerable £cnle some lG years ago and wns first conspicuous on the China sta- tion, whel'C:, 0\\ ing to couditions ashore, tlw prevalence of 't>nerea1 disease in the personnel of our ships reached a startling magnitude. It began as n. purely medical and sanitary measure, mid the results to health promptly recommended it to the military authorities. Prophylaxis then became more or less general throughout the ~avy, but its nclministratiou has always Yaried widely according to the 'iews of indiddual commanding officers of ships and fleets. In home 'raters the moml aspect of prophylaxis soon obtruded itself into the problem nrnl moral and ethicnl <'onsidcrations soon made it. "prac- rically impossible" to administer prophylaxis in a thoront:rhgoing manner. Meanwhile changes in the internal economy of ships and stabons nloo contributed to the decline of prophylaxis. As periods of liberty and furlough were increased and lengthened the possihil i t:v of prompt and efficient prophylaxis was much reduced. Coincidently with these changes and the frank failUTe o.f prophylaxis in many cases, due largely to indifference on the part of the men, in spite of court- martials and fines for fnilnr<' to take prophylaxis, a large proportion of the medical officers of the Nin-y realized the necessity for enlarg- ing the scope of prophylaxis so as to include more instruction on reneral disease, and on the importUIH'l' and Ylllue of contin<'OC<'. It is hard to realize that any portion of the Americnn public is still unaware of t1w Yery pronotmced and outspoken attitude of the present head of the. Navy Department on this ~nbject. The Hon- orable Secretary of the Navy has more than once givC'n pnblic <'X- pre8.<;ion to his convictions and no officer or man in th<' service to-da.v ran be in the full possession of his mental faculties if he claims that the go,'ernment of the N nvy sympathizes with, rondones. or ron- nives at sexual impurity. 770 MILITARY, LEGAL AND INDUSTRIAL. Prophylaxi,- in the X1Hy to-thy is a good dea] more thnn th aclrninistrntion after coitu:-. of an injection or ::mlve. There hns bee~ for ~ome time !\ concentrated and strenuom; effort on the pn1t of thn medical oflicer~ of the :N"avy to impart to officers and men of the ~en·icc :-uch information regarding health and disease and such cone N~ption" of life. worthy effort and true .success us shall build up in the mun n power of inhibition far superior as a deterrent from sin, to the fear of punishment. I n the instruction gi"Ven to-d:i) thl' physical agents like calnmel ointment. and solutiou:, of the siln~r salts are mentioned as the last resort in the attempt to main- tain efliciency, nncl the subject is so hunclled that it is as 11nfuir to ~peak of medicnl preventives o:f Yenereal disease ns incentives to immorality us it wonlcl be to pronounce the Snvior's nton<'mrnt anc\ s:wing grace :i "·arrant for sin. The author has gracefully conceded to Dr. Riggs a "fine sincerity .. and the possible ahility to "give fair consideration to a point of Yi~w opposite his own.'~ The point of view is everything. For one per- son the point of view may be the quiet study room. with ,.ugge...,lions of refinement and culture in books, paintings, ancl furniture. The world is Yiewed through mullioned windows. The glance i,- to the fur horizon and the clear dawn o:f a better era. There arc othl!r!;, ':intelligent medical men~'i for instance. '"ho haYe neither the time nor the type of mentality for casuistry. ncnclemir discus.-.ion-- nncl fine theoretical distinctions. In the heat and burden of the clny the\• fincl thC'msches jostled and pllsbcd about by the struggling. ~went­ ing mass of hnmanity that goes faltering and staggering nlong the rough rond of life, now fainting, now falling, by the wayside. To those thus plunged amid their fellow men, knowing them. pitying them, sympnthiziug with them, one form o:f duty app<'als with special force. It is tbe duty to bind up wounds and to heal bruL"l!Si to reduce by every means in their power the sum total of humnn suffering and sorrow. To the glory of the medical prof('~ion be it said that its members haxe D pre\'ent the de\'clopmcnt of syphilis nnd of gonorrhea in thnt mnn, l\11LITARY1 I.RGAl. AND I:XDUSTRTAL. 771 befnuse every ca:::c of Yenereal cli!,easc is a potential fr1fector of in- nocent women and children: because from one Cll$e of gonorrhea lll:tY come indirectly hundreds of othei; cases and cases of peritonitis and :4erility and an intel'll1inable list of ills: because n ~in!!le case of syphilis may dir<'ctly or inicul inte~rity. com- fort. and happiness, and if the lack of phy:;icnl iutP!!rity nml well- being contributes in any way to immorality, proph~·lnxi~ ha~ a ri!!ht to be carried on. I· seems tmreasonable to a~k that a parental government he re- quirl'cl to replace the nursery governess, the father nnd mot hl•r. the school and the church in the life of the soldier :rnd ;ailor and yet be refused the prerogatives of a big-hearted phy::,ici:rn. Xow, in spill' of her attacks ngninst the Government's uttitndc.'. ,urely the writer in Social Hygiene must know something of the ,·nst and 772 MlLlTAB'.l, LEGAL AXD INDUSTBIA.L. comprchensiYe effort for good represented by the Commi"sion on Training Camp Acti,·ities, the a&;ist::mce of which commission •aa not forced upon the GoYernmept but cheerfully and eagerly accepted The moment government accepts~ fosters, and enlarges the sen·ices oi an ageut, those services may reasonably be considered part of "ov emmcnt effort. It is only £air, therefore, to concede that the Gov. erument is exerting itself directly to promote mornlity in it milit.nry forces if all the inlluences exerted by the Commission on Training Camp A.ctiYities and otheF authorized workers for the Government are really on the side of morality. It is of interest lo rompnre the attitude of the American Government with the aLtitudcs of gulntion is practiced, and, if we may L ·lie\c well authenticated reports, includes the establishment of ca ref t; lly super- vised brothels at the front. The most striking contrnst is furnished by those Governments which, by means of force furnish tlwir armies with meam; to gratify lust, urge one-night marriages aml ,<.>e \-irtue in '·capsule impregnations." The term "own misconduct" includes alcoholic cxccsse:<. drug ad- diction, etc. Just bow far would Hooker"s stnuda.rd com pd us to go if we graded the Govcrmnent's liability to medical aid by the ethical aspect of the genesis of disease? Shall we decline to rnc:cinate a man against smallpox because be was exposed to the disease. while absent without leave, through bis own misconduct~ Shall Wl· refuse to gin> an1itetanic serum to a man who cut his foot on broken glaa or rusty nail becuu1>e the accident occurred us he wns rlimhing a back-yard fence the night the police were raiding the "joint .. , ls the doctor to give tonics, sedatives, soporifics,.food to th<' drunkard verging on the horrors of delirium tremens ~ These are all illus- trations of preventive men!'iurcs against the consequences of <''·ii prac· tices, and since the wrath of God is directed against the sin nnd not against tho sinner, we think that man. and even sinless woman. may incline to mercy. r rnrrou. J Vital Statistics of the l'hilippines. The followln:r fa.c•t,. anti fl:.mr(',; are 26 deaths in ~Ianih. gi~ i ng u. ru.tc of :! ~.G4 per thousand inhabitants. 0£ these~ 56 were due to typhoid fever: t25 to dysentcr.v; ;38 to tetanus: 130 to beriberi: 3GO to tuherculosis. There were no deaths from cholera in the last quarter of UH I in the dt' of Manila. Deaths from cholt!ra in the Provinces W<.'rt' 1.80.). Bubonic plaguc.-There wer<.' no ca::;es and no dealhs from thi..; disease in Maniln during the last quarter of 1917. A total of 30.112 rats were cnught Ly means of fr(lps or poison in tht> city. All wert1 negative for bubonic plague. Regregation of le7Je1·a.-During the quu.rter, or rather during the month of November, a leper-collecting trip was made to rnrious Pro¥inces of the Archipelago, 194 lepers being gathered, 1!>2 of whom '!fere remo\·erl to ('11Jion leper colony and 2 brought to Snn Lnzuro Hflspital. Military Statistics. fbtract from ,\noull.I Rr110rt of tbc Japanetie Navy Departmtnt for tbe J~r 191~16. J . Comparing the number of sick cases and the number of sic~ dsys in the Imperial Japanese Navy in 1915 with those of the preceding year, the sick rate nnd the rate of number invnlided both increased, but the den th rnte clecrcitsed; und comparing with the n.vernge; of the last 18 years, the> sick rate and death rate both decreased, but tho rate of number invnJided increased. The number of death per 1.000 of sick cases decreased, but the rate of the invalided increased. Peraonnel.- The nverage day number of petty officers and men in 1915 is 51A39, showing nu incrPa~ of -!,.H!i o\·er the ~imilm· numlwr of the prececling yeut·, 46,963. Owing to the war, part of the reserve." were cullt>d w nctivt> 5en ice, the term of those in nctive '-t·rvil'e wns lengthened, and tt larger number of volnntc<.'rs nnd con-:cripb were raised; hence the increase. !f umbers in rnrious branches are as follows: Cadets ----------- Petty officel"!i : Senmnn brunch_ ------------------------------ ---------- - - 5. !l'iU Engineer bl'nnch ------------------------------ ------------ - S, 425 Other brunches - ----- - --------------------------------------- l , r.ii:; Men: Seumnn hrnnch --------------------------------------- - --- ::!:!, 43~• Engineer brnncll- ---------- ------------------------------------ 1:1, 616 Other hrnnchcs ----· ·-· ·- - ---------------------------------- 3, 00.i Civil officlnls nnd employees---------------------- - --------------- Mi In '(lrlson - - - -- ---- --· --------------------------- - ------------ 121 Totnl ---------- -------------------------------------- ----- r.t , 439 774 MILITARY, LEGAL AND I~DUSTRUL. . 'ol. X1t Sick cases ... ...... ............. -. -.. -. --.. Died ................................... ··· Invnlidcd from service ..................... . l - I ... , ... ,, ..... ".::- Tot.:11 1 I number. I Atl! I 191.i tQl4 1as& 40,555 40,579 198 208 836 842 788.40 788.88 3.85 4.04 16.25 16.35 'Yt:lrl 755. 70 I ws. is 762. 75 • ·•··•• 3. 58 5 ij !l.24 . 13.71 ... . i5:0:? 13. 71 ........ . ln Lhc abon' titble, in columns "1914" and "1D15" th<' lower figt1l'l'S inrhtclC' the number wounded or killed in the wttr. Numbl'r of cases of the principal contagious disea~C's and of •· knklw '' nrc as follows: ~lenf' l es __ Scarlet fever-------------------------------------------------------- :? Typhoid I e,·er -----------------------------------------------__ -------- 106 Paratyphoid, type A-------------------------- ------------- -------- Gll Pan1tnihoid, type B----------------------------------------------- 80 Dysentcr~· -----------------------------~--------- --------------- 185 l\Ial:u·la--------------------------------------------------------------- 19;; .Mcnin;;'lt!:> cerchro-spfnnlls epidemicus--------------------------------- 2 Intluenzn ------------------------------------------------------------- 183 K:akkC----------------· ----------------------------------------------- 108 Tullt-rculoi;;i1> ot lun~s-- ·-- -------------------------------------------- ;.r_>g REPORTS. JtEPOB.T OF 140 CASES OF PNEUMONIA, UNITED STATES NAVAL HOS- PITAL, CHELSEA, MASS. By L. W. llfc(lurnc, Lieutenant Commander, M. C., United Stat~~ Na~y. Of the HO cases of pneumonia occurring at this hospital betwee11 October ancl Mnrch, bolh inclusive, 98 were typed and 42 were not typed; 14. were type 1, 15 were type 2, 2 were type 3, G7 were type 1. The type 4: includes the cases due to the streptococcu". which wns an important. factor in this series. It was not found prncticahle to separate the pneumococcus type 4 from the streptococcus in nll ra,::es, both being present in some, but in many the streptococcus only w;ts found. .\ s the streptococcus nnd not the pncumol'Ot·cus was found in the pleural exudate which so commonly occu,.recl it can be .;afely stated that a large percentage of type 4 was n streptococcic inftction. These men, when admitted, were seriousir ill, very toxi1·, and mpidly de,·eloped'serious complications, the moist common being empyema. which developed in 50 per cent of this group. In other words, of G7 ca:ses of t.ypc 4 and ~lreptococcic pnpumonia, 3:3 clevclope complications. Clinicnlly it was dif- fkult and oflt•n impossible to difforentiate between the lohar nnd bronchial types, as there was often present a large involn~ment with Aui1·tion pre...,eni in certain localiii<'s in this district, the pneumonia, being nn incident in its activities. It is interesting lo note the stations in which tlll':-.c 1nw11monias tl•'H'loped. If we exdude the ships. lOCi l'a~e:-; dl'\'C'lop<>cl in thi:-. ' cmity, sn of which c1une from two stations, Commonwealth Pi<'r and tlw Ra1lio Srhool. li'rom the Commonwl':llth Pil'r came Hi, 7i:i 776 REPORTS. \•oL XII and from the Haclio ~chool -1~. From the enlira n:n·y yurcl onlv fonr cuc:es ilenloped in this period: the remainJer were isolated c.ases from different istation::.. Of these 89 cases from the Ratlio School and Commonwealth Pier: 58 were typed. Of the :18 typent. - I Avorago Ind ~ries. wru- the most rirulent. due to the presence of streptococcu~. The!. men dcnlopcd fluid early: they wen' commonly nclmitted \\"ith fluid and often with pu in the pleural an·it~·. This pus was u~nlly n thin. "'light!~ colored fluid. which. on l'Xnminntion. showed abundant slr~plol'orci and brokcn-do\rn cell • nncl not tltc tl1ick yc.1- Jow pus common],\• scPn followinz :t loh:ir pncumonin. It wn ... the prncticc to open th!' pleural caYity. resect n rib nncl nt thnl it "·:is not tlw propt'r procedure. Thi::: was dihcontimwcl und repeated aspiration cmTied out with fn.r better rcc::nlts. .\ftc•r aspiration there wns usnnll~· 1empornry im- provem1>11t. Tlw pus wouhl re-collect nnd wns nc::pirntcd ns often ns neccssnr~-. which wn~ sufficient to tide mnny of them m·er tlteir pneu- monia; they "oulcl appan·ntly cle,·elop a resistance. !!nin :-trength nnd weight. un1l become !!ood surgical ric:ks instt'acl of 11 desperate operation. Xone of our cnses were curecl of nn 1•mpyemn by nspira- tion :tlone. ..e' crnl r:m a ilnt temperature for from tw11 dnys to a week between nspirations clurinp; their convnl~cencc and we.re nppnr- ently well of their cmpyl'mn. but all eventunlly Juul to haw the pleural cnvity drnined and with most excellent results. erum trcatmcnt.-.\ll of the type 1 cases recei,·ccl serum nlthough some were sensitiYe lo horse serum, which intcrfl'rcd with :;?i,·ing lnrgc amounts. Tlic 1n·crnge cn.se receh·ed about 400 c. c.1 it being gi,·en intravenously in 100 c. c. doses. In i;e,·ernl cnses nfter admin- istering the type 1 serum the patient had a Jrop of temperature. with n correspond in~ jmprovement of the other symptoms. As one patient remarked, .. I enmc lo the hospital yesterntmem spe..-iks for iLelf. 111 the type 2 part or our cases t'C'cciverl -.erum. some with nppnrent benefit, but on tl1c whol<' the rc<:11lts were not !?:rntifyiu!!. Il is belie' eel thnt better 1·c·snlts may be obtninccl by using larger amounts of the scrum. In t~·pes 3 nnS. l. ThCl'I.! was present :i severe grnde of pncumoniu., in lnr~c p:lrt due to the strcptocoC'cus. "ith n ~igh mortality. 7009S--18-14 778 REPORTS. \"01 XII. 2. The outurcak had no con11ectio11 with mN1~l C':<. h111 1licl follow acute infections of the upper rc-.piratory tract. 3. The bulk of the ca~es occlllTC' of infocting organism. The pneumonia. at. this hospital was of the usual clinical vnriety, and in no cn.se secondary to measles. The diagnosis of pneumonia was made only in those cases presenting definite physical signs and symptoms and in which examination of sputum reYealed one of the varieties of pneumococci. The total number of cases observed was 100, of which 90, or 84.9 per cent, were of the lobar variety and lG. or 15.1 per cent, 0£ the bronchial variety. In this series deaths from all causes (as shown in Table I) totaled 27, yielding a mortality rate of 25.4 per cent. Deaths which could be actually attributed to lobar pneumonia numberecl 15, giving a mortality rate of H.l per cent. "° 4. REPORTS. TABLE I. Empyem:i ............••...........•........•...... -.........• -.. F.ropyem:i a.1!-d dip~th'i!r!a .•...•.•.............•.................• pocnrnorocc1c mamn:.p.tis ..•.....•.............................. ~b:;~o~~~~~r::~ ... ·. ~::::::::::::::::::::::::::::::::::::::::: 779 1.;;-caLhs. Mortnlltf (per cenL). 5 :i 2 2 15 4.71 2.83 1. 88 l. 88 14. lfi With the cooperation of Passed Assistant Surgeon E. A. Case, United States Naval Reserve Force, an attempt was made to study the type determination in all cases, but owing to the scarcity of white mice, this was possible in but GS cases. The result of this study 1-. shown in Table II. T . ...nr. ~: U- Typc 1h;lrrminntion in 68 cases. TY!l-0· !~IL:•••·•••• :• :: ••:•.••• •:·•· Streptococcus ..•. . .............................. Cases Per rent 11 16. l with 2 dealh!I. 4 5. ~with 1 denth. fl 13. 2 with :i deutb~ 3fl 57. :3 with 10 death!! 5 7. :i with l denlh The sputum was collected in sterile Petri dishes aml s(\nt to the laboratory immediately. The greatest number of cases foll in the Type IV group. We observe thnt the type itself is no criterion of the sev<'rity of the Lnfection, inasmuch us many of our Type IV i11 fec•tions were ex- tremely severe and rapidly fatal. It must be borne in mind that the group of organisms classified under Type IV is heterogeneous. Xo satisfactory distinction of the organisms of this group can be made. TABLE III. -Death• due to t.11pea. T~'ll<'· Type I. ........... .................. .......................... . ... ... . !fE!L.:.• .. •••••••·•••: :: ·:•: :••• :•::•: ••• •: .:: •••· •• :•:· :: : ::·: :· Per rent mortality. lR. 18 25 33.33 25.64 20 The study of Tnble Th shows Type III to be the most virulent of the pneumococci. Another interesting fact revealed is the viru- lency of some of th<' orgnnisms classified under Type IV. In pr:tc- 780 REPORTS. \"01. xu tically all the ~tatistics publishc(l prior to the use of .the serurn specific for Type I, a mortalit:v rate is shown muc} higher than that found in Type IV group. In our present series of cases Type I pre<:ents the lowest mortality rate. This is attributed to the u e of specific ::erum which was administered intravenously. The initial dose varied from 30 to 100 c. c., depending on the severity of the infection. "Te were also surprised to find that in pneumonin C III infection •................................. Dur to Typ<' IVinfoction ......................... . ... . ... . Due to streptococci infection ... . . . ....................... . 2 7.68 3 11. 11 4 15.38 2 7. GS Contrary to the usnal expectation, a large percentage of Type III cases de,·elopPd graclunlly. All Type II infections began suorted, the lower lobe of the nber of cases . . jority of men o.dmitted with t of the United States (~0.4 · cent, the East 23.2 per cent, .lso 'distinctly noticeable that n parts of the United Stnte:-; in a greater proportion than REPORTS. 781 TABLE VI.-Dislribution of casu a& to ratiM of men. Cao;es I Per cent i;earoan ........................... ...... .. . . .. ... ............ . Fircm:in .......... . ...... . ........... .. . ..... ............... . Private. \!arine Corps ..... . .. •..•.............................. £lect~i<;ia!1 .......... . .................... . ........ . ......... . )laclumst s mate ....... . .. . ... . .. . ............ . .. ....... . ... . Water tender ................. . ............. . ...... .. .... ... . . . Hospital apprentice . ......................... . ..... . .. . . ..... . . Coxswain ................................................ .... . Oiler ............. . ........... . ...... . ................... ... . Carpenter's mate ............................................•. C'hief boatswain's mate ..... .............. . .................... . Quartermaster ........................ . .... . .. ................• ~~~~~~< ·:.~.: :-::: : : :.::: ::: :- :-:; Pharmaci~t's mate ................. . .......................... I rz I 31.13 20.iG 15 14.15 9 S.49 G 5.liG 3 2.S3 2 1. 89 2 l. B9 3 2. S3 2 1.S9 2 1. !;!) 1 . !l4 I .!l4 1 • 9-1 1 .94 1 .94 1 .94 i I .94 - --- In Table VI it is observed that the greatest number of case~ occurred in the seaman branch. In accord with the experience of the )foclical Department in nll other camps and hospitals we had an unusually large number of cases of empyema1 ull of them following lobar pneumonia. The mortality rate was low chiefly because the pneumococcus nnd not thn streptococcus was tho infecting organism in the large majority of cases. It is also likely that the mortality rate was kept down by the prompt recognition of the onset of empyema. It was our rule to make exploratory aspiration in all cases of pnemnonin in which the crisis did not occur by the eleventh clay of the discnst•. Inuuediately upon the discovery of turbid fluid in the pleural cin ity n rib resec- tion or thoracotomy was performed. By this method the ,cw<'l·e • toxemia, which is so common in cases where pu" is retained in tho vkural cavity for a. considerable length of time. was nYoicled. W1• believe, contrary to the recominendation of certain authors. that thorough surgical drainage should be instituted immediat!.'ly ntl<>n the discovery of turbid fluid instead of resorting to repented aspira- tions until tbirk pn" develops. 'l'AnLE VII.-Complicatiom. Empyerna; 27 cases, all followin!? Johar pneumonia: Type 1 infection . . ..... .... ...................... . Type HT infection ....................................... . Type IV infection ................................... . . ... . ~treptococciciu£cction ................................ . . TypP IT inft>ction.... . ................................ . ~o typ nu- mero\ls and severe. 3. Vaccine treatment of pneumonia was futile. but the treatment with the specific scrum in Group I cases is to be strongly advised. EMPYEMA AS A COMPLICATION OF LOBAR l'NEUMONIA. By J. J. TOLAND, Lleuteuant, M. C., United States Navy. During the past winter at the Naval Hospital, League I sland, in a ,;eries of 107 cases of lobar pneumonia, 27 cases of empyema, or 2ii.2 per cent. developed. The cases were of particular interest in that the,\' were all clue to the pneumococcus and none dne to the streptococcus hemolyticus. The diagnosis and treatment of the cases were of marked interest in that the percentage of empyema was very small in comparison to the statistics of hospitals in Yarious camps and cantonments throughout the country. The early diagnosis of empyema is indeed a most potent factor in early treatment bein~ instituted. In our series, as soon ns it was discovered that the serum was becoming cloudy upon aspira- tion, the cases were turned over to the surgical staff for treatment, whereupon the ~hoice of thoracotomy or rib resection was decided upon. Thorncotomy pro\•ec.1 to be by no means us satisfactory as curly and :fre<> rib resection. The resection of a portion of the sixth rib 784 REPORTS. Yotxu. in the mid-axillary line proved to be the most satisfactory due to the fact that the flnid or pus is not evacuated by gravity to :my great degree. but by lung expansion. Since this is the point on the thoracic wall that the expanding lung touches last an~· fluid rP- maining is more likely to be forced out. The anesthesia chosen depended upon the condition of the patient. Of the three anesthetics used nitrous oxide and oxy~en proYecl to be the most satisfactory from the standpoint of the patient's best interests. This anesthesia relieved the patient of any pulmonary complication that might have arisen from ether or chloroform and so added insult to injury. Local anesthesia was not used on account of the seriousness of the condition of each patient. They all had gone through the siege of a most severe pneumonia and by no means were able to tolerate any added physical or mental perturbation. Opuative tcchnique.-Patients were prepared by thorough bath and purge and at the time of operation the chest wall of the af- fected side was painted with iodine and then cleansed with alcohol. The anesthetic, :was then administered and as soon as the point of anesthesia was reached, aspiration was performed, follm>cd b~ either thoracotomy or rapid partial rib resection, the latter pre- ferred. Tlie drainage tubes were then placed in situ and dres!"ing,, applied. Patients were conscious before they were removed from the operating table. In our early cases, the usual fetid odor that accompanies empyemn prevailed throughout the wards and not only impeded recovery of patients by making them feel repugnance for food, but also caused the attendants to feel disgusted when they had to entC'r war£ pus, which in every case was ! the Wolfe bottles was t•mployed. . m" a few minutes prior to treat r Wolfe bottles and expelled as !(O. 4. REPORTS. 785 Coincident with the modified method of using Dakin ~olution, the odor about the wards al>solutcly disappeared. The patients' appe- tites improYeered post-mortem leadinO' us , "' ' therefore, to make a thorough and most Yaluab]e study of our cases from time to time by the use of the X-ray, the X-ray finding:> being the only po::;sible method of confirming the presence of multilocnlar nbscesses. The X-ray not only reveals the presence of the abscesses, bnt also is an indicator of the lung expansion, the nmonnt of pus, and the extent of the diaphragmatic moYements. Our recoveries were such as to •Yarrant patient:-; returning to the duties of their ratingi;. During the treatment of these ca,,es, the intere"ting phenom<'non~ pleuritic epilepsy, occurred in four cases. In case Xo. 1 the phe- nomenon occurred upon the introduction of the catheter into tho ca• ity; second. upon emptying the pus from the caYity. The symp- toms came on as the amount ceai;ed to flow : in our third nnd fo01 th cases, after the cavity had been filled with Dakin solution. The symptoms were llS follows: First, severe pain ut the angle of the scapula; second, feeling of faintness; third, loss of consciou!'ncs::. with profound shock; fourth, convulsions. In each case the patient recovered in about 10 minutes without any special treatment. The dangers of this treatment arc: First, pleuritie cpilep:;y~ which mnv occur as above noted; second, too great pressur<' from the fluid; th' :I, too rapid injC'ction of the fluid; fourth, distention of the c:lY- ity: fifth, hemorrhage :from the injudicious u,;e of the cathet<>r. The eomplications of the cmpyemas were tv•o ca!;eS of pyopncumo- .hor. x and two of atelectasi;;:. In our two cases of pyopneumothorax. the Dakin f:olution, in fact :rny solution, was not tolerated b~- the pa- tient. The cases are remaining and other trentm<>nt hns been insti- tuted. Tlw two cas<>s of atelectasis arc impro\'inir under this treat- ment. SU:IDIARY. The following points arc emphasized: First. all ca~cs follo" e11 lobar pneumonitt and were of pneumococcic origin. 'This fact prob- ably n.cconnts for our low mortality. Second. early diag110--is fol- low<>d hy prompt surgical intervention and treatment; third, the free, persistent, conscientious use of Dakin solution: fourth. frc•P nsc of the X-ra.y from the diagnostic standpoint . 786 REPORTS, Vol, Xlt THE CYSTOSCOPE AS AN AID IN THE CARREL-DAKIN TREATXENT EMPYEMA. Op By B. C. Wu.l.1~, Lkutenunt (.J. G.), )1. C., United Stutes Navy The nccurate placing of Carrel tubes so that e\·erv port1.on I · • nu, pocket of the \Yountl may be reached, is only second to the thoron l opening :ii1d i·emoval of all devitalized and necrotic tissue. In tt; treatm~nt of empyema we .ha\·e no devitalized and necrotic tissue to dea~ with, so the problem is one of thoroughly dakinizing the entire cavity accurately so that fresh Dakin's Solution may come in con- tact with the entire infected surface. In the United States ~ll\ al Hospital, Newport, H. 1.. there have come to my attention 36 ~\be::. and several of them still dischal'ged pns after most prrsist<'nt <'ffom: had been made to clear them up, the Carrel tubes having b<>cn pushnt it is a pa~-t of the armamentarium of nearly every hospital. The small ~p1·cu­ lmus of one-half inch caliber, electrically lighted might be mon· eratln:; sen1< to ti Sargery his 1,r .. tttudr f 'IS. Vol. Xll E CARREL-DAKIN TREATXENT OP :MA. ;. ), :\!. C., Coiled States :Savy. tubes. so that eYery portion aud ·cl, is only second to the thorough lized and necrotic tissu('. In the en pushed inite jdea of the extent of pockets . if the tnbes c011lrl hl' accurnteh ·mination of the extent of the cm:. ~ct a cure. Being familiar with the I could see no reason why th.~ in- c purpose of thoroughl.v i~1spectin!! ! tubes, and further. to aid in accu- pockets and over surface of large ms an ideal instrnml•nt it is a part every hospital. The smn.11 f'lwcu- ctrically lighted might br more de ic cxnminatioHs of the chest, at op- ml rib resection at the lowrst point ;ion ~L little 1ougcr, remove an inch skin margins down to plenrn of re- ~ider angle of Yiew in the pleuml f the wound edges are approximated :ystoscope is introduced through the spection of the cavity is mnde. nsinir for the location of the tubrs are .;;,e- ·ened with No. 23 silY('r wire is then o the depth Llesirecl and the lutter ·-- through cystoscope, ::-o ns not to pull .umber of holes to the tube is to be ity to be treated. 'Ve luive had the view repeatedly. Eight cases have ·ing the past 10 chys with very snti~­ rnnt aJ1.cl consistency of the dischaq~e. toscope being so near that of the new :ing a new instrument with greater eak. This preliminary report is made r the method and report their results. REPORTS. 787 REl'ORT OF Ol'ERATING UNITS AT THE FRONT.' Uy U. G L1.Co:-;n~. Llcnteoaot Comwand"r, :\1. C .• rolkd States Nav). On J~ne 8, six medi~al offi~ers and four members of the Ho!>pital ~rps reported t.o me in Pans. On the follo'\Ving day we were as- blgn;d ~o duty with the Americ~n Red Cross Military Ho:;pital :So. 1 at Nemlly, wh~re we were detailed to work in the operating rooms. The commandrng officer requested that 4 nurses and an anesthetist be added to our teams from Ilrest, and this additional per::.onnel re· ported at N euilly at 8 a. m., June 10. Our Navy continO'ent theu numbered lG ~ersons. " The Ge~man offensive started May 25 on the Chemin de Dam~ from Rheims to Soissons. Ily May 30 the Germans had taken Chateau-Thierry ~nd were in force on the river :Marne. They had come through a distance of about 40 miles on a 50-mile front. The French, assisted by American troops, stopped their further advance. ~he cas.ualties we~·e l~eavy. A large number of French hospital beds i.n the mvaded district had been lost and new hospitals had to be created back of the present line. Large numbers of wounded arrived at the American. hospitals .in Paris from 1 to 3 days after their pri· mary field dressrng, and, m many instances, without any operative procedure ~xcept the injection of antitetanic serum. This delay of transportat10n caused a repetition of the surgical conditions of 1915 namely, massive infections and gas gangrene. The narrow limits of trench warfa~e, .and, incident thereto, the prompt care of the wounded and the proximity to the battle front, had all disappeared. Before t.his offensive, the hospital at Neuilly was about ht1lf tull and contamed 300 French wounded. Its capacity wah increased quickly to over 1,000 beds, but there wa,; no increa;;e in the staff. The maximum ~f admissions to the hospital in one chy wa~ f1Hl patient...; (all Amen cans), the maximum of evacuations wn.s ~9g, and the max~mum.number of patients, 1.061. More than :2,.iOO pati('nt-.. were admitted :n less than a month and the mortality was about 1.3 per cent. This sudden and enormous increase in the ho:opital activitie;,; exhausted the medical and nursing staffs. manY of whom were work- ing for more than 20 hours a day. Our tea;n~ took charge of the ?perating rooms, .allowing their versonnel a much IH'l'dcd rl'~t. Dur- mg our first two days we operated on about 1()0 ''ounch•cl. of whom more than 20 per cent had multiple wound:". \Y' e nurnned fhe oper- nting tables simultaneously. About 70 per Cl'llt of tlHhl' operated 1 The commanding o!llcer of the Navy Base Hospital, Bre.-t. ~frdlcal lnsJl('ctor II. C. Curl, UnltcJ States Navy, In forwarding this report, 8nys: "I wns 1ntorme1! by tht> ••Dior operntlng surgeon of the A1ncrlcno ambulance at ::'\cullly that the work ~f our men was of the very lllo/lcst cl1aractcr; that be bnd practkally turned O\"tr th• entlrP ~pcratln::; sen·lcc to them. Ile nsked me to cxpr~• to th• nurc:w of ~!rrllcln" nnSmen rnluntccrcd, and Charles L. Steele, Pharmacist's mate, third cla ....... United :Stale" :Naval Rcscne Forcl'. and ~IcWhite Ilarnsberge1, Phnrmacisfs mate, third clnss, United States Xavy, Wl'l'e chosen}~. ·cause their brood reaction was similar to those of the pal icnt'-. This donation of blood contributed more than any other fnctor in th" Sa\'- ing of the;;e t"·o patients: lives. · From this three weeks' duty the follo"'ing conclusions mny be drawn: That the nrnssive infections and gas gangrenes of 1915 were due primarily to delny in operations, and not to a lack of surgical lmowl- l dge. 'While the science of war surgery has vastly impro,·ed in three years, given the same conditions of delay as existed in 1!>15. the ~nme rna::.~ive infections would be. encountered on the operating tablr to-day. Therefore, the statements made last winter by a num- ber of accomplished military surgeons, namely. that an aseptic technique "ith the excision of the damaged tissne ( dehrid()mr.nt) had done away with lhe us:• of antiseptics, can apply only to cnses operated upon within a few hours of the receipt of the injury. In trench warfare this condition exists, but in a war of movement it docs uot exist, and therefore an antiseptic which will retard or pre- vent ma<:siYe infection should be used at the primary dressing. A study .:.hould be made to provide the best antiseptic for this purpose. Patient:-' that Wl're im1mdi::ttely evacuated ,ifter operation, in "'hom the wounds were exei:'ed and then closed or partially closed and drained, did badly and required a complete reopening of the wonnd. Uy c]o::,urc or partial closure the infection spread far be· yonil thP limits of the wound. It therefore again emphasizrs the fact that dcbridement with closure of the wound ran not be done on patil•11b that mnst be C\ iwuated. Excision of the damaged struc- ture's should be clone, but the wound must be left wide open, loosely packed "ith gauze. and ,-ome :rntisC'ptic n~rcl to r1'tn.rd infection. Vol. XII ork then gradually decreased 1elped in the wnnl:, where th~ part of the time, O\\ ing to the 1ad charge of hi-.. warltcr ron- dition for operation. . When the bed capacity of a hospital is sucldcnly doubled, and its activities increased tenfold, the personnel must a.lso be increased. It :s useless to admit 400 cases rPquiring operation when the limit of the personnel is 200 operations a. day. This discrepancy between the number of patients and the personnel at Neuilly contributccl in no small degree to the lateness of the arrival of the wounclcd on the operating table. PLAGUE IN CHINA AND THE FAR EAST IN 1918.' By R. M. STESllOl'SE, I.lcuten•rnt, :II. C .. rnlted f\tntl'S Navy The epidemic of pneumonic plague of 1918 in China will stand out in the annals of medical history as giving proof of the courage and unselfish devotion of doctors and missionaries who riskecl their all in an effort to check the ravagPs of this dread disease, and as a brilliant example of the romplete inefficiency of Chinp..;e in dealing with serious problems. Inside of three months a.\ area of 160,000 square miles was infected, whereas the spread of the disease might readily ha.ve been limited, as far as China was concerned, to the territory north of the Great 'Vall. The epidemic swept rapidly along, at the rate of "300 miles in six days, in a great country where means of communication are of the most primitive nnturc," nnd later by rail in less time. Press dispatches published early in the epidemic illustrate the attitude of the Chinese officials. For example, five days after the dis- ease appeared inside the Great.Wall- People are reported dying by the roadside and in the inns. Disea~e :spread· Ing rapidly. Deaths In one village numbered 32 in three days. Ilun:il The doctors were held prisoners, being refused transportation hack to Peking. rp to this time -.imply clo::;ing the gates of the Great Wall to all traffil' wnuhl huYe rnnfined the epidemic north of the wall an1l the control of that limited :Hl':t would haYe been a co111paratin~ly easy task. But all wtn·nin!?> 11::; to the Jrravity of the c;ituation were either ignored or but half-lwartedly ob:;ened. The actual condi- tion-.. were ma::;keOO miles from his point of emharkation. Dr .. \rth11r Stnnlc>y, health officer of Rh:rnghai. obSl'l'\'ecl that: 1t is tlw 'l'ie1.tsin·l'ukm\ Hnilwa~· which ha-; suhjeet .. •l the lO\\l'I" !'1111 of the Y:lll!!Zlt• \':1111';. lo \<'I'~· t·o,1sil!Pl':1hh• dai11:1gl'. Tl>'s lnt h:l-< for so111e time p:tst Jw1.•11 1wtoriou-; :is :1 f;oldit>l'·ilifrnctl ro:Hl. .\ leak.t;.:<' i11 thf" norttwrn qunranti11c oc·cmTPcl. .\ per>'<•ll from tlw infede•l an':I in not'tllf"rt111w..:t Shnn "hnt'tt"•t. • + • Thi" inf1"t·tPol JJL't'so11 is t'cpot'tPrl as havin;.: tachin:! ht•r h11rne at Fem:~ynn::. Anhui. whi1·h i» nhout 100 mile,; north of Pukow (~ankin~). Thi-; ense in· f~tPnic plague hc>tween Fc>hru:iry 6 nnti 9. Then• is probably no place in the worhl "hen• !"iher an1l gold fail to nffrct the liYes and habits of the people. Ilut China is so literall~· living from hnnd to mouth that money is the enr-prest>nt nspiration of ewryonc. .\ nd money will purchac;e anything. Tf it j,, a q11c>stion of hn.Ying to stop trains or to decimate the popu- lation th<' latter is doomed to die unless more money is to be made by stopping th<' railways. The governor of Suiyuan "refus<'d to belieYe that plague eYen existed." Evidently the gowmor'.;; rca,on for disbeli<'f wa!'i the reYem1c deriYed from the wool carter-<. which amount"' to $.iOO daily, passing through his hands. It wa;; not until tlw .: group banks" came through "ith a loan of $240.000 llnd a promi~e of sl.~00.000 that action was really taken toward pro- tcctinz the lines of communication. And as shown, the practical effectiveness of this protection was nullifi~d h~- fear of a" truculent" roldier. PROeing refused transportation back e gates of the Great Wnll to all clemic north of the wnll and the h:we been a comparatiYely easy e gravity of the situation we~ lly ob,...en eel. Thl' actual condi- 11 optimis1 1 •• of the otllcials. and i::. a soldier carrying a sick child om an infech'r of Shanghai. obserYe1· rt>ad i1 ;.:: h1•r h11me at Fen~· nnl?. h of Pnkow (~fankln;:). Thi-. rn~ in· family :tnrl nei!!hhor..:. who :111 1lle. the \\Oriel· whPrt' sih er an1l gold s of the people. Ilut Chinn is ~ uth that money is the ever-present .oney will purcha~e anything. 1f •p trains or to decimate the popu- e unless more money is to be made governor of Suiyuan " refus<'d to ." Evident]~· the go,·ernor·, rea-on riYed from the wool rnrter--. which ; through his hands. It was not ri.rough with a loan of $2-10.000 and tion was really taken toward pro- cion. And as shown. the practical as nullifi~d hv fear of a " truculent " THE EPIOE)BC. iicle of the epidemic: P atsobolong, Mongolia. · outside and to north of Great Wall. ses south of Yenmen P ass (Great PNEUMONIC PLAGUt JN NORTl1 CHINA 1918 EpLde.mtc slarled al Patsebolon~ Nov. 15, 1917 ll spread alon~ Mon- gollan Trade Route. Jo.n 5, 1918 al 5opmsfu 6 cases oc.c.urred. from lher~ Ll spread rapidly reach mg fengyan~ Feb. c8 , 1918 . The area norlh and south of lhe Great Wall wo.s heavlly infec.h.d. lar~ely be- cause prevenhon wo.s anla~o11i3ed by off ic.io.ls. Ma.rc.h 1, 1918 four deaths were reported Jrom N ins~iafu (Kanslll. Withm lhree and one ha.lJ months infec.hon spread. over .1500 miles, lo.r~ely tn resions without rapLd. lramil. 700 - 1 ~o 4. \fall). Two death other passes closed . • January h. HH four day::- north tkhrd at Kal!!an a \\'a.VS runnmg: as th January 20. 191 .January 21. rn1 5ituation. Brcin 11 deaths to elate. be interceptecl east ,jx days'. Suiyunn Tohsicn. ~prcadi11g .T anuary 22. l!ll tal deaths there t 13 deaths between January ~:~. 1 fll t>ight li distant. S not stopped. F<'a .fonuary 2+. 1fll nuder a physicia Domiliciary in:-,pe teriologicall~-. Ga ct•ipt of adrnnee o{ of ~1.200.000 to h to establish prope Ts'ung; 17 clraths rapidly. Xorth o deaths incrra!'ing. ,January -2i. Hll 11f 34: deaths to <>· 4. REPORT:;>. \full). T"o death~ nt Sinchow. R<'ported present nt Tnichow. All other passes clo$ed. January 1 . l!)l, : DC'aths n•ported ulong road south of Taichow. lfour da)::-. north Taiyu:mfu by cart). PreYention stations estab- \ishNl at Kal!!an and Knu!!chuan. Peking :::itill untouched. All rnil- "·ays running as usual except Peking-Kalgnn road. January 20. l!HS: Increasing at P.aratsi. January 21. 1!)18: Peking officials hegin to rralizc seriousne"" of situation. Begin lo train plague preYention police. .\t Fengchen 11 deaths to elate. Situation serious at Paotowchen. Traffic to be intercepted eastward. _\ll traYelers to be placed in quarantine six days·. Sniyuan go' ernor decides to allow preYenti,·e nwasnres. Tohsien. spreading rapidly. Saratsi, 1.000 tlenths in fin• day:-, . .T anuary 22, Hl18: 'l'wo soldiers die of plague at FengrllC'n. To- tal deaths there to do.le 27. Kweihachen. 100 ipt of aclrnnce of $:240.000 by group banks tD comhnt plague. Total of $1.200.000 to be loaned for that purpose. GoYernmmt con .... ents to establish properly equipped quarantine station at Xnnkou. Sun Ts~ung; 17 deaths to da.te. Taichow; 35 deaths; disea"t' spreading rapidly. Xorth of the Great Wall 1.000 deaths in :> days. Saratsi, deaths incr<'n"ing. Gates 1•losed. Dr. Young working at Taiyuo.nfu . • January 2i. 1918: .\t Fmgchen, 4 deaths among c;oldiers. Total of 34 deaths to dnte. Taiyuanfu; 233 deaths to dak Sarn.tsi. 1warly all village" infected. .\.11 infected die. Kansu r<•ports plague spread- ing westward. Hae: reached Santaoho, north of Xingsiafu. Bel- gian priest die::-: 3 others infe<"ted. February 1, HHS: Peking hopeful of keeping plague from com- ing :::outh. "Ministry of Interior diYide.c; infected area into fonr districts. :l[JSISTRY DWIOE!' I:s'YF.CT'ED AREA J~TO FOUR l>ISTitlCTS. First. Suiynan area under Dr. Chuan Shao·tsing ·'with full power." (Area of 10,QOO square miles.) Most heavil~· infected ter- ritory. Second. Charhar under Dr. Ho Show Yin. Third. From Tatung north to Provincial Boundary and south to Yenmcn Pass. Under Tuchun of Shansi with Dr. S. P. Chen as 792 Iµ:PORTS. Vot XII medical director of quarantine stations at Kalgan and N:mkou to keep Kingsui Railway open. (Area of 35,000 square miles.) Fourth. From Yenmen Pass southward along the Great Wall under Tuchun of Shansi. Boundaries of Chihli, Charhar, and Shansi to be strictly "Watched by troops under Tuchun of Ch; hli. Gen. Chiang is responsible ior preventive and suppressive measures generally. (Area of 75,000 square miles.) February 3, 1918: Sinlo reported infected. Shansi south of Wall · 35 deaths in two days. Fcngchen; total deaths, 70. ' February 5, 1918: Inside "Tall near Yellow River is a newlv-in- fected area. It is announced that the road on both sides of the 'y cl- low River should be watched as well as the river itself when opm to boats. Translations being made of plague literature. No new cases for a week in Taichow district. Feburary 15, 1918: Tingchow; no further ·cases. Chentinfu; sat isfactory. Huts to the number of 200 shipped to Fengchen for ad- vance quarantine station. Pekin announces: "Spread of plague now under control." February 18, 1918: Suiyuan district, 1,500 dead; more in outlyin!? regions. Shansi; 116 dead in past two days. February 23, 1918: Four suspicious deaths in Pekin. Average of 60 deaths a day in Shansi admitted officially. February 28, 1918 : Fengyang, Anhui; 8 deaths :from bubonir plague; Pengpu; 1 death. March 1, 1018: Tsinanfu, 4 cases. March 15, 1018: Nanking, 25 cases. Table of reported cases. ------P-fo.oo_. \. ~~~IE~t:::::: .:.:.:. :. : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : :1 Kwei Wha Chen .......... . ............................ . Tsinfau ............................................. -... . Pengpu .......... _ . _ . _ . _ .. _ ... _ .... _ . _ . _ . _ . __ . _ . _ .. _ ... . S tn tao ho .... _ ...... ....... _ .... _ . _ .. _ ... -... -. -- --.. -... - S.ira!Bi ............... . ........ . ..... _ ....... _. ____ .. _. _ .. ~~;~~~:::::::::::::::::::::::::::::::::::::::::::::::: I Sniyna.n .. _ .. __ ............ _ .... _. _ ........... __ .. ___ . _ .. Run Ts'ung .... -.. . _ ....... ___ ......... -... -... -... . ... . Ta.ichow . . . . . . . . . __ . ..... _ .. ... . . .. -. -... .......... . Ta.iyua.n Fu ....... _ .................................. ' .. . Tatnn Fu .... - . . . : ............. - _ .... -.... - . -......... . Taihsien ....... ............. -..... -......... -........... . Cases. Date roportod. 8 Feb. 28, 1 !ll 76 Feb. 3, l!ll 13 Jan. 16 to:?!?, 1918. 100 Jan. 22, l!ll 4 \Jar. 1, l!l\S 1 Ft>b. 23, 1918 4 Jan. 2:1, 191 1, 000 Jan. lG to 21, 1918. 157 Feb. :l, l!ll 2 Jan. 17, J!JIS 1, 500 Feb. 18, l!lJf; 17 Jan. :!1, l!ll 38 Nono Pince Feb. I, 1!118 233 Jan. 27, WIS 6 Jan. 24. ms 17 I Jan. 21, l'.118 702-1 ---·lllllllllllllfl J'IS. VoL :\O:IJ tions at Kalgan nnd N ankou to :a of 35,000 square miles.) 1uthward along the Great Wall daries of Chihli, Charhar, and troops under Tuchun of Chihli. ventive and suppressive measures e miles.) . infected. Shansi south of Wall; . ; total deaths, 70. near Yellow River is a newly-111 the road on both sides of the Yel- ;rell as the river itself when op ·n le of plague literature. No new :t. no further cases. Chentinfu ; sat- 200 shipped to Fengchen for ad- nnounces: "Spread of plague now :rict, 1,500 dead; more in outlying two days. ious deaths in Pekin. Average of ed officially. 1 Anhui; 8 deaths from bubonic '" ;es. ported cases. -.--1· ................. , ....................... .................... 1::::::::::::::::: Cases. Date reported. 8 Feb. 28, 191" 76 Feb. 3, Hll" 13 Jan. 16to22, l!Jl8. 100 I Jan. 22, 191~ 4 \lar. 1, HHS 1 Feb. 23, 1!J18 4 Jan. 2:l, l'llS 1, 000 Jan. 16to21, 1918. 157 Feb. 3, um 2 Jan. 17, 1'l18 1, 500 Feb. 18, l'll!\ 17 Jan. 24, uns 38 Nono einre Feb. 1, l!\11' 233 Jan. 27, l!\lli 6 Jan. 24. l!llo 17 \ Jan. 21, 1!)]8 792-1 c ., Vi -"' c .. ?; .; .g ... c "E- :;; <.> .!':? 0 0 u , ( 7U2-2 The figures above are n •11ch thing as a registrati .,orts. The only informa t .; that from Yolunteer wo 11·onld at first imagine fr They should only be con iemic. Only 2,952 deaths i.000 deaths were occurri The alteration in the t, ·onic at Fengyang, Anhui 1nitted by human fleas or the disease in a rat. Tingsiang in Shansi :,; . ,fficials than most of th~ .~1rgely through early de with the advice of physic! '.'l'flects credit on all cone 5 of interest : Ju comhatinl{ the pneumon •I\\' vei·y clol'ely the methods 1»t place there is no hmq1it1 ·be second plaC'e there are 111 u:w on the sonth. Finnll. urn! rathl'r than urhan. In n boi= practically the gCO!!:l'll -ampaign an attempt was rea in detention stations at ·rlct city. Within a day or ro correct this ·• travelers ' ut were promptly interned -uch as temples." When plague appeared in . \\"!thin th!' village it!'i>t •llil'e. All the villa!!:es in th "illn ge heing strictly forbid Looking toward the 1anger to China, especi. 7G0!)8-18--15 so. 4. REPORTS. 793 The figures above are not to be regarded as statistics. There is no .uch thing as a registration area in China oubicle the larger treaty ports. The only information to be had from the infected territory ·s that from Yolunteer workers. The situation is ±ar worse than one 1rould at first imagine from a cursory glance at the figures alone. They should only be considered in tracing the progress of the epi- ,!emic. Only 2,952 deaths are there represented. As a matter of fact L.000 deaths were occurring in a few days in some neighborhoods. The alteration in the type of the disease from pneumonic to bn- oonic at Fengyang, Anhui, is noteworthy. This may ha Ye been trans- mitted by human fleas or it may have resulted after deYclopment of the disease in a rat. Tingsiang in Shansi seems to haYe fared better at the hands of officials than most of the plague regions. Herc it 'vas no doubt largely through early devastation that the people fiO readily fell in with the advice of physicians. The plan worked cut in thi:; diHtrict reflects credit on all concerned. The following plan of organization is of interest: Tu combating the pneumonic vlugue in Shnni;;i it bas not been possible to fol- low very cloi;;ely the methods employed in lllnnc:hurin seven years ngo. In the 1ir~t plnee lht•1·e iH no lWHpital in nil llH' north of 8ham:i ahove Talyunnfu. In tile ~ecoml plnee there ure no railwnys hetween Tntung on the north and Tni- ruan on the ~outb. Finally tbC' tcrritor~· at'fectC'd ltn~ hcen predominantly l'lll'lll rnthC't' than urhan. In :Manchuria seYen ~·ears ago il was possible to work in ho;.pitals, with th<> railwa~·s as hases, and 1n·11cticall~· all the work was done in lnrge cities. In 1·iew of tht>~c 1lift'erent (·omlitiom; 11 11ew type of puhllc health ;en· Ice has Ileen tlernlopecl i11 the pre:.:(•nt cnmpa if!n, nnd the 1\Ti ter bclie1·e~ that giving wide publicity lo the methods employed, especially In villages, will be of great service to the Chinese people and to all who may be called upon to 1·ombnt this or similar epidemics in the future. Tlng:.:lang i;. n small district, having a total of hut 9G villages. The llistrict city is practicnlly tbe geographic center of the district. At the beginning of the 1·ampaign an attempt was made to hold all travelers returning from infected area in detention stations at the pnsses, or In the detention ;.tation at the dis- trict city. Within a day or two, howeYer, thc!'le detention stations were filled. To correct this ·• tn11·elers were permitted to return lo their nntive villages, but were p1·ornptly Interned either In their own courts or in public building;:; ~uch as temples." \\'hen plague appeared in n village thnt village was promptly Isolated. • * * Within tbC' villagC' itself there wa>:, or comse, the isolation of the plague patients ·ind contacts. Following this " more drastic measures were adopted. The cit~· gates were rloserl to all persons except tbm•e holding special permits from the nntlplngue iffice. All the Yillag-es in the district wc1·e isolated. Intercourse from village to rlllnge helng strictly forbidden." Looking toward the future we mnst consider another source of ilan~er to China. especially to the Upper Yangtze, from the bubonic 7GODS-1S-l5 794 REPOBTS. plague in India, Siam, and French Inc.lo-China. Thi:s region is · fact nearer than the )fongolian epidemic was. And there is r~!: communication within 100 mih•:s of Szechuan which come:-; throu!!~ Tonkin. one of the infected areas of Indo-China. Furthermore, th main road southwanl out of Chungking passes through Yunnan~ ( tlw French railway terminus). directly to the borders of Burnia tlwnee to the British railway terminus. which runs from :\landala,: almost to the border of Yunnan. ~\lmost all of India i~ infected "ith bubonic epidemics, the Madras PresidC'llC)' being probabh the most heavily infected part. · Stitt in 1914 said: Till' plague epideuiit with whil'!1 nil pnrt>' of th\' \\"l>rld an• now '"' <'Oil (.'erned is supposed to !tan• 01·iµ:i11;1tpd i11 <'hi1111. in the J'roYin<·t' of Y1mni11i. The proximity of Ynnnan to India is significant, and the near11c:,, of Yunnan to Szechuan is equally important. It suggests the po~­ :-.ibility of this interior China being a huge reserrnir of infection. During the past year it is estimated that 100,000 Ynnnan and Kweichow soldiers have entered Szechuan. They ha ,-e taken 00,000. This military migration continues and is utterly mid of any sanitary or hygienic organization or arrangement. Reference to the following table;, and to the map will show morP clearly the danger from this direction. ·when 1rn realize that i;;,ooo junks ply between Ichang and Chungking the year round. and that steamers run between these two cities in the summer and lielow Ichang to Hankow the entire ~rear. '"e can appreciate what i,., in store for China if plague begins to take root in Szechuan. To account for the absence of cases here we can not plead too :strongly for the theory of isolation, although the map shows cer· tain natural barriers. Rivers are more or less an obstruction to rodents. But rivers which are crossed by boats reduce the obstruc- tion, and human cases naturally could be carried across riYer:> dur· ing the incubation period. Mountains arc natural barriers to rodents if they are high enough and afforcl scant vegetation or other food. High altitudes operate against invalid migration. Distance increase• the protection. It seems unlikely that these natuml barriers are wholly respon· sible for Szechuan's freedom from infection. There must be other -----...... -., t~5T TUPJ(.tSTAM I "- Bubonic Type. is pr~valenl soulh of Clunq in Mon~olia and North China. ln India lh1 soldiers have come lo .S3echuan from Yol. XI! ma. This region is in as. _And there is rail 1 wlnch comes throu") . F ~1 ma. ~ urthermore, 1 Ii .ses through Y unnanfu the borders of Bunu a. h runs from .;\fantlal:" tll of India is infert"d idenc~r being probaLI~ lip \\ n1·1t1 a 1·p no\\ so <"on t lit• l'rm·in<·t' of Ym1t1m1. ificant, and the nearrn·ss 1t. It ::;uggests the pos. eservoir of infection. at 100,000 Yunnan and They have taken ov1·r ary operations rec]l1iri11., from the southern com;~ Jeen done by coolies. It oming from questionable )0. probably ±00,000 or s and is utterly void of rrangement. the map will show mor1• When we realize that mgking the year round. :ities in the summer and we can appreciate what e root in Szechuan. L'e we can not plead too ugh the map shows cer- >r less an obstruction to boats reduce the obstruc- arried across rivers clur- atural barriers to rodent" vegetation or other food. ation. Distance increase~ Tiers are wholly respon- n. There must be other Bubonic Type is prevalenl soulh of Ch ma and al fengyans. The Pneumomc. Epidemtc. is in Monsolia and NorH\ China. In India lherc. were 17,000 cases in 14 days 100,000 soldiers have c.ome lo .S3ec.huan from Yunanf u and Kweichow in lhe pasl year 794-1 City wall, Quay Fu, Yangtze Valley. 791-2 Ju nk on upper Yangtz e. No. 4. factors oper:~ or existence c Sectional natural barr n .Prev10us c~ Periodical to learn, tho~ zation fro1n ~ of the Phili1, th!l Philippi1j like intervals that idea witi then director ings haYe bet It may he 1 terval of yea immunity de' to succeeding "Dr. KitaSi A. D., when i were reporte~ the beginnin vanced, was ~ outbreak somi At any ra! Szechuan if would mean rrtts arr. rtr<'P this region. few which w Apr. 15-June 30, July 1-0ct. 20, 1 Oct. 21-0ct. 27, \ No. 4. HFl'UB'I ~ 79f) factors operative, such as sectional immunity or perioclic immunity; or existence of the disrnsr in mild endemic form. Sectional immunity may be due to t"o causes in addition to natural barriers: ( 1) To uctin~ immunization after tl 1 " ra rnges of a previous epidemic; (2) climatic conditions. 0Periodical immunit,\' i!> ~omcthing about "·hich we have still much to learn, though it probably depends to some extent on the immuni- zation from predons epidemics. It was suggestPll by Dr. Clements of the Philippine health service during an epidemic of cholera in the Philippines in 1916. Ile belieYed that cholera returned in waYe- like intervals of lt certain number of years, and he was working on that idea with Dr. Long of the United States Public Health Service, then director of the Philippine health service. No Joubt their find- ings have been published. though we do not have access to them. It may be that plague exhibits this tendency to recur after an in- terval of years, perhaps depending upon the persistence of active immunity dcYelopecl in a previous outbreak and transmitted weakly to succeeding generations. "Dr. Kitasato, in a lecture, traced the plague as far back as 200 A. D., when it found its way to Egypt and Europe. TJH' visittttions were reported until between the end of the thirteenth century and the beginning of the fourteenth. Europe, as medical science ad- vanced, was able to drive out the pest except for an inconsequential outbreak some 11 years ago." At any rate, there is nothing to prevent plague spreading in Szechuan if introduced unless it can be explained as above. It would mean periodical rat immunity as well as human immunity, for rats are accepted on equal social terms with the average resident of this region. Rat .fleas are not conspicuous by their absence if the few which we have examined are to be taken as examples. Statistical table. L'WIA. _ D~tc. - - - - I Apr. 15-June 30, 1917 ........................................ . July 1-0ct. 20, 1917 ............................ ... ........... . Oct. 21-0ct. 27, 1917 ......................................... 1 Cases. 43,992 45,657 13,571 Deaths. 30, 1U7 34,074 9, 390 796 REPORTS. Yo!. XI! stoli.~tico/ 111/111'.-( '011lint1Ptl. DISTRifll"TlON. PlaC<'. Dale. Coses. J,a.st r~port. I Ca~~s. -- Bassein ........ _ .\pr. 1-June 30 ... . . 54 July 1- 0ct. 13. l 917. Bombay ............. Apr. 22-June 30 .... :;!)7 July 1-0ct. 20, 1917. Calcutta .......... _ .. Apr. 29-June 2 ..... 38 July I- July 21, 19I7. Ileuzada ........... Apr. I-June 30 ..... 35 Aug. 12-Sept. l5, l!Jl7. Karachi. ........... .\pr. 22-J u ne 30 .... 468 July 1- 0ct. 20, 19I7. Madras Presidency .. A pr. 22-J une 30 .... 250 July I-Oct. 20, I9f7. Mandalay ........... Apr. 8-May 12 . .... !l July 29-0ct. 10, I9I 7 Moulmein ........... Apr. I-June 30 ..... 74 July 1- 0ct. 10, 19I7. MyingyJ.n ......... . . Afar. l-Afu1" 7 ...... I None ............... I'egu ............... .r. ay 27- une 2 ..... 2 July 29-Sept. 22, 19I7. R1tagoo11 ........... . Apr. 15-June 30 .... l83 July I-Oct. 20, I9I7. Toung:>o ....... ..... Apr. 8-Apr. 14 ..... 2 July 29-Sept. l, I917 INDO-CIIIi\A. Dale. Cases. ----------- --- Feb. I-June 30, 19I7 ...... . ................................. . July I-Aug. 3I, I9I7 ........... ........ _ .................... . 730 119 DISTRIBUTION. Place. Dato. Coses. -, ~ Last report. 2!l 432 4 7 4!l 5,490 (j(j 39 ···-····· 2 605 12 Dea tits. 491 89 Cases. Anam ........ ....... Feb. I-June 30 . . . . Cambodia .......... Feb. I-June 30 . .. . 232 132 219 Aug. l-31..... . ... 7 Cochin China ....... _ Feb. I-June 30 ... . Aug. 1-31. . . . . . . . . 26 Kwarg Chow Wan ... May I-June 30 .... . Aug. I-31. . __ ..... 16 Tonkin .............. Feb. I- June 30 ... . 34 113 -------······----- -· ········· Aug. I-31. ....... . SIAM. Place. Date. Cases. Deaths. -- Bangkok ........•... . ..... ...... _ ........ Apr. 22-June 30 ... _ I3 12 July 3-0ct. 27 ...... 31 29 RELIEF WORK AT GUATEMALA CITY. After the earthquakes of December, 1917, and January, 1918. By S. M. TAYLOR, Lieutenant, M. C., United States Navy. Having received orders from the Navy Department to visit the city of Guatemala and report on conditions and render what aid we 796-1 \·nl. XI ( 'olltillUPtl. x. :;es. 54 ;197 38 35 468 250 9 74 1 2 183 2 \. 'I. ~s. 232 132 219 34 113 La.st r~port. I Cn~~•. Julyl- Oct.13, l!ll7.1--~ Julyl-Oct.20,1917. 432 July I July21 , 1917. 4 Aug. 12- Sept. 15, 7 1917. July 1-0ct. 20, l!ll7. ·Hl July 1-0ct. 20, 1917. 5, 400 July29-0ct.10, 1917 (i(i Julyl- Oct.10,1917. 3!l None ....................... . July 29-Sept. 22, 2 1917. July 1-0ct. 20, 1917. 605 July 29-Sept. 1, 1917 12 Cases. D~n tlti. Last report. 730 119 4!ll S!l Cases. ·1--------1---- Aug. l-31. . . . . . . . . 7 Aug. l-31. . . . . . . . . 2() Aug. 1-31. . . . . . . . . 16 ---················· ········ · Aug. 1-31. ....... . Date. Cases. Deaths. 22-June 30.... 13 12 3-0ct. 27..... . 31 29 EMALA CITY. l917, and January, 1918 . . , United States Nnvy. tvy Department to visit the ions and render what aid we 796-1 !'o. 4. could. Capt. Brumby an one hospital appre1~tice. the morning by ,.pecial o·clock in the aft{'rnoon. ber of buildings along t earthquake. Dr. ~\.. M. at the train. and he and went to the first-aim. The sewage dispornl was only fair before the earthquake, the dis- charge emptying into a creek below the city. After the quake all. or pracitically all, of the pipes burst, and their contents were emp- tied into the streets. Before the quake there were two water ~up­ plics, one coming from a large spring, and the other from a ri' er. The one coming from the river was considered bad. This condition had been reported to the Government, but no effort was made to rem- ed:v it. After the quake there was no water to be had in the city, and it was a common occurrence to see the people drinking the water from the sewers. There were 70 native doctors in the city before the quake, but I am sorry to say that 40 of them left imediately after the first quake. There were 50 drug stores that were completely destroyed and prac- tically nothing could be saved. Great credit must be given tho~ native doctors who did stay and gave all their efforts to help relieve the dreadful situation. BULLETIN NO. 1 OF THE BOARD OF I-IEAT,TII OF THE ROCKEFELLER FOUNDATION. With the idea of preventing typhoid fever, dysentery, and other intestlDal Infections the following measures should be tnkcn: 1. Each family will endeavor to build provisional toilets. In order that these f::hould fulfill tlieir full object, they should be a yard in depth. 2. The water for drinking should be used boiled, filtered, or mixed with an- otlicr chemical substnnce, among the most practical are the hypochlorite of lime and the tincture of iodine. In order to use the hypochlorite of lime. take one gmm of it and mix with one liter of water, shake it and use It 15 minut~ after. The tincture of iodine should be used in the following manner-to s liter of water add two drops, shake and wait 15 minutes before using. 3. In order to llrcYcnt smallpox It is necessary that one be vncclnatell. This office has reque,.ted of the home office in New York a sufficient quant ty of the vnccine to vaccinate a;minst smallpox, t~·phoid fever. etc. As soon as it arrives it will be distributed grntultously. This board estahlishcd an emerg('nr~- hospital on the second avenue south, opposite the Escuela Practica Senoritas. GUATEMALA, Decembc,. 31, 191"'1. Among the most prevalent diseases were typhoid; typhus (in out- skirts of the city) : malaria; smailpox; tuberculosis common, especi- :\O· 4. ally grandular; goiter comm amebic and bacillary (high in{ preYa.lent: hook-worm. 22 to :! 111eningitjs. mostly amon~ th ~till worse the officials try to The medical authoritie..;; w thing. They would recomme irrnored. They coulcl not get first-aid station, ancl "·hen t that the naliYe sol· would not first-aid stations properly. Among the most se,·ere in of all kinds; fractures. c;imp n~rc lacerations of an kincls. to haw, nothing physically " fering from shock. whirh wa :md vomiting. During the month of De earthquakes. but the people The first powerful earthqual ing, the second at 10.·!:i. and shocks practically de..;troyed ing the night. On Saturdt~. the next large shock. Tln native physician. The nex Year's night. The last and 10.30 on the eYening of .J American Legation. This f'evcrc. This last sho<'k cm ception as stated before of t Fortunately the food con had established stations wh supplies, the condition~ w nothing left. It is eshma and 800 wounded. In the cemetery at leas irra ves by the force of the burned in oil. . Great credit is due Chie Pharmacist's Mate (Thircl _ tice (Second Class) \Y. \\ peatecl1y expose~ t?em~<>h to bring out the m1ured. \·01. Xlt practically a l1 e fact that the >f the patient~ ; to ho" many every hospital. tally destroved . ' ;h away in the ~ only building 3, 1918, and it cracks in them. 1quake, the dis- r the quake all, tents were emp~ two water sup- ar from a river. This condition >as made to rem- had in the city inking the wate; the quake, but I :r the first quake. troyed and prac- .t be given those ts to help relieve ~LJ,ER FOUNDATTON. and other intestinal In order that these 1th. 'I, or mixed with an- tbe bypochlorite of :blorite of lime. tal>e nd use It 15 minutes ,owing manner-to a before using. ; one he vaccinated. n. sufficient quantity :r • etc. As soon as it second avenue south, .d; typhus (in out- ;is common, especi- 799 REPORTS. tillY grandular; goiter common, especia Uy among men; dysentery ;in1ebic and bacillary (high infant mortality) ; venereal diseases, very prevalent ' hook· wonn. 22 to 25 per cent; and epidemic cerebro-spinal 111eningit,i.:;. mostly among the nati Ye sohllers. To make matters still worse the officials try to conN.'al the contagious diseases. so. 4, The medical authorities were practically powerless to do any- • thin~. They would recommend sanitary measures only to have them ignored. They could not get the people to c:ury the wounded to the first-aid station. and when told to work they refused. It is true that the native soldiers shot a great many people :for looting, but it seemed that they would not help to guard the hospitals and the first-aid stations properly. Among the most seYere injuries were tl1e :following: Contusions of all kinds; fractures, c;iroplc and compound; peritonitis; and se- vere lacerations of all kinds. A great many of the 'people seemed to havo nothing physically wrong with them, but seemed to be suf· fering from shock, whic11 was characterized by extreme nerYousness and vomiting. During the month of December there had been a great many earthquakes. but the people dicl not pay much attention to them. The first powerful earthquake occurred at 10.30 on Christmas even- ing. the second st 10.45, and the third about 11 p. m. These three shocks practically destroyed the city. Smaller shocks occurred dur- ing the night. On Saturday. at 2 o'clock in the afternoon, occurred the next large shock. Thi.s shock killed Dr. Volla, a prominent native physician. The next large shock came at 12 o'clock New Year's night. The last and most terrible of all the shocks came at 10.30 on the eYening of ,January ;~ \Vhi1e we were there in the American Legation. This shor.k was considered by all the most severe. This last shock completely deslroyed the city with the ex- ception as stated before o-f the American Legation. Fortunately the :food conditions were good, and the Government had established stations where food was given out. A.s to medical supplies, the conditions were ve<"J bad, as there was practically nothing left. It is estimated that about 350 persons were killed and 800 wounded. In the cemetery at least 10,000 bodies were thrown out of the graves by the force of the shocks. These bodies were immediately burned in oil. Great credit is clue Chief Pharmacist's Mate William Schofield, . Pharmacist's Mate (Third Class) C. A. Ray, and Hospital Appren- tice (Second Class) W. W. Methven, United States Navy, who re- peatedly exposed themselves to (\anger in falling buildings in order to bring out the injured. 800 REP0.HTS. Vol. :\ 11 REPORT OF AN EPIDEMIC OF 3-DAY FEVER AT THE UNITED STATES NAVAL AIR STATION, -- FRANCE. Hr IJ F1:n1;i·so:-;, LIPnt••nnnt. '.\I. C' .• United Stat"" Xa\'J". An epidemic res<'mbling influenza, which has been sweeping through Europe\ reached the United States Nan1l Air Station at ---,France, on June 24, 1918. The French authorities reported an epidemic in Algiers. in the eastern :\Iediterranean States, and th!' eastern Adriatic liUoral during the spring and summer of 191 i, and according to information received by medical officers of the United States Army considered these epidemics as dengue and pappataci :fever. It is now thought that these epidemics were Lhf' beginning of the one now prevailing. Etiology.-Vp to May 27, 1918, the exciting organism was not definitely identified. Since then, in eight cultures made on cases in the --- Regiment, United States Army, American Expeditionary Force, at Base Laboratory, Base Section No. 1, five cultures were positive for an influenza-like organism, described as a small gram negative bacillus in symbiosis with the pneumonias. It grows only on blood medium and presents the characteristic dew-drop colonies. It is very difficult to grow alone and to transplant. l\forphologically it is indistinguishable from Pfeiffer's organism, but, due to the dif- ficulties attending research, it has been impossible as yet to de- termine accurately its biological characteristics. Cultures ar<' non- toxic for rabbits. In a series of 20 blood cultures all were negative, 1hough every- thing pointed to a general infection. A series of 20 pharyngeal cultures were made at Base Hospital No. 8, American Expeditionary Force, and the results will be avail- able for our study on the return of the Lacteriologist from detached duty at the front. The final opinions of the laboratory men of the American Expeditionary Force as to the identity of the organism will be forwarded as soon as they become available. No immunizing work has been attempted as yet. White and colored races are equally susceptible. Symptoms.-Sudden onset of fever, varying from 90° to 105°, more commonly 102°, with jntense headache, backache, and general pains throughout the body. The degree of prostration varies greatly in different cases. Pain in the chest, made worse by deep inspira- tjon, and some cough without corresponding physical signs were cha1·acteristic of the majority of cases. Physical signs.-Tbe majority of cases were negative on physical examjnation except for infection of the pharynx and infection o:f the conjunctiva, the latter givjng the appearance of" pjnk eye." ~o . .J. Clinic((l 1·011 hours. falls ra hours. ~\. ppC't i usually got·~ to Comp! icafir11 ity, and the onl a case of front T1·ecttme11t is P1·eventio11. s Navy. which has been sweepin ~tates Naval Air Station a~ . F~ench authorities reported . ed1terranean States, and the ng.and summer o:f 1917, and .ed1cal officers of the United :s as dengue and pappatac· .d . i n em1cs were the beginning exciting organism was not ht cultures made on cases in ny, American Expeditionary Jn No. 1, five cultures were , described as a small. gram pneu?1~nias. It grows only acter1st1c dew-drop colonies. :ran~plant. Morphologically ·gamsm, but, due to the dif- m impossible as yet to de- teristics. Cultures are non- .-ere negative, though every- vere m~de at Base Hospital :md the results will be avail- bacteriologist from detached >:f the laboratory men o:f the he identity of the organism e available. No immunizing and colored races are equally varying from 90° to 1050 lache, backache, and generai of prostration varies greatly nad~ worse by deep inspira- ondmg physical signs were es were negative on physical pharynx and infection of the ·ance of " pink eye." No . ..J. REPORTS. 801 . Clinical cou1•se.-The fever attains the highest point within 36 hours. falls rapidly, and is generally normal at the end of 48 or 72 hours. Appetite returns with the fall of the fever and the patient usually goes to duty after 3 days in the sick bay. Complications.- In the 163 cases treated here there was no mortal- ity, and the only serious complications were a case of otitis media an were made. These cilli but positfre for strepto- a local treatment, while tinc- e administered internally. On i>e for anthrax bacilli and ~o There was no improYement in 0 the cultures made on J anuarv tx bacilli, but the infection ha~l )n of the pustule was thought nperature dropped to 101°, the became delirious, vomited. and irritation. A spinal puncture a fluid showed it to be loaded ied at 6.45 p. m., January 31, THE VIRGIN ISLANDS OF THE I.TES. ), United States Navy. who has never been a way from ' dizzy " and of frequent loose .scaris lumbricoicles, Trichiuris motile Balantidium coli Wl'r<' nedication with santonin and >rms of Balanticlium coli. Sub- :lays later showed them as thev •e the first case of Balantidim~ ~ difficult to distinguish this or- es, but this can be overcome by s in water at a temperature of st be seen by using the method R. Stitt, M. C., United States lution (Lugol's). JS INFECTION. nder, M. C., United Stales Navy. physician whom I have Im.own out 10 years in Germany, wherl' ' served in a hospital in Berli11 REPORTS. 803 : 1nd told me that, soldiers who had rccei-.;·ed wounds at the front. when operated upon subsequently for any rea'-on what$OCYer. as an appPn- dectomy. for example. frequently clewloped tetanus and died. It ap- pears that tetanus bacilli were introduced into the patients _at the time of the original wounds and remained latent or local until they became active in consequence of a lowered resi:oJance due to the second operation. It is now the rule in the hospitab in Germany that all 5nch patients, before a second operation, receiYe an immunizing e made him peculiarly well qualified to impart instruction in a simple and lucid style. A MANUAL OF CLINICAL DIAGNOSIS, BY 11!EANS OF LABORATORY Mt-:THOOS. l"OR STl'- DENTS, HOSPITAL PHYSICIANS, AND PRACTITIONERS, by Cl1nrlc.~ E. Si111011. B. A., M. D. Ninth Edition. J,eu & Febiger, Philndelphi:t nnd :'\ew York. 1918. In general this book attains a high standard of usefulnel'S. and thl• fact that a ninth edition has been called for is no small tribute to so;:; BOOK XOIICES. \'ol, XII. the >alue of the book. It would be ungenerous to allude to minor defects but for the fact that by mentioning oversights or inaccuracie~ these may be corrected in a possible tenth edition. Four types of pneumococci are mentioned, but the methods of determining and differentiating them are not given. No mention is made of the dif- ferent types of meningococci nor of the Dryer technique for de- termining typhoid and paratyphoid infections. In f animals is described but . . ' g1 ,·en mtra venously, intra- rm typhoid serum is used ieant. The author has not 1thorities in the matter of iium immac:ilatum instead naria a111ericana instead of ;tric contents no mention is duodenal contents are not ~cen, U. D., LL .D. Second edi- 1918. ~ed and improved since the It now forms a compact, )al features of modern war :{Jue Charleton, M. D., Ji'. A. O. S. )}ume is a reprint of a lim- gift for Base Hospital No. manifestations, each accom- end are instructions to men nple of the bookmaker's art red, however, as a contribu- sease, its value is qucstion- education should be toward and self-control. Without s acts only during the ab- rregular methods of sexual upposed to' be less. On the book to a patient having a use so many of them have ent. No. 4. BOOK NOTICES. 807 '.rHE MEDICAL HEPORT OF THE RICE EXPEDITlON TO BRAZIL. 'By IV. 'I'. Councilman, .1f. D., and R. A. l~ambert, M. D. Fl'om the School of Tl'opical Medicine, Har· val'd Univel'Sity. Cambridge. H:uYarcl Univer sity P ress, 1918. . .\n interesting account of an expedition primarily undertaken for a study of physical geog1·nphy, especially that of the region between the Rio Negro and the 01:inoco RiYer. Owing to the extremely low water in the Rio Negro the original intention could not be fnlly car- ried out. ThP report contains a chapter on the Amazon Valley. ~peaking of the Indium; of the Rio Negro, the report says: Certain of the customs a re also to the advantage of 1hc male, as when a woman giYeS birth to a child the father goes through a pcriocl of rest in his lrnmmock and receives delicacies and congratulations. The valley of the Amazon is the 1uost unchange nsed for n common purpose, not eYen for t he production of wood pulp. Doubtless, howeYe1', the time is approaching when t he demand fur lum· her, "·itlt the rapidly decreasing suppl~', will compel the world to drnw upon rhis seemingly inexhaustible source. " Much of the life is inimical or certainly unfriendly to man." The unprovoked attack on a man by the jaguar is unusual. The boa constrictor, though rare, has been known to attack man. Among poisonous reptiles are the rattlesnake, the coral snake, and the jacaraca. Mention is made of an ant an inch or more in length, found chiefly in the forests, whose sting produces great pain and prostration and sometimes death. ·This is the Tucandera or conga. Of the " forag- ing ants" the most interesting is the Saliba or leaf-cutting ant, which carries sections of leaves to its nest. After the material has been prepared by chewing, it provides a soil for the growth of a fungus, which constitutes the ant's favorite food. It excavates long tunnels in the earth, with communications extending hundreds of feet, and . os BOOK XOIICES. VoL XU. throw!-, up mounch; of earth seYeral feet high. Xests an' fot'llwd 111 the trees. Some species are winged. The region is characterized by a small biting fly, 2 to 3 mm. in length and 1 mm. in breadth. Protection from the bite can he ob. tained only by close-meshed head nets and gloYes. This fly is know11 as the pium and to it are ascribed the ulcers so common in this regio11. A more tormenting insect than the pium is the larrnl form of a "pecies of Trombicliclea. It has a soft body, with 6 legs pro,·ic\t>il with claws and a powerful h~' J)()stoma, which it clrins into tlw skin. It is so small as to b<' barel,Y ,·isible lo the naked eye ancl is ln·i ~h t orange in color. Tht' sting pro(111c<'s no irritation at tlw mon1P11t hut later an indmated wheal se,·eral centimeters in ([inmetPr fo1·111". The small towns of the upper Amazon are usually situated on high ground and appear comparaliYely healthy. the ~nalaria hc>i11g milder than that seen on the lower Rio Negro. . In discussing malaria on the Rio Negro, 3 general typt>s of in fc('- t1on are recognized: ( 1) An infection characterized by the pr<'sern•t• of numerous parasites in the blood with little or no disturbance i11 health, especially in children under 10 years; (2) a chronic infection showing moderate anemia, weakness with considerable splenic en- largement. There is an absence or scar city of organisms in the cir- culating blood. This corresponds to the so-called "malarial ca- chexia " of many writers. It is a predominating type in the Amazon r~gion; ( 3) the ordinary type of infection as we see it in suscep- tible people from the temperate zone who visit the Tropics. Chronic malaria is extremely prevalent in the Amazon Valley. ~\cute and malignant malaria was not observed by the Rice Expedi- tion, but it is said to exist. Of the cases examined, only 7.2 per cent showed organisms in the circulating blood. No quartan forms were found. Leprosy is widespread. No cases of yaws or filariasis were seen. Ulcers are extremely common and haw recently acquired greater in- terest through the discovery in them of Leishmania. The accepted mode of treatment consists of intrannous use of tartar emetic. ( ' J.I:\'IC.\J, ll1AGl'\OS1S. .\ llfANUAL OF LABORATORY METHODS, by Jame.~ Campbell Todd, Ph. B., JI. D. Fourth IDdition. W. B. f;nunders Co., Philaclelphi:i, Pa .. 1918. .A work of oYer 600 pages filled with illustrations of 11nus11a l merit. DISI:ASES OF TTU: :\LA L~; UlU~TlillA, INCLUDI:\G Hil'O'n::\CE .\ND STEIU1'1'l'Y, h~· J. /:). I\.oll, B. S .. M. D .. /1'. A. C. S. Illustrated. W. B. Saunders Co., Philndelphlu, Pa., 1918. The type, paper. and illustrations are of the high order which characterizes Saunclers's publications. Besides many new c1rawin~s, ~o. 4 . illustrative of the te trate the reYelations confusion has arisen on pages 80 and ol an The chapters on no rhea, and on tumors rial not commonlv fo The author claims from 5 to 10 days~ p the discharge has be in 20 days, he is clo known. He puts his patien drink 15 to 25 glasse ~1£ bicarbonate of so albargin are made th istered as a 1 per ce base, with glycerin a 15 minutes, and then this material should If the patient can no take injections of pr strength and twice treatment includes water. If the germ treatment has failed necesarily, a proof o germs are found aft several times a day aminations have bee " preferably a glass followed the alcohol the penis. an anterio Next morning exa has been effected. form a fa>orable o sketchiness and lack fied and unconYinccd advice, regarding pr he has to off er in co and without a guide. ence to surgical trea 76098-18--Hi ES. Vol.XU. high. Nests are formed in all biting fly, 2 to 3 mm. in ion from the bite can be ob- nd gloves. This fly is known Jers so common in this region. um is the lal'\'al form of a body, with 6 legs provided \\·hich it drives into the skin. the naked eye and is hright 10 irritation at tlw moment ntimrters in t. "'. B. ~a u111l en; Co .. Pllilatlel- phiu, Pu., 1918. A nontechnical presentation of the topic has long been needed and this work fully meets the requirements. Being intended not for med- ical officers or members of the Hospital Corps but primarily for of- ficers and men of other branches of the military establishments, the strictly medical topics have been lightly touched upon, while matters that should be generally known are discussed in greater detail. Ex- cellent judgment has been shown in making this distinction in the lan- guage employed, in the illustrations, and in the size of the book. It does not seem unreasonable to require the mastery of its contents by all officers intrusted with the command of troops. In spite of the re- peated lessons from previous campaigns, military and naval men are slow to grasp the extreme importance of hygiene and sanitation for the successful issue of their enterprises. Though it may be far off, the day is undoubtedly coming when the loss of from 5 to 20 times as many men from disease as from wounds will be as discreditable to those in command as a fault in strategy; when to permit any con- siderable proportion of one's available force to be made unavailable, through preventable sickness, will be held as criminal as to permit them to lose their lives through failure to afford adequate protection in trench, bomb-proof, and turret. TROPICAL SUl!OERY AND DISH.SE& o :i,- THE F ,\U EAST, by J. R. ill cDill, M. D., I•'. A. 0. S., Major, Jlerlica/ Reserce Corps, U. S. A. C. V. l\fosby Co., St. Louis, Mo., 1918. The author has collected and, undrr a misleading and inappro- priate title, presents to the reader in a most attractive way many facts of interest regarding tropical clisetl.ses. His personal observations and suggestions are valuable. The illustrations are profuse and de- rived either from the author's collections or periodical literature. Without having much to say nbout surgery and without in any sense exhausting the topic of tropical diseases, the book still deserves a place in the library of a doctor going to the Far East. Trrn SUBMARINE IN WAR AND PEACE. ITS DEVELOPMENTS AND ITS POSSIDILITIES, by Si11101i Lake, M. I. N. A. With 71 illustrations and u chart. J . B. pppincott Co., l'lliladelpllia and London, 1918. This is the history of the development of the submarine from the time of David Bushnell's quasi achievement to the present time, writ- ten in a singularly interesting style, free from technicalities. Ample space is devoted to the achievements of Mr. Hollanntire camp (o There has the America third Street, S"OTICES. vo1. xn. set forth. The concluding chapters .rine. ! inventors and inYeiglu; against the • world, though he magnanimously ap<; which prevent the nan.1 oflicer •ith proper avidity, but this narra- 1 of the hesitation felt by the gen- mtor. The failures, the narrow es- tt mark the progress of some great as an idea to its birth and later de- 1mercial value, mtty well give the ~liability of the inventor has been ermnent. The bold imaginative and II' arc the very antithesis of the .s operations of ordinary businPS". ustify his control o:f men and his s eminently practical and reliable, roposition as a: new invention, is t-0 )le asset of his professional reputa- ANNOUNCEMENTS. Mr. Herbert Putnam, the Librarian of Congress, ancl General Di- rector of the Library War Service, American Library Association, has asked the Bulletin to give publicity to the following facts about the work of the Library War Service. In a period of 7 months 1,271,800 books have been shipped to 39 large camps, where there are trained librarians and 36 library buildings; 185,000 books to 211 small camps; 130,000 books to 111 naval stations; 30,000 books to 111 vessels; 20,000 books among 81 hospitals-Army and Navy; 200,000 books for use on transports and overseas. Thus 2,000,000 gift books have been sent out through 600 agencies. In addition to all this, 350,000 new books, mainly technical, have been pur- chased and put to use. The subjects covered range from fiction. poetry, history 11.1 technical aml scientific works. I:f there is any ship, camp, hospital or station withouL a supply of suitable reading matter for the men, send the following data to the Library War Service Headquarters, Library of Congress, 'Vashing- ton, D. C.: Same and address of camp (or vessel) ; Kind of cnmp (or vessel) ; Approximate number of men in camp (or on board) ; What agencies are supplying reading matter and to what extent; What local library, if any, is cooperating; How many and what kind of books are needed; How many magazines are needed; Where will reading matter be housed; Who should be notified wben books and magazines are shipped; Will he arrange for the circulation of this reading matter throughout the mtire camp (or vessel). There is no red tape about getting the books; men in charge will be asked to keep simple records, instructions for which are furnished with each library. There has recently been organized in X ew York a c:ociPt~· en lleOLOGY has recently made its appearance. The preface is an attempt to justify the "establishment of a new scientific journal. * * * at this critical period." The other articles are: Hrdlicka, Ales: "Physical anthropology : Its scope and aims." :Miller, G. S., jr.: "The piltdown jaw." Hooton, E. A.: " On certain Eskimoid characters in Icelandic skulls." Holmes, W. H.: "Organization of the Committee on Anthropol- ogy of the National Research Council, and its activities for year 1917." When contributl desirable. Fasten an abomination. • form such as Iette paragraphs. nil of LETIN endeavors t•> editor can be spnr viated if autho~ , sues. This is not views. For l'X:11UJ of the Gai;seriun c; By fl .. \I If a reYi<>w ls su F. R. C. S. (En;:.). of Texas, <>ntitlE'sociatlon Press, it Is best to write the name of the perio1\i<-nl In full. The greatest accurc1cy antl f11llncs11 should. be emploucd in all citations, as it . ias sometimNl b<.'ell necessary to decline articles otherwHe <\c..;lrahle because h: was impossible for the editor to understand or verif~- references, quotations, etc. The frequency of gross errors in orthography in many contributions Is conclusive evidence that authors often fail to read over their munul:'crlpts after they have been typewritten. Contributions wblch require lilustrntlon must be received two months prior to the date of the Issue for which they are intended. Only the names of actual reviewers for a current number appear. The BULLETIN prints only original articles, translations, In whole or in part, and reviews and all original contributions are accepted on the assumption that they have not appca1·ea previously and. are n-0t to be reprinted. elscichcrc wit• out an 1111dcrstanding to that ctJect. 815 I1DEX TO U~l'1 [Articles not a Abdomen, wounds oL_ Abdominal draina~e-- Abdominal pain _____ _ Abdominal self-protecti Abscess of metliastlnu Abscess, mastoid ____ _ Abscesses after tonsil! Accidents, aeroplane _ Accommodation, spasm Aeroplane accidents, Air chambers for the ~ Alcohol, cetylic ------ Altitude for the tuber1 American Defense SOC! Amputation stumps _ Anaerobes --------- Anaphylaxis, acute _ Anemia, splenic ----- Aneurysm after salYa Aneurysm and ruptur Animal parasitoloi:y, r Anthrax ----------- Anthropology, Amer! Anthropology, pb~-sica Antityphoid in)__ 89 Abdominal drainage ___________________________________________ (ab)__ 91 .Abdominal pain------------------------------------------------------ 385 Abdominal self-protection ____________________________ ----·-----(ab)__ 750 .Abscess of mediastlnum ________________ ··----------------------------- 449 Abscess, mastoid-------------------------·---------------------------- 478 Abscesses after tonsillectomy ___________________________________ (ab)__ 10:5 Accidents, aeroplane ------------------------------------------(ab)__ 809 .Accommodatlon, spasm oL------------------------------------- (ab)__ 10:; Aeroplane accidents, medical aspects of ________________________ (ab)__ 309 .Air chambers for the Navy stretcher__________________________________ 441 .Alcohol, cetylic -----------------------------------------------(ab)__ 295 Altitude for the tubercular ____________________________________ (ab)__ 277 .American Defense Society ------------------------------------------- 813 Amputation stumps ------------------------------------------(ab)__ 744 .Anaerobes ---------------------------------------------------(ab)__ 494 Anaphylaxl~. acute ------------------------------------------------- 447 Anemia, splenic ----------------------------------------------------- 13 .Aneury;;m after salvarsan____________________________________________ 715 .Aneurysm and rupture of left posterior cerebral artery________________ 702 Animal parasitology, review·s of literature on __________________ 99. 293, 494, 75!l .Anthrax ----------------------------------------------------------- 801 .Anthropology, .American Journal of----------------------------------- 814 Anthropology, physical ----------------------------------------------- 814 Antltypboid inocnlntion in Italian Nary ________________________ (al>)__ 93 .Antltyphoid vaccine, the dangers of Intravenous injection oL__________ 1 .Appendicitis, surgery of--------------------------------------------- 393 Athletics and their relation to war---------------------------------- 592 Aviation candidates ----------------··-------------------------lews Editorials __ _ Emphy~ema Empyemn Streptoco Treutmen Endocrine m Entries ot " Epidemic ot Epidhlymoto Erythema bu Er~·thrma no Examination Eye-dis 'l~e. ne,·iews Face. wound. Fever, three U~IE XII. Paee. ______________________ (ab)__ 292 ----------------------------- 75 ______________________ (ab)__ 405 ______________________ (ab)__ 730 ______________________ (ab)__ 7:;4 ----------------------- 342,57~.so~ ----------------------------- ----------------------------- ----------------------------- ----------------------------- ----------------------------- ·----------------------------- ----------------------------··- diagnosis, preventive treatment 720 710 327 78 ·--------------- ------------ ~S4 lkin's solution nrnl lh<' l:i --------------------------- 195,20~ ------------------------------ f the left posterior ___________ _ Station, Great L akes, IIL _____ _ ------------------------------ ________________________ (abl -- ------------------------------ ------------------------------ 212 702 627 1:.!l 271 84 474 lning Camp, San Diego. CaL___ 131 ·------------------------------ 140 ________________________ (ab)-- 735 ------------------------(ab)__ 740 ----------------------------- 103,295 ______________ (ab)-- 307 of--- ------------------ ------- 712 i4 Diphtheria bucllll, virulence of------------------------------- -- (ab)-- 100 Diphtheria, cutaneous------------------------------------------------ 70!l Disabled soldier, future oL------------------------------------ (uh l-- :-JOG Disabled soldiers and sailors. what France is doing !or __________ (ub )-- 112 Diseases, mental and nervous, reviews of literature on--------- ------ 279, 4S3 Dislocation of carpal semilunar bone---------------------------------- 701 Drainage, abdominal ------------------------------------------ (ab)__ 91 Drilling, axiuL-----------------------------.------------------ (ah l -- !l:.! Drink, relation of to work and health-------------------·-----s oL __________________________________ (nb l-- 502 Reviews of literature on---------------------------- ------- 10~. !:!f!S. 4!);-, Editorials----------------------------------- --------------- 65, 243, 433, 6'.J3 Emphysema of conjunct! 'I'll------------------------------------------- 473 Empyema--compllcatlng pneumonia----------------------------------- 783 Streptococcal____________________________________________________ 453 Treatlllent of---------------------------------------------------- 786 Endocrine Illanlfestations -------------------------------------- ------ 609 Entries of vaccinations on cover of health record-------------------- 76 Epidemic of three-day fever---- ------------------------------------ -- 800 Epidldymotony in military surgerY--------- -------------------------- 623 Erythemn bullosum-------------------------------------------------- 464 Er~·thPma nodosum -------------------------------------------------- 467 Examination of tnintors, The---------------------------------------- 30 Eye--<, ntal Infection in__________________ ---------- ( nb l-- 50:~ Reviews of literature on---------- --- ---------------------- 105, 2!l8, 4!l5 F. Face. wound::; of ------------- __________________________ (ah) __ Fever, three-day, epi S_vphil is of _ -------- - - ----------------------------- - ------------- 200 !110. 4. INDEX Malaria: Chronic--------------------- Histology of---------------- Prevention oL _____________ _ Treatment of--------------- Mandible, fractured _____________ _ :\Iastoid abscess ________________ _ ~Ieat, condemned, use of_ _______ _ )fediastinum, abscess oL _______ _ l!edical school, Salem o _________ _ :Uedical sciences, progress in : Chemistry and 11hnrmac:y ___ _ Eye, ear, nose, and throat_ __ General medicine ------------ Hygiene and :;anitution ______ _ Mental ancl nervous diseases Military, legal <.nd imlustria Pathology, bacteriology and Surgery ___________________ _ Tro1)ieal medicine --------- Medical service, Italian _________ _ l\Ieanitary, from a marine trai Operating units at Neuilly ____ _ Ophthalmolo~y and oto-laryn:;ol Os calcis, fracture or_ ________ _ E XII. Vol. XII., ------------~-----(ab) __ ake at __________________ _ __________________ (ab) __ ·------------------ (ab) __ r of ____________________ _ Pare. 220 568 739 796 704 341 765 251 275 76 366 ------------ --- ---- ------ 452 __________________ (ab)__ 481 ------------------------- 577 ---------------- 59,225,419,653 ------------------------- 443 --------------,---------- 347 184 21 27 653 ---- -- ------------- (ab) __ 754 ·------------------(ab)__ 481 ------ - - -------- 93,286,489,757 442 560 --------------- 108,300,504,762 ------------ - ----------- - 1 __________________ (ab)__ 108 __________________ (ab) __ 756 _____ _____________ (ab)__ 773 --------- --- ______ (ab)__ 763 59 ------------------------- 805 ------------------------- 331 __________________ (ab)__ 295 __________________ {ab)__ 284 ·-------------- 108,300,504,762 ·------------------------ 813 ___________________ face__ 86 __________________ (ab)__ 317 455 266 No. 4. INDEX TO VOLUME XII. 821 M. Malaria : Paite. Chronic------------ ------------.. ·-------------------------------- 457 Histology of-------------------··-------------------------- (ab)__ 87 Prevention oL-----------------··-------~------------------ (ab)__ 279 Treatment of ---------------------------------------~-----(ab)__ 725 Mandible, fractured__________________________________________________ 478 Mastoid abscess------------------------------------------------------ 473 Meat, condemned, use oL--------------------------------------- lab)__ 490 ~fediastinum, abscess of______________________________________________ 449 Medical school, Salerno_______________________________________________ 225 Medical sciences, progress in : Chemistry and pharmacy _______________________________________ 103, 295 Eye, ear, nose, and throaL--------------------------------- 105, 298, 495 General medicine---------- - - --------------------------- 87, 271, 481, 725 Hygiene and sanitation __ :._ _______________________________ 93, 286, 489, 757 Mental and nervous diseases----------------------------------- 279, 483 Military, legal and industrial_ _________________________ 108, 300, 504, 762 Pathology, bacteriology and animal parasitology ________ 99, W3, 494, 759 SurgerY---------------------------------------------------- 89,282,742 Tropical 1uedicine --- ------ - ------------------------------------- 95 Medical service, Italian---:--------------------------------------(ab)__ 492 l\Ie4, 75!l Penis, tuberculosis oL ________________________________ --------- (ab) -- 4S.~ Pericardia! effusion__________________________________________________ 717 Pbarinacy-war and------------------------·----·--------------- (ub l-- 103 Reviews of literature on __________________________ -------------- 103. ~:; Plague !u China, spread of------------------------------------------ 789 Pneuinococcus-growth of ______________________________________ (ab) -- 101 Research OD------------------·-------------·- -- --- ---------------- 150 Pneumonia-Empyemu coinpiicating ______________ ---------- ----------- 783 Report of cases------------------------------------------------ 775, 77s Serum in ______________________________________ ------------------ 102 Sy01ptoins------------------------------------------------------- 447 Pneumothorax, spontnneous ---------------- ----------·---------------- 451 Polson gases--------------------------------··------------------------ 173 Poisoning, chlorine ____________ -------------- ----- -----·-------- (nb l-- 307 Pouch, llospitul Corps ___________________________ --- ------------------- 44:~ Progress in medical sciences. (See Medical scl-en.:es.) Prophylaxis, venereuL _____________________ ___ ------ ----·------(ab) -- 767 Prosthetic nppllances ----------------------------------------(ab)__ 751 Psychiatric material in Portsmouth prison____________________________ 406 Psychin try, Wassermann test in ________________________________ ( n b) -- 279 Purgation before operation ____________________ -- -----------------(nb) __ 742 Purpura hemorrhaglca _____ ---~------------- ------------- ------------ 5."i~ Putrefactions---------------------------------·---------------- (ab l-- 2SG Supernumerary-limbs------- ------------------------------- ---fnce__ 86 Tooth __________________________________ : ________________________ 270 R. Recruiting ----------------------------------·------. ··---------------- GG2 Recruits, report on heart murmurs iD-----------··----~---------------- 577 Reports------------------------------------------·--------- 121, 327, 527, 77:1 Daily sanitary ________________________ : _______________ ------------- 2'23 Repression of war experience __________________________________ (ab)__ 485 Retina, cletuchment of-----------------------------------------(ab)__ 2!>8 Revue, Interallice --------------------------------------------------- 814 s. Salerno, medical school of------------------------------------------ 225 Salivary glands---------------------------------------------------- 71!> Salva rs:i 11---------------------------------------------------------- 4-18 Deu th from---------------------------------------------------- 262 l\fanufacture oL------------------------------------------------- 1:12 Ruptured nneurysm after--------------------------------------- 715 Sanitary notes, marine training camP--------------------------------- 327 Sanitary report on Vladirn!'ltok------------------------------------- 146 San! ta tlon-enmp and trench --------------------------------- (ab) -- 300 Reviews of literature on ________________________________ 93, 286, 4S!l, 757 Scnbles, treatment of ---------------------------------------(ab) -- 2SV, 756 :'.\o. 4 i:;(;!er:t, re'-eet ion of Screen, bedside ___ _ Sebaceous cysts __ _ Semllunar bone, ca Ship, hospital ___ _ Sing Sing, ndmissl Skin grufting ----- Solar-ruy tl1erupy_ Soy bean --------- -"IJleni c· a 1emla __ Splnnl fluid in rein system -------- !'.'ta tis tics, ceusus S tutu re ---------- Sterilizer for drln Stethoscope bell, o. Stretcher, air cha St. Thomas, Yirgi Student medicnl o Substitute for ha Surgeon, naval, w Surgery, reviews Surgical judgment Surgical notes __ _ Swimming 1.ools, Syphilis-cerebral Ear, in ____ _ In IlaltL __ _ Legal ennctm Of lung ____ _ Of nervous s Tags, iuentific-ntio Teeth- Dead ______ _ Septic ____ _ Tetanus ------ In Haiti_ __ _ Thi~h fractures Thorax, tlf:.wa~es Throat, reYicws 1 Thyroglos::;al due Thyroid cllsortlet Tonsil, Jin~nL __ Tonslllectomy In Tooth, supNnun Troplct.l di-eu-:es Tropkal lllL'(licin Tropical ukers. Tubercle liacilli rn XII. Vol. XU . Pace. 385 ------ - - ----- ------------- 79 ----------------------- --- 70~ } ________________ 99,293,494, 759 --- - ----- -------- --------- 6;)3 ----------------- 99, 293, 494, 75n ----------- --------- (ab)__ 4S.l ____________________ (ab) __ 717 103 ------------------------ 103,2fl~ --- --- - -------------- - ---- 789 _____________________ (ob) __ 101 mo 783 - ---- ------ ------------- 775,77~ ---- ---· ------------------ 102 ---------------------- - --- 447 __ __________________ (ab) __ scl~nces.) --------- __________ (ab) __ ____________________ (ob) __ --------------------(ab) __ ---- __________ ______ (ab) __ --------------------(Rb) __ ____________________ face __ 451 173 307 44:l 767 751 406 279 742 53S 2S6 86 270 5G2 577 - - ---------- ----- 121, 327, 527, 77() - - - - --------- - ------------ 225 ____________________ (ab)__ 485 ____________________ (ab ) __ 298 814 225 719 448 262 152 -------- ----------------- 715 -------------- ------- ----- 827 ------------------------- 146 -------------------- (ab) __ 800 ----------------- 03, 2S6, 4S0,757 ________________ (ab) __ 28!>,756 :So. -1. INDEX T O VOLU M E XII. Stlera, re-.ertion of_ ___________________________________________ (ab) __ Screen, bedslde-- - - --- - ---------- - - -------------------------------- Sebaceous cysts--------- - - --------------------------------------- Semllunar bone, carpal, dislocation of ________________________________ _ Ship, hospital ______________________________________________________ _ Sing Sing, a-) 317 2::l3 75 441 ti15 ]41 2::ll Suggested devices------------------------------------------ 75, 2;:;1, 441 Surgeon, naval, what he shoul Surgical notes- -------------------------------------------- - - - - 527,530 s"·imruing pools, snnltn ti on of _________________________________ (nb) __ 7:;7 Syphilis-cerebral ____________________________________ _:____________ 469 Ear, In ---------- --- -------- ------------ --------------- (ab)__ l 00 In Ilaltl------------------------------------- ------------------ 300 Legal enactments agalnsL---------------------------- - - - - ( ub) __ 315 Of lung--- ---------------------------------- ------- ------------- 266 Of nen ·ous system ------------ --------------------------- (ab>-- 2S2 T. T ags, iclentification _________________ -------- - - ------------------ --- --- 412 T eeth- Dead ____________________________________________________ (ah)__ 2S5 Septic ------------------------------------------------------ 727 Tonsil, linguaL---------------------------------- -------------- (ab) -- ~ Tonsillectomy tu tuberculosis ----------------------------------------- 751 Tooth, supel'llumerarY-------------- - - - - - ------- - ---- - --------------- 270 Tropical d i ~ca~es ___ ----------------- --------- -------- _______ (ah l-- n;:; Tropical medicine, reviews of litrrature on____________________________ 95 Tropical ulcers, new mclho-- 293 INDEX TO VOLUME Xll. Vol. XU. 824 Tubercular conditiuns ________________________________________ (ab) __ Tuberculosis- Altitude in------------------------------------------------ (ab) __ Of penis __________________________________________________ (ab)-- Renal ---------------------------------- ------------------(ab)-- Tonsillectomy in------------------------------------------------- X-ray diagnosis oL--------------------------------------- (ab)-- Typhoid bacilli in urine ________________ ________________________ (ab) __ Typhus ----------------------------------- -------------------(ab) __ Prophylaxis oL------------------------------------------- (ab) __ Transfusion for-------------------------------------------(ab) __ u. liltra-violet therapy----------------------------------- ------------ Undesirable candidates, detection oL---------------------------------- .Undulant fever------------------------------------------------------ t;rlnals for camps, portable--------------------------------------- --- v. Vaccines, seu.sitir.e-- 765 A\-cry, 0. T ____________ (ab) 101, 102 Axelrad, S _____________ (ab)-- 293 B. Bachmann, R. A -------------- 30, 262 Ba ird. G. W ____________ face__ 8G Balestra, D ----------- - (ab)__ 108 Barber, .T. R ________________ 271, 286 Barrier, C. W ----------------- 20i:i Bassett-Smith, P. \V ____ (nb) __ 271 Blacklock, B_ ___________ (nb >-- 725 Blnckwell, E. 1\L______________ 347 rnoedorn. w. A________________ 85. 271,279,289,292,481,48~ 725,727,730, 732,739,740 Boaz. F ________________ (ab)__ 317 Page. Carter, C. F ---------------- 457, 471 Carter, H. F ____________ (ab)-- 725 Castellani, A ___________ (ab> - - 95 Cauch, ·w. A__________________ 270 Carn llini, E ____________ (ab)__ 279 Cecil, R L _____________ (ab)-- 732 Chickering, H. T ________ (ab)-- 102 Choisser, R. M________________ 205 Clark, G. F- ------------~---- 87, 100, 101, 271,294,331,481,495,759,762 Clark, N. H___________________ 452 Cla rkc, c _______________ (ab>-- 87 Clough, i\f. c ___________ (ab)__ 293 Cohen, H. B__________________ 299 Cole, R. C-------------- (ab)__ 102 Collie, ,}_ ______________ (ab)__ 483 Connole, J. V ----------------- 706 Cooper, C. F ------ - ----- (ab)__ 725 Conleiro, F. J. B______________ 577 Corner, E. M ___________ (ab)__ 744 Crnndon, L. R. G______________ 393 Cl'eSS, C. C-------------------- 257 C1·ow, G. B _____________ 271, 276, 277 Cumming, H. s _________ 271, 275, 735 Cul'I, II. C------------- ------- 394 D. Bo~an, I<'. ~r_ ___________ 87, 89, 94, 734 Dalanil. .J_____________________ 802 Boles, R. S ______________ 71;:;, 719, 778 Dnnielopoulu, D _________ (ab) __ 750 Bonime, E ------------- (ab) -- 27G Da Yid son, A. B_______________ 266 Bouquet, fl ____________ (ab)__ 3Vi Dennis, F. L ____________ (ab) __ 751 Brill, A. A------------- (ab) -- 763 De Yer, F. J __ ~---------- 455, 715, 778 Bruce, J --------------- (ab) -- Brunet, vV. 1\L-----------,---- Bryant, W. S------------ (ab) __ Bull, L.· L ------------------- - B urrows, H ____________ (ab) __ Butler, L. A -------------- ---- c. Callawny, E _________________ _ Camerer, C. B---------------- Cnntlie, .J ___________ . ___ (:ih) - - Carr, C. \V - - ----------------- 76098-JS--l 7 289 Do!'.bez, A. n ___________ (ab) 101, 102 33G DO\\'JH'Y, .J. W., j1· _______ (ab> - - 106 502 nu Roi;:, B. F ----------------- 75 551 Du1Jgpon, L. s __________ (ab)__ 87 90 . null'. ,L______________________ 568 27 E. Eatn11, "" ].] ___________ .. _____ _ '.WI\ Eber~on, !•' __ _________ _:_(ab} __ 146 Etldy, W. IL ___________ (ab)-- 2!)2 I E spach , W. C----------------- 447 Ewart, W -------------- (ab) __ ~ 25 443 759 94 457 88 8~6 l~DEX TO A"GTHORS. Yol.Xll. F. J. Page. Fnrenholt, _\_ _______________ 131, GOl Joslin. TI. I\:_________________ :!t rell. E. "°---- --------(ah) __ :!I!) Jacob~-. A. L------------------ 40(1 Ft'rguson, D------- ------------ 800 Ft>rry, X. S----------- (ah) 21;:; K. Fi;;ke, C. ::\" _________ ·-· _ :i:J, 87, 1]!) Knhelek, J ______________ (ab) 1~.;; F•1reman, F. ".---------(ah) __ 287 F t•X, Q __ ______ -------- --- - 87. 103 -rank, L-- - ---- -------- (nb) __ JO:i ""rac;er, J --------------- (ah)__ :iOl n·aser, J. s __________ (:th)-- 501 . G. t,,, tes, )I. F------------------- c,;ueck, B _____________ (ah) _ c 1et.sch, }·; ____________ (a Ii ) Golden. \Y. E----------------- 17,75 52-t 727 474 7:!1 G •Ulll. E. \Y _ G··aham-Smith, G. s ____ (ab) _ 2SG ( ray, G. A------------------ 467, 722 Ci·eenough, R. n __ ----------- 141 ( uillot, )f ______ (ah) _ 2.'l2 H. Ha~er, B ... \. ------------------ 79 Hale, G. D----· --------------- 1 H;1lpin . .T. _\ __ --------------- 80 H.1milton . .-\. ___________ (abl -- 765 Hartman, F. W --· ------ 1, 13, 70. 46 ~ Ha~·nes, H. g ___________ (ab l-- 7'10 Hebblethw:1ite, A. S---- (ab) __ 307 Ht.>ltl, I. W _____ .------ (ab) __ 734 Henry, H _____________ (ab)-- 49-t Hen r~·. R. R------------------ 76 ff •rmun, L -· _____ --------- 623 He:-rick. \Y. W __________ (ab)-- 735 H: . .!!iee, n. l~ --- --------- 3, :t:!'i :\Iartini. E ______________ (ah) 1-.1 :\kDonell, \Y. X __________ --- .J;", .• IcDowell, R. \\' __ 87,n~.:.:71,:lBl,~l)l ~,fcG uire, L. W ____ ·-· 140. jj:", :.\kMullin, J. J . .\_. ______ ----- i'll:l Ri'l. n _______________ (nb)-- 91 Holbrook. Jt. \Y ________ ·------ 447 H •nker, 1':. II. __________ (ab)-- 767 \11-Xierney. F. B--------------- -HS :\IC'llllel, L. B __________ (tlh) __ ~f\\.l Hnp])l'. Ii. TI ____________ (ab)-- 73!) Ht1tel Dien of Pari..;, history oL 65!~ Hough, P. \\'_____ __ --· __ 144 fl<'nghton, .T. E _______ 87, 101 , 271, 205 Honzel. G ---------· ----- ___ 3 H .. yt, R. E - ----------------- 701 Hn~hes, F . . \ Hutt. c. \\' -----·-· ·----- -- ---- ( nh) __ J. 473 506 :·.Iii inn. IJ __ ------------ ( :1h) __ i';Jli :1[ills, C . K- ____ (nh)__ l(.i:! i\linuker, .\. ,J_ _________ -- ----- 1 !l:"> l\looa~-. E. E --------------- .J:ii'. lil i\iorishimn, K ---------- (ab)__ !l!I )fnrphy, l'. J__ :~s~. ?"'. :;\onchi, lL ·--· .. (:th) :'\oYitzky, .T ____________ (ab)-- 473 :!\"o~·es, B. H _____ ------· _____ _ .rsrael, .T. p __ _ .JI :\o. 4. 0. Oshorne, '.f. n P. Parham. J. c; _______ _ Parish. B. [> _______ _ l'nrke;;;, C. JI P :1r,:on~. ll. P ------ l':lton. L ______ _ l \•net. :r. M _______ _ l'l'tl ei·son, H. (' ___ _ l'llllllll1l'l', l:. \\' ___ _ R. Hau. Y ___________ _ Hho. p ____ _ l: ic·hnn1>'. T. \\' ___ _ Hivers, \\'. II. H Hoerner, J ------- Hoper .. J. C Hos,.;. G. G ________ _ Hossiter, l'. ::-; __ l t.1·<1l'Cll. Il ________ _ s. f-i< holler;;. II. ;\[ S('hoonmnkl•r, IL __ l"<·lnrnh, S. L S hor! . .T. T __ ----- !'-'in<:l:t :r . .T . ... \. H Rllll'Ptou. )I. .\ __ _ Smirh. <'. E_. 8111i1h. t'. ,,. __ _ Rmith. .1. \\' _ f-ip<>i) __ ..JS:1 L. ~ F. F-------------------- Gl3 !onte, R G ___________ 527, 710. 787 .lbPr~. II. B _______ - - ----- 801 .1. ii _____________ (ah)__ 772 ·. D. F __________________ 330, 392 . G-------~-------- (nb) __ 489 ·h, G. R ____________ ( :t b) __ 271 ]\[. lllum. A. B _________ ( uu) -- 1e, .J. \\'. s _________ (ab) -- 730 12:; {CH%iC, G. i\l______________ 173 glrnm, s ____________ (ob l-- 271 n, W. L ______________ 78, 2G3, 3'.?i :ini. E ______________ (nh) __ 7:Ji\ ·onell, "._ ~ -----~--------- 4:; ·owcll, R. W ___ 87, 9~ . ~71, 284, 2fl0 uire, L. ""-----------··-- HO. 77:> lnllin, .T . .T. ,\_______________ 702 ·iern e~· . F. B _______________ 448 llel, L. B ___________ (ub) _ 290 ;111. G _______________ ( 11h) __ 7;:>G s, C. K _____________ (nh) __ 7G2 iker, .\. J _________________ 1n;-, dy, E. E ________________ ..J:l~471 ishimn, K ---------- ( nh) __ 9!) phy, P . J _________ _________ ~S;:;. d1i, r-1_ ______ ________ (:1u) 702 itzk~·, .T ____________ (:tl.J)__ 28:i es, R H___________________ .JI. No. 4. lNDEX TO AUTHORS. 827 0. Page . ·Osl.Jorne, 'l'. B ___________ (ab)__ 290 P. Parlrnm, J. Q ______________ 87, 92, 723 Parish. B. D __________________ 713 P :1 rkcs, C. H ___________ (ab)__ 28-! Parsons. R. P _________________ 155 l 'aton. L _______________ (ub) __ 103 l'enet. .T. l\L_________________ 717 Pt•ttcrson, IL Q_______________ 341 l'llllllllH.'l', H. 'V --------------- 2fi5 R. Rau. '°----------------------- 27 It ho, F - - ------- - - - - - - -- (al>)__ 93 Itich:t nl~. '.I'. w --------------- 18-! fliYers, "\\-. I-I. R ________ (ab)__ 485 Ht1t>111er. J_ _____________ (ab)__ 734 novt·r . .T. Q _____________ (ab)__ !)-! Hoss. G. G____________________ 72() Ho!"siter , P. S---------------·-- lfl:l H~·tlt>en. H -------------------- 802 s. .Pap. Strnuss, S. G________________ 609 St1·ine, H. F -------------- 87, ~. 572 Stnnrt, M. A________________ '442 Sund, A. G ________________ 449,451 Sutton, D. G ___________ 271, 286, 281., 282,481,485,525,762, 763,7.65 Swift, H. F _____________ (.ab~ -- 282 T. 'J'n~·Ior, J. s _________ 3,61,65,67,225, 243, 246, 419, 43H, 4;~7, 653, G9a, 767 'L'aylor, S. lVL_________________ 79G 'l'engnc, Q ______________ (ab,__ 99 'l'olirn